Small Ani. Med 2- Hepatic diagnostics

wilsbach's version from 2016-02-28 14:58


Question Answer
Clinical signs of liver disease? (3 most important are?)****Encephalopathy, icterus, Change in liver size, Depression, Anorexia, diarrhea, diminished growth, hge, drug intolerance, weakness, vomiting, weight loss, polydipsia/polyuria, dark colored urine, ascites, hypersalivation
so you have a liver pt. what 3 situations call for you to refer?(1) These C/S: icterus, hepatomegaly, microhepatica, hepatic encephalopathy +/- enzyme elevation (2) Non-specific signs + liver enzyme elevation (3) Isolated liver enzyme elevation
Isolated enzyme elevation-- when do you wait (how long) when do you do test (what test) and who is the exception to all this again? Asymptomatic patient: recheck in 4-6 weeks-- UNLESS IT IS A DOBIE THEN TEST RIGHT AWAY (tend to have asymptomatic liver dz) Then can do bile acids test--- if normal bile acids, check in 4-6wk. IF abnormal BAs, do further diagnostics
So you have an icteric dog! how can you tell (with minimum tests/ just PE and CBC chem) if it is prehepatic, hepatic, or post-hepatic?PRE: Hemolysis= pale & yellow MM. HEPATIC: ALT > ALP. POST-HEPATIC/DESTRUCTIVE: ALP high, ALT variable
you can confirm if hepatic vs posthepatic what what two tests?for both, obv look at US!!! Then HEPATIC: ALT > ALP. POST: ALP > ALT
what is a patho cause of Hepatosplenomegaly? What 3 breeds are associated with hepatosplenomegaly and why?Portal hypertension causes this. Breeds: Scottish Terrier, German Shepherd (has a prominent spleen), Greyhound (has very caudal spleen location)
if there is hepatomegaly, you should first exclude intoxication, such as with...anticonvulsive drugs, acetaminophen, sulfadiazin, carprofen, methimazol, etc....
Hepatomegaly: upon clinical exam, heaptomegaly due to congestion, you will see what other signs?cardiac insufficiency, murmur, arrhythmia
Hepatomegaly: upon clinical exam, heaptomegaly due to systemic illness, you will see what other signs?lymphnodes, pale mucous membranes, fever, collapsing trachea…
Generalized hepatomegaly DDs: Toxic?steroidinduced hepatopathy, acetaminophen, carprofen, sulfadiazin, anticonvulsive drugs
how does hepatic lipidosis appear on US?hyperechoic (fat is hyperechoic)
how would acute vs chronic hepatitis differ on US?ACUTE: hypoechoic CHRONIC: hyperechoic (can be hypoechoic also)
7 major ddxs for generalized hepatomegaly? Toxic, Hepatic lipidosis, Hepatitis, Neoplasia (1* or metastatic), Collapsing trachea, Biliary obstruction (pancreatitis, FB), Storage disease
what are two storage dzs which can cause hepatomegaly?Amyloidosis, Mucopolysaccharidosis
Generalized hepatomegaly DDxs... hyperechoic vs hypoechoic vs mixed conditions
lipidosis on UShyperechoic
chronic hepatitis on UShyperechoic
fibrosis/cirrhosis on UShyperechoic
lymphoma on UShyper/hypoechoic
hepatic congestion on UShypoechoic
acute hepatitis on UShypoechoic
cholangitis on UShypoechoic
necrosis on UShypoechoic
Histiocytosis on US(abnormal increase in the number of immune cells that are called histiocytes. Histiocyte= a stationary phagocytic cell present in connective tissue) hypoechoic (think: pus?)
