Therapeutic percutaneous ultrasound-guided cholecystocentesis in three dogs with extrahepatic biliary obstruction and pancreatitis

Gall bladder ejection fractions in dogs investigated for chronic altered appetite: 14 cases (2015-2017)

OBJECTIVES

To determine if gall bladder dysmotility occurs in dogs investigated for chronic altered appetite and to determine if gall bladder dysmotility warrants further investigation as a contributing factor to altered appetite.

MATERIALS AND METHODS

Case series of dogs investigated for chronic gastrointestinal disease. Gastrointestinal clinical signs were assessed before and after a 6-week hydrolysed protein diet. Gall bladder ejection fractions were determined at the end of the 6-week hydrolysed protein diet as part of an investigation that included a full blood cell count, biochemistry, abdominal X-rays and ultrasound. The gall bladder ejections fraction results of dogs with normal appetite were compared to dogs with general inappetence and dogs with diurnal inappetence in the morning.

RESULTS

In this retrospective case series of 14 dogs, altered appetite was the most frequent and persistent clinical sign associated with chronic gastrointestinal disease. Nine dogs had suboptimal gall bladder function and this occurred in dogs with, and without, gravity-dependent biliary sludge. Gall bladder function and volumes of dogs in this study were comparable to those of dogs with nongravity-dependent gall bladder sludge or gall bladder mucoceles in other studies. There was an observable difference in gall bladder ejection fractions between groups defined by appetite but no statistically significant difference was present. Small sample sizes meant the effect size was large.

CLINICAL SIGNIFICANCE

Gall bladder dysmotility and distension can occur in the absence of gall bladder sludge and mucocoeles in younger dogs. Gall bladder dysmotility requires further investigation as a potential contributing factor to altered appetite in dogs.

Percutaneous transhepatic cholecystostomy drainage in a dog with extrahepatic biliary obstruction secondary to pancreatitis

CASE DESCRIPTION

An 8-year-old 36.3-kg (79.9-lb) spayed female Rottweiler was evaluated because of anorexia and vomiting.

CLINICAL FINDINGS

Extrahepatic biliary obstruction (EHBO) secondary to pancreatitis was suspected on the basis of results from serum biochemical analyses, CT, and cytologic examination.

TREATMENT AND OUTCOME

Only marginal improvement was observed after 24 hours of traditional medical management; therefore, novel continual biliary drainage was achieved with ultrasonographically and fluoroscopically guided placement of a percutaneous transhepatic cholecystostomy drainage (PCD) catheter. Within 24 hours after PCD catheter placement, the dog was eating regularly, had increased intestinal peristaltic sounds on abdominal auscultation, no longer required nasogastric tube feeding, and had decreased serum total bilirubin concentration (7.7 mg/dL, compared with 23.1 mg/dL preoperatively). Bile recycling was performed by administering the drained bile back to the patient through a nasogastric tube. The PCD remained in place for 5 weeks and was successfully removed after follow-up cholangiography confirmed bile duct patency.

CLINICAL RELEVANCE

Transhepatic PCD catheter placement provided fast resolution of EHBO secondary to pancreatitis in the dog of the present report. We believe that this minimally invasive, interventional procedure has the potential to decrease morbidity and death in select patients, compared with traditional surgical options, and that additional research is warranted regarding clinical use, safety, and long-term results of this procedure in veterinary patients, particularly those that have transient causes of EHBO, are too unstable to undergo more invasive biliary diversion techniques, or have biliary diseases that could benefit from palliation alone.

