Extrahepatic biliary tract diseases in cats. Case reports ...still little described rare diseases....

7
Introduction Biliary tract diseases in domestic carnivores and in parti- cular in cats are still little described rare diseases. Cholelithiasis in cats have been reported by different authors [7, 8, 12, 17]. They have no clinical repercussions or may be responsible for an acute obstruction of the extrahepatic biliary tract [17]. TROUT has described 5 cases of gallblad- der tumors (cystadenoma) in cats [19]. Three cases of carci- noma of the biliary tract were reported by FELDMAN in 1976 [10]. Congenital anatomical anomalies of the extrahe- patic biliary tract in cats are rare but not exceptional. HIRSCH has reported a suppurative cholangiohepatitis asso- ciated with a bilobed gallbladder [13]. Inflammations of the biliary ducts (cholangitis) and of the gallbladder (cholecysti- tis) are the best known affections, but generally in associa- tion with the cholangiohepatis complex in the cat [1, 4, 6, 13, 20]. Lower common bile duct obstructions are frequently associated, like in dogs [16, 17], with a pancreatic tumours, but are also very often the result of inflammatory diseases affecting the pancreas, the biliary tract and the intestine [1,17]. A study by MAYHEW et al. has described 22 cases of obstruction of the extrahepatic biliary tract as a result of a pancreatitis, a cholangiohepatitis, a cholelithiasis or a chole- cystitis in 15 cases, and a biliary or pancreatic adenocarci- noma in 6 cases [17]. A sphincter of Oddi dysfunction, a cicatricial stenosis or an inflammation of this sphincter (Odditis) are causes of cholestasis which are known in man and more and more frequently suspected in cats. This article aims at describing different pathological situations of the extrahepathic biliary tract which we have observed and trea- ted. It provides a bibliographic synthesis of the current data pertaining to these affections. Case No. 1 A 12-year-old Burmese cat was presented to us for chronic vomiting that had been developing for three months. The animal had been worn out and anorexic for three days. The clinical examination showed an animal in good condition. Abdominal palpation resulted in a defense reaction of the animal and seemed to be painful in the lower front area. The cardiorespiratory auscultation was normal and the palpation of the cervical region showed no abnormalities. The hemato- biochemical assessment revealed a significant leucocytosis (22,800 leukocytes/mm 3 N 5,000-18,900) with mature poly- neutrophilia (19,600 PNs/mm 3 N 2,500-12,500), and sho- wed a disturbance in hepatic parameters (bilirubin 8mg/L N 0-4, alkaline phosphatase PAL 145 IU/L N 14-111,gamma- glutamyl transferase GGT 27 IU/L N 1-5, alanine amino- transferase AAT 147 IU/L N 20-85), aspartate amino-trans- ferase AST 98 IU/L N1-37). Extrahepatic biliary tract diseases in cats. Case reports and bibliographic synthesis P. LECOINDRE 1 * and M. CHEVALLIER 2 1 Clinique Vétérinaire Les Cerisioz, 69800 St Priest - France 2 Laboratoire Marcel Mérieux, 69007Lyon - France * Corresponding author : [email protected] RÉSUMÉ Affections des voies biliaires extrahépatiques du chat. Description de quelques cas cliniques et synthèse bibliographique. Par P. LECOINDRE et M. CHEVALLIER. Les affections des voies biliaires des carnivores domestiques et plus par- ticulièrement du chat sont des affections rares et encore peu décrites. Elles regroupent les anomalies anatomiques congénitales, les affections inflam- matoires (cholangites, cholécystites), les tumeurs, les cholélithiases, les sté- noses inflammatoires ou traumatiques, les dysfonctionnement du sphincter d’oddi. Toutes ces affections entraînent secondairement une cholestase qui peut Ítre responsable d’affections graves hépatobiliaires. Elles peuvent éga- lement être la conséquence d’une infammation chronique intestinale, pan- créatique ou hépatique. Il existe chez le chat une véritable trilogie patholo- gique associant le tractus digestif et ses glandes annexes. Cet article décrit différentes situations pathologiques des voies biliaires extrahépatiques et réalise une synthèse bibliographique des données actuelles concernant ces affections. Mots-clés : chat - voies biliaires - vésicule biliaire - cho- lestase. Revue Méd. Vét., 2004, 155, 12, 591-597 SUMMARY Biliary tract diseases in domestic carnivores and in particular in cats are still little described rare diseases. They group together congenital anatomi- cal anomalities, inflammatory affections (cholangitis, cholecystitis), tumors, cholelithiasis, inflammatory or traumatic stenosis, sphincter of Oddi dysfunctions. All these affections lead secondarily to a cholestasis which may be responsible for serious hepatobiliary affections. They may also be the result of a chronic intestinal, pancreatic or hepatic inflammation. There is in cats a real pathological trilogy associating the digestive tract and its ancillary glands. This article describes different pathological situations of the extrahepatic biliary tract and provides a bibliographic synthesis on cur- rent data pertaining to these affections. Keywords : cat - biliary tract - gallbladder - cholestasis.