amyloidosis on UShypoechoic
Focal / multifocal hepatomegaly DDsNodular / vacuolar Hyperplasia, Neoplasia (1* or metastatic aenoma, carcinoma, sarcoma) biliary dz (Cholangitis, Caroli), Granuloma, Abscess, Cyst, Hematoma, Thrombosis, Torsion
wut is caroli?Caroli disease is a rare inherited disorder characterized by dilation of the intrahepatic bile ducts
Microhepatica/hepatic encephalopathy-- what are the two things that can cause this? (who does age play into this? what dx tests woul you run based on this?)Portosystemic Shunt or Cirrhosis.. If they are young, consider serum bile acid test, ATT (ammonia tolerance test) and US. If they are OLDER, consider a chem panel and coag tests., US and bx (cirrhosis suspect)
2 things you can DX with US? (And what can it let you differentiate but not dx?)DX: (1) .portosystemic shunt (2) gallbladder mucocele. DIFFERENTIATE: extrahepatic / intrahepatic, Focal/multifocal, diffuse
wut dis? hypo+hyperechoic areas? CHRONIC HEPATITIS
wut dis? Severe Cirrhosis + Ascites
wut dis? see fluid filled lesions-- if you move around you can see there is not flow (not flow bc bile duct not blood)-- so this is huge Intrahepatic bile ducts
which breeds/what age tend to get gallbladder mucocele? What dz do you need to exclude if you see this?Cocker Spaniel, Mini Schnauzer, Collie.. Middle age – old. Exclude HYPOthyroidism (hypo= slow things down= GB not aqueezing enough is how imma think of it)
3 ways to dx shunt?bile acids, NH3/ATT (Ammonia tolerance test), Ultrasound
***which type of shunt (intra or extrahepatic) do LARGE BREEDS get? (what is the specific condition it usually is?) WHICH breeds are particularly prone?tend to get INTRAhepatic (i think of it like: they are huge enough for things to be in the liver....little dogs have such a small liver the shunts have to be outside of it) usually a persistent ductus venosus in large breeds. PRONE BREEDS: Old English Sheepdog, Australian cattle dog, Irish wolfhound, Labrador Retriever
***which type of shunt (intra or extrahepatic) do SMALL BREEDS get? Which breeds are particularly prone?SMALL=EXTRAHEPATIC (i think of it like: they are huge enough for things to be in the liver....little dogs have such a small liver the shunts have to be outside of it). PRONE BREEDS: Dandie Dinmont terrier, Yorkshire terrier, Mini schnauzer , Cairn terrier, Havanese, Maltese, Pug
what is a risk of closing off a shunt surgically?you can create severe portal hypertension as the liver isnt used to handling that much blood at once, and so all the vessels around and in will open up and cause acquired shunting
things you should do before you do your Ultrsound guided biopsy Heavy sedation/anesthesia, Coagulation profile prior (CHECK FIBRINOGEN she said)
what kinda things can cytology be diagnostic for?nodular hyperplasia, extramedullary hematopoiesis, lymphoma, carcinoma, MCT, some infectious agents
what should you know if you suspect liver carcinoma?DONT put a needle in it-- seeds easily
what does hepatic lipidosis cytology look like? cholestasis?obv with hepatic lipidosis you see fat droplets everywhere. cholestasis= see lots of bile
explain the relation between Bleeding Abnormalities and liver dzLiver synthesizes most clotting proteins!
explain how extrahepatic bile duct obstruction can affect clottingdecreases vitamin K absorption bc fat malabsorption due to no bile to uptake it-- vit K needed for clotting factors
how does portal hypertension lead to clotting problems?Vascular congestion and fragility--> clotting probs
what clotting problem is related to severe liver failure?DIC
*What clotting factor is not made by the liver ? a deficiency in this factor is what dz?Factor VIII, made by endothelial cells in sinusoids within the liver AND outside the liver (factor deficient in hemophilia A). Tissue factor (= cleaves factor VII): in endothelial cells
what are the major clotting tests we care about in relation to liver dz?PT, aPTT (vit K dependant= clotting factors, vik K is fat soluble and need bile to absorb fat) and fibrinogen (produced by liver directly)
what should be sthing important you should know about bx samples in cats?DONT USE AUTOMATIC BX GUN IN CATS-- often fatal (semiautomatic did not have the same problems)... this might be due to Vagotonia (vagal shock)/ hypotension
what is the Menghini technique? benefits of it?Blind biopsy in diffuse disease (dogs)-- done in one hour! short time, can eat again soon after ((it's basically just a giant needle + aspiration thing)
what is the Plasma Protein C Activity test all about?this is a Anti-coagulant protein which is Synthesized in liver, and Assesses hepato-portal circulation/ PSS. (detects Congenital and acquired, better after sx)
what can we use MRI / Scintigraphy to assess?MRI: count rate lung versus liver => shunt fraction (Normal <15%, PSS >85%)... SCINT: see Macroaggregates in capillaries. (1) Injection in splenic vein (2) Injection in cephalic vein (said basically know that scintig is still done some places, can dx a shunt )
Transudate vs modified transudate vs exudate?