Becky Urion PO Box 1188 Crystal Beach FL 34681 727 4300060 Mentors Johanna Elfenbein DVM DACVIM Sarah Reuss VMD DACVIM University of Florida Veterinary Medical Center Gainesville Florida ID: 935326
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Slide1
CHOLANGIOHEPATITIS IN A TENNESSEE WALKING HORSE GELDING
Becky UrionPO Box 1188Crystal Beach, FL 34681(727) 430-0060Mentors: Johanna Elfenbein, DVM, DACVIM; Sarah Reuss, VMD, DACVIMUniversity of Florida Veterinary Medical CenterGainesville, Florida
Slide2SIGNALMENT & HISTORY
15 year old Tennessee Walking Horse gelding Trail horse living in central FloridaHistory of fever and anorexia in July 2010Evaluated by referring veterinarianSerum chemistry & Lyme titer performed at the timeTreated with month-long course of doxycyclineParameterResultNormal ValueTotal Protein
8.2 (H)5.7-8.0 g/dL
Globulins
5.2 (
H
)2.7-5.0 g/dLGGT71 (H)5-24 u/LIFA Titer12800 (H)>200 strongly suggestiveK-ELISA280>380 positive
Lyme’s disease suspected based on high titer
Clinical signs resolved with therapy
Slide3RECENT HISTORY
Presented to referring veterinarian again for fever and anorexia of one week’s duration in March 2011Fever non-responsive to several oral doses of flunixin meglumine
On day of presentation:Owner noted passage of chocolate-colored urine
Bloodwork
performed by referring veterinarian
Referred to UF CVM for further diagnostics
Slide4RECENT HISTORY
Biochemistry - performed by referring veterinarian on day of presentationParameterResultNormal ValueParameterResultNormal Value
Na+134126-146 mmol/L
AST
481 (
H
)175-340 U/LK+3.52.5-5.2 mmol/LT Bili10.4 (H)0.5-2.3 mg/dLTCO22720-33 mmol/LGGT
201 (H)5-24 u/LCPK
76120-470 u/LAlbumin3.42.2-3.7
g/
dL
Glucose
118
65-110 mg/
dL
T
Protein
7.7
5.7-8.0 g/dLCa+13.411.5-14.2 mg/dLHemolysis00BUN97-25 mg/dLLipemia00Creatinine1.00.6-2.2 mg/dLIcterus2+ (H)0
Slide5RECENT HISTORY
Hematology - performed by referring veterinarian on day of presentationParameterResultNormal ValueParameterResult
Normal ValueWBC11.65.5-12.5
HGB
14.2
11-19 g/
dLLymphocyte %10.6HCT35.832-52%Monocyte %0.8MCV5436-52 flGranulocyte %88.6
MCH21.312.3-19.7 pgLymphocytes
1.2 1.8-5MCHC39.5
34-39 g/
dL
Monocytes
0
0.2-0.8
RDW
15.3
17-21%
Granulocytes
10.4 (H)3-7PLT278100-600RBC6.656.5-12.5MPV5.14-6 flFibrinogen600 (H)100-400 g/dLPCV38.535-45%
Slide6CLINICAL FINDINGS
Bright, alert, responsiveBody condition score: 5/9Oral mucous membranes pink with yellow tingePale yellow scleraTemperature: 103.8 °F Pulse: 48 beats per minuteRespiratory rate: 36 breaths per minuteInappetance with no overt colic behavior and normal gastrointestinal borborygmi 500 mg of flunixin meglumine given intravenously
Slide7DIAGNOSTIC PLAN
Urinalysis Additional bloodworkSDH Bile acids AmmoniaPT, PTTRebreathing examinationThoracic & abdominal ultrasound Liver biopsy
Fever likely hepatic in origin but additional diagnostics pursued in order to rule out extra-hepatic causes, e.g. peritonitis, pneumonia, neoplasia, abscesses
Slide8LABORATORY FINDINGS
Urine Dipstick (free catch sample)ParameterResultpH8.5Urine Specific Gravity1.012
GlucoseNegativeBilirubin+++ LargeBlood
Negative
Protein*
+ (30 mg/
dL)UrobilinogenNormal (0.2 mg/dL)*Proteinuria considered spurious due to alkalinity of urine
Slide9DIAGNOSTIC PLAN
Additional Laboratory TestingCytosolic enzyme with short half-life, making it ideal for evaluating ongoing disease; increased value indicates hepatocellular damageIncreased levels indicate decreased hepatic function and resulting inability of liver to clear ammonia from blood and convert to blood urea nitrogenMeasure of hepatic function; increased value indicates bile acids ineffectively cleared from blood by liver; may be due to failure of uptake, conjugation, or excretion, or regurgitation due to biliary obstruction
SDH
14.3
(
H
)Normal = 0-6 IU/LAmmonia30 Normal = 3-40 uMol/LBile Acids95.7 (H
)Normal = 0-6 uMol/L
