Page 381 - Cote clinical veterinary advisor dogs and cats 4th

Chole(cysto)lithiasis 163

• Cholelithiasis associated with clinical signs Initial Database ■ Enrofloxacin 5-15 mg/kg (dogs; 5 mg/
○ Gastrointestinal disease • CBC: often normal; possible anemia, although ■ Add ampicillin 22 mg/kg IV q 6-8h
kg for cats) q 24h IV
VetBooks.ir ○ Peritonitis when cholelithiasis is associated • Serum biochemistry profile: increased liver to cefoxitin for gram-positive coverage Diseases and Disorders
usually mild; inflammatory leukogram
○ Biliary obstruction
(dogs and cats)
with biliary disruption/rupture
enzymes (proportional alkaline phosphatase
HISTORY, CHIEF COMPLAINT [ALP] > alanine aminotransferase [ALT]), ○ Specific long-term therapy based on
increased bilirubin with obstruction; ±
culture and sensitivity test results
• Generally nonspecific: malaise and increased amylase and lipase concentrations; • Possible administration of fresh-frozen plasma
gastrointestinal signs predominate ± hypokalemia (if hypoproteinemia, coagulopathy)
• Dogs: vomiting, anorexia, lethargy, weakness, • Survey abdominal radiographs: may delineate • Vitamin K administration
polydipsia, polyuria, weight loss radiopaque choleliths • Removal of choleliths/relief of extrahepatic
• Cats: vomiting, dehydration, anorexia, • Survey thoracic radiographs: rule out biliary obstruction
lethargy metastatic disease if neoplasia is suspected. • Duodenotomy and retrograde flushing of
• NOTE: choleliths may be an incidental the biliary system
finding in dogs and cats and may not be Advanced or Confirmatory Testing • Choledochotomy for removal of one or two
associated with any clinical signs. Abdominal ultrasound examination: large choleliths
• Common bile duct dilation • Cholecystectomy
PHYSICAL EXAM FINDINGS ○ Further delineate choleliths ○ Results in the best long-term prognosis if
• Icterus is common when cholelithiasis is ○ Normal diameter of common bile duct all stones are removed and biliary system
associated with cholangitis, cholecystitis, in dogs and cats: 3-4 mm is patent
gallbladder obstruction, or gallbladder ○ Common bile duct dilation signifying • Common bile duct stenting
rupture and bile peritonitis. obstruction: > 5 mm in cats, varies in • Cholecystoduodenostomy/jejunostomy
• Fever may be noted in dogs in association dogs • Tube cholecystostomy
with infection and/or bile peritonitis. • Evaluate gallbladder in dogs with concurrent • Treatment of bile peritonitis if biliary disrup-
• Signs of abdominal pain are not consistently cholecystitis tion has occurred (p. 779)
noted, even when biliary obstruction is ○ Wall thickness
present. ○ Contents: choleliths, mucocele Chronic Treatment
○ Presence of attached omentum: indicates Maintain bile flow using ursodeoxycholic acid
Etiology and Pathophysiology rupture 10-15 mg/kg PO q 24h; contraindicated while
• Cause is poorly understood ○ Surrounding fluid: indicates severe inflam- gallbladder obstruction is present
• In dogs and cats, most choleliths consist mation or rupture
mainly of calcium rather than cholesterol • Evaluate intestine for increased wall thickness Nutrition/Diet
(as seen in humans). and loss of layering associated with neoplasia Provide access for enteral feeding if patient is
• Choleliths may obstruct the extrahepatic or inflammatory bowel disease. anorexic (pp. 1106, 1107, and 1109).
biliary system (p. 118). • Obtain and perform analysis of peritoneal • Gastrostomy/jejunostomy tubes may be
• Hypercoagulability has been documented in fluid (pp. 1056 and 1343) placed intraoperatively.
dogs with extrahepatic biliary obstructions ○ Bilirubin concentration (elevated: bile
by using thromboelastography. peritonitis) Possible Complications
• Decreased bile secretion into the intestine ○ Cytologic examination and microbiologic Recurrence of cholelithiasis, bile leakage,
may result in decreased binding of endotoxin, culture and sensitivity testing: septic pancreatitis, peritonitis, endotoxemia, sepsis,
predisposing to endotoxemia. peritonitis death
• Cholelithiasis has been associated with • Coagulation profile (p. 1325), thromboelas-
concurrent cholecystitis and gallbladder tography Recommended Monitoring
rupture, resulting in bile peritonitis (pp. • If clinical signs were/are present
118 and 779). TREATMENT ○ Clinical and laboratory parameters
assessing perfusion, including capillary
DIAGNOSIS Treatment Overview refill time, pulse rate and quality, blood
• If the choleliths are an incidental finding, no pressure, urine output, arterial pH, and
Diagnostic Overview treatment is required. The patient should be lactate concentrations
Diagnosis of this problem generally requires monitored for development of clinical signs ○ Respiratory function
diagnostic imaging. Abdominal ultrasonography associated with cholelithiasis. ○ Serum liver enzymes and bilirubin
is the best diagnostic method. • If signs of biliary stasis, disruption, or concentrations
obstruction are noted, patient stabilization ○ Coagulation profile
Differential Diagnosis and surgical intervention are necessary. • If incidental finding
Cholelithiasis with extrahepatic biliary obstruc- ○ Physical exam and serum biochemistry
tion and jaundice (p. 528): Acute General Treatment profile every 6 months
• Hemolysis (i.e., prehepatic icterus) (pp. 59 • Rehydration by intravenous administration
and 60) of balanced electrolyte solution PROGNOSIS & OUTCOME
• Hepatic disease (i.e., hepatic icterus) (pp. • Normalization of serum electrolyte
172, 442, 452, 458, 543, and 740) concentrations • Fair in clinically ill animals if all chole-
• Biliary obstruction or rupture (i.e., post- • Parenteral antibiotics effective against gram- liths removed and a cholecystectomy is
hepatic icterus): pancreatitis, mucocele, negative bacteria and anaerobes performed
biliary rupture, cholangitis, neoplasia, ○ Empirical therapy • Guarded if cholelithiasis is associated with
stricture, foreign body obstruction in the ■ Cefoxitin 30 mg/kg IV q 4-6h peri- biliary leakage and aseptic bile peritonitis
duodenum, diaphragmatic hernia operatively, then q 6h (dogs and cats), • Poor for patients with septic bile
• Cholelithiasis without biliary obstruction: or peritonitis
often incidental finding for any issue prompt- ■ Metronidazole 7.5-15 mg/kg IV q 12h • Open prognosis for patients without clinical
ing abdominal imaging studies with signs (incidental finding)

www.ExpertConsult.com