Cholangitis, Lymphocytic

Also known as: Lymphocytic-plasmacytic cholangitis —Cholangiohepatitis — Non-suppurative cholangitis

Introduction

Lymphocytic cholangitis is a slowly progressive chronic disease characterised by infiltration of the portal areas of the liver with inflammatory cells, mostly lymphocytes and plasma cells. Bile duct hypertrophy and fibrosis are present. However, lymphocytic cholangitis does not progress to biliary cirrhosis. An immune-mediated aetiology has been postulated but this has not been substantiated to date. It is rarely associated with pancreatitis, compared to Cholangitis, Neutrophilic

Signalment

Young to middle-aged cats, 50% are under 4 years old. Persians are often predisposed.

Diagnosis

Clinical Signs

History of chronic waxing and waning low-grade illness. Vague clinical signs which may include anorexia, depression, weight loss, intermittent vomiting and diarrhoea, jaundice,lymphadenomegaly. Severe illness and pyrexia is less likely compared to Cholangitis, Neutrophilic. Some cats in the UK are polyphagic and are frequently presented with ascites and/or jaundice. Many show hepatomegaly and some have generalised lymphadenopathy. Possible sequel is chronic biliary cirrhosis and ascites. Due to the likelihood of liver being affected too, hepatic encephalopathy and bleeding disorders may occur.

Laboratory Tests

Haematology

Neutrophilia is less common than with Cholangitis, Neutrophilic

Biochemistry

Increased alkaline phosphatase (ALP), alanine aminotransferase (ALT), Hyperbilirubinaemia and Hyperglobulinaemia.

Diagnostic Imaging

Radiography

Radiographic signs are non specific. Hepatomegaly due to enlargement of biliary ducts and in some cases ascites is also seen.

Ultrasonography

Ultrasonography is more helpful. Biliary tract dilation can be seen in all cases. Common bile duct is normally dilated and the gall bladder may also be dilated with "sludge". Main differential is extrahepatic biliary obstruction.

Histopathology

Liver biopsy is important to rule out Feline Infectious Peritonitis . It is vital to obtain a haemostasis profile prior to biopsy due to risk of prolonged coagulation with liver disease. It is unnecessary to obtain a bile sample unless the presentation is acute, in which case Cholangitis, Neutrophilic needs to be ruled out.

Treatment

• Immunosuppressives

Glucocorticoid at initial immunosuppressive dose for 6-12 weeks. This should be tapered gradually to alternate day dosing. However, recurrence is common following initial amelioration of clinical signs. Response to therapy is hard to assess due to the slowly progressive nature of this disease. A persistent rise in ALT and/or increasing total serum bilirubin indicates an inadequate control of the disease.

Azathioprine has been trialled but this is not recommended due to its side effects which include inappetence and leucopaenia. Methotrexate at low weekly dose has also been used in a few affected cats.

Antibiotic may be given at early stages of treatment until an infectious cause has been ruled out.

Ursodeoxycholic acid may be given as it has hepatoprotective (anti-inflammatory, immunomodulatory and antifibrotic effects) properties and choleretic effect. The latter promotes increased fluidity of biliary secretions for treating or preventing sludging. Additionally antioxidants such as S-adenosylmethionine and vitamin E can be given to counteract the potent oxidising property of bile.

Prognosis

Poor due to the waxing and waning feature of this disease. In cats, this disease does not usually progress to end-stage cirrhosis and therefore it does not usually result in death, which is in contrast to dogs.

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References

Ettinger, S.J. and Feldman, E. C. (2000) Textbook of Veterinary Internal Medicine Diseases of the Dog and Cat Volume 2 (Fifth Edition) W.B. Saunders Company.

Nelson, R.W. and Couto, C.G. (2009) Small Animal Internal Medicine (Fourth Edition) Mosby Elsevier.

Marks, S.L. (2003). Update on the Diagnosis and Management of Feline Cholangiohepatitis Waltham Feline Medicine Symposium.

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