Small Ani. Med 2- Feline Liver Dzs

wilsbach's version from 2016-02-28 18:57

intro, hepatic lipidosis

Question Answer
what are the primary liver dzs cats tend to get?Biliary: cholangitis (neutrophilic and lymphocytic) Vascular: portosystemic shunts (so tend to only get biliary and vascular problems as 1*, not liver parynchyma primary stuff)
3 common secondary liver dzs cats get?Lipidosis/steatosis, Drug induced hepatopathy, extrahepatic bile duct obstruction
systemic dzs cats can get?pancreatitis, HyperT, DM, Lymphoma, FIP, amyloidosis
Hepatic Lipidosis: When is it 1* and when is it 2*?1*= idiopathic! Obese cats, Middle aged, stressful event. 2*= secondary to anorexia, which could be from HYPERT, DM, PANCREATITIS...
what is hepatic lipidosis?Massive accumulation of fat in hepatocytes
explain the path of how stress in an overweight cat leads to PRIMARY hepatic lipidosisso there is something that causes Stress / anorexia (Improper litter, New litter sort, disease, new cat, somebody missing, moving, boredom, vacation, vet..) and it is an overweight cat. So there is Excessive mobilization of peripheral lipid ("more cat can mobilize more fat" lol!) an export out of the liver becomes restricted bc anorexia also leads to a deficiency in ESSENTIAL amino acids (Arginine -> HE aka hepatic encephalopathy-> less appetite) (Methionine, carnithine, taurine... -> Glutathion reduced)
explain primary versus secondary hepatic lipidosis (what is the cat like?)
the thin cat gets which HL?2* (bc dz)
the fat cat gets which HL?1* (bc stress--> stop eating)
what other problem is related to HL?hepatic encephalopathy (HE)
CSs of HL?Very ill, Anorexia, HEPATIC ENCEPHALOPATHY signs ( Depression, Ptyalism), Icterus, Vomiting, dehydration
what are CSs of hepatic encephalopathy in cats?Depression, Ptyalism
2 major diagnostic results which point the finger at HL?95% high Bilirubin, 80% high ALP Others include:
which liver enzyme is most often raised in HL?HIGH ALP!!! ALP >> GGT (primary)
which bx method is best for HL? Wedge better than True cut
how do you definitively dx HL?BX!
what is the downside and what is the alternative to bx for HL?downside to bx: High risk procedure with anesthesia-- HL cats often already very will with Coagulation abnormal. So often instead need to do FNA & clinpath & chemistry-- Possible to miss ethiology with cytology only ( But need short anesthesia to place feeding tube anyway sooo weight your options)
what is the #1 tx you need to do with these HL cats?PROB IS THEY ARE NOT EATING/NOT GETTING ENOUGH NUTRITION-- PUT IN A TUBE. (4-6week!!!)
explain method for putting feeding tube in HL cat?*dont forget to close the feeding-tube tight, put on a bandage, put an Elizabethan collar
wut dis? hepatic lipidosis grossly
Txs for hepatic lipidosis? Treat any possible underlying cause , ***Tube feeding 4-6 weeks, Fluids & add Phosphate & Potassium to fluids (low from refeeding syndrome -> hemolysis possible), vitamin K1, Cobalamin, Vitamin E, SAMe (Glutathione depletion), This form of HE is treated with amino acids/protein, no protein restriction!, High NH3: use lactulose, Ranitidine / metoclopramide
