Cholangitis, Lymphocytic

Also known as lymphocytic-plasmacytic cholangitis or cholangiohepatitis, lymphocytic portal hepatitis and non-suppurative cholangitis or cholangiohepatitis.

Signalment

Young to middle-aged cats, 50% under 4 years old.

Description

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 Neutrophilic Cholangitis

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 Neutrophilic Cholangitis.
• Some cats in the UK are polyphagic and are frequently presented with ascites and/or jaundice.

Laboratory Tests

Haematology

• Neutrophilia is less common than with Neutrophilic Cholangitis

Biochemistry

• Increased alkaline phosphatase (ALP)
• Increased alanine aminotransferase (ALT)
• Hyperbilirubinaemia
• Hyperglobulinaemia

Imaging

• Radiographic signs non specific. Hepatomegaly due to enlargement of biliary ducts and in some cases ascites is also seen.
• Ultrasonography is more helpful. Biliary tract dilation can be seen in all cases. Common bile duct is normally dilated and the gallbladder 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 Neutrophilic Cholangitis needs to be ruled out.

Treatment

• Immunosuppressives
  • Glucocorticoid at initial immunosuppressive dose of 2-4 mg/kg q24 hours 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 at 15 mg/kg q24 hours PO may be given.
  • 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.
• Antioxidants such as S-adenosylmethionine at 20 mg/kg and vitamin E at 100 IU/day.
  • These are used 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.

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.