Gallbladder disease and your pet Tarleton state university Advanced veterinary medical terminology Mid-term Spring 2016 Tiffany Bartlett, lvt

What is the gallbladder? Stores bile from liver Bile travels from gallbladder to duodenum via cystic duct-common bile duct Digests fats

Cholecystitis caused by cholelithiasis AKA: Gallbladder inflammation caused by gallbladder stones

Causes of choleliths Excess bilirubin in the bile Excess cholesterol in the bile Mucocele formation (bile turns gelatinous) preventing adequate emptying Low bile salt concentration

What you (the owner) should look for Depression Anorexia (loss of appetite) Vomiting Dehydration secondary to vomiting- tacky gums, tented skin Icteric (yellow) mucous membranes and sclera (gums and whites of eyes) Abdominal pain Hunched position, can mimic back pain Pacing- can’t get comfortable

Your trip to the veterinarian Initial Exam Bloodwork Advanced Imaging Treatments Discharge

Initial exam History of your pet Vitals Examination Current concern- onset, duration, severity Pertinent medical history Vitals Weight Temperature Heart rate/rhythm/sounds Respiratory rate/lung sounds Blood pressure Examination Head to tail medical assessment

Very vague findings-could be several hundred different causes Initial exam findings Painful abdomen Icteric (if severe) Vomiting Lethargic Fever (temperature >102.5°F) Very vague findings-could be several hundred different causes Not all patients will have all or any clinical signs

Your trip to the veterinarian Initial Exam Bloodwork Advanced Imaging Treatments Discharge

Bloodwork Complete Blood Count (CBC) Electrolytes Leukocytosis (elevated white blood cells) Can be normal Electrolytes Imbalanced due to dehydration Hypokalemia (decreased potassium in the blood)

Bloodwork Chemistry panel Assesses liver, kidney, pancreas, and other vital organs Varies widely Elevated hepatic (liver) enzymes; ALT and GGT most commonly- not always seen Hypercholesterolemia (elevated cholesterol)- not always seen

Additional bloodwork Rule out other causes of clinical signs Canine Pancreatic Lipase (cPL) snap test- pancreatitis can occur conjunctively or be root cause Bile Acids- elevation is indicative of hepatic or gall bladder disease Does not distinguish mucocele, stones, rupture, or other causes

Your trip to the veterinarian Initial Exam Bloodwork Advanced Imaging Treatments Discharge

Advanced imaging Radiographs (aka x-rays) 2 or 3 view abdomen ( left and/or right lateral and ventrodorsal) May not be diagnostic if the gall bladder has ruptured or not fully distended Ruptured gall bladder causes peritonitis A radiolucent distended gallbladder is seen (arrow) on this ventrodorsal view

Ultrasonography Full abdominal ultrasound Best diagnostic tool Diagnosis and rules out other disease processes The gall bladder appears Kiwi shaped- gallbladder mucocele May also see pancreatitis (inflamed pancreas) caused by cholecystitis

Your trip to the veterinarian Initial Exam Bloodwork Advanced Imaging Treatments Discharge

treatments Emergent Non-emergent Icterus is present Severe clinical signs Fully distended gallbladder Gallbladder rupture Peritoneal effusion Needs surgery within hours Minimal to no clinical signs Finding of choleliths or biliary mucocele was incidental

Non-emergent Surgery is planned- cholecystectomy or cholecystoduodenostomy Alternatively the gall bladder could be imaged every 6 months but is not recommended increases chance of non-emergent patients becoming emergent RX Ursodiol Bile acid- reduces uptake, synthesis, and production of cholesterol s-adenosylmethionine (SAMe, Denosyl®) Nutritional supplement, liver protectant Omega-3 fatty acid supplementation Famotidine (Pepcid AC®) Low-fat diets

Surgery Cholecystectomy Cholecystoduodenostomy Gall bladder removal For choleliths, gall bladder mucocele, or ruptured gall bladder Relocating the gallbladder from the liver Creating a new hole directly from the gall bladder to the duodenum Bypassing the common bile duct For bile duct stricture, tumor, or pancreatitis leading to obstruction of the bile duct

cholecystoduodenostomy cholecystectomy Typical cholecystoduodenostomy

Emergency May need plasma transfusion Depending on bloodwork; hypoproteinemia Increased anesthetic and post operative complications Sepsis, coagulopathies (clotting disorders), pancreatitis, hepatitis, dehiscence, cardiac/respiratory collapse IV fluids, antibiotics, and pain medication- hospitalized for several days

Emergency If ruptured gallbladder, may need abdominal drains placed This condition has a decreased change of survival Mortality rates are between 20–39% for this disease- early surgical intervention may significantly reduce mortality rates All questions regarding your specific pets prognosis should be discussed with the surgeon.

