Difference between revisions of "Cholangitis, Neutrophilic"

Revision as of 21:46, 6 August 2009

Also known as suppurative cholangitis, exudative cholangitis/cholangiohepatitis and acute cholangitis/cholangiohepatitis.

Signalment

More common in cats than in dogs. Cats of all breeds and ages can be affected, but often young to middle-aged cats. Male cats are more at risk.

Description

Neutrophilic cholangiohepatitis is characterised by infiltration of large numbers of neutrophils into portal areas of the liver and into the bile ducts. It results from ascending bacterial infection from the small intestines. Escherichia coli, Staphylococcus spp., Streptococcus spp., Clostridium spp., Bacillus spp., Actinomyces spp., Bacteroides spp. and occasionally Salmonella spp. have been isolated. Concurrent biliary tract disease are common in cats, especially pancreatitis and inflammatory bowel disease. Other predisposing factors include congenital or acquired abnormalities of the biliary system such as that of anatomic abnormalities of the gall bladder or common bile duct, bile duct obstruction caused by inspissated bile, cholelithiasis and cholecystitis.

Diagnosis

Clinical Signs

Acute presentation with pyrexia, abdominal pain, lethargy, jaundice.

Haematology & Biochemistry

Increased segmented and band neutrophils. Increased ALT and total bilirubin concentration

Imaging

A coarse or nodular texture to the liver on ultrasonography. More chronic cases may have dilation of the biliary tract.

Cytology and Culture

Bile samples for cytology is needed for a definitive diagnosis. Histopathology of the liver alone is not adequate as the disease tend to be confined to the biliary tract and pathology of the liver can be non specific and mild. Cytology shows bacteria and neutrophils. Culture and sensitivity should be performed for appropriate choice of antibiotics.

Treatment

Long course, 4-6 weeks, of an appropriate antibiotic following culture and sensitivity should be used. Amoxicillin at 15-20 mg/kg PO q8hours is a good initial choice.
Ursodeoxycholic acid at 15 mg/kg q24hours may be given due to its choleretic, which promotes increased fluidity of biliary secretions to treat or prevent sludging, and hepatoprotective (anti-inflammatory, immunomodulatory and antifibrotic effects) properties.
A high protein diet rather than a protein-restricted diet is more appropriate for feeding anorexic cats to prevent the development of hepatic lipidosis

Prognosis

Good provided the cats are treated early and appropriately.

