Case Study

Inflammatory bowel disease (IBD) pattern with liver nodular hyperplasia in a 16 year old FS DSH cat

A 16-year-old SF DSH cat was presented for evaluation. Abnormalities on serum biochemistry were azotemia (BUN 43, creatinine 3.2) and elevated liver enzyme activity (ALT 443, ALP 151). Survey radiographs revealed hyper inflated lungs and excessive upper gastrointestinal gas.

DX

Inflammatory bowel disease, liver nodular hyperplasia and splenic extra medullary hematopoiesis

Sonographic Differential Diagnosis

Mild splenic enlargement.
Minor heterogenous liver.
IBD gastrointestinal pattern

Image Interpretation

The spleen measured 1.12 cm and was enlarged, which his likely reactive. The spleen revealed hyperechoic nodules. This is consistent with lipogranulomas. The spleen presented scalloping contour. The liver was coarse in architecture and slightly enlarged. The liver was isoechoic to the surrounding fat with minor, heterogenous parenchymal changes. This is most consistent with benign hepatopathy and potential underlying lipidosis. There is no overt suspicion of neoplasia. The gallbladder and common bile duct were normal. Minor, heterogenous parenchymal changes were noted.
The gastrointestinal presentation revealed mild uniform prominence of the gastric mucosa as well as areas of “ropey” small intestinal wall with slight disruption of the normal 1:3 muscularis/mucosal ratio. The intestinal mucosa was slightly irregular, thickened and hyperechoic suggestive of low grade, chronic inflammation. No significant lymphadenopathy was visible. No evidence of obstruction was present. Chronic inflammatory bowel disease is probable with a low possibility of an early neoplastic event such as lymphoma. Full thickness tissue biopsies via open laparotomy would be necessary to rule out this possibility.

Outcome

The azotemia in this patient is a prime concern. Given the renal infarcts and degenerative changes an acute on chronic presentation may be the underlying issue. Inflammatory bowel is likely. There is a mild potential for underlying neoplasia such as lymphoma. If any evidence of inflammation or infection is noted in the urinary sediment then aggressive treatment for pyelonephritis is recommended or renal infection that may be causing an acute on chronic presentation. Coordinate aspirate results with appropriate treatment. This is likely benign hepatopathy, potential lipidosis and reactive spleen. There is a mild potential for lymphoma or mast cell disease.

Clinical Differential Diagnosis

Kidney – chronic kidney disease, renoliths, pyelonephritis, obstructive uropathy, granulomatous disease, neoplasia
Liver – cholangio-hepatitis complex, lipidosis, neoplasia, acute hepatitis (viral, bacterial, toxins), granulomatous disease
Asthma

Sampling

FNA of the spleen and liver were performed. Liver FNA is consistent with nodular hyperplasia and possible early lipidosis. Splenic FNA is consistent with extramedullary hematopoiesis and normal lymphoid tissue.