Case Study

Gall Bladder (GB) Mucocele in a 10 year old FS Shetland Sheepdog

A 10-year-old FS Shetland Sheepdog with history of being medicated concurrently with steroids and NSAIDS, presented for progressive anorexia with occasional vomiting. Physical exam found the abdomen in this dog slightly painful. Blood chemistry (11/11/08) revealed elevated Alkaline Phosphatase, high ALT, hypercholesterolemia, markedly high GGT, and high BUN:Creatinine ratio. CBC found lymphocytopenia, elevated neutrophils, elevated segs, and thrombocytopenia. Patient had a low T4 and free T4 was within normal limits.

A 10-year-old FS Shetland Sheepdog with history of being medicated concurrently with steroids and NSAIDS, presented for progressive anorexia with occasional vomiting. Physical exam found the abdomen in this dog slightly painful. Blood chemistry (11/11/08) revealed elevated Alkaline Phosphatase, high ALT, hypercholesterolemia, markedly high GGT, and high BUN:Creatinine ratio. CBC found lymphocytopenia, elevated neutrophils, elevated segs, and thrombocytopenia. Patient had a low T4 and free T4 was within normal limits. Urinalysis showed high pH (7.5) and normal specific gravity, a clear, yellow appearance, proteinuria (3+), and trace hematuria. Blood chemistry (12/30/08) revealed markedly elevated Alkaline Phosphatase, high ALT, hypercholesterolemia, and still markedly high GGT and elevated BUN:Creatinine ratio. CBC found eosinopenia, low HCT and RBC’s, lymphocytopenia, leukocytosis, high absolute monocytes, and high absolute neutrophils and band cells. Patient had a low T4 and free T4 was within normal limits. Urinalysis showed high pH (7.5), low specific gravity (1.012), a cloudy, yellow appearance, proteinuria (2+), hematuria (3+), WBC (11-20), RBC (11-20), and bacteriuria (cocci 3+). Recheck CBC (1/16/09) still showed eosinopenia, low HCT and RBC’s, lymphocytopenia, low monocytes, high platelets, increased platelet estimate, leukocytosis, and high absolute neutrophils and band cells.

DX

Gallbladder mucocele

Sonographic Differential Diagnosis

Gallbladder mucocele with minor pericystic inflammation more definitive if + Murphy sign is present during imaging of this region. Likely concurrent inflammatory hepatopathy.

Image Interpretation

Significant gall bladder distention is present with suspended debris in the near field and coalesced echogenic debris in the far field. No evidence of rupture is noted but minor echogenic pericystic fat is noted that may represent inflammation in the near field adjacent to the gallbladder neck and/or distal enhancement in the far field distal to the gallbladder itself (arrow).

Outcome

A cholecystectomy, liver biopsy, and investigation of the stomach and gastric evacuation and assessment with left adrenalectomy were performed. Blood chemistry (01/28/09) revealed improved hyperphosphatemia, improved high ALT, and low creatinine. CBC found high basophil, low HCT, low RBC, thrombocytopenia, T-4 was low and Free t-4 was within normal limits. Urine culture yielded no growth. The patient recovered uneventfully.

Clinical Differential Diagnosis

Liver pathology: Hepatitis, hepatopathy- toxic, metabolic, biliary disease-cholecystitis, cholelithiasis, gallbladder mucocele; multi-organ pathology: urinary tract infection, suspect anemia of chronic disease, neoplasia, ulcerative gastritis, pancreatitis