015esavs-猫病专题ii-9肝胆疾病黄色hepatobiliary diseases

FelineHepatobiliary„TheYellowDr.StefanUntererDiplomateECVIM FelineHepatobiliaryNJaundiceduetoelevatedNDifferentialdiagnosesIncreasedproduction/hemolysis生成增加/LivercellBiliaryobstructionFelineHepatobiliaryDisease猫的肝胆疾病原因Hepaticlipidosis脂肪肝Inflammatoryliverdisease肝炎Lymphoma淋巴瘤FIPAcute(Toxins,drugs ，药物FelineHepatobiliaryDiseaseEnzymepatternscangiveNALT>>ALP:Livercelldestruction(poss.Nalt>>alp:肝细胞破坏( 的可能性NALP,GGTincreased:Nalp,ggt升高：胆汁淤NExceptionALP>>GGT:hepaticALP>>GGT:Enzymepatternsarenon-specific酶谱没有特异性NFNAlymphomalipidosis细针抽吸(淋巴瘤，脂肪沉积)NBiopsy(cholangiohepatitis,…)(胆管肝炎)HepaticLipidosis脂肪Progressiveliverfailureduetomassivelipidstorageithinhepatocytes肝细胞内的大量脂 导致的进行性的肝功能衰Excitingcauses:Stress,otherillness+anorexia,speciallyinobesecats诱因：紧张，其他疾病+厌食，特别在肥Symptoms:Lethargy,jaundice,anorexia,weightHepaticLipidosisClassichistory经典的病NObesecatstopseating(WhyotherillnessNWeightloss体重减轻NStartsvomiting,turnsyellow! HepaticLipidosisClinical脂肪 ALPusuallyelevatedALP通常升高ALTandnotoronlyslightlyALT和GGTHepaticLipidosisFineneedleaspirationNLipidosiseasilydiagnosed脂肪NUnderlyingliverdiseaseoftenLiverbiopsynecessaryfordefinitivediagnosisHepaticLipidosis脂肪肝HepaticLipidosis脂肪Therapy:miscellaneousNRehydration,electrolytesubstitution(K!,Mg,AdequateAdequatenutritionislife-saving!TubefeedingNCa.60kcal/kg/day约60千卡/公斤/N200–300HepaticLipidosisSupportivemeasures支持治NAntiemetics(Metoclopramid0.25mg/kgBID-NAminoacids–necessaryforhepaticNArginine精氨酸(1000NTaurine牛磺酸(500NL-Carnithine左旋肉碱(250-500NVitamins plexBNVitaminK维生素NVitaminE维生素NS-Adenosylmethionine 苷甲硫氨酸(抗氧化剂SignalementSiamese暹罗猫11years11岁Male雄性HistoryNMorequietforthelastNLethargicandanorecticforacoupleofNVomitingforacoupleofNFoundseizuringPhysicalexaminationLateralrecumbency侧躺Statusepilepticus持续癫痫Heartrate80/min80/分CRTnotmeasurablehypothermicEmergency Emergency 2xDiazepam0,5mg/kgi.v1minapart2x0.5mg/kg1stopsseizuringAtropine0,4mli.v.0.4mlheartrateincreasesto150/min心律升到150/Glucosemeasurement:1mmol/l血糖测量：1glucosei.v4mlof25%glucose25%葡萄糖Schockinfusion20ml/kgin10min在10分钟内完成抗休克输液20ml/kgExternalheat外部加热Physicalexaminationafter稳定后的临床mucusmembranes:pale-pinkslightlysticky黏膜：白-CRT:<2sec毛细血管再充盈时间：<2秒 Bodycondition:gaunt HR RR 呼吸：15/Auscultationlungs Palpationabdomen腹部触诊soft,hartfecesincaudalabdomen,bladder y柔软腹腔后部有硬的粪 中度充nitialproblemlistnitialrule-outlistnitialdiagnosticandtherapeuticReferencex5-5.6–0.3–x150–x6–-x0.04–-x1–-x0–-x3–-x0–9Reference0–0–0–AP00–0–2280–0–0–0–0–