Transcript of Extrahepatic biliary tract diseases in cats. Case reports ...still little described rare diseases....

Page 1: Extrahepatic biliary tract diseases in cats. Case reports ...still little described rare diseases. They group together congenital anatomi-cal anomalities, inflammatory affections (cholangitis,

IntroductionBiliary tract diseases in domestic carnivores and in parti-

cular in cats are still little described rare diseases.Cholelithiasis in cats have been reported by different authors[7, 8, 12, 17]. They have no clinical repercussions or may beresponsible for an acute obstruction of the extrahepaticbiliary tract [17]. TROUT has described 5 cases of gallblad-der tumors (cystadenoma) in cats [19]. Three cases of carci-noma of the biliary tract were reported by FELDMAN in1976 [10]. Congenital anatomical anomalies of the extrahe-patic biliary tract in cats are rare but not exceptional.HIRSCH has reported a suppurative cholangiohepatitis asso-ciated with a bilobed gallbladder [13]. Inflammations of thebiliary ducts (cholangitis) and of the gallbladder (cholecysti-tis) are the best known affections, but generally in associa-tion with the cholangiohepatis complex in the cat [1, 4, 6, 13,20]. Lower common bile duct obstructions are frequentlyassociated, like in dogs [16, 17], with a pancreatic tumours,but are also very often the result of inflammatory diseasesaffecting the pancreas, the biliary tract and the intestine[1,17]. A study by MAYHEW et al. has described 22 casesof obstruction of the extrahepatic biliary tract as a result of apancreatitis, a cholangiohepatitis, a cholelithiasis or a chole-cystitis in 15 cases, and a biliary or pancreatic adenocarci-noma in 6 cases [17]. A sphincter of Oddi dysfunction, a

cicatricial stenosis or an inflammation of this sphincter(Odditis) are causes of cholestasis which are known in manand more and more frequently suspected in cats. This articleaims at describing different pathological situations of theextrahepathic biliary tract which we have observed and trea-ted. It provides a bibliographic synthesis of the current datapertaining to these affections.

Case No. 1A 12-year-old Burmese cat was presented to us for chronic

vomiting that had been developing for three months. Theanimal had been worn out and anorexic for three days. Theclinical examination showed an animal in good condition.Abdominal palpation resulted in a defense reaction of theanimal and seemed to be painful in the lower front area. Thecardiorespiratory auscultation was normal and the palpationof the cervical region showed no abnormalities. The hemato-biochemical assessment revealed a significant leucocytosis(22,800 leukocytes/mm3 N 5,000-18,900) with mature poly-neutrophilia (19,600 PNs/mm3 N 2,500-12,500), and sho-wed a disturbance in hepatic parameters (bilirubin 8mg/L N0-4, alkaline phosphatase PAL 145 IU/L N 14-111,gamma-glutamyl transferase GGT 27 IU/L N 1-5, alanine amino-transferase AAT 147 IU/L N 20-85), aspartate amino-trans-ferase AST 98 IU/L N1-37).