Slide10DIAGNOSTIC PLAN
Additional Laboratory TestingTests of extrinsic and intrinsic pathways of clotting cascade, respectivelyPerformed prior to biopsy to ensure adequate clotting abilityMildly prolonged PT was considered clinically insignificant as it represented <20% increase above normal reference range
ParameterResult
Normal Value
PT
13.7 seconds (
H)8.5-11.7 secondsPTT 51.2 seconds37.7-52.4 secondsRebreathing Exam & Thoracic UltrasoundPerformed to rule out non-hepatic causes of fever, e.g. pneumonia, neoplasia, abscessesBoth exams unremarkable
Slide11DIAGNOSTIC PLAN
Trans-Abdominal UltrasoundEvaluation of liver shape, size, position, textureIdentification of abscesses, cysts, neoplastic masses, dilated bile ducts, choleliths, fibrosis, peritonitisLiver seen on right side, caudoventral to lung in 8th-14th intercostal spaces; can also be seen on left cranioventral abdomenAllows for biopsy instrument guidance
Liver edges roundedLikely indicates some degree of liver disease and fibrosisParenchymal pattern difficult to assess due to large abdominal fat storesNo evidence of biliary tree
distension,
choleliths
Does not entirely rule out presence
No other abnormalities noted
Slide12PROBLEM LIST
Fever*Increased serum GGT, AST, SDH*Increased serum bile acids*Icterus, hyperbilirubinemia, bilirubinuria*Rounded liver edges*Hyperfibrinogenemia & neutrophilia
*InappetanceTachycardia *Denotes most significant problems
Slide13DIFFERENTIAL DIAGNOSES
FeverInfectionInflammationNeoplasiaIncreased liver enzymes & bile acidsChronic active hepatitisHepatic abscessationPyrrolizidine alkaloid toxicityAflatoxicosis
CholangiohepatitisCholelithiasisSerum-associated hepatitisNeoplasia
Hemochromatosis
Icterus,
Bilirubinemia
& BilirubinuriaPre-HepaticAnorexiaHemolysisHepaticCholangiohepatitisPyrrolidizine alkaloid toxicityHepatic abscessationStreptococcus spp.,
Corynebacterium pseudotuberculosisSerum-associated hepatitisAcute or chronic hepatitis
NeoplasiaPost-HepaticCholelithiasisAnterior enteritis
Slide14DIAGNOSTIC PLAN
Percutaneous Liver Biopsy – infectious or inflammatory process involving liver considered most likely
Performed to determine diagnosis & prognosis
(Durham 2003; Equine Vet J.;35:534-40)
Diffuse or zonal lesions (e.g. most
toxic, infectious, metabolic liver diseases) can usually be diagnosed by biopsyFocal lesions (e.g. abscesses, granulomas, neoplasias) easily missedBleeding is major complication; occurs in 13% of cases but is mostly subclinical (Johns 2008; J Vet Intern Med.;22:185-189)
Slide15DIAGNOSTIC PLAN
Performed in right 9-14th ICS at intersection of line drawn from tuber coxae to mid-humerusSite aseptically prepared, anesthetized with lidocaineStab incision made with #15 blade before placement of 14-gauge Tru-cut biopsy instrumentUltrasound guidance usedAt least 4 samples takenOne for aerobic & anaerobic culturesRemainder fixed in formalin for histopathology
Percutaneous Liver Biopsy
Slide16DIAGNOSTIC PLAN
Percutaneous Liver BiopsyHISTOPATHOLOGIC ANALYSISSuppurative cholangiohepatitis, multifocal, marked, with marked portal abscessation, chronicPortal fibrosis, biliary proliferation, periportal hepatocyte loss, multifocal, severe, chronicNodular hepatocellular regeneration, multifocal, marked, chronic
Gross samples greenish in color
Consistent with biliary stasis
Aerobic and anaerobic culture
No growth on either plate at 48 hours
Approximately 50% of bacterial
cholangiohepatitis
cultures yield no results
Normal hepatocytes
Inflammation
Fibrosis
H&E 20x; Photo courtesy of Dr. William Craft
Slide17DIAGNOSIS
Common CausesPrimarySecondaryCholelithiasis or biliary stasisChronic active hepatitisDuodenal inflammationIntestinal obstructionNeoplasiaParasitismCertain toxinsOften ascending bacterial infectionCommon Clinical FindingsAnorexiaPyrexia
IcterusIntermittent signs of colicHyperammonemic hepatic encephalopathy possibleDiagnosis