which electrolytes do you want to suppliment with HL and why?want to add phosphate and potassium bc they are at risk for refeeding syndrome (Refeeding syndrome is a metabolic complication that occurs when nutritional support is given to severely malnourished patients (Box 2). Metabolism shifts from a catabolic to an anabolic state. Insulin is released on carbohydrate intake, triggering cellular uptake of potassium, phosphate, and magnesium.)
why give SAMe to a HL cat?bc not eating--> not getting amino acids (Methionine, carnithine, taurine...) --> Glutathion reduced (and SAMe helps get more glutathione back)
once again, why do cats get HE with HL?bc not eating--> depletion of argenine (pathway not explained)
what do you want the protein levels in the diet to be like with the hepatic encephalopathy concurrent to the HL?NOT LOW!! THIS HE IS DuE TO ARGININE (AMINO ACID AKA PROTEIN) DEFICIENCY!! SO TREAT BY SUPPLIMENTING AMINO ACIDS/PRTEINS IN CASES OF HE DUE TO HL
so HL--> HE, therefore, what do you wanna use to treat the high NH3?LACTULOSE!! remember dec transit time and make pH of colon more acidic, thus ionizing NH3 to NH4+ which means it cant be absorbed and it will be excreted in feces
how aggressively do you wanna do tube feeding for HL? (how long again?)(4-6wk)... gradually!! DAY 1: check position of tube with water-- 20-50% RER (resting energy requirement) (RER:50 x BW), andd frequent small amounts. DAY 2/3: increase to 1 x RER kcal, frequent small amounts. DAY >4: gradual increase to MER (metabolic energy requirement)slow decrease in frequency while increasing amount fed per meal MER = 70 x BW (bodyweight)
why do we want to gradually inc the feeding in an anorexic HL cat, instead of giving them all the food they need right away?REFEEDING SYNDROME!!
resting energy requirement (RER) calc?50 x BW
metabolic energy requirement (MER) calc?70 x BW
percentages of RER or MER for feeding on days 1, 2, 3, 4?DAY 1= 25-50% RER. DAY 2= 50-70% RER. DAY3= 100% RER. DAY 4= MER.
explain refeeding syndromeInsulin INC from refeeding (sugar in blood stim insulin to be released): Uptake of K into cells via sodium-potassium ATPase + glucose, Mg + P taken up into the cells. Water follows by osmosis--- so have hypokalemia and cell edema :(
calculate DAY 1 refeeding plan with a 4kg catDAY 1= 20-50% RER kcal, RER(resting energy requirement)= 50 x BW kcal. ---> 20–50% of 50 x 4 kcal=200, then 200x 0.2 or 0.5 ---> 40 – 100 kcal (now take however much food is work 40-100 kcal and divide that into 6 meals for the day-- flush tube before and after) (so one can of AD is 1151 kcal/kg, so 180kcal/5.5oz aka 156g 1/2 can divided into 6meals)
calculate DAY 2 refeeding plan with a 4kg catDAY 2= 50% - 70% RER kcal. Remember RER(resting energy requirement) is 50xBW so 50x4=200, then 50-70% of that= 100-140kcal (divide into 6 meals) (so one can of AD is 1151 kcal/kg, so 180kcal/5.5oz aka 156g can= 3/4 can)
calculate DAY 3 refeeding plan for a 4kg catDAY 3= 100% RER so 50x4= 200kcal (divide into 6 meals) (so one can of AD is 1151 kcal/kg, so 180kcal/5.5oz aka 156g can= 1 and 1/4 can)
calculate DAY 4 refeeding plan for a 4kg catDAY 4= MER!! for 70x4= 280 kcal (divide into 6 meals) (so one can of AD is 1151 kcal/kg, so 180kcal/5.5oz aka 156g can= 1 and 1/2 can) (Day 5: almost increase to 2 cans per day...)
what do if feeding tube is blocked with junk?pour some coke in there lol
feline pairmary liver dzs= ____ dzsBILE DUCT DZs

