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sihirlifil's version from 2018-04-11 23:46

Feline Inflammatory Liver Diseases

Question Answer
Patient presentationAsymptomatic
Acute or chronic
Icterus
General malaise, GI signs, weight loss
Diagnosis based onHistology! LIVER BIOPSY DIAGNOSIS
Feline cholangitis/cholangiohepatitis: what are the Liver Standardization Group classifications (according to World Small Animal Veterinary Association, WSAVA)Neutrophilic
Lymphocytic
Mixed inflammatory
Cholangitis associated with liver flukes
What's special about NEUTROPHILIC classification?Concurrent pancreatitis common
Both neutrophilic and lymphocytic cholang(iohepat)itis can have what concurrently?IBD/food-responsive enteritis
Sadie here presents to you with elevated ALT on her pre-anesthetic bloodwork, 2 weeks later it was higher. How do you work up INITIALLY?
Basic bloodwork
<Total T4<br>Abdominal ultrasound
Chest radiographs
FeLV/FIV test
Bile acids (more helpful for monitoring)
(elevated ALT) How would bloodwork look?
Hepatocellular pattern, normal liver function
(elevated ALT) How would ultrasound look?
Hyperechoic biliary tree
Sediment in gallbladder
Rounded liver margins
(elevated ALT) After abnormal bloodwork & ultrasound findings, further workup?
Cholecystocentesis --> cytology & culture
Liver biopsies (do PT & PTT beforehand!!!)
(elevated ALT) Final dx: Lymphocytic cholangitis. Tx?
Ursodiol, SAM-e, Prednisolone tapered over 4 months. Monitor ALT & BA
Tigger presents for weight loss & decreased appetite, previous hx of food sensitive enteritis treated with diet alone. On PE had weight loss, muscle tone, thick intestines. Workup?
Bloodwork
Total T4
fPLI
Abdominal ultrasound
Chest rads
FeLV/FIV test
Cholecystocentesis
Liver & GI biopsies
(thickened GI) How would bloodwork look?
Hepatocellular pattern
(thickened GI) How would ultrasound look?
Diffuse GI thickening, pancreas hypoechoic, GB wall thick
(thickened GI) Final dx: Neurtophilic cholangitis + bacterial (underlying to chronic inflammation) + IBD + pancreatitis. Tx?
Marbofloxacin 6 weeks (good empirical drug), Ursoldiol + SAM-e, Prednisolone taper (low dose long term). Monitor weight, GI signs, bloodwork, GB US
Chelsea presents with acute V+, lethargy, not eating for 1 day. She's dull & icteric. Workup?
Bloodwork
Total T4
fPLI
Abdominal US
Chest rads
FeLV/FIV test
Then cholecystocentesis & liver FNA for final dx
(acute icteric) How would bloodwork look?
Hepatocellular & cholestatic mixed, elevated Tbili
(acute icteric) How would abdominal US look?
Hypoechoic liver, GB wall sludge, tortuous common bile duct
(acute icteric) Final dx: Bacterial cholangitis. Tx?
Hospitalization --> home care when stable & eating
Amoxicillin x 6w, Ursodiol + SAM-e, nutritional support, anti-emetics
(acute icteric round 2) After 8 weeks initial treatment, liver values & GB US didnt return to normal. What do?
Repeat cholecystocentesis, liver biopsy
(acute icteric round 2) Final dx: Mixed pattern cholangitis. tx?
Ursodiol + SAM-e
Prednisolone
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Canine Inflammatory Liver Diseases