Extrahepatic biliary tract diseases in cats. Casereports and bibliographic synthesisP. LECOINDRE1* and M. CHEVALLIER2

1 Clinique Vétérinaire Les Cerisioz, 69800 St Priest - France2 Laboratoire Marcel Mérieux, 69007Lyon - France

* Corresponding author : [email protected]

RÉSUMÉ

Affections des voies biliaires extrahépatiques du chat. Description dequelques cas cliniques et synthèse bibliographique. Par P.LECOINDRE et M. CHEVALLIER.

Les affections des voies biliaires des carnivores domestiques et plus par-ticulièrement du chat sont des affections rares et encore peu décrites. Ellesregroupent les anomalies anatomiques congénitales, les affections inflam-matoires (cholangites, cholécystites), les tumeurs, les cholélithiases, les sté-noses inflammatoires ou traumatiques, les dysfonctionnement du sphincterd’oddi. Toutes ces affections entraînent secondairement une cholestase quipeut Ítre responsable d’affections graves hépatobiliaires. Elles peuvent éga-lement être la conséquence d’une infammation chronique intestinale, pan-créatique ou hépatique. Il existe chez le chat une véritable trilogie patholo-gique associant le tractus digestif et ses glandes annexes. Cet article décritdifférentes situations pathologiques des voies biliaires extrahépatiques etréalise une synthèse bibliographique des données actuelles concernant cesaffections.

Mots-clés : chat - voies biliaires - vésicule biliaire - cho-lestase.

Revue Méd. Vét., 2004, 155, 12, 591-597

SUMMARY

Biliary tract diseases in domestic carnivores and in particular in cats arestill little described rare diseases. They group together congenital anatomi-cal anomalities, inflammatory affections (cholangitis, cholecystitis),tumors, cholelithiasis, inflammatory or traumatic stenosis, sphincter of Oddidysfunctions. All these affections lead secondarily to a cholestasis whichmay be responsible for serious hepatobiliary affections. They may also bethe result of a chronic intestinal, pancreatic or hepatic inflammation. Thereis in cats a real pathological trilogy associating the digestive tract and itsancillary glands. This article describes different pathological situations ofthe extrahepatic biliary tract and provides a bibliographic synthesis on cur-rent data pertaining to these affections.

Keywords : cat - biliary tract - gallbladder - cholestasis.

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An echography of the liver showed no masses or notablealterations in the echogenicity of the hepatic parenchyma,but one clearly observed an anechogenic cystic formationwhose lumen seemed to be in continuity with the cystic duct(figures 1 and 2). The gallbladder seemed to be dilated, itsechogenic wall maybe slightly increased with respect to thecontent of the gallbladder. No parietal alterations of thedigestive tractus and no adenopathy were observed.

The endoscopic examination of the upper digestive tractand the histology of the perendoscopic biopsies revealed noabnormalities at the level of the stomach and of the proximalsmall intestine.

A celiotomy confirmed the presence of a cystic formationthat had developed at the expense of the cystic duct. Thegallbladder wall was obviously thickened. A cholecystec-tomy with ablation of the cystic duct and of the cyst was per-formed.

The histology of an hepatic biopsy performed during theintervention confirmed moderate lesions of suppurative cho-langiohepatitis. The examination of the cyst and gallbladdercontents showed a very thick bile. However, a bacteriologi-cal examination remained negative. The postoperative treat-ment included a fluidtherapy and an antibiotherapy (metro-nidazole 30mg/kg SID, amoxicilline 10mg/kg BID) whichwas set up for a 2-month period. The animal showed a satis-factory recovery with normalization of its biochemical para-meters within 4 weeks.