Primary liver dzs (bile duct dzs!!)

Question Answer
3 forms of cholangitis cats get? (how do they present?)(1) Neutrophilic (exsudative) cholangitis (Acute, septic, febrile) (2) Lymphocytic cholangitis (Chronic, non-septic?) (3) liver fluke infection ("lizard poisoning" in flordia and hawaii) (Chronic, often asymptomatic)
which colangitis is acute in cats?Neutrophilic (exsudative) cholangitis (makes sense-- neuts are always the first on the scene)
what is liver poisoning? where does this geographically tend to occur?flordia and hawaii-- this is a liver fluke infection causing cholangitis
Neutrophilic cholangitis--> aka? aka? aka?suppurative cholangitis , exsudate cholangiohepatitis, acute cholangitis-cholangiohepatitis
what is the relation between neutrophilic and lymphocytic cholangitis?Neut=acute can become lymphocytic=chronic (Significant overlap between chronic neutrophilic cholangitis and lymphocytic cholangitis...)
Cholangitis, presenting signs: how do they differ between neut and lymphocytic?NEUT: lethargy>weight loss. LYMP: weight loss/anorexia>lethargy (anorexia, vomiting, jaundice in both)
Initial clinicopathologic abnormalities of cholangitis?normal WBCs, INC ALT, INC BILE ACIDS (moreso in lympho), INC GLOBULIN (moreso in lympho)
Neutrophilic cholangitis: what usually causes this? hallmark CS?Acute disease of Neutrophilic septic inflammation. Frequently E. coli infection ascending from GI tract/pancreas (others: Clostridium, Streptococcus, Salmonella) -- acute= see ****Hyperthermia
how might bile/gallbladder be affected in neutrophilic cholangitis? Bile may be turbid and more echodense, Wall of the gallbladder may be thickened, BUT: No abnormalities in many cases (In chronic cases dilatation of bile ducts)
Bile examination in neutrophilic cholangitis: how do you do this? what will an abnormal result look like?Echo-guided puncture of the gall bladder with thin needle (24G) through liver --> NORMAL BILE SHOULD BE BROWN!! IF IT IS GREEN=bacterial formation of biliverdin (prolly see neuts/bact on cytology) and prolly bact culture positive
green bile sampled from GB means?bacterial formation of biliverdin
neutrophilic cholangitis--> most common bact culture isolates from gall bladder bile exam? E. coli, Staphylococcus, (beta-haemolytic Streptococcus), (Clostridium,anaerobic)
neutrophilic cholangitis-- what will histo look like? (pros and cons) neutrophils in lumen and intraepithelial of bile ducts (one school of thought it that Cytologic smear is not diagnostic! but another school of thought is that Histology is not always abnormal AND high risk of biopsies! try FNA first and see what I get)
*what should you remember about taking liver bx in cats?High complication rate of an automatic Tru-Cut biopsy gun device for liver biopsy in cats!! DONT USE AUTOMATIC GUNS can cause fatalities
hwo do you tx neutrophilic cholangitis?#1= **Amoxycillin – clavulanic acid!!!! (why abx? bc might be immune mediated bc of some other thing causing immune system to freak out) Also can try: Metronidazole. 3-4-6 weeks, Combination with ursodeoxycholic acid. HIGH protein diet!
If a cat is acutely ill, anorexic, (icteric, high ALT / γGT / bile acids) what cholangitis do you think it is?Neutrophilic
Lymphocytic cholangitis aka aka aka? lymphocytic cholangiohepatitis, lymphocytic portal hepatitis, non-suppurative cholangitis
which cholangitis is chronic? (how long is chronic?)LYMPHOCYTIC cholangitis is Very chronic disease: months - years
what CSs WONT lymphocytic cholangitis have that neutro would?LYMPHO= NO LEUKOCYTOSIS/NO FEVER
Lymphocytic cholangitis is dx how? (what DONT you do?) Histological biopsy with 16G true cut needle, for evaluation of liver structure. (Fine needle aspirates are not diagnostic and often misleading --> lipidosis)
main CSs of lymphocytic cholangitis?********weight loss + nausea + vomiting
Lymphocytic cholangitis Histologic diagnosis looks like? (what might it be hard to distinguish from?)SEE: Small lymphocytic infiltrate in lumen, epithelium of bile ductuli & portal. Tortuous bile ductuli. Fibrosis --> cirrhosis (might be hard to distinguish from lymphoma :( )
what will Lymphocytic cholangitis look like on US?Wide tortuous bile ducts (entire length), Bile duct wall may be thickened, dilated intrahepatic bile ductuli, Indentical to extrahepatic obstruction, but patent Vater’s papilla (The ampulla of Vater, also known as the hepatopancreatic ampulla,or as hepatopancreatic duct, is formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla.)
lymphocytic choliangitis in cats as to ___ in dogschronic hepatitis
remember there differences in definitions of chronic and acuteHISTO: acute has no fibrosis. clinically: chronic >2weeks
Diagnosis: Lymphocytic cholangitis CSs(Signs are not specific but uniform) 80% icterus, 90% high ALT and bile acids, High γ-globulins in (almost) all cases
main 2 ddx of lymphocytic cholangitis?FIP or lymphoma
Chronic lymphocytic inflammation (Lymphocytic cholangitis) treatment?(not sure if immune mediated so there is disagreement on coorect therapy) Prednisone/prednisolone (BUT: not successful in all chronic cases), Ursodeoxy cholic acid= best choice ? SAMe , Tube feeding, concurrent IBD?
Lymphocytic cholangitis-- possibly immune mediated, so what are things which might "cause/trigger" it?High γ globulin may indicate chronic persistent infection ≈ FIP, Leishmania... Potential bacteria which may survive in bile are Spirochaetes (Leptospira, Borellia, Helicobacter) and Clostridia..... Bartonella? Liver flukes in endemic areas