Case Study

Elevated Liver enzymes in a 13 year old MN DSH

A 13-year-old NM DSH with a history of urinaty bladder atony and constipation was presented for evaluation of elevated liver enzyme activity (ALT 421, ALP 314). Current therapy was bethanechol, prazosin, buprenorphine, denamarin, and miralax. The only abnormality on urinalysis was bilirubin crystals.

Radiograph Findings: large bladder/constipated

DX

Aggressive, extensive, pancreatitis.

Sonographic Differential Diagnosis

Aggressive, extensive, pancreatitis.
Mild interstitial nephrosis renal pattern.

Image Interpretation

The pancreas was enlarged, hypoechoic and irregular with pericapsular inflammatory pattern. The pancreas measured 1.85 cm in width. The pathology within the pancreas measured approximately 4.5 x 2.0 cm, yet significant, hyperechoic fat was noted throughout the cranial abdomen. This walled off the pancreas. There was mild dilation of the pancreatic duct. The inflamed fat extended to the right kidney in this patent, yet is likely the extension of the pancreas with secondary influence upon the kidney. Ultrasound-guided FNA is strongly encouraged in this case to assess inflammatory cell type and rule out the potential for neoplasia. However, this is not suspected.

Outcome

FNA of the pancreas is strongly recommended to define inflammatory cell type and refine therapy. There is a significant amount of pancreatic pathology for a cat. Regarding the prior history of azotemia toxin shower deriving from the pancreas likely sent this patient into emerging renal failure. Aggressive treatment for pancreatitis is warranted. Plasma expanders, broad spectrum antibiotics and pain management would all be recommended. A recheck sonogram is recommended in 3-5 days.

Clinical Differential Diagnosis

Liver – cholangio-hepatitis complex, drug-induced, toxins, lipidosis, FIP, neoplasia, granulomatous disease, abscessation
Pancreas – pancreatitis, neoplasia
Gall bladder – cholecystitis, neoplasia, obstruction (lith, duodenal/pancreatitic disease)