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1 Introduction Garret Pachtinger, VMD, DACVECC Emergency evaluation and management of the icteric canine patient COO, VETgirl Dr. Garret Pachtinger, DACVECC Co-Founder, VETgirl Introduction Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl VETgirl On-The-Run The tech-savvy way to get online veterinary CE! A subscription-based podcast and webinar service offering veterinary RACE-approved CE VETgirl ELITE Up to 5 members: $599/year Up to 10 members: $999/year podcasts/year plus 30+ hours of webinars! $199/year 40+ hours of RACE-CE > 10 members: Ping us 1

2 Video Archives! New and improved video! Download our itunes podcasts free! Social media and our blog! Logistics: CE Certificates n n n n n Type in questions ed to you 48 hours after the webinar Active participation = no quiz Watching video later, must complete quiz n ELITE members only / contact with ANY questions n garret@vetgirlontherun.com n justine@vetgirlontherun.com 2

3 Introduction Jaundice, also known as icterus Yellowish or greenish pigmentation Due to high bilirubin levels Clinical Approach to Icterus The key question that must be answered when evaluating an emergency patient: Are they truly icteric? Clinical Approach to Icterus The key question that must be answered when evaluating an emergency patient: Why are they icteric. Clinical Approach to Icterus 2 general ways I try to break down WHY they are icteric. Clinical Approach to Icterus NUMBER 1: Prehepatic Hepatic Posthepatic Clinical Approach to Icterus NUMBER 2: Excessive bilirubin production Impaired hepatic uptake/conjugation Decreased excretion 3

4 Clinical Approach to Icterus Putting these 2 together: Excessive bilirubin production (pre-hepatic) Impaired hepatic uptake/conjugation (hepatic) Decreased excretion (post-hepatic) Icterus - Prehepatic Hemoglobin in red cells is the principle source of bilirubin Red cells are destroyed rapidly typically in an extravascular location Associated with moderate-marked anemia. IMHA Icterus - Prehepatic Icterus - Hepatic Canine Autoimmune hemolytic anemia Transfusion reactions Babesia and Haemobartonella Drug reactions Chemical ingestion Neoplastic Enzyme or membrane defects Feline Haemobartonella Babesia Toxins: methylene blue and acetaminophen Immune mediated disease FeLV Liver function is compromised No longer able to clear the normal daily bilirubin load. May be seen with both acute and chronic conditions Quite a long differential list Icterus Hepatic - Acute Hepatotoxins Xylitol Prescribed medications (e.g., idiosyncratic valium toxicity in cats, paracetamol) Biotoxins (e.g., aflatoxins, blue-green algae) Heavy metals (e.g., zinc, iron). Infectious disease (e.g., leptospirosis) Inflammatory disease (e.g., hepatitis) Infiltrative hepatic neoplasia such as lymphoma. Icterus Hepatic - Chronic Chronic but acute deterioration History of compatible clinical signs PU/PD Weight loss Inappetence Vomiting Possibly abdominal distension) 4

5 Icterus Posthepatic Biliary system is unable to excrete it via the GI tract. Biliary obstruction (e.g., severe pancreatitis) or biliary system rupture. Icterus Patient Signalment Establish some level of probability for many of the DDX Age? Breed? Acute? Chronic? Intact? Neutered or spayed? Icterus Patient Examination Systematic approach Examination of the mouth and pharynx Lymph nodes carefully palpated Fever? Abdominal pain? Organomegaly? Fluid wave? Rectal examination? Icterus Initial Diagnostics IVC (?) PCV and TS Blood glucose Azo / BUN Pull blood to hold Simple Tools Icterus Other Initial Diagnostics CBC/Chemistry UA (avoid cysto?) Urine culture hold PT/PTT 5

6 Icterus Other Available Tools FAST Ultrasound FAST 3 Ultrasound Origin of Focused Assessment with Sonography for Trauma exam Triage, Tracking, and Trauma FAST 3 Ultrasound Diaphragmatico-Hepatic (DH) Spleno-Renal (SR) Cysto-Colic (CC) Hepato-Renal or (HR) Save NO Shave Preferred position RIGHT lateral recumbency PC: Orange urine x 4 days Vomiting and anorexia x 2 days Urinalysis at the PDVM showed bilirubin Referred to the specialty hospital for further evaluation - T 102.7º F - P R 30 - Muzzled - Icteric Sclera 6

7 IVC MDB PCV TS BG AZO/BUN Tells you all you need to know in < 3 minutes! PCV 41%/TS 7.8 g/dl Icteric serum Blood glucose 142 mg/dl BUN 5-15 mg/dl 7

