Case Study

Peritoneal pericardial diaphragmatic hernia in a 15 year old Himalayan cat

A 15-year-old Himalayan cat with a history of peritoneal pericardial diaphragmatic hernia, polycystic kidney disease, and a liver cyst was presented for trouble breathing. Additional history was that a pericardial tap had been performed. Survey thoracic radiographs showed marked cardiomegaly and a markedly globoid heart.

A 15-year-old Himalayan cat with a history of peritoneal pericardial diaphragmatic hernia, polycystic kidney disease, and a liver cyst was presented for trouble breathing. Additional history was that a pericardial tap had been performed. Survey thoracic radiographs showed marked cardiomegaly and a markedly globoid heart.

DX

Pericardial peritoneal diaphragmatic hernia with large hepatic cysts.

Sonographic Differential Diagnosis

Pericardial peritoneal diaphragmatic hernia with large hepatic cysts encompassing the majority of the pericardial sac. These were drained, which allowed for increased cardiac output and ventricular filling. Parenchymal changes in the liver and the pericardial sac were likely due to anoxia and compression. Dilated hepatic veins and vena cava were seen secondary to right-sided failure from elevated right-sided pressures.

Image Interpretation

The diaphragm was incongruent, and it was easily visualized that the liver was traversing into the thoracic cavity. The hepatic veins and vena cava appeared to be dilated. There were cysts noted within the abdominal liver, with a very large cyst noted in the thoracic liver, which filled the majority of the pericardial sac. After the fluid was removed from the pericardial sac, the stomach was noted to traverse into the diaphragmatic hernia as well. The heart was noted to be compressed by a very large fluid filled cyst within the pericardial sac and was difficult to image. The large bi-lobed cyst appeared to originate from the hepatic parenchyma within the pericardium. The cyst was drained by a pericardiocentesis and 128mls of straw colored fluid was removed. After the tap, the echocardiogram revealed normal fractional shortening, normal atrial and ventricular size, wall thicknesses and flow profiles through all outflow tracts. After the tap was performed, it was noted that the liver directly adjacent to the heart had hyperechoic densities within it and was more abnormal and coarse in appearance.

Outcome

A recheck double-cavity ultrasound 2 months later found both cavities relatively unchanged with the exception of fluid build-up in the cyst. Another follow-up double cavity ultrasound a few months later again showed minimal changes except the size of the cyst which was now impinging on the heart. 50 cc of clear fluid with a total protein of 4.4 was removed.