Exam 3 - Feline Liver Disease

Question 1

what are the 5 most common hepatic diseases in cats?

Answer 1

1. hepatic lipidosis - > 50% of feline hepatic disease
2. feline cholangitis syndrome - 25% of feline hepatic disease
3. lymphosarcoma
4. feline infectious peritonitis
5. reaction to a drug or toxin

Question 2

how do you differentiate hepatocellular disease from biliary tract obstruction in a cat?

Answer 2

abdominal ultrasound

Question 3

what is the classic history of a cat with hepatic lipidosis?

Answer 3

obese cat that stops eating & then becomes icteric

Question 4

what is the pathophysiology of hepatic lipidosis in cats?

Answer 4

cat stops eating - starvation causes lipidosis by causing body fat to be mobilized

too much fat is mobilized, so there is more fat entering the hepatocytes than there is exiting & at the same time the fat is being broken down, less protein is being taken into the body due to anorexia

fat can’t get out of the liver because there is no protein to form lipoproteins

Question 5

why are obese cats more at risk for hepatic lipidosis?

Answer 5

these cats can mobilize large amounts of fat very quickly

Question 6

why is hepatic lipidosis a positive feedback loop?

Answer 6

cat can get sick from any cause & become anorexic

cat breaks down fat while simultaneously becoming deficient in protein

fat builds up in the liver & hepatic cytoplasm is replaced with fat

hepatic insufficiency develops & this hepatic disease causes anorexia

Question 7

what are the classic clin path findings seen in hepatic lipidosis cats?

Answer 7

hyperbilirubinemia, increased ALP despite normal ALT

Question 8

what further diagnostics are needed for a cat with a high ALP, hyperbilirubinemia, normal ALT, & normal GGT? why?

Answer 8

liver biopsy

FNA can easily miss other infiltrative hepatic diseases that could cause lipidosis - if an FNA only detects mild to modest amounts of fat in hepatocytes of a seriously ill cat/cat fails to respond to treatment

consider a more substantial liver biopsy

Question 9

what treatment is absolutely necessary for a cat with hepatic lipidosis?

Answer 9

feeding tube!!!!! high protein/high energy dense diet & monitor for refeeding syndrome

appetite stimulants - can help prevent lipidosis but are poorly effective in patients with established clinical lipidosis

IV fluids - may have to supplement potassium & phosphorus

vitamin K

SAMe, vitamin E

Question 10

what is the prognosis of hepatic lipidosis in cats?

Answer 10

20-30% mortality depending upon how sick the animal is upon admission

Question 11

what are the two types of feline cholangitis syndrome?

Answer 11

due to ascending infection - neutrophilic cholangitis

immune-mediated disease - lymphocytic cholangitis

Question 12

what are the classic clin path findings seen in feline cholangitis syndrome?

Answer 12

increased ALT, ALP, & bilirubin

finding a major increase in ALT is classic for cholangitis but isn’t reliable for distinguishing cholangitis from lipidosis however increased GGT is more common in cholangitis

Question 13

how do you make a definitive diagnosis for feline cholangitis syndrome?

Answer 13

usually need a hepatic biopsy & culture/cytology on bile

Question 14

what supportive therapy is used for treating both types of feline cholangitis syndrome patients?

Answer 14

ursodeoxycholic acid, vitamin E, & SAMe

Question 15

what treatment is indicated for neutrophilic cholangitis in cats?

Answer 15

ANTIBIOTICS!!!! amoxicillin, ampicillin, cefazolin, cefadroxil, or enrofloxacin

need to use something that kills both aerobes & anaerobes

Question 16

what treatment is indicated for lymphocytic cholangitis in cats?

Answer 16

prednisolone at 1-2 mg/kg/day, ursodeoxycholic acid, & SAMe - don’t send home too many meds

chlorambucil may be useful in cats that don’t respond to pred

NO AZATHIOPRINE!!!

Question 17

what drugs are known to be hepatotoxic to cats?

Answer 17

azathioprine

oral diazepam

aspirin

voriconazole

acetaminophen

Question 18

what causes FIP?

Answer 18

mutated feline coronavirus

Question 19

what clinical signs are seen in cats with FIP?

Answer 19

fever, CNS signs, ocular lesions

Question 20

how is FIP diagnosed?

