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sihirlifil's version from 2018-03-18 02:37

Feline Hepatic Lipidosis

Question Answer
How does feline hepatic lipidosis present?Acute illness
Icterus
Hepatic enceophalopathy
General malaise
GI signs
What is PRIMARY hepatic lipidosis?Rare! (healthy animal not given enough food, then happens all of a sudden)
What is SECONDARY hepatic lipidosis?Secondary to ANY dz that causes anorexia
Any disease ever but commonly pancreatitis, acute gastroenteritis, concurrent liver dz (i.e. cholangitis)
Who is predisposed?Obese cats (concurrent or historical obesity)
Timeframe for development of hepatic lipisosis?Anorexia or decreased caloric intake (
Problem with IDing the CS of hepatic lipidosis?CS may include underlying dz signs! so can look like any dz ever
Can also develop in hospital!
RED FLAG OF HLANY CAT (esp overweight) WITH HYPOREXIA
Clue: ALKP creeping up while GGT remains the same
Prognosis of HLNo tx: mortality 90%
Aggressive tx: 20-40%
Much rather prevent than treat!
What could you see on PE for hepatic lipidosis?Mentation
Hypersalivation (nausea, hepatic encephalopathy)
Icteric
+/- decreased BCS, muscle mass esp dorsal
Dehydration --> hypovolemia (can be profound, dull mentation = brain not telling them to drink)
Muscle weakness
Hepatomegaly (actually palpable), round margins
+ underlying dz!
Bloodwork: liver enzymes?ALKP & ALT elevated. Initially ALKP>ALT (usually)
GGT usually nromal
Bloodwork: Tbili?+/- elevated
Bloodwork: Coag?PT prolonged 75% (Vit K dependent, not true liver failure)
Clinical bleeding common with venipuncture, not as presenting sign
Bloodwork: Electrolytes?HypoK+
HypoMg++
HypoPhos (neg energy balance)
Bloodwork: CBC?+/- Heinz bodies (from hypoP)
Which dx tests would you do for HL?Ammonia
Abdominal US +/- liver FNA cytology
Chest rads
Urine culture
T4
Guided by hx, PE, bloodwork, abdominal US
Diagnostics: what does Ammonia tell you?HIGH: Hepatic encephalopathy
Normal or low: DOESNT RULE OUT HE! Could be other endogenous compound that doesnt get measured (e.g. Benzodiazepine)
Diagnostics: after ammonia, how could you confirm HE?Flumenazil trial
Has short t1/2, expensive, but confirms HE
Diagnostics: Abdominal US looks like?Uniformly hyperechoic
Diagnostics: What do you do US for?Look for concurrent dz
Evaluate GB/CBD
Cholecystocenesis (guided)
What is this cholecystocentesis sample showing?
Bile with bacteria in it
Diagnostics: Liver FNA cytology looks like?Full of lipid vacuoles
Diagnostics: what other concurrent disease can FNA help with?Round cell neoplasia (could have been caused by it)
**Before doing FNA in a cat, what do you want to do?Premed with diphenhydramine beforehand! Histamine release if MCT
Visceral MCT can be in liver, spleen, and intestines (solid mass), mast cells can degranulate whenever --> anaphylaxis
**Ulcers in a cat, what are you thinking?Visceral MCT
(Famotidine long-term)
Tx of feline HL: #1?CALORIES CALORIES CALORIES
What's going on here? when do we do it?
Nasoesophageal tube, first 1-2 days
What's this? when do we do it?
E-tube. Replace NE tube, better liver function for ANX
What's the ideal plan for HL?NE tube 1-2 days (get some liver back to normal), then place E-tube (feed real food, give meds, patient can go home with this, needs ANX to place). Helps to give Vit K for a few days
What is RER?Resting energy requirement. 70 x [BW (kg)]^0.75
Don't want to feed more than this! takes energy to store extra calories
How serious if re-feeding syndrome?Life-threatening!
How does re-feeding syndrome happen?Occurs 2-5d after feeding re-implemented
Massive endogenous insulin release --> electrolyte shifts
MONITOR FOR THESE!
Re-feeding syndrome: what happens with K+?Hypokalemia --> severe muscle weakness, neurologic depression
Re-feeding syndrome: what happens with phosphate?Hypophosphatemia --> hemolytic anemia (already low from not eating)
Re-feeding syndrome: what happens with Mg2+?Hypomagnesemia --> refractory hypoCa2+
How to prevent re-feeding syndrome?Gradually work up to RER!
Day 1 feed 1/3 RER
Day 2 feed 2/3 RER
Day 3 feed full RER
Treatment of feline HL (after calories)Fluid therapy (boluses, maintenance)
Electrolyte supplementation
Supportive care (anti-emetics, Ursodiol)
HE tx (lactulose, antibx)
Vit K
Tx of feline HL: how is Ursodiol helpful?Getting toxic bile stasis moving again to prevent inflam of hepatocytes, keep the inflamed ones from apoptosis-ing
Tx of feline HL: how is lactulose helpful?Reduce # of bacteria in gut (osmotic laxative), adjusts pH in colon (ammonia --> ammoniUM shift)
Tx of feline HL: why Vit K?Need to fix coagulopathy if cutting for esoph tube, jug stick, etc
(chart of drugs)
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Misc 'Sort of Cholestatic'

