Case Study

Splenic necrosis and gallbladder perforation in a 7 year old FS Jack Russell Terrier dog

A 7-year-old FS Jack Russell Terrier with a history of regulated hypothyroidism, was presented for vomiting, lateral recumbency, and abdominal pain following ingestion of a ham bone. The owner also reported that the patient had been showing polyuria/polydipsia prior to the incident. On physical examination, the patient was laterally recumbent and very painful. CBC showed polycythemia and low band neutrophils. On blood chemistry, mildly elevated BUN, elevated creatinine, elevated ALP activity, elevated lipase, severely elevated ALT activity, and elevated cPLI were evident. A hemorrhagic diathesis was present on coagulation panel. Blood pressure was 145/80. The patient was treated with I.V. fluids, hetastarch, morphine/ketamine drip, fresh frozen plasma, antibiotics, and placed in an oxygen cage. On survey abdominal radiographs, bony fragments were evident in the gastrointestinal tract. The patient was sedated, given an enema, and a large piece of bone was produced. After 42 hours on therapy the patient developed dyspnea, which, on survey thoracic radiographs, was suggestive of fluid overload. Lasix was administered, which resulted in resolution of the dyspnea. Recheck blood chemistry showed hypoproteinemia, elevated ALP activity, hyperglycemia, improved azotemia, and normalization of cPLI. Physical examination, after 72 hours of supportive care, found the patient BAR and ambulatory, not interested in food, and still extremely painful upon palpation of the right mid-abdomen. Syringe feedings were started, which were well tolerated with no vomiting. However, the following morning the patient was less bright and more painful in the abdomen.

DX

Splenic necrosis and gallbladder perforation

Sonographic Differential Diagnosis

Cholecystitis with gall bladder collapse/perforation and concurrent hepatitis/bile peritonitis is likely. Lack of blood flow in areas of the spleen support splenic infarction, torsion, splenitis, and/or potential for neoplasia.

Image Interpretation

The spleen was enlarged with areas of dramatic hypoechoic parenchyma with structural detail loss. Power Doppler assessment reveals an area void of positive signals, suggestive for splenic necrosis and infarction. Areas of hyperechoic pericapsular fat reactivity suggest an aggressive disease process. The liver reveals a seemingly unremarkable gall bladder with some suspended debris and mildly echogenic wall. However, the peri-gall bladder region reveals localized free fluid, coarse and irregular parenchyma with capsular swelling and echogenic ill-defined fat. The patient was reported to be painful upon scanning this region (positive Murphy Sign). This presentation would suggest gall bladder perforation and collapse, likely secondary to mucocele formation and gall bladder mural necrosis or infarction.

Outcome

The patient thrived postoperatively long term with no complications.

Comments

This is a difficult interpretation regarding the gall bladder. Much has been reported in the literature regarding gallbladder mucoceles but little information is available regarding the appearance of gall bladders when they have perforated and collapsed. The peri-gall bladder presentation and positive Murphy sign were key to the diagnosis and recommendation for immediate surgery in this case.

Clinical Differential Diagnosis

Acute pancreatitis, acute hepatitis/cholecystitis (viral/bacterial/toxic), intestinal obstruction, intestinal perforation with peritonitis.

Sampling

Splenectomy and cholecystectomy were performed. Gallbladder perforation was present, resulting in bile peritonitis. There was also splenic necrosis. Histopathology samples were lost so could not be reviewed.