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Show all small animal articles

Cholangitis Complex in the Cat

Professor Danielle Gunn-Moore BSc BVM&S PhD FHEA MACVSc MRCVS RCVS Specialist in Feline Medicine - 06/03/2014

Cholangitis Complex In The Cat

Pathogenesis

anatomy of the feline liver, intestine and pancreasThe pathogenesis and interaction of lymphocytic and neutrophilic cholangitis is poorly understood. Both forms can be associated with Inflammatory Bowel Disease (IBD) and/or pancreatitis.  This is because, in the cat, the accessory pancreatic duct is small or, in most cases, absent and the pancreatic duct joins up with the common bile duct, entering the intestines at the sphincter of Oddi (see figure 1).  It is therefore very easy for infection and inflammation to spread and affect all three organs.  This is commonly termed “Triaditis”.

Figure 1: Anatomy of the liver, intestines and pancreas in the cat

Clinical Signs

Neutrophilic cholangitis can affect cats of any age. Acute disease results in fever, anorexia, vomiting, lethargy and jaundice (see figure 2) with or without abdominal pain. Chronic disease causes episodic anorexia, vomiting, weight loss and jaundice with or without hepatomegaly or ascites. Acute disease may progress to chronic disease and/or secondary hepatic lipidosis: ~80% of cases have concurrent IBD, ~50% have pancreatitis.

conjunctival jaundice in a cat with liver diseaseLymphocytic cholangitis typically affects young to middle-aged cats: Persians may be predisposed. Signs are usually chronic and insidious: jaundice but appearing well, often polyphagic, some show weight loss, anorexia and vomiting with or without diarrhoea; most have an enlarged liver and they may have generalized lymphadenopathy. This can progress to chronic biliary cirrhosis with ascites. Both forms can result in hepatic encephalopathy, ascites and bleeding tendencies.


Figure 2 :  Conjunctival jaundice in a cat with liver disease

 Diagnosis

Diagnostic tests include:

  • Serum biochemistry (increased liver enzymes, bile acids, bilirubin, and globulins; decreased albumin)
  • Haematology (mild anaemia, lymphopenia or lymphocytosis, monocytosis, ± thrombocytopenia)
  • Prolonged clotting
  • Ascitic fluid is typically high in protein
  • Ultrasound examination: blotchy hepatic hyperechogenicity, biliary tree distension and irregularity (see figure 3), 'sludging' of bile, a thickened gall bladder wall ± common bile duct obstruction; enlarged mesenteric lymph nodes, pancreatic irregularity, ± thickening of duodenal walls (the latter changes are associated with concurrent pancreatitis)

Definitive diagnosis requires liver biopsy: fine-needle aspirate is rarely diagnostic. Blood clotting times and/or PIVKA (proteins induced by vitamin K antagonism or absence) test should be assessed first, plus a platelet count!! Typical gross findings are a friable/firm irregular liver, thickened/distended gallbladder and common bile duct, inspissated bile; enlarged mesenteric lymph nodes, pancreatic irregularity, with or without thickening of the duodenal walls

  • Exploratory laparotomy: check for patency of biliary outflow, and collect biopsy specimens from liver, mesenteric lymph nodes, small intestines and pancreas for histopathological evaluation and send bile and liver for culture

ultrasound demonstrating a tortuous common bile duct
Figure 3: Ultrasound demonstrating a tortuous common bile duct

Treatment

Treatment is largely empirical. Immediately following biopsy, administer analgesics (e.g. buprenorphine), intravenous fluids (add potassium), feeding (may need tube feeding), antiemetics and antibiotics. Antibiotics (with neutrophilic cholangitis) should ideally be selected by culture and sensitivity of bile and/or liver samples. Ampicillin, amoxicillin/clavulanate, cephalexin and marbofloxacin (all well concentrated in bile) may be appropriate; add low-dose metronidazole if needed. One to three months of treatment may be required.

Immunosuppressive agents are used for chronic neutrophilic cholangitis and lymphocytic cholangitis: immunosuppressive doses of corticosteroids may be needed, but reduced for long-term treatment. Also consider methotrexate, chlorambucil or cyclosporin A, but all are potentially hepatotoxic.

Supportive measures for all forms of cholangitis include:

  • SAMe (antioxidant and detoxifying)
    • converted into glutathione, an important liver antioxidant that is reduced in 75% of cats with liver disease
  • Vitamin E – liver antioxidant
  • Silybin (milk thistle) – converted into the liver antioxidant superoxide dismutase
  • Ursodeoxycholic acid (aids bile flow and is antiinflammatory)
  • Metoclopramide (antiemetic/ prokinetic)
    • low dose constant rate infusion useful in hospitalised patients
    • for homecare administer by mouth 30 minutes before a meal
  • Ranitidine/famotidine (antacid)
  • Colchicine (antifibrotic)
    • can use if fibrosis is severe but not a benign treatment
  • B-vitamins (B12, B1 and B complex)
    • vitamin B12 deficiency can occur rapidly with anorexia and can cause further anorexia.  Administering a vitamin  B12 injection may therefore help to stimulate appetite
  • Vitamin C
  • L-carnitine
  • Liver support diets
    • High quality protein, extra potassium, not too high in fat

Altered haemostasis is seen in >80% of cats with liver disease.  This is because the liver is responsible for the manufacture of most clotting factors.  In addition, vitamin K levels are low in 50% of cats with liver disease.  This is because:

  • Anorexia is common, so cats take in less vitamin K from the diet
  • Reduced bile flow results in a reduction in the absorption of fat soluble vitamin K

Treatment is with vitamin Kand correction of cholestasis.  In the acute phase, higher dose of SC vitamin K may be needed and, if the liver disease is very severe, fresh whole blood or plasma transfusions may be indicated.  In the chronic situation, low grade oral supplementation of vitamin K can also be useful.

Surgery may be required where complete biliary obstruction occurs. Associated conditions should also be addressed, e.g., IBD, pancreatitis, extrahepatic bile duct obstruction or cholecystitis.

Prognosis

This is variable and unpredictable. Once severe fibrosis, cirrhosis or ascites develop prognosis is guarded.

HEPATOSYL® PLUS helps to maintain liver function and contains four key ingredients:

  • SAMe
  • Vitamin E
  • Silybin
  • Vitamin K
    If you would like to find out more about Hepatosyl® Plus, please contact CEVA Animal Health on (01494) 781510 or e-mail fraser.broadfoot@ceva.com.

Please note this article was first published in November 2010

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