Answer 20

history, physical exam, hyperglobulinemia, thrombocytopenia, may see ALT/ALP, & may see jaundice

Question 21

T/F: cats with FIP always have effusions

Answer 21

false

Question 22

what disease is a major cause of CNS signs in cats under 5-8 years of age?

Answer 22

feline infectious peritonitis

Question 23

_________ lesions, especially uveitis, can be suggestive of FIP

Answer 23

ocular

Question 24

T/F: FeLV status is not useful in diagnosing or eliminating lymphoma in cats

Answer 24

true

Question 25

what lab abnormalities may be seen in a cat with hepatic lymphoma?

Answer 25

normal or increased ALT and/or ALP

Question 26

what are some pre-hepatic causes of icterus in cats?

Answer 26

causing hemolysis secondary IMHA - mycoplasma, FeLV, cytauxzoon, lymphoma primary IMHA - uncommon non-immune mediated - heinz bodies, hypophosphatemia

Question 27

what pathology is seen on this blood smear?

Answer 27

heinz bodies

Question 28

what are some hepatic causes of icterus in cats?

Answer 28

cholangitis hepatic lipidosis neoplasia - lymphoma, biliary carcinoma, biliary cystadenoma FIP toxins - acetaminophen, diazepam, phenols, & tetracycline

Question 29

what are 6 examples of post-hepatic causes of icterus in cats?

Answer 29

1. cholecystitis 2. pancreatitis 3. biliary carcinoma/cystadenoma 4. liver flukes 5. biliary rupture 6. cholelithiasis

Question 30

what are the 4 most common causes of icterus in cats?

Answer 30

1. feline hepatic lipidosis 2. cholangitis 3. hemolytic anemia 4. feline infectious peritonitis

Question 31

what is the first question you should consider when presented with an icteric cat?

Answer 31

is the cat anemic or not!

Question 32

is there a steroid induced ALP in the cat?

Answer 32

no

Question 33

are minor increases in ALP/ALT in cats clinically significant?

Answer 33

YES!!! the magnitude of liver enzyme increases in cats is less than dogs & extrahepatic disease can cause secondary increases in ALT/ALP activity

Question 34

what 4 body organs/systems are you checking for abnormalities in an abdominal ultrasound in an icteric cat?

Answer 34

1. hepatobiliary 2. pancreatic 3. gastric 4. intestinal

Question 35

what happens when there is triglyceride accumulation in the liver of cats?

Answer 35

intrahepatic cholestasis icterus vitamin K deficiency

Question 36

what are the risk factors for hepatic lipidosis?

Answer 36

obese cats periods of anorexia - protein/calorie malnutrition underlying disease

Question 37

what is the most common underlying disease in cats with hepatic lipidosis?

Answer 37

IBD

Question 38

what is the typical signalment of cats with hepatic lipidosis?

Answer 38

middle aged cats no breed or sex predilection

Question 39

what is the minimum age of cats with hepatic lipidosis? median? max?

Answer 39

minimum - 6 months median - 7 years old max - 20 years old

Question 40

what signs are seen on physical exam of cats with hepatic lipidosis?

Answer 40

icterus - 70% of cats overweight/obese cats weakness - cervical ventroflexion & plantigrade stance ptyalism rare - signs of hepatic encephalopathy vomiting/diarrhea

Question 41

what may be seen on urinalysis of a cat with hepatic lpidosis?

Answer 41

bilirubinuria lipiduria

Question 42

what is seen on hematology of a cat with hepatic lipidosis?

Answer 42

non-regenerative anemia - heinz bodies & poikilocytosis mild lymphopenia & neutrophilia inflammatory leukogram suggests that there is an underlying inflammatory disorder

Question 43

what is seen on abdominal ultrasound of a cat with hepatic lipidosis?

Answer 43

enlarged hyperechoic liver changes can occur in obese or diabetic cats useful for diagnosing underlying diseases

Question 44

how is a presumptive diagnosis made for hepatic lipidosis?

Answer 44

FNA showing lipid type vacuolation of the liver alongside clinical signs, lab tests, & imaging

Question 45

what is required to make a definitive diagnosis of hepatic lipidosis in cats?

Answer 45

biopsy for histology!

Question 46

what electrolytes are you worried about in a cat with hepatic lipidosis?

Answer 46

hypokalemia - can lead to muscle weakness hypophosphatemia - can lead to hemolysis hypomagnesemia - can lead to muscle weakness

Question 47

what makes up the initial supportive care for a cat with hepatic lipidosis?