Question Answer
How does Vacuolar hepatopathy present? Who gets it?Often incidental, no CS. ALKP>>>>>ALT
Canine>>>>>>>>feline
Genetic form of vacuolar hepatopathy in who? how does it progress?Scottish Terrier
Progresses to hepatocellular carcinoma
Inducible form of vacuolar hepatopathy caused by?Steroids
Endocrine form of vacuolar hepatopathy caused by?HAC, hypoT4
How do you tx vacuolar hepatopathy?Tx underlying cause (endocrine)
Monitor liver fxn
Protect liver from inflammatory dmg: SAM-e, Denamarin (antioxidants), Ursodiol (help bile flow)
Scottish terriers: monitor for devp of hepatocellular carcinoma (ultrasound)
Cholestasis of sepsis: often accompanied by?Icterus
How do patients present for cholestasis of sepsis?For sepsis lol...
Icterus devps after dx of sepsis, OR present septic AND icteric
If a patient presents septic AND icteric, what must you do?RULE OUT BILE PERITONITIS
How do you rule in/out bile peritonitis?Abdominocentesis
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Toxic Hepatic Injury

Question Answer
How does the patient present for toxic injury?Acute usually
Icterus
Hepatic encephalopathy
Coagulopathy
General malaise, GI signs (acute hepatocellular dmg)
Something to keep in mind about hepatic injury after exposure?CS may not occur immediately after!
E.g. xylitol toxicity: initial exposture --> hypoglycemia (clinical/subclinical), then 2 weeks later hepatotoxicity
Some common hepatotoxic medicationsAcetominophen, Carprofen, other NSAIDs
TMS
Azathioprine
CCNU (lomustine)
Diazepam (Cats PO)
Idiosyncratic (doxycycline, methimazole, phenobarbital, amiodarone, etc)
BEST TEST for heptatotoxic medications?HISTORY! Ask specifics!
(Monitor liver values for medications youre giving for a long time, tell O to monitor, stop meds if icterus & bring in right away)
Some common hepatotoxic toxins (lol)Amanita mushrooms
Sago palm
Blue-green algae (cyanophyceae)
Aflatoxins in food
Xylitol
Heavy metals
Phenols
Herbal remedies
Diagnostics for hepatotoxinsChem panel
If liver function affected: ammonia, bile acids, coag times
Ultrasound
Biopsy (FNA not helpful)
Diagnosis of exclusion. BETTER TEST = History
What would Chem look like with toxic injury?ALT mildly-markedly high (thousands!)
+/- decreased liver functional parameters
What would ultrasonography findings be like with toxic injury?Diffusely enlarged, hypoechoic... OFTEN looks normal!
General treatment of toxic injuryDecontamination (as in any toxin) = induce emesis, activated charcoal, fluid therapy
N-acetylcystein IV --> SAM-e PO (once eating)
Vit E
Cholestyramine (sequesters bile acids --> bind toxin & pooped out together)
Nutrition
Specific antidoes for toxic injuryMilk thistle/silymarin
Patient dependent: Dextrose in fluids for hypogllycemia, Plasma for coagulopathy
How is recovery from toxic injury?Can be fatal... days to weeks
AMAZING ability to regenerate as lont as 10% hepatocytes remain --> can have normal function
Residual fibrosis common --> mild chronic liver enzyme elevations can result (cholestatic>hepatocellular) (tx w/ anti-fibrotic drugs?)
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Infectious Liver Disease