Clinical and Prognostic Findings in Dogs with Suspected Extrahepatic Biliary Obstruction and Pancreatitis

Pancreatitis in dogs may lead to extrahepatic bile duct obstruction as a result of local inflammation. Medical records of 45 client-owned dogs with clinical suspicion of extrahepatic bile duct obstruction secondary to pancreatitis were reviewed to determine clinical findings, outcome, and factors associated with survival. Survival times were determined using the Kaplan-Meier product limit method. Cox multivariable survival methods were employed to determine factors associated with survival time following diagnosis. The median survival time was 241 days (95% confidence interval [CI] 25–631), with 34 of 45 dogs (76%) surviving to discharge. Dogs 9 yr of age or older with azotemia at presentation had a 9.9 greater hazard for death (95% CI 2.5–38.1; P = .001) compared with dogs younger than 9 yr old without azotemia at presentation. Dogs without subjective ultrasonographic gallbladder distension had a 4.4 greater hazard for death (95% CI 1.3–15.4; P = .018) compared with dogs with subjective gallbladder distension. Dogs with a body temperature ≥102.5°F at admission had a 3.1 greater hazard for death (95% CI 1.3–7.7; P = .013) than dogs with a body temperature <102.5°F at admission. This information may help clinicians discuss prognosis with owners of affected dogs.

Application of ultrasound-guided cholecystocentesis to the evaluation of the metabolite profiling in bile of dogs and cynomolgus monkeys

In this study, we describe a novel approach for collecting bile from dogs and cynomolgus monkeys for metabolite profiling, ultrasound-guided cholecystocentesis (UCC). Sampling bile by UCC twice within 24 hours was well tolerated by dogs and monkeys. In studies with atorvastatin (ATV) the metabolite profiles were similar in bile obtained through UCC and from bile duct-cannulated (BDC) dogs. Similar results were observed in UCC and BDC monkeys as well. In both monkey and dog, the primary metabolic pathway observed for ATV was oxidative metabolism. The 2-hydroxy- and 4-hydroxyatorvastatin metabolites were the major oxidation products, which is consistent with previously published metabolite profiles. S-cysteine and glucuronide conjugates were also observed. UCC offers a viable alternative to bile duct cannulation for collection of bile for metabolite profiling of compounds that undergo biliary excretion, given the similar metabolite profiles in bile obtained via each method. Use of UCC for metabolite profiling may reduce the need for studies using BDC animals, a resource-intensive model.

Ultrasonographic appearance of the major duodenal papilla in dogs without evidence of hepatobiliary, pancreatic, or gastrointestinal tract disease

OBJECTIVE To determine the ultrasonographic appearance of the major duodenal papilla (MDP) in dogs without evidence of hepatobiliary, pancreatic, or gastrointestinal tract disease. ANIMALS 40 adult client-owned dogs examined because of conditions that did not include hepatobiliary, pancreatic, or gastrointestinal tract disease. PROCEDURES Ultrasonographic examination of the MDP was performed. Each MDP was measured in 3 planes. Intraobserver reliability of measurements was determined, and associations between MDP dimensions and characteristics of the dogs were investigated. Histologic examination of longitudinal sections of the MDP was performed for 1 dog to compare the ultrasonographic and histologic appearance. RESULTS The MDP appeared as a layered structure with a hyperechoic outer layer, hypoechoic middle layer, and hyperechoic inner layer that corresponded to the duodenal serosa, duodenal muscularis, and duodenal submucosa, respectively. Layers visible during ultrasonographic examinations were consistent with layers identified histologically. Intraobserver reliability was substantial for each plane of measurement. Mean ± SD length, width, and height of the MDP were 15.2 ± 3.5 mm, 6.3 ± 1.6 mm, and 4.3 ± 1.0 mm, respectively. An increase in body weight of dogs was significantly associated with increased values for all measurements. CONCLUSIONS AND CLINICAL RELEVANCE The ultrasonographic appearance and approximate dimensions of the MDP of dogs without evidence of hepatobiliary, pancreatic, or gastrointestinal tract disease were determined. Additional studies are needed to evaluate possible ultrasonographic lesions of the MDP in dogs with hepatobiliary, pancreatic, or intestinal diseases and to investigate clinical implications of these lesions with regard to diagnosis and prognosis.

Percutaneous Ultrasound-guided Cholecystocentesis and Bile Analysis for the Detection of Platynosomum spp.-Induced Cholangitis in Cats

Background

Examination of bile could be useful to diagnose Platynosomum spp.‐induced cholangitis in cats. Obtaining bile via percutaneous ultrasound‐guided cholecystocentesis (PUC) is possible but raises safety concerns in cats with severe cholecystitis.