Question Answer
Patient presentationAsymptomatic incidental finding
Acute/chronic illness
End-stage
Idiopathic chronic hepatitis: WSAVA Liver Standardization group histologic descriptionsHepatocellular apoptosis or necrosis
Mononuclear or mixed inflammatory cell infiltrate
Regeneration
Fibrosis
Idiopathic chronic hepatitis: how do diagnose?Liver biopsy
Idiopathic = rule out other causes
Signs of liver failure = 70-80% hepatocyte loss
Signs of portal hypertension
Idiopathic chronic hepatitis: tx is more effective when...The disease is diagnosed EARLY! Fibrosis = irreversible :(
Idiopathic chronic hepatitis: TreatmentAnti-inflammatory/immunosuppresion: Prednisolone (prednisONE gets converted in liver). 2nd line azathioprine, cyclosporine (not empiric!!)
Antifibrotics: Colchicine (also for amyloidosis), glucocorticoids
Cholerhetic: Ursodiol
Antioxidant: SAM-e
If hepatic encephalopathy and/or ascites, treat those too
Copper-associated hepatopathy: forms? how does it present?Genetic & non-genetic
Can present in all stages (subclin to end stage)
Copper-associated hepatopathy: Genetic in who?Lab retriever, Bedlington terrier, Doberman (mishandles copper in the liver)
Copper-associated hepatopathy: Diagnosis?BIOPSY (inflam + copper)
Submit biopsy & liver sample sepearte to quantify amount of copper
Copper-associated hepatopathy: how does it come about?Multifactorial! Breed + diet + time (so, not every dog with gene gets it)
Copper-associated hepatopathy: what leads to 2ry copper accumulation?Hepatic inflammation & cholestasis (usually don't need chelation)
Copper-associated hepatopathy: TxChelation therapy 6 months: D-penicillamine, Trientene, zinc?
Diet: VITAL AFTER CHELATION! Low copper, high zinc to prevent buildup (sometimes have to chelate again)
Antioxidant
+/- anti-inflammatory Pred
Copper-associated hepatopathy: SEffx of chelation?GI! sever V+ (sometimes to the extent that chelation isn't possible, can try anti-emetics)
Breed-specific hepatopathis: American Cocker Spaniel?
Young (5-8y), M>F
Severe fibrosis, cirrhosis
Breed-specific hepatopathis: English Cocker Spaniel?
Young (7m-8y), F>M
Severe signs, poor prognosis (about 6m)
+/- pancreas, renal involvement
Breed-specific hepatopathis: Doberman Pinscher?
Young (5y), F>M
Lobular dissecting hepatitis, quick progressive (chelation won't help, suspect underlying infx)
F/o copper-associated
**Does low/normal ALT always mean normal liver?No! Even if severely diseased, with fewer working hepatocytes ALT can appear low! Bile acids helpful as monitoring tool
Breed-specific "hepatopathies": Shar-Pei?
Amyloidosis
Can present as hepatopathy
Breed-specific "hepatopathies": lysosomal storage diseasesVarious types, rare, many breeds
Liver + CNS signs + skeletal (+/- ocular)
Prognosis of canine inflammatory hepatopathiesGeneral 18.3 months (RANGE of 0-49 months)
Depends on what type, what stage when diagnosed (e.g. English Cocker Spaniel = 6 months)
Negative prognostic factors of canine inflammatory hepatopathiesAscites
Prolonged PT, PTT; thrombocytopenia
Hypoalbuminemia
Hyperbilirubinemia
Hyperglobulinemia
Portal hypertension signs
What is "reactive" hepatopahy?Not fully understood, may be hepatic inflammatory reaction to GI food sensitivity (r/o food sensitive enteritis)
Biopsy diagnosis "reactive" (liver is innocent bystander)
When do you suspect "reactive" hepatopathy?Young dog or cat (1-6y)
Asymptomatic or GI signs
Mild ALT elevation, not progressive but persistent
Food trial --> resolution of ALT elevation
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Liver Neoplasia

Question Answer
Patient presentationAsymptomatic
Chronic usually, but can be acute! (was progressing, finally hit clinical threshold)
General malaise, GI
Hemoabdomen
Any (lol)
What morphologies are possible? (3)Discrete mass
Diffuse/infiltrative
Nodular (=multiple nodules in multiple lobes)
Most are metastatic
Primary hepatic/biliary neoplasia: CANINE?Hepatocellular carcinoma
Hepatocellular adenoma
Histiocytic sarcoma
Dogs: which tumors are solitary masses with low/no metastatic rate?Hepatocellular carcinoma & adenoma
Dogs: which tumor has a high metastatic rate?Histiocytic sarcoma
Primary hepatic/biliary neoplasia: FELINE?Biliary cystadenoma
Lymphoma
MCT
Cats: which cancer has a low metastatic rate?Biliary cysadenoma
Cats: Which cancers have a diffuse morphology?Lymphoma, MCT
Hepatic neoplasia: what can you appreciate on PE?May feel cranial mass
Diffuse neoplasia = hepatomegaly
Biliary neoplasia = icterus
Hepatic neoplasia: DiagnosisHepatocellular OR cholestatic enzyme pattern
Variable liver fxn
Chest radiographs!!!!!
Abdominal US AND FNA vs. biopsy
Definitive tx or neoplasiaChemo/surgery
Palliative tx of neoplasiaPrednisone/prednisolone
Supportive medical treatment: Gastroprotectants (proton pump inhibitors), anti-emetics, hepatic encephalopathy tx, slow bleeds: Yunnan Baiyao, aminocaproic acid, tranexamic acid (anti-thrombolytic)
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