Abdominal US on a 12 YO Feline (Oriental Shorthair) with vomiting and weight loss. Current weight is 6.5#.
Radiographs reveal suspected Stones in Common Bile Duct (Choledocholiths).
Lab work:
- Hyperglobulinemia (6.1)
- Albumin low normal (2.5) A:G = 0.4
- Mild increase BUN (37)
- Normal Creat
- CBC- Leukocytosis (24,000) with a monocytosis and eosinophilia
There is no evidence of Anemia or elevated liver values noted.
US findings:
Abdominal US on a 12 YO Feline (Oriental Shorthair) with vomiting and weight loss. Current weight is 6.5#.
Radiographs reveal suspected Stones in Common Bile Duct (Choledocholiths).
Lab work:
- Hyperglobulinemia (6.1)
- Albumin low normal (2.5) A:G = 0.4
- Mild increase BUN (37)
- Normal Creat
- CBC- Leukocytosis (24,000) with a monocytosis and eosinophilia
There is no evidence of Anemia or elevated liver values noted.
US findings:
- Liver is hypoechoic with slightly coarse echotexture and hyperechoic reflections with shadowing noted.
- Kidneys: Small, Hyperechoic with increased Corticmedullary Demarcation. Left renal pyelectasis of 0.52 cm.
- Mildly Dilated Common Bile Duct with a few small stones seen; There is obstruction (tissue/swelling/mass) at the duodenal papilla.
- Pancreas looks pretty quiet, but is slightly enlarged and may be some pancreatic duct stones near the papilla
- GI: Hyperechoic mucosal layer of the Duodenum and thickened Duodenal papilla. Prominent Muscularis layer of the ileum with a roughly 1:1 Mucosa to Muscularis ratio.
- Mild jejunal lymphadenopathy
Fine needle biopsy of the left kidney, jejunal lymph node, and duodenal papilla performed with 1 1/2″ 25 gauge needle. Cyto returned with no evidence of neoplasia noted. Lymph node revealed reactive lymphoid hyperplasia.
So I am recommending treating for IBD and likely chronic pancreatitis. Just would like to know what others think obout the duodenal papilla. Should i get more agressive and recommend biopsy (duodenum and lieum to rule out Small Cell Lymphoma)? Also, recommend urine culture based on concurrent or previous pyelonephritis.
Comments
Beautiful Image Jeff… the
Beautiful Image Jeff… the mineralization in the end of the cbd-dpap is either embedded stones with hypertrophied inflammatory tissue but also bile duct carcinoma does this as well. As long as hi res scanning of the liver doesnt reveal isoechoic to mildly echogenic mets then I would recommend regardless a bile duct deviation because if inflammatory its obviously not functional and if carcinoma it needs to come out. The old school though is the bili has to be up for surgical bile duct but thats not the thought so much in these ADR cats with this presentation… its irridative and biliary disease causes ADR whether the serum bili is up or not. Can get a shopping spree of bx of anythign else while in there. In my experience these cats do really well with a plumbing rerouting.
As liver enzyme activity is
As liver enzyme activity is normal it is likley that the bile duct is incidental but would monitor for progression. The clinical signs and low albumin points towards IBD and the leukocytosis and elevated BUN towards active bacterial pyelonephritis. Ideally would be to culture urine from the renal pelvis.
Thanks for the input.
Thanks for the input. Something inflammatory is going on and we are addressing the kidneys with a urine culture, but patient has been on antibiotics prior to, so not expecting too much to show up at this time. I know that stones in the bile ducts of cats don’t usually cause any problems, but this is the second one I have seen that i think could be. Hard to tell with the overlapping of laboratory findings/clinical signs/US findings in this patient, but IBD, Pyelo and disease at dpap are all possibilities. I am a fairly conservative with medical/surgical recommendations, but this is one I am worried that a more aggressive therapy may be in this patient’s future if it doesn’t respond quickly.