Objectives

The objectives of this study were to investigate the use of PUC to collect bile samples from cats with known platynosomosis and to determine if bile analysis could be a diagnostic test.

Animals

Twenty‐seven free‐roaming cats positive for Platynosomum spp. eggs via fecal examination.

Methods

In this prospective study, fecal egg counts were performed by double centrifugation with Sheather's solution. Bile was collected using PUC from anesthetized cats. Egg counts in bile were performed with a stereoscope. Euthanasia and postmortem examination were performed immediately after PUC.

Results

All cats had ultrasound (US) evidence of cholangitis or cholecystitis. Thirty‐nine PUCs were performed with 14 cats having 2 PUCs 12 or 24 days apart. Postmortem examinations showed no overt gallbladder damage or leakage but fresh blood was noted in the gallbladder lumen of 3 cats. Median Platynosomum spp. egg counts were higher in bile (1450 eggs/mL; IQR, 400; 5138 eggs/mL) as compared to feces (46 eggs/mL; IQR, 10; 107 eggs/mL) (P < .001).

Conclusion and Clinical Importance

Bile egg count analysis is an alternative method with higher egg counts as compared to fecal egg count analysis for the diagnosis of platynosomosis. Obtaining bile via US guidance is technically feasible and safe in cats with cholangitis/cholecystitis. Cholecystocentesis and bile analysis are especially relevant for those cats with chronic cholangitis/cholecystitis and negative fecal egg counts for Platynosomum.

Initial experience with endoscopic retrograde cholangiography and endoscopic retrograde biliary stenting for treatment of extrahepatic bile duct obstruction in dogs

OBJECTIVE

To describe techniques for endoscopic retrograde cholangiography (ERC) and endoscopic retrograde biliary stenting of the common bile duct (CBD) for minimally invasive treatment of extrahepatic bile duct obstruction (EHBDO) in dogs.

DESIGN

Experimental study and clinical report.

ANIMALS

7 healthy research dogs and 2 canine patients.

PROCEDURES

ERC and endoscopic retrograde biliary stenting were performed in healthy purpose-bred research dogs and client-owned dogs with a diagnosis of EHBDO that underwent an attempted biliary stent procedure. Research dogs were euthanized after completion of the procedure and underwent necropsy. With dogs under general anesthesia, the pylorus was cannulated with a side-view duodenoscope, and the duodenum was entered. The major duodenal papilla (MDP) and minor duodenal papilla were then identified, and the MDP was cannulated. Endoscopic retrograde cholangiography and endoscopic retrograde biliary stenting were attempted with the aid of endoscopy and fluoroscopy in all dogs. Procedure time, outcome for duodenal and MDP cannulation, and success of stent placement were recorded.

RESULTS

Endoscopic retrograde cholangiography was successfully performed in 5 of 7 research dogs and in 1 of 2 patients. Biliary stenting was achieved in 4 of 7 research dogs and 1 of 2 patients, with a polyurethane (n = 4) or self-expanding metallic stent (1). One patient had a mass such that visualization of the MDP was impossible and no attempt at biliary cannulation could be made. After placement, stent patency was documented by means of contrast cholangiography and visualization of biliary drainage into the duodenum intra-operatively. No major complications occurred during or after the procedure in any patient. Follow-up information 685 days after stent placement in 1 patient provided evidence of biliary patency on serial repeated ultrasonography and no evidence of complications. CONCLUSIONS and

CLINICAL RELEVANCE

ERC and endoscopic retrograde biliary stenting were successfully performed in a small group of healthy dogs and 1 patient with EHBDO, but were technically challenging procedures. Further investigation of this minimally invasive technique for the treatment of EHBDO in dogs is necessary before this may be considered a viable alternative to current treatment methods.

