TREATMENT OF THE YELLOW CAT!

Transcription

1 GARRET PACHTINGER, VMD, DACVECC TREATMENT OF THE YELLOW CAT! INTRODUCTION Garret Pachtinger, VMD, DACVECC COO, VetGirl INTRODUCTION NAVC THANK YOU! Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl NAVC THANK YOU! CE CERTIFICATES! ed to you 48 hours after the webinar! Active participation = no quiz! Watching video later, must complete quiz! / contact with ANY questions! garret@vetgirlontherun.com! justine@vetgirlontherun.com 1

2 CASE PRESENTATION - Fluffy, 4yo MC DSH - Arrives with the PC: - Decreased appetite for 1 week - Anorexic for 2 days now - Lethargic - Vomiting x 2 days - Urinating but not defecating for past 4 days - Strictly indoor cat - UTD on vaccines CASE PRESENTATION - Physical Examination - Previously 14 pounds, today 8 pounds - QAR - BCS 3/9 - Mm pale-pink, tacky, CRT 1.5 seconds - Moderate dental calculus / mild gingivitis, - Yellow tint soft palate - Slightly sunken eyes - HR=180, RR=40, T=38C (101.5F) - Thoracic auscultation NSF - Abdominal palpation - Doughy abdomen - Moderate sized bladder - Cranial organomegaly PROBLEM LIST - Inappetence/anorexia - Weight loss - Icterus - Dehydration - Dental disease - Cranial organomegaly - Lethargy / depression - Vomiting - Decreased fecal production DIFFERENTIALS - Hepatic Lipidosis-primary vs. secondary - Cholangiohepatitis - Cholangitis - Cholecystitis - Toxic hepatopathy - Extra-hepatic bile duct obstruction - Intussusception - Gastroenteritis - GI foreign body - Pancreatitis - Pancreatic cyst or abscess - Cholelithiasis - Neoplasia - Diabetic ketoacidosis - FeLV/FIV/FIP - Anything that may cause hemolysis 175 CASES CSU 175 CASES CSU Histologic diagnosis Percent Hepatic Lipidosis 26% Cholangitis 25% Neoplasia 20% Reactive hepatopathies 16% Vascular anomalies 4% Toxic hepatopathies 5% Cystic lesions 2% Miscellaneous 2% 2

3 1/26/14 Introduction - Intrahepatic cholestatic process - Association with prolonged anorexia and catabolism. - Most affected cats are: - Median age 7 years - DSHA - Obese or overweight. Hepatic Lipidosis - Introduction " Feline Hepatic Lipidosis can occur as either a primary idiopathic disease syndrome or secondary to another disease process examples include " Pancreatitis " Small intestinal diseases " Renal disease or Neoplasia. PRESENTING COMPLAINT 2 Clinical signs and Testing - Inappetence - Weight loss - Vomiting - Diarrhea lethargy. - Less commonly more serious illness hepatic encephalopathy or weakness as a result of hypokalemia. HEPATIC LIPIDOSIS PHYSICAL PE FINDINGS EXAMINATION PHYSICAL CBC FINDINGS EXAMINATION - Nonregenerative anemia - Stress leukogram. A Clinically astute clinician should be able to see icterus when the bilirubin level is greater than 1mg/dl 3

4 /26/14 BIOCHEMISTRY PANEL BIOCHEMISTRY PANEL Serum biochemical changes primarily reflect cholestasis. HYPO / HYPERGLYCEMIA Hypoglycemia is uncommon, as more than 70% of the functional liver mass must be lost before hypoglycemia ensues. In contrast, hyperglycemia is present in about 50% of cases due to either a stress hyperglycemia or the underlying disease process, a primary example being diabetes mellitus. ELECTROLYTE PANEL Important electrolytes to assess include: - Potassium - Phosphorus - Magnesium. BLOOD GAS EVALUATION Common venous blood gas abnormalities include: - Metabolic acidosis - Ketones - Lactate Evaluation of Prothrombin time (PT) and Partial Thromboplastin Time (PTT) is an essential part of the diagnostic evaluation in feline hepatic lipidosis 4