Case No. 2This eight-year-old neutered male cat had been presenting

a history of chronic digestive disorders for approximatelytwo years, dominated by chronic vomiting occurring in moreor less spaced-out crises and disappearing spontaneously.The diarrhea had appeared recently. The animal was presen-ted to us for weight loss associated with anorexia that hadbeen persisting for 4 days. During the clinical examination,one noted moderate thinness and dehydration. Abdominalpalpation showed significant rigidity of the small intestine.Mesenteric lymphatic node could not be palpated. The exa-mination of the ventral cervical region was normal.

The hematological assessment revealed a moderate leuco-cytosis. In addition, one observed a significant increase inbilirubin (10mg/L) and in the serous activity of alkalinephosphases (215 IU/L), gamma-glutamyl transferase (48IU/L) and of hepatic transaminases (ALT 186 IU/L, AST 75IU/L). The other biological parameters explored (total pro-teins, albumin, cholesterol, urea, creatinine) were within theusual values. A coproscopic examination (flotation, directspreading and staining) did not allow to reveal a parasitosis.In particular, the search for Giardia was negative.

During the endoscopy, the esophagus and the stomach loo-ked normal (figure 3). The examination of the duodenumshowed an hyperemia and a suspect friability of the mucosa.The significant rigidity of the small intestine prevented theprogress of the probe toward the jejunum. Biopsies of theduodenal mucosa were performed and complemented withbiopsies of the gastric mucosa during retraction of the endo-

scope. The histology of gastric biopsies revealed nothingabnormal. On the five biopsies of the small intestine, oneobserved a diffuse infiltration of the mucous chorion by apopulation of inflammatory cells of the lymphocytic andplasmocytic type. There was a major exocytosis through thesurface epithelium. The villosities were not atrophic.

A diagnosis of Chronic Intestinal Inflammatory Disease ofthe lymphoplasmocytic type localized to the small intestinewas proposed. According to the intensity of the histologicallesions, this lymphoplasmocytic enteritis was classified inthe moderate to severe grade (stage 2/3 in a grading thatincludes 3 stages).

Treatment was based on a corticotherapy (prednisone) at adose of 1 mg/kg twice a day for three weeks. Spiramycineand metronidazole in association (Stomorgyl® 10, Merial) atthe rate of one tablet a day (which amounts to a dose of 25mg of metronidazole and of 150,000 IU/kg/day of spiramy-cine) complemented this corticotherapy. While the improve-ment had been significant ever since the first week of treat-ment, the owner suddenly noted a worsening of the conditionof his animal which was quite worn out, anorexic, and pre-sented significant vomiting. The clinical examination sho-wed an icterus which was particularly visible at the level ofthe palatine mucosa. The bilirubin level was high (35mg/L).An abdominal echographic examination showed a signifi-cant dilatation of the extrahepatic biliary tract that appeartortuous (the diameter of the common bile duct was biggerthan 5 mm) with an abnormally thickened aspect of the duo-denal papilla (figures 4 and 5). The examination of the rightlobe of the pancreas showed decreased echogenicity givingcause for suspecting a pancreatic inflammation. A surgicalexploration confirmed a dilation of the biliary tract and avery marked reflux of the bile at the level of the pancreaticducts (figure 6). In addition, the pancreas showed a signifi-cant edema. An enterotomy performed on the opposite of theduodenal papilla allowed to perform a sphincterectomy ofthis papilla which looked highly fibrosed and stenosed. Thissurgical intervention appeared to be effective at first, but anew increase in serum bilirubin made it necessary to performa cholecystoduodenostomy. The anastomosis was performedusing the EndoGIA® 30 Autosuture stapler.

The histology of an hepatic biopsy performed during theintervention confirmed the existence of moderate-grade lym-phocytic cholangiohetatitis lesions. An antibiotherapy and aprolonged corticotherapy have allowed to date to obtain cli-nical stability in the animal.

