Dear colleagues,
This is Patches, 1y1m old MN persian cross presented last week for a second opinion to assess a 3rd episode this year of increased liver enzimes and triditis. First episode in April treated with liver protectants and supportive therapy, second episode in July and when liver enzimes were getting better cat had a fall and it is suspected that this could have triggered this last third episode.
Dear colleagues,
This is Patches, 1y1m old MN persian cross presented last week for a second opinion to assess a 3rd episode this year of increased liver enzimes and triditis. First episode in April treated with liver protectants and supportive therapy, second episode in July and when liver enzimes were getting better cat had a fall and it is suspected that this could have triggered this last third episode.
Full abdominal scan last week showed mild GB distension with CBD 0.35cm and a 2.5cmdiam nodule in right liver lobe. Thick hypoechoic pancreas although no discrete masses, regional Lns enlargement no distorted. ALthough nodule looks of bening appearance I thought regenerative nodular hyperplasia may cause more nodules and not just a single one so an organized hematoma, FIP and LSA are also in my list, mainly because there are quite a few small pockets of free fluid (anechoic) unable to sample. Intestines appear of normal thickness and wall detail but there is a bit of general ¨dirty shadowing¨ which I atributed to pancreatitis process. No masses but some Lns enlargement.
I recommended a review scan to monitor GB and biliary system. I did this yesterday and to my surprise, I think there is an embolus in Portal vein with pre’embolus dilation (0.8cm) and post embolus decreased diameter (0.29cm). The free fluid is more obvious but I still cannot sample it. Owners are reluctant to FNA for now ( I would like to know what we are dealing with and what kind of embolus it is…clot from traumatic episode or more neoplastic or …granulomatous? is that possible?) I am also surprised at location of clot…I would expect a clot to be in hepatic veins…not in portal vein…
Questions: am I seeing this correctly?? is this a portal vein embolus? I think now the fre fluid is more related to this than to a possible neoplastic procedure or FIP. Biochemistry and CBC is all normal except for a slight ALT elevation )still in the 100s). Cat is doing much better according to owner…What would be your next step? I am rescanning this patient again on monday or friday if cat not well to monitor this finding until owners make up their minds for further sampling. My colleague is hoping that this is a thrombus and it will reabsorb…but I am concerned at the speed of dilation of portal vein in 5 days…
Thanks so much for any input…
Comments
I think you are getting
I think you are getting overlying vessels on the cbd. This looks like a cbd mass like biliary adenoca or similar and would make more sense as cbd masses in an 11-yr old cat are much more common that a pv thombus. The far field pv has solid flow into it. The cbd is above the pv in the image normally and in the still image the structure looks slightly vascularized which is what cbd masses do and thrombi do not. Maybe some more views?
Seee similar cases form the basic search:
http://sonopath.com/members/case-studies/cases/0300430-baby-b-bile-duct-neoplasm-ehbdo
http://sonopath.com/members/case-studies/cases/post-hepatic-bile-duct-obstruction-14-year-old-mn-dsh-cat
Ah, thank you! Well… It
Ah, thank you! Well… It makes sense, because why would a thrombus be in the portal vein!? But also… It looked so much like a one vessel…I tried to sweep from aorta to CBC and to portal vein in such way it would be unequivocal where I was but it just doesn’t make sense to have anything I PV, also… How fast would a mass grow in the CBD? That was definitely not there the week before. And how does that fit in the car doing better ( even on bloods) but scan being worse… ?anyway, I have many videos I will try and attach another one in case it helps, although you are most probably right.
Thank you for the response, I’ll be scanning this case again on Monday… I
some of these mass looking
some of these mass looking structures are bile plugs or proliferative tissue … that latter more likely given the doppler signal if not a carcinoma. I have seen them grow overnight or insidiously. Best to have a probe on it in a week or less and see what it does and surgicate if persistent with bile duct reconstruction if not mets in liver alreayd as those can be isoechoic.
Here are some portal vein thrombosis cases. Essentially any hypercogulable state can cause pv thrombus but I look hard for them when pancreatitis is going on or splenic or other portal draining lymphoma occurs.
http://sonopath.com/members/case-studies/search?text=portal+thrombus&species=All
EL, thank you for your
EL, thank you for your input…I have reviewed the videos to provide you with more views. I have 2 questions or aspects that do not fit with th CBD mass…in the new videos (and that is what made me think it was in PV in the first place), there seems to be flow of RBCs in the anechoic area…which i thought that meant flow of blood hence PV. The second aspect is that the clips are from a sagittal view on RLR so the dilation is caudal to the embolus, which makes sense for a PV but not so sure about a CBD since the bile flow would come from cranial to caudal…is that right?
Anyways, here are 3 more clips. i hope it´s ok to post them. I know you prefer not too many. My main question is to know whether it´s PV or CBD. If it is CBD with that mass…the TBIL and the cat…wouldnt be worse? in any case, I will keep you updated about the next scan and review. really appreciate your help. Thanks.
OOPS! It seems I cannot attach anymore videos…new post?
Oh! I have just realized you
Oh! I have just realized you thought this cat is 11y old. It is actually 1year 1 month old:)
ahhh 1 year well that changes
ahhh 1 year well that changes things:) Then bile plug-cholangitis fits more and maybe that minor CF is an adjacent vessel overriding it. I would tx cholangitis and add actigal and recheck th escan in a week. yes we can’t for technical reasons at themoment add video to a current string without upgrading the whole system… likely will do soon but what seems like an easy fix is a large expense. Weclome to the world of IT financing as I have to prioritize what to invest in to improve the site. This additional video issue is on the list for sure though. Bigger membership helps this so please tell friends:)
You can start another thread with the video and we go from there though and you or I can attach the url to this thread to cross link.