S
upported By
Elevated
cholestatic & hepatocellular enzymes HyperbilirubinemiaInflammatory leukogramHyperfibrinogenemiaPRESUMPTIVE BACTERIAL CHOLANGIOHEPATITIS
Slide18THERAPEUTIC PLAN
Enteric organisms commonSalmonella speciesEscherichia coliCitrobacterKlebsiellaAeromonasAcinetobacterCommonly used antibioticsTrimethoprim-sulfonamideCeftiofurEnrofloxacin
Penicillin and gentamicinAmpicillinChloramphenicol
*
Usually 4-6 weeks of antimicrobial therapy required based on culture & sensitivity results
Started one month course of chloramphenicol
(50 mg/kg TID)Empirical choice based on lack of positive cultureExcreted in bile ductsBroad spectrum of activityGood penetration of abscessesCan be given orally for long-term treatment**Owners warned to wear gloves while handling chloramphenicol because of potential for aplastic anemia in humans**
Slide19ADDITIONAL THERAPEUTIC OPTIONS
Dietary ModificationGrain with high carbohydrates, low proteinEx: 2 parts beet pulp (or sorghum, bran, or milo), one part cracked corn in molassesDivide ration into multiple small mealsOat hay is best roughage, followed by other grass haysEncourage to graze in grass pasturesAlfalfa & legumes should be avoided if possible because of high protein (Can be included if more calories needed)Anti-inflammatories
Flunixin meglumineDimethyl sulfoxide
May help dissolve
interbiliary
sludge or small calcium
bilirubinate stonesPentoxifyllineProvides anti-endotoxic effects
Slide20PROGNOSIS
Can be successfully treated but depends on long-term antimicrobial therapy and appropriate supportive care
Clinical signs usually not manifested until ~75% of liver function lostSevere periportal and bridging fibrosis generally poor prognostic indicators, with or without hyperammonemic encephalopathy
Leukocytosis associated with poorer prognoses
(Durham 2003; Equine Vet J.;35:542-547
)
Often result of neutrophilia due to systemic inflammatory response following loss of Kupffer cells or glucocorticoid-mediated stress response
Slide21OUTCOME
Serum biochemistry repeated by referring veterinarian after one month of treatment with chloramphenicolTreatment recommended to continue until normalization of GGT levelsDecision made to pursue additional month of therapy with chloramphenicol with recheck of GGT & bile acid levels following completionTwo months after presentation, continues to do well at home with good appetite & no fevers
ParameterResultNormal Value
GGT
174
(
H)5-24 u/LAST181175-340 U/LT Bilirubin1.70.5-2.3 mg/dL*Clinical recovery often precedes normalization of biochemical values
All other parameters within normal limits
Slide22REFERENCES & FURTHER READING
Durham, AE, Newton, JR, Smith, KC, et al. Retrospective analysis of historical, clinical, ultrasonographic, serum biochemical and haematological data in prognostic evaluation of equine liver disease. Equine Vet J. 2003;35:542-547.Durham, AE, Smith, KC, Newton, JR. An evaluation of diagnostic data in comparison to the results of liver biopsies in mature horses. Equine Vet J. 2003;35:554-559.Durham, AE, Smith, KC, Newton, JR, et al. Development and application of a scoring system for prognostic evaluation of equine liver biopsies. Equine Vet J. 2003;35:534-540.Johns, IC, Sweeney, RW. Coagulation abnormalities and complications after percutaneous liver biopsy in horses. J Vet Intern Med. 2008;22:185-189.Reed, SM, Bayly, WM, Sellon
, DC. Disorders of the liver. In: Equine Internal Medicine, 2nd ed. Ed: Fathman L, Elsevier, St Louis, MO. 2004. Pp. 951-994.Peek SF and
Tivers
TJ. Medical treatment of
cholangiohepatitis
and cholelithiasis in mature horses: 9 cases (1991-1998). Equine Vet J. 2000;32:301-306.
Slide23ACKNOWLEDGMENTS
Photographs courtesy of Dr. Johanna Elfenbein and Dr. Sarah Reuss Thanks to both for their time, assistance, and patienceThanks to Drs. Barbara Sheppard and William Craft for histopathology evaluation