Case No. 3A 12-year-old European cat was presented for extensive

vomiting (watery vomiting more than 10 times a day) thathad appeared 2 weeks earlier and was developing in crisesthat looked very painful. The clinical examination showedan animal in good condition. However, the abdominal palpa-tion was painful. An abdominal radiographic examinationrevealed the presence of a bone density mass 2 mm in dia-meter whose location gave cause to suspect a gallstone(figure 7). An abdominal echography confirmed the pre-

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sence of this gallstone and showed a dilated gallbladder,though its wall appeared to be moderately thickened (figure8). The extrahepatic biliary tract was not dilated. The hema-tobiochemical assessment was normal and showed no cho-lestasis. Surgery was motivated by the appearance of thesemore and more frequent and painful vomiting crises and bythe possibility of occurrence of an acute biliary tract obstruc-tion caused by this stone. A cholecystectomy was performedto prevent any recurrence. The animal quickly improved andshowed no relapse 3 months after the intervention. An hepa-tic histology revealed no hepatobiliary disease known to pro-mote the appearance of choleliths. The stone contained cal-cium bilirubinate and carbonate (figure 9).

Case No. 4A 3-year-old queen had been presenting for 6 months a

progressive weight loss, periods of anorexy associated withthe appearance of vomiting crises. Hematobiochemicalassessments performed regularly over the last two monthsallowed to reveal a progressive rise in the serum activity ofhepatic transaminases and bilirubinemia. The clinical exami-nation of the animal confirmed a subicterus, an abnormallythin condition. The abdominal palpation was normal. Anabdominal echography showed a liver that had increased insize, an homogenous but increased echogenicity. The intra-hepatic biliary tract was not visible. The gallbladder showeda very abnormal aspect with a bilobed structure and signifi-cant dilation (figure 10). A biopsy under echographic gui-dance allowed to perform an histopathological examinationof the liver that revealed a periportal lymphoplasmocyticinfiltrate and a fibrosis characterizing a chronic cholangiohe-patitis. The surgical decision was based on the chronic evo-lution of the disease in spite of the treatments undertaken andon the possibility of existence, described by several authors,of an anatomical abnormality of the biliary tract, in particu-lar of the gallbladder, which may induce a chronic cholesta-sis and the appearance of chronic inflammatory lesions ofthe intrahepatic biliary tract. A cholecystectomy was there-fore performed and allowed to confirm an abnormality in theconformation of the gallbladder which was quite clearlybilobed (figures 11 and 12). The animal had a satisfactoryresponse to the treatment which associated antibiotics, corti-coids and ursodesoxicholic acid over a 6-week period.

Discussion

CONGENITAL ABNORMALITIES OF THE EXTRAHE-PATIC BILIARY TRACT IN CATS

The best described congenital abnormalities of the biliarytract in man are cystic dilations of the choledoch (commonbile duct) which for certain authors are the consequence of ajunction abnormality of the common bile duct and of theduct of Wirsung forming an abnormally long biliopancreaticjoint duct. Congenital anatomical abnormalities of the extra-hepatic biliary tract in cats are rare but not exceptional.HIRSCH has described a suppurative cholangiohepatitis

associated with a bilobed gallbladder [13]. We have descri-bed two cases of malformation of the gallbladder (a bilobedgallbladder-case no. 4-and a diverticulum of the cystic duct-case no. 1) in cats suffering from chronic cholangiohepatitis.It is likely that these abnormalities induce a chronic choles-tasis predisposing to the infection and inflammation of thebiliary ducts.

