Bile Peritonitis

Signalment Tanner, 6.5 yo MC Cocker Spaniel

History 1 week history of vomiting (yellow liquid),

diarrhea, anorexia Has been seen at rDVM for 1 week with inc

ALP, ALT, GGT, T-bili, dec BUN, glucose, elevated bile acids, fever, inflammatory leukogram

Has been treated with enrofloxacin, metronidazole, famotidine and maropitant

Physical Exam Findings Abdomen tense and painful (1-2/4) on

palpation Obese T: 103.2F P: 132bpm R: 24 br/min CRT <2sec Wt 17.6kg BCS: 7/9

Clinical Pathology CBC: marked leukocytosis (62.51K/uL RR:

4.39-11.61) characterized by a neutrophilia (51.883K/ul RR: 2.841-9.112) with a regenerative left shift (1.250K/ul bands) and monocytosis (8.126K/ul RR: 0.075-0.85). Mild microcytic, hypochromic anemia (Hct = 32.1%). Thrombocytopenia (150K/uL) with increased MPV. Mild hypoproteinemia (5.8 g/dL RR: 6.1-7.5).

Chemistry Panel: Markedly elevated ALP (3804 IU/L), mildly

elevated ALT, GGT and T-bili, hyperphosphatemia, hypocalcemia, hypomagnesemia, hypoalbuminemia, low normal glucose, low normal BUN. Electrolytes are within normal limits.

Clinical Pathology

Clinical Pathology Resting Ammonia: Increased at 43 umol/L

(RR: 3-30). Bile Acids Tolerance: Increased resting

and post-prandial levels (pre = 55.7, post = 71.5 umol/L RR: 25)

Coagulation Profile: High normal PT, prolonged PTT. D-dimers 500-1000 ng/ml. Thrombocytopenia.

Liver

Liver

Liver

Hepatic lymph nodes

Hepatic lymph node

Gall bladder

Gall bladder

Gall bladder

Gall bladder

Right Adrenal

Abdominal Ultrasound Probable hepatic cirrhosis - no evidence of

portal hypertension Biliary mucocele Hepatic lymphomegaly - probable reactive

hyperplasia Right adrenomegaly - hyperplasia vs.

neoplasia

Abdominal Fluid Analysis Highly cellular specimen with large numbers of

inflammatory cells with a pale blue to green mucinous material that is consistent with bile. Rare bilirubin crystals noted. Inflammatory cells consist of 84% slightly degenerate neutrophils and 16% activated macrophages.

Interpretation/assessment: Bile peritonitis with marked suppurative inflammation

Bilirubin: 1.5mg/dL (Serum 2.0mg/dL)

Outcome Owners elected to euthanize based on the

diagnosis of bile peritonitis Necropsy: Microhepatica with diffuse

nodules, distended gall bladder with inspissated brown-green mucoid material and rupture of the common bile duct, fibrin at the defect and diffusely throughout abdomen, bile and inflammation throughout the mesentery, thoracic lymphadenopathy