5 /26/14 NORMAL ULTRASOUND An abdominal ultrasound allows a non-invasive evaluation of the abdominal organs, notably the liver, pancreas, stomach, small intestine, large intestine, spleen, and kidneys. ABNORMAL ULTRASOUND With hepatic lipidosis, the liver is characteristically large (hepatomegaly) with diffuse hyperechoic parenchyma, hyperechoic to the falciform fat and renal cortex, and isoechoic to the spleen. Abnormal Normal ABNORMAL ULTRASOUND Additional concerning findings on ultrasound include: - Pancreatitis - Triaditis - Biliary disease - Inflammatory bowel disease. Triaditis is a term referring to inflammatory diseases involving three specific organs, namely the liver, pancreas and small intestine. A wavy, spastic appearance of the duodenum, thought to be secondary to pancreatitis SAMPLING? CONFIRMATION? Liver aspirates may also be considered for a presumptive diagnosis of hepatic lipidosis. The expected cytological finding is hepatocellular lipid vacuolation 3 TREATMENT WAYS TO MAKE A HEPATIC LIPIDOSIS CASE BECOME A SUCCESSFUL CASE! 5

6 %3AArticle&mid=8F3A F18BE895F87F791&tier=4&id=28126F6EF06E40C18C2E6BFB7F57B465&AudID=43A035C1ADDF4F5F823E087E3BEE4975 1/26/14 FEEDING OPTIONS? FORCED FEEDING PHYSICAL FEEDING EXAMINATION TUBE! For this reason, adequate nutritional support often involves the use of a large bore feeding tube, nasoesophageal (NE) tube, esophageal tube (E- Tube) or Gastrostomy tube (G-Tube). NASOESOPHAGEAL TUBE NE TUBE PLACEMENT However, when the patient is not stable enough for the placement of an E-tube, initial feeding via a NE- tube is an accepted alternative. - Risk of anesthesia? - Coagulopathy? - Nausea / Trickle feeding? A NE-tube is inexpensive and does not require anesthesia in most cases. 6

7 E-TUBE PLACEMENT E-TUBE PLACEMENT - PROCEDURE E-TUBE PLACEMENT E-TUBE PLACEMENT E-TUBE PLACEMENT E-TUBE PLACEMENT CHECK Following the placement of any feeding tube (NE tube, E-Tube, or G- Tube) a radiograph is recommended to confirm placement. Securing the E-Tube is imperative. While traditionally, gauze and Vet Wrap TM has been used The Kitty Kollar ( has been used with success. This is a washable, fabric collar designed to wear in conjunction with an esophageal feeding tube. 7

8 1/26/14 RER = RESTING ENERGY REQUIREMENT Common formulas used to calculate the RER for a feline patient: 1) RER = 70 x (current bodyweight in kilograms) 0.75 (for > 5 kg) 2) RER = 30 x BW kg +70 (for < 5 kg) 3) RER = 60kcal x BW kg Example: 5kg cat 30 x BW kg +70 (30 x 5) KCal / 24 hours RER PHYSICAL CALCULATION EXAMINATION EXAMPLE For example: a cat that has a 5kg ideal body weight: 5kg cat = 220Kcal over a 24 hour period. Day 1 RER = 220kcal * 25% = 55kcal total, or approximately 14kcal every 6 hours. Day 2 RER = 220kcal * 50% = 110kcal total, or approximately 28kcal every 6 hours. Day 3 RER = 220kcal * 100% = 220kcal total, or approximately 55kcal every 6 hours. Diet Choices FLUID THERAPY We commonly use Hill s A/D. Undiluted Hill s A/D contains 1.2 Kcal per ml. 1 can + 50ml of water = 1.0 KCal per ml + better consistency Essential for: - Rehydration - Maintenance - Correction of electrolyte abnormalities A balanced electrolyte solution is recommended ELECTROLYTE MONITORING ELECTROLYTE SUPPORT PHOSPHORUS PHYSICSAL / EXAMTION MAGNESIUM Supplementation is indicated at PO4 levels less than 2mEq/l. Kphos can be supplemented at 0.01 to 0.12 mmol/ kg/hr IV for 6 hours and PO4 level reassessed. Magnesium is supplemented with magnesium sulfate at 1mEq/kg/day. 8

