Case Study

Emphysematous hepatitis with possible mass formation and hiatal hernia of the liver lobe in a 10 year old FS Australian Shepherd

A 10-year-old SF Australian Shepherd was presented for evaluation of acute hematemesis, vomiting, diarrhea, and lethargy. Abnormalities on physical examination were lateral recumbence, dehydration, and pyrexia (106.8). Blood work showed thrombocytopenia and elevated ALT (655) activity. On survey radiographs possible mass in mid abdomen and hepatomegaly was evident.

DX

Emphysematous hepatitis with possible mass formation in the cranial liver with hiatal hernia of the liver lobe

Sonographic Differential Diagnosis

Emphysematous hepatitis with possible mass formation in the cranial liver with hiatal hernia of the liver lobe.
Possible splenitis or infiltrative disease involving the spleen with regional peritonitis.

Image Interpretation

The liver in this patient presented parenchymal 6.5 cm region of the left cranial parenchyma in which air accumulation is noted. This is consistent with emphysematous hepatitis. Variable areas of hepatic parenchyma revealed emphysematous penetration within the parenchyma. A hyperechoic portion of the liver appeared to enter into the esophageal inlet. This is consistent with hiatal hernia of the liver lobe. This is particularly aggressive. Underlying neoplasia is possible such as carcinoma; however, ultrasound-guided FNA of the general hepatic parenchyma and the emphysematous portion of the parenchyma would be recommended. Surgical consult is recommended as well. This is in an exceedingly difficult position to assess surgically given the cranial aspect of the liver. Stabilization of the patient prior to surgical consultation is recommended. The gallbladder was mildly thickened.

The spleen was mildly irregular with micronodular changes.

Variable areas of consolidation were noted in the thorax. A portion of the liver appeared to be present in the caudal thorax. Radiographic review would be recommended.

Outcome

Aggressive treatment for anaerobic infection is recommended. Adding Clindamycin or Metronidazole would also be recommended for triple antibiotic therapy. Plasma transfusion, plasma expanders and eventual FNA of the spleen and liver would be warranted to rule out underlying neoplasia followed by surgical consultation depending upon follow-up sonogram over the next 48-72 hours. Very guarded prognosis.

Clinical Differential Diagnosis

Liver – acute hepatitis (viral, bacterial, toxins), neoplasia, abscessation, chronic-active hepatitis
Leptospirosis
Gall bladder – cholecystitis
Pancreas – acute pancreatitis
Intestinal perforation with regional peritonitis