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-{{OpenPagesTop}}
+{{unfinished}}
-Also known as: '''''Exudative Cholangitis — Cholangiohepatitis —Suppurative Cholangitis'''''
-==Introduction==
+Also known as ''suppurative cholangitis'', ''exudative cholangitis/cholangiohepatitis'' and ''acute cholangitis/cholangiohepatitis''.
-'''Neutrophilic cholangiohepatitis''' is characterised by infiltration of large numbers of [[Neutrophils|neutrophils]] into portal areas of the [[Liver - Anatomy & Physiology|liver]] and into the [[Liver - Anatomy & Physiology #Hepatic Duct Systems|bile ducts]].  It results from ascending bacterial infection from the [[Small Intestine Overview - Anatomy & Physiology|small intestines]].  ''[[Escherichia coli]]'', [[:Category:Staphylococcus species|''Staphylococcus spp.'']], ''[[:Category:Streptococcus species|Streptococcus]] spp.'', ''[[:Category:Clostridium species|Clostridium spp.]]'', ''[[Bacillus species|Bacillus spp.]]'', ''[[:Category:Actinomyces|Actinomyces spp.]]'', ''Bacteroides spp'' and occasionally ''[[Salmonella|Salmonella spp.]]'' have been isolated.  Concurrent biliary tract disease are common in cats, especially [[Pancreatitis|pancreatitis]] and [[Inflammatory Bowel Disease|inflammatory bowel disease]].  Other predisposing factors include congenital or acquired abnormalities of the biliary system such as that of anatomic abnormalities of the [[Gall Bladder - Anatomy & Physiology|gall bladder]] or common bile duct, bile duct obstruction caused by inspissated bile, cholelithiasis and cholecystitis.
 ==Signalment==
-More common in cats than in dogs. Cats of all breeds and ages can be affected, but often young to middle-aged cats. Male cats are more at risk.
+More common in cats than in dogs.  Cats of all breeds and ages can be affected, but often young to middle-aged cats.  Male cats are more at risk.
+==Description==
+Neutrophilic cholangiohepatitis is characterised by infiltration of large numbers of neutrophils into portal areas of the liver and into the bile ducts.  It results from ascending bacterial infection from the small intestines.  [[Escherichia coli]], [[Staphylococcus spp.]], ''Streptococcus spp.'', ''Clostridium spp.'', ''Bacillus spp.'', ''Actinomyces spp.'', ''Bacteroides spp.'' and occasionally ''Salmonella spp.'' have been isolated.  Concurrent biliary tract disease are common in cats, especially pancreatitis and inflammatory bowel disease.  Other predisposing factors include congenital or acquired abnormalities of the biliary system such as that of anatomic abnormalities of the gall bladder or common bile duct, bile duct obstruction caused by inspissated bile, cholelithiasis and cholecystitis.
 ==Diagnosis==
-===History and Clinical Signs===
+===Clinical Signs===
-Acute presentation with severe illness in contrast to cats with [[Cholangitis, Lymphocytic|Lymphocytic cholangitis]] who often do not appear ill. Signs include pyrexia, depression, lethargy, abdominal pain, [[Icterus|jaundice]], dehydration ,anorexia and vomiting. If presented whilst the disease is chronic, signs will include episodic anorexia, vomiting, jaundice, weight loss and possibly hepatomegaly or ascites. Many cases will have concurrent [[IBD]].
+Acute presentation with pyrexia, abdominal pain, lethargy, jaundice.
-===Laboratory Tests===
+===Haematology & Biochemistry===
-====Haematology====
+Increased segmented and band neutrophils.
-Mild [[Neutrophilia|neutrophilia]] with left shift
+Increased ALT and total bilirubin concentration
-====Biochemistry====
+===Imaging===
-Increased alanine aminotransferase (ALT), Normally to slightly increased alkaline phosphatase (ALP) and Normal to slightly increased total bilirubin concentration
+A coarse or nodular texture to the liver on ultrasonography.  More chronic cases may have dilation of the biliary tract.
-===Diagnostic Imaging===
+===Cytology and Culture===
-====Ultrasonography====
+Bile samples for cytology is needed for a definitive diagnosis.  Histopathology of the liver alone is not adequate as the disease tend to be confined to the biliary tract and pathology of the liver can be non specific and  mild.  Cytology shows bacteria and neutrophils.  Culture and sensitivity should be performed for appropriate choice of antibiotics.
-A coarse or nodular texture to the liver can be seen.  However, most have variable or no detectable changes in echogenicity of the liver parenchyma.  More chronic cases may have dilation of the biliary tract.
-===Histopathology===
-Liver cytology or tissue biopsy is required to differentiate inflammatory liver disease from [[Hepatic Lipidosis|hepatic lipidosis]] and [[Neoplasia - Pathology|neoplasia]].  Bile samples for cytology is needed for a definitive diagnosis.  It is not adequate to perform liver biopsy alone as the disease tend to be confined to the biliary tract and pathology of the liver can be non specific and  mild.  Cytologically, neutrophilic cholangitis usually shows bacteria and [[Neutrophils|neutrophils]].  Culture and sensitivity should be performed for appropriate choice of antibiotics.
 ==Treatment==
-A long course (4-6 weeks), of an appropriate antibiotic should be given in light of bacterial culture and sensitivity results. Selected antibiotic should be excreted in the bile in active form, and should be active against aerobic and anaerobic intestinal coliforms. [[Penicillins|Amoxicillin]] potentiated with clavulanic acid is a good initial choice. [[Nitroimidazoles|Metronidazole]] may be added to extend the spectrum of anaerobes and coliforms.
+*Long course, 4-6 weeks, of an appropriate antibiotic following culture and sensitivity should be used.  Amoxicillin at 15-20 mg/kg PO q8hours is a good initial choice.
-Surgery is warranted if discrete choleliths or complete biliary obstruction is identified. In cases of complete extrahepatic biliary obstruction, surgical decompression and cholecystoduodenostomy or cholecystojejunostomy should be performed.
+*Ursodeoxycholic acid at 15 mg/kg q24hours may be given due to its choleretic, which promotes increased fluidity of biliary secretions to treat or prevent sludging, and hepatoprotective (anti-inflammatory, immunomodulatory and antifibrotic effects) properties.
-[[Liver Drugs|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.
+*A high protein diet rather than a protein-restricted diet is more appropriate for feeding anorexic cats to prevent the development of hepatic lipidosis
-Aggressive supportive care is required due to severe illness. Fluid and electrolyte derangements should be corrected and Vitamin K1 may be given if bleeding diatheses develop. A high protein diet rather than a protein-restricted diet is more appropriate for feeding anorexic cats to prevent the development of [[Hepatic Lipidosis|hepatic lipidosis]]
-Monitor response to treatment with serial complete haematology and biochemistry.
 ==Prognosis==
-Good prognosis provided the cats are treated early and appropriately.
+Good provided the cats are treated early and appropriately.
-{{Learning
-|literature search = [http://www.cabdirect.org/search.html?q=title%3A%28Cholangitis%29+AND+title%3A%28Neutrophilic%29 Neutrophilic Cholangitis publications]
-}}
-==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''.
-{{review}}
-{{OpenPages}}
-[[Category:Gall_Bladder_and_Tract_-_Pathology]]
-[[Category:Expert Review]]