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
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