1. Bile Peritonitis

2. Signalment Tanner, 6.5 yo MC Cocker Spaniel

3. 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

4. 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

5. 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).

6. 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

7. 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.

8. Liver

11. Hepatic lymph nodes

12. Hepatic lymph node

13. Gall bladder

17. Right Adrenal

18. Abdominal Ultrasound Probable hepatic cirrhosis - no evidence of portal hypertension Biliary mucocele Hepatic lymphomegaly - probable reactive hyperplasia Right adrenomegaly - hyperplasia vs. neoplasia

19. 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)

20. 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