ACQUIRED AFFECTIONS OF THE EXTRAHEPATICBILIARY TRACT

They are numerous. An inflammation of the extrahepaticbiliary ducts (cholangitis), of the gallbladder (cholecystitis),an obstruction of the extrahepatic biliary tract, a cholelithia-sis, a tumor of the gallbladder or of the biliary tract are theextrahepatic biliary tract diseases in cats described in theliterature [2, 7, 8,11, 12, 19]. All these affections induce acholestasis and promote inflammation and infection.However, they may themselves be the consequence of a tran-sitory cholestasis resulting from an enteritis, a pancreatitis, adysfunction or a stenosis of the sphincter of Oddi or of thelower choledocian section [2, 4, 6, 13]. One can thenobserve, like in the case no. 2, a reflux of pancreatic secre-tions into the biliary tract or of the bile into the pancreaticducts. This is the direct consequence of the particular anato-mical conformation of the common bile duct which joins themajor pancreatic duct to form the ampulla of Vater limited bythe sphincter of Oddi. Furthermore, the lower section of thecholedoch is adjacent to the pancreatic parenchyma and anedema, an inflammation or a fibrosis of the gland may resultsecondarily in an extrinsic obstruction of the biliary duct. Itis suggested today by several authors that, in cats, cholan-giohepatitis and pancreatitis would be extraintestinal mani-festations of a chronic intestinal inflammatory disease pro-moting a pancreatic and hepatobiliary reflux [1, 4, 6, 11, 20].This theory seems conceivable by reason of the anatomicalparticularities of the pancreatic and biliary ducts which wehave mentioned above.

CHOLECYSTITIS

The non-specific inflammation of the gallbladder mayevolve in an insidious, chronic way probably inducing clini-cal disorders which are not very specific. It is likely that thisinflammation of the gallbladder comes within the frameworkof the suppurative or chronic cholangiohepatitis and cholan-gitis well described in the feline species [6, 7, 13]. The roleof bacterbilia in the aetiology of cholecystitis is not very wellknown in cats. Five cats in the study of MAYHEW [17], hadbile cultures performed and were positive for bacterialgrowth. The infection may be hematogenic in origin, butmore probably of an ascending origin because of the above-mentioned reasons involving anatomical conformation [6,20]. E. coli, Klebsiella, enterococci, Pseudomas, Proteus,streptococci or anaerobes are the types of bacteria found.The cholestasis associated with a cholecystitis promotes theformation of cholelithiasis and extrahepatic biliary obstruc-tion. But the cholecytitis can occur due to the proinflamma-tory effects of bile stasis or irritant effects of choleliths pre-sent in the gallbladder [17]. The echography may reveal a

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FIGURES 1 AND 2.—Case No. 1 - Echography. One clearly observes an anechogenic cystic formation whose lumen seems to be in continuity with the cys-tic duct. The gallbladder seems to be dilated, its echogenic wall is maybe slightly increased with respect to the content of the gallbladder.

FIGURE 3.—Case No. 2 - Endoscopy. The endoscopic exam shows inflam-matory lesions of the duodenal mucosa : abnormal granularity, friability,rigidity of the bowel wall.

FIGURES 4 AND 5.—Case No. 2 - Echography. An abdominal echographic examination shows a significant dilation of the extrahepatic biliary tract (thediameter of the choledoch is bigger than 5 mm) with an abnormally thickened aspect of the duodenal papilla.

FIGURE 6.—Case No. 2 - Surgery. A surgical exploration confirms adilation of the biliary tract and a very clear reflux of the bile at thelevel of the pancreatic ducts.

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thickening of the gallbladder wall which may be hyperecho-genic with respect to the content of the gallbladder and theliver [13, 14]. Indirect signs of extrahepatic cholestasis withthe presence of an abundant biliary mud, of a dilation of thegallbladder, of the cystic duct, of the choledoch, of altera-tions in the hepatic echogenicity and signs of intrahepaticcholestasis are elements to be looked for, especially in thefeline species in which cholecystitis are most often associa-ted with the cholangiohepatitis complex [4, 6, 15, 18].