Answer 47

IV fluids - account for dehydration, ongoing loss, & maintenance requirements electrolyte correction vitamin K n-acetylecysteine anti-emetics - maropitant or ondansetron

Question 48

what is the maintenance fluid rate used for cats in this class?

Answer 48

40 ml/kg/day

Question 49

what is Kmax?

Answer 49

0.5 mEq/kg/hr

Question 50

how is nutrition approached in cats with hepatic lipidosis?

Answer 50

correction of protein is crucial!!! it is the most important of the macronutrients - feed a calorie dense food aim to feed 30-40% of metabolizable energy as protein give vitamin K first & place a feeding tube - need to avoid syringe feeding

Question 51

why give a cat with hepatic lipidosis antioxidants?

Answer 51

oxidative damage plays an important role in feline hepatic lipidosis - beneficial

Question 52

how is cobalamin supplemented for cats with hepatic lipidosis?

Answer 52

given when serum levels are <400 ng/L give cyanocobalamin - 250 ug SQ once weekly for 6 weeks & then once monthly also can be used as an appetite stimulant

Question 53

why is l-carnitine used for cats with hepatic lipidosis?

Answer 53

shuttles the fatty acids to the mitochondrial matrix & increases hepatic utilization of fatty acids during weight loss 250 mg/cat PO every 24 hours

Question 54

what are some negative prognostic factors for cats with hepatic lipidosis?

Answer 54

anemia, hypokalemia, & incurable underlying disease

Question 55

T/F: cats can make a complete recovery with early & aggressive treatment

Answer 55

true

Question 56

what is feline cholangitis? what are the 3 types seen clinically?

Answer 56

inflammation centered around the biliary tract with expansion into the parenchyma 1. neutrophilic 2. lymphocytic 3. liver-fluke associated

Question 57

why do we believe cats to be more sensitive to developing cholangitis/pancreatitis?

Answer 57

they have a shared duct between the pancreatic duct & bile duct entering the duodenum

Question 58

what clinical signs are associated with neutrophilic cholangitis?

Answer 58

acute onset of illness - pyrexia, anorexia, vomiting, icterus

Question 59

what clinical signs are associated with lymphocytic cholangitis?

Answer 59

chronic signs - lethargy/hyporexia that can wax & wane or be progressive

Question 60

what signs are seen upon physical exam of a cat with cholangitis?

Answer 60

dehydration, icterus, pyrexia, cranial abdominal pain, & emaciation

Question 61

what clin path abnormalities are seen in cats with cholangitis?

Answer 61

increased liver enzymes hyperbilirubinemia hyperglobulinemia hypoalbuminemia

Question 62

what is seen on hematology that is supportive of cholangitis in a cat?

Answer 62

neutrophilia - +/- a left shift, but less common with lymphocytic cholangitis non-regenerative anemia thrombocytopenia

Question 63

what is seen on abdominal ultrasound of a cat with cholangitis?

Answer 63

findings consistent with inflammatory disease hepatomegaly, bile duct dilation, & choleliths

Question 64

how is a cholecystocentesis done?

Answer 64

use a right-sided transhepatic approach - get an FNA of the bile & look for the presence of bacteria & neutrophilic inflammation

Question 65

what are some examples of different ways a liver biopsy can be performed?

Answer 65

needle biopsy laparotomy laparoscopy

Question 66

how long do you treat a cat with antimicrobials for neutrophilic cholangitis?

Answer 66

4-6 weeks

Question 67

what do you do for treatment if you have a cat with neutrophilic cholangitis that has a negative culture & doesn't respond to antibiotics?

Answer 67

prednisolone!!!

Question 68

what is triaditis?

Answer 68

syndrome encompassing concurrent inflammation of the liver, pancreas, & small intestines

Question 69

how is RER calculated?

Answer 69

(30 X BWkg) + 70 70 X (body weight in kg ^0.75)

Question 70

how is a feeding plan used for a cat with hepatic disease?

Answer 70

only feed 25% of RER on the first day & increase to 100% over 3-4 days dividing the daily ration into 4 meals fed over 10-15 minutes

Question 71

T/F: cats commonly get combinations of chronic enteropathy, pancreatitis, & inflammatory liver disease

Answer 71

true

Question 72

T/F: failure of a cat to respond well to prednisolone does not rule out small cell lymphoma

Answer 72

true