Cytologic diagnosis of bile peritonitis

Uncommon but valuable for diagnosis: Green deposits on peritoneal fluid cytospins

When ascites fluids are observed under the microscope, unshaped greenish deposits should not be considered as artifacts but should rather prompt to bile leakage assessment.

Bilothorax Associated with Bile Peritonitis in a Dog with No Diaphragmatic Disruption: A Case Report

A 4-year-old intact male mixed-breed dog was presented with vomiting and severe depression of 6-day duration after being struck by a car 2 weeks before presentation. Clinical examination revealed hypothermia, respiratory difficulty, jaundice, and a bicavitary (pleural and peritoneal) effusion. Hematological and biochemical abnormalities included neutrophilic leukocytosis, increased total bilirubin concentration, and increased serum lipase activity. Biochemical and cytological evaluation of both abdominal and thoracic fluids were suggestive of bilious effusions. During celiotomy, a rupture of the cystic duct was observed, which necessitated cholecystectomy. A diaphragmatic rupture was not found. A thoracostomy tube was inserted in the right pleural space, and continuous suction was maintained for 48 hours. The dog was discharged 20 days after surgery and no abnormalities were detected on either blood tests or ultrasonographic examinations of the thorax and abdomen on follow-up examination 7 months after surgery. The presence of a bilothorax should be considered in animals with bile peritonitis, grossly intact diaphragm and pleural effusion. The exact mechanisms of the development of bilothorax are unclear, but the transport of bile through microscopic congenital or acquired weaknesses or defects of the diaphragm, via abdominal lymphatics penetrating the diaphragm and draining into the thoracic lymphatics represent the most probable route.

Cytological findings in a sample of peritoneal aspirate from a case of bile peritonitis

Bile peritonitis (BP) is a rare and serious condition warranting urgent surgical intervention to prevent the high incidence of mortality. BP is ascribed to the leakage of bile into the peritoneal cavity usually due to a perforation of the gallbladder or common bile duct caused by stones or a trauma. The radiological studies are useful in suggesting the diagnosis. The cytological findings of BP have been reported rarely in the literature characterised by the presence of lakes of stringy bile material admixed with variable numbers of histiocytes, mesothelial cells, and some inflammatory cells. Recently, we have examined an aspirate sample of peritoneal fluid (PF) obtained under ultrasound guidance in a case of BP ascribed to the perforation of the gallbladder in a 19-yr-old female patient in which apart from occasional bile pigment-laden macrophages admixed with a few mesothelial cells and inflammatory cells, numerous crystalline structures of varying shapes, sizes, and colour with birefringence along with some microspheroliths were found. At operation, the abdominal cavity showed a large amount of bile and the gallbladder specimen showed two perforations and gangrenous cholecystitis with numerous yellow-brown somewhat friable stones. The foregoing findings in the aspirate appeared to be of interest because to the best of our knowledge, numerous crystalline structures along with the cytological features of BP have not been described in the English literature.

Three cases of canine bile peritonitis with mucinous material in abdominal fluid as the prominent cytologic finding

BACKGROUND

Bile peritonitis is a severe, nonseptic inflammatory response to bile in the peritoneal cavity. It may result from generalized or localized leakage of bile due to spontaneous rupture of the biliary system or as a complication of biliary tract inflammation, obstruction, manipulation, or trauma. Cytologically, bile in abdominal fluid appears as golden-green granular pigment.

OBJECTIVE

The purpose of this report is to describe the atypical cytologic features of abdominal fluid in 3 dogs with bile peritonitis.

METHODS

As part of a diagnostic workup, abdominal fluid was obtained from 3 dogs with bile peritonitis and analyzed. In 2 dogs, fluid bilirubin concentration was determined and Hall's bile stain, Alcian blue-periodic acid-Schiff stain, and Mayer's mucicarmine stain were applied to direct smears of the fluid.

RESULTS

Acellular mucinous fibrillar material in clumps and lakes was the prominent cytologic finding in the abdominal fluid from all 3 dogs. Bile pigment was not observed. Fluid from the 3 dogs contained increased numbers of inflammatory cells, predominantly neutrophils. Total protein concentration ranged from 2.9 to 5.6 g/dL. Fluid total bilirubin concentration was greater than twice that of the concurrent serum bilirubin concentration. Based on results of the special stains, the amorphous material was positive for mucosubstances, but was negative for bilirubin. In all dogs, bile peritonitis originated from a rent in the common bile duct.

CONCLUSIONS

Bile peritonitis with fibrillar mucinous material in abdominal fluid has not been described previously in dogs. The material was similar to "white bile" observed in humans and experimentally in dogs as a sequela to extrahepatic biliary tract obstruction. When mucinous material is observed in abdominal fluid from dogs and the fluid bilirubin concentration is greater than twice the serum bilirubin concentration, rupture of the extrahepatic biliary tract should be suspected.

Chemical meningitis from bile reflux in a lumbar-gallbladder shunt

OBJECTIVE AND IMPORTANCE

The gallbladder is used to divert cerebrospinal fluid (CSF) in patients with hydrocephalus when all other sites have been exhausted. This is seen in hydrocephalic patients who have reached teenage years but have undergone multiple shunt revisions, abdominal operations and repeated neck vein cannulations during childhood. One complication of the lumbar-gallbladder shunt is discussed as well as its pathophysiologic theory and management.

CLINICAL PRESENTATION

A case of a patient with a lumbar-gallbladder shunt who developed chemical meningitis from reflux of bile into the CSF space is presented. The patient presented with generalized seizures.

INTERVENTION

Included: ventilatory support, externalization of the shunt, correction of the metabolic abnormalities and administration of anticonvulsants and steroids.

CONCLUSION

This case illustrates an unusual occurrence of reflux of bile into the CNS through a lumbar-gallbladder shunt in a patient with long-term complex communicating hydrocephalus. It also demonstrates its mode of presentation and successful management. To our knowledge, this is the first case report of its kind.