9 POTASSIUM SUPPLEMENTATION ADDITIONAL THERAPY Serum K+ K+/Liter fluids (meq/l) > Key Drug Dose Range Frequency Route Dolasetron mg/kg Q hrs IV, SQ Famotidine mg/kg Q hrs PO, IV Ondasetron mg/kg Q 8-24 hrs IV, SQ Vitamin K1 1-5mg/kg Q 24 hrs SQ < **Kmax 0.5 meq/kg/hr ANTIBIOTICS DRUGS / MEDICATIONS TO AVOID - Primary? - Secondary?. - Stanozolol (a 17-alpha alkylated steroid) - Tetracyclines; drugs imposing oxidative challenge - Propylene glycol carrier in diazepam and etomidate - Sedatives requiring glucuronidation (diazepam, oxazepam) - Drugs associated with idiopathic hepatic necrosis (benzodiazepines, cyproheptadine). FELINE INFLAMMATORY LIVER DISEASE (CHOLANGITIS) # Inflammatory disorder of the hepatobiliary system. # Disease complex that may be concurrently associated with # Duodenitis # Pancreatitis # Cholecystitis # Cholelithiasis. # Three histological groups # Neutrophilic cholangitis # Lymphocytic cholangitis # Cholangitis ass. with liver flukes. 9

10 NEUTROPHILIC CHOLANGITIS DIAGNOSIS # Acute, neutrophilic - neutrophilic or suppurative # Chronic - inflammatory pattern - neutrophils, lymphocytes and plasma cells # ALT and ALP are increased but variable # Cats are frequently icteric # Ultrasound to rule out: # Pancreatitis # Biliary obstruction # Histopathology to confirm the diagnosis # Liver should always be cultured NEUTROPHILIC CHOLANGITIS THERAPY # Fluid and electrolyte therapy as needed # Antibiotics # Ampicillin / Ampicillin-clavulanic acid # Treated for at least 1 month # Ursodeoxycholic acid (Actigall mg/kg/day) # Buprenorphine (pain?). # Infection ruled out? Lack of response? # munosuppressive therapy # Prednisolone at 2 4 mg/kg daily # Tapering over 6 to 8 weeks LYMPHOCYTIC CHOLANGITIS FELINE TRIADITIS # Represent a later stage of neutrophilic cholangitis or a separate disease entity # Moderate to marked infiltration of the portal areas by small lymphocytes ± biliary hyperplasia, portal or periductal fibrosis, or bridging fibrosis. # Diseases associated: # IBD / pancreatitis. # Cholangitis-cholangiohepatitis, chronic pancreatitis and duodenitis. # Common bile duct and pancreatic ducts join a common channel before they enter the duodenum # Some of these cats also have lymphocytic, plasmacytic infiltrates within the duodenum (IBD) # Often associated with chronic, intermittent vomiting, lethargy, and anorexia. TOXIC HEPATOPATHY HEPATIC NEOPLASIA # Limited hepatic glucuronide transferase activity. # Relatively uncommon due to picky nature # Idiosyncratic reactions? # Drugs: # Acetaminophen, acetylsalicylic acid, megesterol, ketoconazole, phenazopyridine, tetracycline, oral diazepam, and griseofulvin. # Environmental toxins # Pine oil, isopropanol, inorganic arsenicals, thallium, zinc phosphide, white phosphorus, amanita phalloides, aflatoxin, phenols can also contribute to liver pathology. # Primary neoplasms uncommon. # Cholangiocellular carcinoma and hepatocellular carcinoma # Metastatic neoplastic causes are more common # Lymphoma, systemic mast cell disease, hemangiosarcoma, and myeloproliferative disorders. # Clinical signs are non-specific # Imaging studies (radiography, ultrasonography 10

11 EXTRA-HEPATIC BILE DUCT OBSTRUCTION # Pathogenesis # Extra-hepatic cholangitis, malignancy, pancreatitis, cholelithiasis # Progressive cholangitis accounts for over 50% # Marked persistent hyperbilirubinemia # Marked elevations in ALT, AST, ALP, GGT # Ultrasound!!! # Exploratory laparotomy and biliary decompression. Summary Prognosis for feline liver diseases is fair to good. Many of our patients respond dramatically to therapy Specifically regarding hepatic lipidosis, the prognosis is good. The earlier they are treated, the higher the recovery rate which is why I do not delay nutrition Most owners are able to manage the esophagostomy tubes well at home Don t give up on these patients! QUESTIONS? GARRET PACHTINGER, VMD, DACVECC GARRET@VETGIRLONTHERUN.COM JUSTINE LEE, VMD, DACVECC, DABT JUSTINE@VETGIRLONTHERUN.COM 11