Complications of the extrahepatic biliary surgery in companion animals

Surgery of the biliary tract is demanding and is associated with several potentially life-threatening complications. Veterinarians face challenges in obtaining accurate diagnosis of biliary disease, surgical decision-making, surgical hemostasis and bile peritonitis. Intensive perioperative monitoring is required to achieve early recognition of common postoperative complications. Proper treatment and ideally, avoidance of surgical complications can be achieved by gaining a clear understanding physiology, anatomy, and the indications for hepatobiliary surgery.

Surgical intervention in the management of severe acute pancreatitis in cats: 8 cases (2003-2007)

OBJECTIVE

To evaluate clinical characteristics and outcomes of cats undergoing surgical intervention in the course of treatment for severe acute pancreatitis.

DESIGN

Retrospective observational study from 2003 to 2007 with a median follow-up period of 2.2 years (range 11 d-5.4 y) postoperatively.

SETTING

Private referral veterinary center.

ANIMALS

Eight cats.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Quantitative data included preoperative physical and clinicopathologic values. Qualitative parameters included preoperative ultrasonographic interpretation, perioperative and intraoperative feeding tube placement, presence of free abdominal fluid, intraoperative closed suction abdominal drain placement, postoperative complications, microbiological culture, and histopathology. Common presenting clinical signs included lethargy, anorexia, and vomiting. Leukocytosis and hyponatremia were present in 5 of 8 cats. Hypokalemia, increased total bilirubin, and hyperglycemia were present in 6 of 8 cats. Elevated alanine aminotransferase and aspartate transferase were present in all cats. Surgery for extrahepatic biliary obstruction was performed in 6 cats, pancreatic abscess in 3 cats, and pancreatic necrosis in 1 cat. Six of the 8 cats survived. Five of the 6 cats that underwent surgery for extrahepatic biliary obstruction and 1 cat that underwent pancreatic necrosectomy survived. All 5 of the cats with extrahepatic biliary obstruction secondary to pancreatitis survived. The 2 nonsurvivors included a cat with a pancreatic abscess and a cat with severe pancreatitis and extrahepatic biliary obstruction secondary to a mass at the gastroduodenal junction. Postoperative complications included progression of diabetes mellitus, septic peritonitis, local gastrostomy tube stoma inflammation, local gastrostomy tube stoma infection, and mild dermal suture reaction.

CONCLUSION

Cats with severe acute pancreatitis and concomitant extrahepatic biliary obstruction, pancreatic necrosis, or pancreatic abscesses may benefit from surgical intervention. Cats with extrahepatic biliary obstruction secondary to severe acute pancreatitis may have a good prognosis.

Diseases of the gallbladder and biliary tree

Most disorders of the biliary system are associated with increased activity of parenchymal transaminases (alanine aminotransferase, aspartate aminotransferase) and cholestatic enzymes (alkaline phosphatase and gamma glutamyl transferase) with or without hyperbilirubinemia or jaundice. While parenchymal liver disease is most common in the dog, inflammatory disorders involving the small- and medium-sized bile ducts and zone 1 (periportal) hepatocytes predominate in the cat. Historically, the incidence of disorders restricted to the gallbladder is low in both species; however, with routine diagnostic use of abdominal ultrasonography, the incidence of gallbladder mucoceles and cholelithiasis has increased. Extrahepatic bile duct obstruction is a well-recognized syndrome because of its association with pancreatitis and obvious jaundice. Less common disorders of the biliary system include a cadre of diverse conditions, including necroinflammatory processes, cholelithiasis, malformations, neoplasia, and an emerging syndrome of gallblader dysmotility.

Characteristics and outcomes in surgical management of severe acute pancreatitis: 37 dogs (2001-2007)

OBJECTIVE

Describe clinical characteristics and outcomes associated with canine patients undergoing surgical intervention for treatment of acute pancreatitis.

DESIGN

Retrospective outcome study from 2001 to 2007.