Reference0–0–

0–

1.8–0.57–57–26–5–0–3.7–0–

Reference0.97–100–146–3.5–2.3–11–0.7–Reference--65.5–-----------+----spec.1.015–腹部超声“Whatisyour你的解释是什么腹部超声腹部超声InflammatoryLiver(WSAVALiverStandardisationInflammatoryLiverDisease肝炎分类NAcuteMostcommonbileductdiseaseInfiltrationofportalareawith+acuteNAnorexia,weightloss,lethargy,vomiting,厌食，体重减轻，昏睡 ，发Cause:mostlikelyascendingbacterialinfectionthrobileductsEspeciallyinyoungtomiddleold急性嗜中性粒细胞胆管MostlikelybacteriaIntestinalNE.coli,Enterococcus,NBacteroides,Clostridia,NStaphylococcus,StreptococcusNHelicobacterspp.CharacteristichistopathologicNNeutrophilsinwallsandlumenofbileNBacteriamightbevisibleNBileductdegenerationandnecrosisNPosthepaticlesionsNibd炎性肠NClinicalpresentation临床表现NMiddleoldtooldercats终年到老年猫NAcutesymptoms急性症状NNDiarrhea腹泻NAnorexia厌食NLethargyNPhysicalexamNFeverNJaundiceNPainfulabdomenDiagnosisNIncreasedliverenzymeactivityNIncreasedbilirubin胆红素上升NLeukocytosis白细胞增多NEnlargedbileduct5NThickenedgallbladderwall1DiagnosisNLiverbiopsyNCytologyliver/bile(fineneedle肝/胆管细胞学(细针抽吸NBacterialculture(bile/liver细菌培养(胆管/肝脏组织Ncave:注意CheckcoagulationbeforeliverGiveVitaminK(1mg/kgBIDscTherapyN4-6,maybeeven8-10NCulture/sensitivity培养/NAmoxicillin/Clavulanicacid阿莫西林/NIfpatientstableandculturependingN3067%sensitivetoAmoxicillinFluorquinolonesN80sensitivetoCiprofloxacin1超过80%Enrofloxacin+Amoxicillin/Clavulanic沙星+阿莫西林/克拉维酸NIfpatientnotstable,intensiveantibiotictherapyNEnrofloxacinmax.5mg/kg/day(retinal5mg/Kg/(视网膜退形Metronidazol甲硝NAnaerobicbacteriaofteninvolved(Clostridiaspp,BacteroidesNIfanaerobicbacteria ed(gasingallbladder,non-responsiveto TherapyNNutritionalsupport,especiallyenergyrequirements(hep营养支持，尤其是对能量的需要(脂肪肝NHigh-proteincontentNTube-feedingNCholeretics(Ursodesoxycholicacid)利胆剂(熊去氧胆NAntioxidants:VitaminE,SAMe, gesics止NInfiltrationwithlymphocytes,plasmacellsandneutrophilsportalareaandaroundbileducts在肝门区和胆管周围的淋巴细胞，浆细胞和嗜中性粒细胞NSignsofchronicity慢性的标志NBileductproliferation胆管增生NFibrosis纤维化NEtiologyunclearNChroniccourseofacute急性胆管性肝炎的慢性表NIndependentimmunemediated自主免疫系统疾Medianage9years平均发病 Clinicalpresentation临床表现NNon-specific,waxingandwaning没有特异性， Clinicalpathology临床病理NIncreasedbilirubinandliverenzymeNCholelithiasis(rare) (罕见NLong-termantibioticsNConsiderPrednisoloneafter2weeksofantibioticsStartingdose:2mg/kg/day 开始剂量：2mg/kg/天Taperaccordingtoclinicalsymptoms(e.g.2mg/kgfor2weeks,1mg/kgfor2weeks,0.5mg/kgfor2weeks,0.5m(例如：2mg/kg使用2周，1mg/kg用2周，0.5mg/kg使用2周，0.5mg/kgNSupportive gesics,antioxidants,nutrition,Treatment治NBesttreatment?NLong-termantibioticsNConsiderPrednisoloneafter2weeksofantibioticsStartingdose:2mg/kg/day开始剂量：2mg/kg/天Taperaccordingtoclinicalsymptoms(e.g.2mg/kgfor2weeks,1mg/kgfor2weeks,0.5mg/kgfor2weeks,0.5(例如：2mg/kg使用2周，1mg/kg用2周，0.5mg/kg使用2周，0.5mg/kgNSupportive gesics,antioxidants,nutrition,InfiltrationwithlymphocytesandplasmacellsaroundbileRelativelyyoungcats,PersianNJaundiceNPossiblehypergammaglobulinemiaNPossibleascitesEtiologyundeterminedNIndependentimmunemediateddiseaseNHelicobacterpylori?幽门螺旋杆菌Therapy

