Cholangitis, Neutrophilic

Also known as: Exudative Cholangitis — Cholangiohepatitis —Suppurative Cholangitis

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.

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.

Diagnosis

History and Clinical Signs

Acute presentation with severe illness in contrast to cats with Lymphocytic cholangitis who often do not appear ill. Signs include pyrexia, depression, lethargy, abdominal pain, 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.

Laboratory Tests

Haematology

Mild neutrophilia with left shift

Biochemistry

Increased alanine aminotransferase (ALT), Normally to slightly increased alkaline phosphatase (ALP) and Normal to slightly increased total bilirubin concentration

Diagnostic Imaging

Ultrasonography

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 and 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. 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. Amoxicillin potentiated with clavulanic acid is a good initial choice. Metronidazole may be added to extend the spectrum of anaerobes and coliforms. 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 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. 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 Monitor response to treatment with serial complete haematology and biochemistry.

Prognosis

Good prognosis provided the cats are treated early and appropriately.

Literature Search

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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.