Post operative testing Bloodwork to recheck hepatic values, coagulation times, and other parameters will be periodically monitored Critical cases will have an arterial catheter placed for constant blood pressure and heart rate monitoring A central catheter, esophagostomy tube, and urinary catheter may also need to be placed Culture of the gall bladder and biopsies will be sent out for testing Culture allows for specific antibiotic use instead of an educated guess Biopsies to rule out an underlying cause

Your trip to the veterinarian Initial Exam Bloodwork Advanced Imaging Treatments Discharge

At home Confined for 10-14 days Low fat diet for life It takes ~2 weeks for the muscle, subcutaneous, and cutaneous layers to heal Excessive movement puts strain on healing tissues causing dehiscence Low fat diet for life <10% of fat

At home RX Pain medications Antibiotics Famotidine NSAID (non steroidal anti-inflammatory) use will depend on hepatic values Opioids- (Tramadol) Antibiotics Depending on culture results, can be multiple Famotidine Cerenia- antinausea, only if indicated Ursodiol Denamarin- liver protectant

Rechecks Typically the surgeon only needs to see your pet 2 weeks after discharge Unless complications arise Life time care should be overseen by your regular veterinarian Prescription refills (Ursodiol and Denamarin) Annual or biannual blood work (complete blood count, chemistry, and electrolytes)

References American College of Veterinary Surgeons. (2015). Gallbladder Mucocele | ACVS. Retrieved February 28, 2016, from https://www.acvs.org/small-animal/gallbladder-mucocele (Slides 5; 8; 15-18) Animal Surgical Center of Michigan. (2009). Gallbladder Mucocele in Dogs. Retrieved February 28, 2016, from http://animalsurgicalcenter.com/Library_articles/gi_gallbladder_mucocele (Slides 25-27) Cornell. (2016). Biliary System [Digital rendering]. Retrieved from http://weill.cornell.edu/cms/health_library/images/ei_0054.gif (Slide 2) Crews, L. J., Feeney, D. A., Jessen, C. R., & Rose, N. D. (2009, February 1). AVMA - Journal of the American Veterinary Medical Association - 234(3):359 - Abstract. Retrieved February 28, 2016, from http://avmajournals.avma.org/doi/abs/10.2460/javma.234.3.359 (Slide 17)

References Degner, D. (2004). Gall bladder disease. Retrieved February 28, 2016, from http://vetsurgerycentral.com/gallbladder.htm (Slides 19; 20-23) DVM 360. (2014, August 1). Female veterinary lab technician [Photograph]. Retrieved from http://files.dvm360.com/alfresco_images/DVM360/2014/08/01/7fdf6331-0eee-4690-ac75-18660eefc9b4/veterinary- blood-lab-work-female-tech-485204871_460x284.jpg (Slide 11) Heartland Vet Supply. (2016). Ursodiol [Photograph]. Retrieved from http://www.heartlandvetsupply.com/popup.aspx?src=images/Product/large/2930100.jpg (Slide 18) IDEXX. (n.d.). CPL Snap Test [Photograph]. Retrieved from http://www.idexx.co.uk/images/en_gb/smallanimal/snap/png/cpl-interpreting-results.png (Slide 12) Lyman, R. (2009, August 1). Gallbladder mucoceles: Surgery still recommended due to risk of rupture. Retrieved February 27, 2016, from http://veterinarynews.dvm360.com/gallbladder-mucoceles-surgery-still-recommended-due-risk-rupture (Slides 10-11; 14; 21-23; 26)

References Meditoons. (2012, December 2). Acute Cholecystitis (Gallbladder Attack) Meditoons™ [Video file]. Retrieved from https://www.youtube.com/watch?v=Ih2mEsh46Ug (Slide 3) Medscape. (2016). Radiograph [Radiograph]. Retrieved from http://img.medscape.com/pi/emed/ckb/gastroenterology/169972-1340257-173885- 1927876tn.jpg (Slide 14) Pet MD. (2016). Ursodiol - Pet, Dog and Cat Medication and Prescription List | petMD. Retrieved February 26, 2016, from http://www.petmd.com/pet-medication/ursodiol (Slide 18) Quizlet. (2016). Blood smear [Picture]. Retrieved from http://o.quizlet.com/i/9Dq7FNvLpC3a5fPr7LENIw_m.jpg (Slide 10)

References Rodriguez, D., & Jasmer, R. (2015, March 26). What Are Gallstones? | Everyday Health. Retrieved February 26, 2016, from http://www.everydayhealth.com/gallbladder/gallstones/ (Slide 4) Romich, Janet Amundson (2014-04-03). An Illustrated Guide to Veterinary Medical Terminology (Page 304). Delmar Cengage Learning. Kindle Edition. (Slide 2) Spielman, B., & Morgan, R. (2015, July 13). Jaundice in Dogs. Retrieved February 26, 2016, from http://www.petplace.com/article/dogs/diseases-conditions-of- dogs/symptoms/jaundice-in-dogs (Slide 4) The Awkward Yeti. (2014). Gallbladders' last day [Cartoon]. Retrieved from http://theawkwardyeti.com/?s=gallbladder (Slide 4) VCA Animal Hospitals. (2016). Serum Bile Acids | VCA Animal Hospitals. Retrieved February 28, 2016, from http://www.vcahospitals.com/main/pet-health- information/article/animal-health/serum-bile-acids/122 (Slide 12)