8 Major Summary: CBC 31.5K CHEM Bun/Creat Normal ALT Normal ALKP, GGT, Tbili elevated PT/PTT Normal IH Lepto Snap negative Which of the following liver enzymes is a marker of cholestasis in dogs? a. ALP b. AST c. ALT d. GGT Which of the following liver enzymes is a marker of cholestasis in dogs? a. ALP b. AST c. ALT d. GGT In dogs, increased GGT largely parallels increased ALKP Largest ALKP increases occur with diffuse or focal cholestatic disorders and hepatic neoplasms. Do gall stones cause disease? Often look elsewhere for the cause of the patient's illness. Other issues responsible for causing hepatobiliary tract disease? Bacteria in the bile? 8

9 Princess, 4 yo FS Cocker Presenting complaint: O noticed the following clinical signs: Orange urine (snow!) Lethargy Vomited once this week Anorexia for 2 days T: HR: 180 Panting Bounding pulses Pallor Icterus 2/6 heart murmur Hepatosplenomegaly Princess initial exam As soon as you see this, what do you do? IVC MDB PCV TS BG AZO/BUN Princess MDB Tells you all you need to know in < 1 minute! PCV 15%/TS 7 g/dl Icteric & hemolyzed serum Blood glucose 170 mg/dl BUN 5-15 mg/dl PACKED CELL VOLUME AND TOTAL SOLIDS High PCV High TP Hemoconcentration Low PCV Norm TP - Hemolytic anemia - Anemia of chronic disease - Pure red blood cell aplasia Low PCV Low TP - Blood loss - GI - Body cavity (abdominal, thoracic, etc) Normal PCV Low TP - Protein Losing Enteropathy (PLE) - Protein losing nephropathy (PLN) - Acute blood loss, splenic contraction - Liver disease / failure 9

10 Clinicopathologic data Blood smear: Spherocytes Found in 80% of IMHA patients Slide agglutination test (SAG) 1 clean slide 1 drop of direct blood 1 drop of 0.9% saline Shake Stir Rock & Roll Examine slide! Lulu, 6 yo FS Rottweiler Lulu Presenting Complaint - Urinating in the house for 1 week - pdvm Rx a course of Clavamox due to a suspect UTI - Profuse vomiting and nearcollapse the morning of presentation. Lulu Triage Examination - T 99.8º F - P R 40 - Severe abdominal splinting - Intermittent prayer position IVC MDB PCV TS BG AZO/BUN Lulu Initial Diagnostics 10

11 Lulu MDB Results Lulu MDB Results Tells you all you need to know in < 3 minutes! PCV 45%/TS 8.2 g/dl Icteric serum Blood glucose 125 mg/dl BUN 5-15 mg/dl Lulu Additional Diagnostics Lulu Abdominocentesis FAST Ultrasound Free peritoneal effusion Serosanguinous effusion PCV/TP 7/6.5 Lulu Abdominocentesis Other comparative tests: fluid analysis Cytology: Dilute blood Severe leukocytosis Degenerate neutrophils Bacteria seen! Bile Peritonitis A fluid bilirubin concentration greater than the plasma bilirubin concentration (typically about twice that of plasma) supports bile rupture. 11

12 Treatment Stabilization should be based on the major body systems assessment. The range of diseases causing icterus is large Work-up may take a prolonged period of time Hence stabilization is likely to be empirical. Brief Therapeutic Plan Discussion Fluid therapy Hypovolemic Dehydrated Both Ongoing Losses Maintenance Brief Therapeutic Plan Discussion Blood glucose should be checked as a priority Supplemented if necessary 1 ml/kg of 50% dextrose solution diluted 1:3/4 Supplementation at 2.5% or 5% glucose in the IV fluids). Brief Therapeutic Plan Discussion Avoid invasive procedures Cystocentesis Jugular Catheters / Jugular venipuncture Brief Therapeutic Plan Discussion Prehepatic icterus Transfusion therapy Treatment being tailored to hemolytic anemia IV Fluids Steroids Doxycycline 2 nd agent Other? Brief Therapeutic Plan Discussion Hepatic icterus Toxic cause? Principally supportive. Leptospirosis? Antibiotic therapy Neoplasia? Biopsy? Steroids? Hepatic support? Denamarin? Other? 12

13 Brief Therapeutic Plan Discussion Posthepatic icterus Biliary rupture? Extrahepatic biliary obstruction Surgical treatment required. Pancreatitis? Supportive and nutritional therapy Icterus will resolve as the pancreatic swelling goes down This material is copyrighted by VETgirl, LLC. None of the materials provided may be used, reproduced or transmitted, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any information storage and retrieval system, without the consent of VETgirl, LLC. Unless expressly stated otherwise, the findings, interpretations and conclusions expressed do not necessarily represent the views of VETgirl, LLC. Medical information here should be references by the practitioner prior to use. Under no circumstances shall VETgirl, LLC. be liable for any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the information provided including, without limitation, any fault, error, omission, interruption or delay with respect thereto. If you have any questions regarding the information provided, please contact 13