Question Answer
Patient presentationAcute or chronic!
General malaise, GI signs
+/- icterus
Infectious causes (6)Bacterial, viral, parasitic, fungal, protozoal, systemic infxn involving liver
What enzyme pattern do you expect to see?Hepatocellular (cholestatic if in biliary tree)
**Which infectious agent has cholestatic enzyme pattern?Lepto
Spriochetes invade tubular epithelium
Bacterial: 2 forms?Diffuse or focal (abscess)
Bacterial: how does an abscess usually occur?Underlying neoplastic cause or other abnormality (fast growth with abnormal vasculature & iummune fxn)
Bacterial: who are the culprits?Ascending from GIT (often involves liver & GB, E. coli most common)
Leptospirosis (can present liver / kidney ONLY, vasculitis...)
Salmonella
**If suspect salmonella...ISOLATE
Bacterial: Diagnostic planBloodwork: hepatocellular pattern (except lepto)
Abdominal ultrasound
Bacterial: US findings? based on those, then what?DIFFUSE: no specific finding! --> FNA & culture, including bile
Abscess: neoplasia, abscess. --> FNA for cytology & culture, broad spectrum antibiotics until get culture results back (Empiric: triple spectrum coverage)
Bacterial: Dx for Salmonella?Liver culture, blood culture, fecal culture
LEPTO TESTING: PCR on blood and urine?Tests bacterial DNA
BacterEMIA day 0-7, bacterURIA day 7-10 onwards & phasic
LEPTO TESTING: titers?Tests for antibodies
Takes about 2 weeks for Ab formation
Vax interference?
LEPTO TESTING: ideal?Titer AND PCR! ZOONOTIC!
Which test for Lepto titers?MAT!!! (microscopic agglutination test) serial diulations
Serovar cross-reactivity occurs
What is a positive MAT titer on a VAX dog? UNVAX?Unvax: 1:800
VAX: convalescent titer increase 4x (=repeat titer in 14 days)
Lepto titers point of care: What's a positive SNAP? benefits?Positive = titer 1:400 or higher (false pos if vax)
Turnaround time is 10 min :) (vs. MAT = 5-7 business days)
Lepto titers point of care: WITNESS test tells you what?Result = positive or negative, IgM titer ONLY so less vax interference! (but not none)
Catches earlier than MAT. Can give false negative 0-7 days into infection (no antibodies)
(Example algorithm: Lepto testing)
(Example algorithm: In-house tests)
Viral: which agent causes probs in DOGS?~Infectious canine hepatitis (CAV-1)
Viral: CS of CAV-1Respiratory, ocular, CNS
NOT USUALLY ICTERIC
Hepatocellular pattern
Viral: Dx of CAV-1PCR or ELISA (titer)
Viral: Tx of CAV-1Supportive only. Can recover
Vax protects against type 1 & 2
Viral: which agent causes probs in CATS?Feline infectious peritonitis (FIP)
Viral: dx of FIP?WET form easier than dry
Yellow, high protein effusion --> ~Pyogranulomatous inflammation of cytol/bx = increased suspicion
Biopsy & IHC
PCR of fluid/tissue (CSF, effusions)
FCoV titer negative = rule out
Other: which parasites can cause infection?Toxocara (parasitic migration --> hepatocellular
Platynosum fastosum (cholestatic)
Toxoplamsa gondii (hepatocellular)
Other: what does Platynosum cause? dx? tx?Cholestasis, can even cause obstruction!
Dx: fecal, sx remove adults
Tx: Praziquantel
Other: what does Toxoplasma cause? dx? tx?Hepatocellular damage, rare to cause hepatitis in cats. +/- concurrent respiratory, ocular, CNS, muscle
RED FLAG: LIVER + RESPIRATORY
Dx: Cytology, IgG & IgM titers
Tx: Clindamycin x 4w
Infections that CAN cause hepatic disease, but not usuallyHepatozoon (ocular d/c, fever, anemia, muscle, leukocytosis)
Cytauxzoon (MO) (fever, lymphadenopathy, acute liver failure in cats)
Leighmania (skin lesions, lymphadenopathy, GN)
Babesia (anemia, fever)
What dictates infectious testing in a patient?Geographic prevalence
(CAN cause hepatic dz, not usually) Tick-bourne causing vasculitis (-->inflam of blood vessels in liver)Borrelia
Ehrlichia
Rickettsia rickettsia (RMSF)
Anaplamsa
CLUE for tick-bourne?Other signs of vasculitis! (things that leak out = albumin, platelets, elevated liver enzymes, peripheral edema, joint pain)
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