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FIGURE 7.—Case No. 3 - Radiography. An abdominal radiographicexamination has revealed the presence of a bone density mass 2mm in diameter whose location allows to suspect a gallstone.

FIGURE 8.—Case No. 3- Echography. An abdominal echography hasconfirmed the presence of this gallstone and has shown a dilatedgallbladder whose wall seems, however, to be moderately thicke-ned.

FIGURE 10,11,12.—Case No. 4 - Echography and surgery. The gall-bladder shows a very abnormal aspect with a bilobed structure anda significant dilation.

FIGURE 9.—Case No. 3 - Gallstone. The cholelith analysed is com-posed entirely of calcium carbonate.

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CHOLELITHIASIS

Cholelithiasis is a frequent clinical problem in man. Incats, several cases of cholelithiasis or of choledolithiasishave been reported by different authors, although this affec-tion remains rare [7, 8, 12]. There is probably several factorswhich may induce the formation of cholelith. A biliary sta-sis, an alteration in the bile composition, a cholecystitis, acholangiohepatitis, dietary factors are often mentioned ascauses predisposing to the formation of gallstones [12, 13].The infection of the biliary tract, especially when caused bybacteria producing the β glucuronidase, is also at the originof cholelith formation. These bacteria are indeed capable ofdecombining bilirubin. Once free, bilirubin can then precipi-tate with calcic salts and induce choleliths. A study on 5cases of suppurative cholangiohepatitis has shown two casesof cholelithiasis [13]. A case of cholelithiasis has been des-cribed in a cat suffering from hyperthyroidism [8]. For theauthor, cholelithiasis in that case would be the consequenceof a disturbance in the motricity of the gallbladder inducedby the hyperthyroidism. Any biliary stasis results in a severeinflammation by reason of the cytolitic agents it contains(lysocythin). This inflammation increases the secretion ofcholesterol which quickly results in a precipitation of choles-teric crystals, the production of a thick viscous bile and theformation of choleliths.

In a series of 9 cats that suffered from cholelithiasis, 7 catspresented multiple choleliths, 6 cats suffered from cholecys-titis, 7 had lesions of cholangiohepatitis and 2 suffered fromhepatic lipidosis [7]. The prognosis after a cholecystectomyis good, but darkened when an hepatic lipidosis occurs.These gallstones are mainly composed of biliary pigments orcalcium derivatives [12]. In that series, various types of aero-bic and anaerobic bacteria had been isolated. A cholelithiasisis more frequently observed in old cats of the male sex.Clinical signs appear only when the choleliths are sufficientin size to cause an obstruction. These clinical signs are notvery specific and dominated by vomiting, an anorexia, anadynamia. In our case, the cat suffered from real crises of«hepatic colic» with intense vomiting and pain. Most of thecats suffering from cholestasis caused by an obstruction areicteric, present an hyperbilirubinemia and a rise in hepatictransaminases, gamma-glutamyl transferase and alkalinephosphatase [17]. When the stone(s) induces (induce) noobstruction, there are few alterations in the hepatic parame-ters unless if the formation of stones is the consequence of anunderlying hepatic disease. A leucocytosis is less constantthan in dogs. Although there is potentially a deficiency invitamin K1 with a biliary obstruction, cats presenting a cho-lelithiasis show no coagulation disorders [7]. The confirma-tion of a cholelithiasis in cats is often echographic [15, 18].A diameter of the choledoch bigger than 5 mm is significa-tive of an extrahepatic biliary obstruction. Some calculi arevisible on a radiography (presence of calcium) and very fre-quently detectable in an echography, like in the case descri-bed here.

TUMORS OF THE EXTRAHEPATIC BILIARY TRACT

A recent study (cystadenoma) has described 5 cases of

tumors of the gallbladder in cats [19]. These tumors werebenign cystadenomas which were all revealed during theechographic examination. A cholecystectomy was perfor-med in all these cats with no postoperative complicationsand no tumoral recurrence. Three cases of carcinoma of thebiliary tract were reported by Feldman in 1976 [10].