ANIMALS

Thirty-seven dogs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The following data were collected for dogs who underwent surgical intervention in the course of treatment for severe acute pancreatitis: preoperative clinicopathologic and physical data, ultrasonographic findings, surgical procedure detail, histopathologic findings, and transfusion requirements. The survival rate was 80.8% in dogs with extrahepatic biliary obstruction, 64.3% in dogs undergoing necrosectomy, and 40.6% with pancreatic abscess. Overall survival was 63.6%. Surgical complications included intraoperative and postoperative hemorrhage in 12 dogs, postoperative development of diabetes mellitus in 3 dogs, exocrine pancreatic insufficiency in 1 dog, and bacterial peritonitis in 2 dogs.

CONCLUSION

Surgical intervention and aggressive postoperative care may be pursued in select dogs with severe acute pancreatitis. In dogs with extrahepatic biliary obstruction secondary to acute pancreatitis, surgical intervention may be associated with a good prognosis whereas dogs with pancreatic abscess formation may have a more guarded prognosis.

Treatment of pancreatitis-associated extrahepatic biliary tract obstruction by choledochal stenting in seven cats

OBJECTIVES

To report the clinicopathological findings and outcome in cats with pancreatitis-associated extrahepatic biliary tract obstruction (EHBO) treated by choledochal tube stenting.

METHODS

Medical records of cats with EHBO secondary to pancreatitis that underwent choledochal stenting were reviewed. Information on outcome was obtained by re-examination of the cat or by telephone interview with the owners.

RESULTS

All cats had pancreatitis confirmed by histopathological examination of biopsy samples (n=6) or suspected based on gross examination at surgery (n=1). In six cats, a section of 3.5 to five French gauge red rubber catheter and in one cat a section of 22 G intravenous catheter were used as a choledochal stent. Two cats developed re-obstruction of the biliary tract within a week of the original surgery. One cat had confirmed episodes of ascending cholangitis postoperatively. Two cats had chronic intermittent vomiting in the postoperative period. Two cats died during the perioperative period. Five cats survived to discharge, three of which died seven to 24 months postoperatively and two of which remain alive to date.

CLINICAL SIGNIFICANCE

Choledochal stenting is an alternative to biliary diversion for management of feline pancreatitis-associated EHBO in select cases. However, there may be greater morbidity with this technique in cats compared with dogs.

Minimally Invasive Cholecystostomy in the Dog: Evaluation of Placement Techniques and Use in Extrahepatic Biliary Obstruction

OBJECTIVE

To evaluate 4 methods of cholecystostomy catheter placement and to report on laparoscopic (Lap) cholecystostomy for the management of extrahepatic biliary obstruction (EHBO) in 3 dogs.

STUDY DESIGN

Experimental study and clinical report.

ANIMALS

Cadaveric dogs (n=20); 2 canine and 1 feline patient.

METHODS

Pigtail cholecystostomy catheters were inserted in 20 canine cadavers using ultrasound (US) or Lap guidance. Insertion routes were either transperitoneal or transhepatic. Methods studied included Lap-transperitoneal, US-transperitoneal, US-transhepatic, and US-Seldinger (n=5 dogs/group). Insertion success, pleural penetration, and insertion site leakage (Lap-transperitoneal group) were evaluated. Three clinical EHBO cases were treated by Lap-transperitoneal technique.

RESULTS

Insertion success was 100% by Lap-transperitoneal but 0% with US-transperitoneal and US-Seldinger methods. US-transhepatic yielded 3 of 5 successful placements. The pleura was penetrated in all US-transhepatic and US-Seldinger insertions. Leakage pressure for Lap-transperitoneal catheters averaged 75 cm H2O (+/-20 cm H2O). Lap-transperitoneal cholecystostomy resulted in marked improvement in 2 dogs, but the catheter became obstructed in the cat. One dog spontaneously regained common bile duct patency and the remaining 2 animals had successful cholecystoenterostomy.

CONCLUSIONS

In cadaver testing, the Lap-transperitoneal cholecystostomy method was superior based on high insertion success with no pleural penetration. In 2 clinical cases, Lap-transperitoneal placement successfully provided biliary drainage for patient stabilization.

CLINICAL RELEVANCE

The role for temporary cholecystostomy has yet to be established, but may aid patient stabilization and mortality reduction in EHBO.