1 1/2 year old Cockapoo. Hx of on and off poor appetite – has improved with some treatment for potential emerging mucocele. Occasional vomiting. Blood work in May showed ALT 350. T4 was only 1 and free T4 was in middle of normal ref range at 1, no TSH done. Had an ultrasound 6/23 (one still and one video from then). Went on Baytril and ursodiol and repeat ultrasound performed today. Seems to be minimal improvement and looking for advice. Is this one you would consider cholecystectomy?
1 1/2 year old Cockapoo. Hx of on and off poor appetite – has improved with some treatment for potential emerging mucocele. Occasional vomiting. Blood work in May showed ALT 350. T4 was only 1 and free T4 was in middle of normal ref range at 1, no TSH done. Had an ultrasound 6/23 (one still and one video from then). Went on Baytril and ursodiol and repeat ultrasound performed today. Seems to be minimal improvement and looking for advice. Is this one you would consider cholecystectomy?
Comments
some of the bile still looks
some of the bile still looks mobile and overdistention is mild. I just heard of an internist ensuring to image the Gb 2 hours postprandial which i think is a pretty valid thing to do in these cases. Otherwise a GB motility study is veryintuitive i think. Regarding when to cut or med or watch take a look at our survey amongst some really talented clinical sonographers regarding mucoceles from a few years ago (Defining a GB mucocele) and number 2 abstract from ECVIM 2009 on surgical biliary disease.
https://sonopath.com/educationevents/research-publications
Thank you, Eric. I will
Thank you, Eric. I will recommend next recheck be 2 hours post prandial. Since no gall bladder wall thickening or distention and no pain, do you think continuing the Baytril is overkill? Planning to continue monitoring liver enzymes and ultrasound every few months while at least on ursodiol. Full thyroid panel just came back normal. Would you recommend a low fat diet like WD?
I should have asked this
I should have asked this before, but what is the motivation for the 2 hours post prandial? Should be more empty than in fasted state?
yes cholecystikinin release
yes cholecystikinin release post prandial should empty it more than a fasted state. A dilated fasted GB wiht some sludge is normal. So should reduce post prandial as contactrion occurs… its almost a brief gb motility study.
With the ALT of 350 and the
With the ALT of 350 and the first image looks like a touch of gb wall edema so minor cholcystitis may be in play. Baytril penetrates the biliay tract well so i like it here for about 10 days and assess the ALT and gb wall and then decide to continnue or not. Can add metronidazole as well.
Thank you!
Thank you!
UPdate on this case. First
UPdate on this case. First of all, typo in that he is 11 years old. He is feeling much better after being on 3 1/2 weeks of metronidazole, enrofloxacin, and ursodiol as well as a low fat diet. Today he came back to recheck ALT and do a focused ultrasound recheck. The ALT unfortunately went from 275 to 945. On ultrasound, the amount of echogenic debris looks less and less inspisated than the first ultrasound in June, but about the same as the one in July. I did a serial scan today from fasting, to 1 hour post prandial and then 2 hours post prandial. No change in GB size from fasting to 1 hours. Slight decrease in size at the 2 hour mark (sagital measuremnt went from 4.8×2.1 cm to 4.8×1.6 cm). The liver is always more hyperechoic compared with the liver, but homogenous with no other obvious abnormality. Would love your thoughts on this one. Owner had a cholecystectomy herself so wants to be proactive. Liver aspirate and biopsies have not been performed yet. I think she would be on board with full biopsy.
Well you can aspitate for
Well you can aspitate for predominant inflam cell type and manage medically from there. Its not a full mucocele even though likely some gb dysfunction but tough to push a surgeon for removal when criteria is nebulous. If this were my personal dog I would remove the Gb and bx the liver and manage based on what i have on paper but that’s me. Im a bit more proactive on these things especially if my pet but if Im not making the sx decision then its a bit more problematic. But sx bx are ideal and you would be there for the Gb and cbd lavage so gets down to the point and removes a likely low grade problem in the emerging gbm. Gb are extra parts anyway:)