OBSTRUCTION OF THE EXTRAHEPATIC BILIARYTRACT

A study by Mayhew et al. describes 22 cases of obstruc-tion of the extrahepatic biliary tract resulting in 15 casesfrom a pancreatitis, a cholangiohepatitis, a cholelithiasis or acholecystitis, and in 6 cases from a biliary or pancreatic ade-nocarcinoma [17].

In our experience, stenosis of the intrapancreatic commonbile duct section are the main biliary tract diseases that wehave had to treat. In our observations, stenosis of the chole-doch appear to be the consequence of a chronic inflamma-tion of the duct resulting of duodenal refluxes or recurrentpancreatic inflammations. Although the mechanism is stillimprecise, stenosing lesions of the extrahepatic biliary tractand in particular of the choledoch are probably frequentcomplications of the Chronic Inflammatory Bowel Diseases-Chronic Pancreatitis-Cholangiohepatitis complex, asMayhew reports in his study [17].

A case of obstructive cholangiohepatitis has been descri-bed in a cat [2]. This obstruction was caused by a cyst of thecholedoch associated with lesions of fibrosing pancreatitis. Itmust be noted that in dogs the first cause of extrahepatic cho-lestasis is a pancreatic pathology [5, 9, 16].

An increase in hepatic parameters (ALAT, ALP, AST,GGT, Bilirubin) in nearly 90% of cases is observed in obs-truction cases, but is not specific and appears in the majorityof hepatobiliary affections. A dilatation of the gallbladder, adilated and tortuous aspect of the biliary tract observedduring an echographic examination are highly suggestive ofan obstruction of the biliary tract [14, 18]. The treatment issurgical (cholecystoduodenostomy or jejunostomy), but theperioperative mortality and morbidity are high.

LOWER CHOLEDOCIAN OBSTRUCTIONS AND OBS-TRUCTIONS OF THE SPHINCTER OF ODDI

Obstructions of the ampulla of Wirsung or of the sphincterof Oddi by a tumor, a cyst or a fibrosis are, in our opinion,more frequent than obstructions of a lithiasic origin, but maybe not well known. They result in an acute cholestasis aswell as a pancreatitis caused by biliary reflux into pancreaticducts (case no. 2) [4]. Personally, we have observed severalcases of stenosis of the sphincter of Oddi in cats that sufferedfrom chronic inflammatory bowel diseases and chronic cho-lestasis that resulted in the appearance of a suppurative cho-langiohepatitis. A sphincterotomy was attempted in severalcats, but did not always allowed to obtain a restoration of thebiliary flow. A cholecystoduodenostomy was performedseveral times by second intention. The dysfunctions of thesphincter of Oddi with no true anatomical stenosis are sus-pected by many authors of being a cause of cholestasis and

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Page 7: Extrahepatic biliary tract diseases in cats. Case reports ...still little described rare diseases. They group together congenital anatomi-cal anomalities, inflammatory affections (cholangitis,

of cholangiohepatitis [1, 20]. In man, disturbances in themotricity of the biliary tract and of the sphincter of Oddi or«biliary and Oddian dyskinesis» are an indisputable reality,even though they are difficult to explore with no surgicalintervention. It may be that these dyskinesis occur in relationwith a dysfunction of the neurovegetative system and theyare difficult to quantify in animals.

While many cases of cholelithiasis or of choledolithiasis incats have been described in the literature even though theseaffections remain rare, there are other extrahepatic biliarytract diseases in cats which may result in an acute cholestasiswith major clinical consequences. These biliary tractdiseases in cats fit in with a pathological complex that groupstogether chronic intestinal inflammatory diseases, pancreati-tis and cholangiohepatitis.

AcknowledgementsThanks are due to the Merial Laboratory for assistance in

these study.

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