Biliary Tract Rupture
See also: Biliary Tract Obstruction
Introduction
Rupture of the biliary tract is a severe disease that results in localised or diffuse chemical peritonitis as bile leaks into the abdomen. If the biliary tract is infected, the peritonitis will be septic from the outset. If the tract is not infected at the point of rupture, the peritonitis may still become septic as the presence of bile in the peritoneal cavity reduces the integrity of the gut mucosal barrier.
Biliary tract ruptures may occur:
- Secondary to obstruction of the biliary tract.
- After blunt abdominal trauma, with the common bile duct rupturing more frequently than the gall bladder.
- If the tract is eroded by a neoplasm.
- Secondary to severe inflammatory disease of the gall bladder, including cholelithiasis and ascending cholecystitis[1].
- After gall bladder torsion[2].
Signalment
Shetland sheepdogs appear to be predisposed to gall bladder disease[3].
Diagnosis
It is important that biliary tract rupture is diagnosed promptly as the peritonitis becomes more severe with time.
Clinical Signs
The affected animal may show few clinical signs initially besides icterus and evidence of an ascites. As chemical peritonitis develops, the animal may show signs of:
- Abdominal pain and reluctance to move
- Pyrexia, anorexia and depression
- Shock and collapse
In cases of septic peritonitis, the animal may suffer from septic or endotoxic shock.
Laboratory Tests
Analysis of blood samples may show evidence of an acute inflammatory response, with a neutrophilic leucocytosis and elevated fibrinogen. The neutrophilia may have a left shift or, in severe cases, it may have a degenerative right shift. Cases with a very marked inflammatory response may develop a leukaemoid response with mobilisation of very large numbers of neutrophils from the bone marrow pools.
Aspiration and cytological analysis of fluid from the abdomen will reveal it to be a form of exudate with an evident green colouration. The fluid may contain mucinous or fibrillar material and it should be expected to have a bilirubin concentration at least twice that of serum[4].
Diagnostic Imaging
Plain radiographs of the abdomen may show evidence of an abdominal effusion with loss of serosal detail.
Ultrasonography may be used to detect the presence of free abdominal fluid and to guide fine needle aspiration. A scan may also reveal the site of the rupture.
Other Tests
As with other forms of peritonitis, diagnostic peritoneal lavage may be employed to reach a diagnosis in cases where free abdominal fluid cannot be easily aspirated. This procedure involves injecting a small volume (20 ml/kg) of warmed isotonic crystalloid solution and then re-aspirating this fluid. Cytological analysis of this fluid may then allow a diagnosis of (bile) peritonitis to be made.
Samples of peritoneal fluid should be submitted for bacterial culture and sensitivity to guide future antibiotic therapy.
Treatment
Where possible, urgent surgical intervention is indicated to repair the site of the rupture. Biliary re-routing procedures (such as cholecystojejunostomy) may be indicated in cases where the biliary tract is severely disrupted. The bile peritonitis should be managed aggressively.
Prognosis
The prognosis depends on the speed with which the condition is diagnosed and on whether the peritonitis is septic. In one study of cats and dogs, a mortality rate of 54% was reported and this represented those animals that had septic peritonitis[5].
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References
- ↑ Brömel C, Léveillé R, Scrivani PV, Smeak DD, Podell M, Wagner SO. Gallbladder perforation associated with cholelithiasis and cholecystitis in a dog J Small Anim Pract. 1998 Nov;39(11):541-4.
- ↑ Corfield GS, Read RA, Nicholls PK, Lester N. Gall bladder torsion and rupture in a dog. Aust Vet J. 2007 Jun;85(6):226-31.
- ↑ Aguirre AL, Center SA, Randolph JF, Yeager AE, Keegan AM, Harvey HJ, Erb HN. Gallbladder disease in Shetland Sheepdogs: 38 cases (1995-2005). J Am Vet Med Assoc. 2007 Jul 1;231(1):79-88.
- ↑ Owens SD, Gossett R, McElhaney MR, Christopher MM, Shelly SM. Three cases of canine bile peritonitis with mucinous material in abdominal fluid as the prominent cytologic finding. Vet Clin Pathol. 2003;32(3):114-20.
- ↑ Ludwig LL, McLoughlin MA, Graves TK, Crisp MS. Surgical treatment of bile peritonitis in 24 dogs and 2 cats: a retrospective study (1987-1994). Vet Surg. 1997 Mar-Apr;26(2):90-8.
Ettinger, S.J, Feldman, E.C. (2005) Textbook of Veterinary Internal Medicine (6th edition, volume 2) Elsevier Saunders
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