Bile Peritonitis
Signalment
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Tanner, 6.5 yo MC Cocker Spaniel
History
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1 week history of vomiting (yellow liquid),
diarrhea, anorexia
Has been seen at rDVM for 1 week with inc
ALP, ALT, GGT, T-bili, dec BUN, glucose,
elevated bile acids, fever, inflammatory
leukogram
Has been treated with enrofloxacin,
metronidazole, famotidine and maropitant
Physical Exam Findings
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Abdomen tense and painful (1-2/4) on
palpation
Obese
T: 103.2F P: 132bpm R: 24 br/min
CRT <2sec Wt 17.6kg BCS: 7/9
Clinical Pathology
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CBC: marked leukocytosis (62.51K/uL RR:
4.39-11.61) characterized by a neutrophilia
(51.883K/ul RR: 2.841-9.112) with a
regenerative left shift (1.250K/ul bands)
and monocytosis (8.126K/ul RR: 0.0750.85). Mild microcytic, hypochromic
anemia (Hct = 32.1%). Thrombocytopenia
(150K/uL) with increased MPV. Mild
hypoproteinemia (5.8 g/dL RR: 6.1-7.5).
Clinical Pathology
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Chemistry Panel:
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Markedly elevated ALP (3804 IU/L), mildly
elevated ALT, GGT and T-bili,
hyperphosphatemia, hypocalcemia,
hypomagnesemia, hypoalbuminemia, low normal
glucose, low normal BUN. Electrolytes are within
normal limits.
Clinical Pathology
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Resting Ammonia: Increased at 43 umol/L
(RR: 3-30).
Bile Acids Tolerance: Increased resting
and post-prandial levels (pre = 55.7, post =
71.5 umol/L RR: 25)
Coagulation Profile: High normal PT,
prolonged PTT. D-dimers 500-1000 ng/ml.
Thrombocytopenia.
Liver
Liver
Liver
Hepatic lymph nodes
Hepatic lymph node
Gall bladder
Gall bladder
Gall bladder
Gall bladder
Right Adrenal
Abdominal Ultrasound
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Probable hepatic cirrhosis - no evidence of
portal hypertension
Biliary mucocele
Hepatic lymphomegaly - probable reactive
hyperplasia
Right adrenomegaly - hyperplasia vs.
neoplasia
Abdominal Fluid Analysis
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Highly cellular specimen with large numbers of
inflammatory cells with a pale blue to green
mucinous material that is consistent with bile.
Rare bilirubin crystals noted. Inflammatory cells
consist of 84% slightly degenerate neutrophils
and 16% activated macrophages.
Interpretation/assessment: Bile peritonitis with
marked suppurative inflammation
Bilirubin: 1.5mg/dL (Serum 2.0mg/dL)
Outcome
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Owners elected to euthanize based on the
diagnosis of bile peritonitis
Necropsy: Microhepatica with diffuse
nodules, distended gall bladder with
inspissated brown-green mucoid material
and rupture of the common bile duct, fibrin
at the defect and diffusely throughout
abdomen, bile and inflammation throughout
the mesentery, thoracic lymphadenopathy