I am currently monitoring 2 gallbladder cases, and was hoping to start an ultrasound and internal medicine discussion about them.

CASE 1 – Pup Pup – 5 year old F/S Bull Terrier weighing 34.2kg (BCS 4.75/5)

– Sept 12, 2015 – presented for vomiting. CBC – Mild leukocytosis characterized by mild neutrophilia. CHEM – ALP 3455, ALT 1725,  Cholesterol 12.51, GGT 53, TBIL 125, GLOB 51. Snap CPL negative. aPTT normal.

I am currently monitoring 2 gallbladder cases, and was hoping to start an ultrasound and internal medicine discussion about them.

CASE 1 – Pup Pup – 5 year old F/S Bull Terrier weighing 34.2kg (BCS 4.75/5)

– Sept 12, 2015 – presented for vomiting. CBC – Mild leukocytosis characterized by mild neutrophilia. CHEM – ALP 3455, ALT 1725,  Cholesterol 12.51, GGT 53, TBIL 125, GLOB 51. Snap CPL negative. aPTT normal.

                   – treated with IV fluids, ampicillin, famotidine, cerenia, denamarin over the weekend.

– Sept 14, 2015 – CBC – WNLs, CHEM – ALP 1953, ALT 899, CHOL >13.42, GGT 58, TBIL 21. Full abdominal ultrasound performed and radiologist telemedicine results –> “Hyperchoic mesentery the region of the pancreas. Rule outs should include pancreatitis. Gallbladder debris with hyperchoic focus exhibiting acoustic shadowing which most likely represents a small calculus within the gallbladder neck. Ursadiol therapy should be considered. Recheck ultrasound in 4 to 6 weeks to reevaluate the gallbladder is recommended. Overall, no intraparenchymal hepatic abnormalities were appreciated. Elevated liver enzymes may be due to inflammation adjacent at the level of the gallbladder and pancreas. If clinical signs do not improve with treatment of gallbladder/pancreas issues, follow-up fine needle aspirate of the liver could be considered.”

– Sept 15, 2015 – dog doing well, discharged with clavaseptin, denamarin, ursodiol, PVD EN.

– Sept 22, 2015 – CBC – HCT 65.2, HGB 22.2. CHEM – ALP 1083, ALT 346, CHOL > 13.42, GGT 25, TBIL 15. Above tx continued.

– Oct 13, 2015 – CHEM – ALP 306, otherwise WNLs (ALT 56). Ultrasound gallbladder – moderate amount of sludge adherent to walls, cholelith still visible but less echogenic and perhaps a bit smaller? Inflammation in cranial abdomen has resolved. Continued with denamarin and ursodiol.

– Nov 10, 2015 – Ultrasound gall bladder – no change. Dog asymptomatic and stone non-obstructive. Continued with denamarin and urosdiol.

– March 2016 – CBC/CHEM – WNLs. Ultrasound gall bladder – no change. Dog still asymptomatic and stone non-obstructive. No change in stone size. Continued with denamarin and ursodiol.

– Sept 2016 – CBC/CHEM – WNLs. Dog also continued to gain weight during the year despite adjusting caloric intake (and she’s heat seeking!). Thyroid panel – Free T4 13.6 (7.7-47.6), T4 20.3 (13.0-53.0), TSH K9 0.36 (0-0.60). Ultrasound gall bladder (attached) – stone is perhaps 0.1cm smaller than 6 months ago, but really no change. VIDEO ATTACHED – “Pup pup”

CASE 2 – Brady, 12 year old M/N Papillon.

– August 6, 2016 – presented for vomiting and weight loss. CHEM – ALKP 861U/L, ALT 1702U/L, GGT 138U/L, TBIL 26umol/l, cholesterol 10.95mmol/l, BG 4.01mmol/l, globulin low normal, other protein parameters WNL, renal function appears normal. Treat in hospital on IV fluids, cefazolin, baytril, buprenorphine, cerenia, famotidine, liver diet, denamarin.

– August 9, 2016 – full abdominal ultrasound performed. GB was distended and contained a large volume of anechoic bile with some echogenic material that was adherant to the walls in some areas, and gravity dependent at the entrance to the cystic duct. No dilation of extrahepatic biliary tract, obstructions along the tract, or changes in the area of the duodenal papilla. There is no inflammation around the gallbladder, or edema associated with the gallbladder wall, but the dog is painful upon scanning this area. Discussed possible ddx with rDVM (cholecystitis, emerging mucocoele) and owner opted to monitor serially and continue with tx plan and add ursodiol. ATTACHED – “Brady Aug 9”

– August 10, 2016 – CHEM – ALP 612, ALT 469, GGT 80. Dog doing well, so discharged on baytril, clavaseptin, denamarin, urosdiol, tramadol, liver diet.

– August 16, 2016 – Ultrasound gallbladder – no worse (no edema or thickening of wall, no free fluid or inflammation surrounding GB), and while the GB is full of echogenic debris there is none adhered to the wall. Dog doing well at home, putting on some weight. Continued with above tx plan for 4 weeks. ATTACHED – “Brady Aug 16”

– Sept 12, 2016 – CHEM – ALP 462, ALT 827, CHOL 9.50, GGT 86, TBIL 16. Ultrasound gallbladder – no changes noted. Dog has lost 8% body weight in the last month but not eating as well. Not painful over GB. rDVM recommended continuing with same tx plan and repeating bloodwork and u/s in a month. ATTACHED – “Brady Sept 12”

My questions – when serially monitoring GB, we need to monitor for:

1) GB wall thickness,

2) GB distension and material present,

3) Inflammation or steatitis around GB.

So….what do we do when nothing changes?

Case 1 – stone has been there forever, not affecting bloodwork, not obstructive but still on denamarin and ursodiol…do we just continue with this and monitor with u/s q6 months (or sooner if symptomatic)?

Case 2 – material is adherant and doesn’t appear to be resolving, but no evidence of inflammation or wall edema….so do we just keep monitoring?…

I don’t want to be charging clients for unnecessary work, but I also don’t want to miss the start of deterioration….

Thanks for all comments and suggestions.

Jennifer