NImmunsuppressivetreatmentN NNotalwayseffectiveNChlorambucilNInadditiontoPrednisolone NSmallcats 1mg/cat2xper小猫：1毫克/2NLarge 2mg/cat2xper大猫：2毫克/2NLong-termtreatmentNRescuewithMethotrexatenfiltrationwithlymphocytesandplasmacellsinportalareaductsnotaffected在门管区的淋巴细胞和浆细胞浸润-胆管不受影Commonhistopathologicdiagnosisinold在老猫中常见的组织病理学诊80%ofcats>1010%ofcats<10

Signof‚oldagewithoutclinicalsymptoms老猫，没有临nsymptomaticcases(liverenzymeactzivity,increasedIndependentimmunemediateddiseaseNBirmaN6months6NmalehistoryNweightloss体重减轻NPUPDN„redcoloredistorylivesin-and vaccination:deworming:physicalproblemlistproblem„redcoloredurine“referencereference--65.5----------------spec.1.015-erythrocytesfurtherexamination ysisbacterialcultureproblemroblemPU/furtherexaminationdiagnosticfurtherexaminationhemogram-MCV37.3fl(range40–平均细胞容积37.3fl(40–55)-mildneutrophilia轻度嗜中性粒细胞增furtherexaminationFIV/FeLVSNAPreference0-total57-26-5-0-3.7-reference0-0-furtherexaminationabdominalultrasound-newNmicrocytosis小红细problemNBirmaN6months6NmalehistoryNepisodeofdiarrhea(respondedtoNweightloss体重减轻NPUPDN„redcoloredhistoryNlivesinandoutdoorsNdeworming:currentphysical其他正problemlistN„redcoloredurineNPUPDNweightlossNlethargyproblem„redcoloredurine“问题“红色的尿”NhematuriaNhemoglobinuriaNmyoglobinuriareferencereference--65.5----------------spec.1.015-erythrocytesfurtherexamination ysisNbacterialcultureproblemhematuriableeding -thrombocytopenia/-pathy血小板减少/-coagulopathy-vasculopathy血管-local局-kidney-ureter输尿-

--neoplasmroblemPUPDprimary endocrine(diabetesmellitus, liverinsufficiency肝功能不primary liverinsufficiency肝功能不furtherexaminationdiagnosticplanNcompletebloodcountNdifferentialbloodcountNFIV/FeLVSNAPNultrasoundabdomenfurtherexaminationhemogramNcompletebloodcount-MCV37.3fl(range40–Ndifferentialbloodcount-mildneutrophilia轻度嗜中性粒细胞增furtherexaminationFIV/FeLVSNAPreference0-total57-26-5-0-3.7-reference0-0-furtherexaminationabdominalultrasoundNurinarybladder:：newproblemurolithiasismicrocytosisproblemurolithiasisNhematuriaNproteinuriaNpyuriaproblemmicrocytosisNportosystemicshuntNlackofironNsequestrationofironfurtherexaminationpreprandialbileacids85.2µmol/l(range0–furtherexaminationabdominalultrasound腹腔超声Nrathersmallliver非常小的肝脏Nshuntvesselvisualizedbetweenportalveinandcaudalvena

PortaliagnosiscongenitalportosystemicsecondaryammoniumurateurinarytreatmentNamoxicilline(12.5mg/kgNphenobarbital(1.5mg/kgBID)(1.5mg/kg一天二次)Nlactulose(2mlBIDp.o.)Nproteinrestricteddietrtherexaminationandportographysurgicaltreatment-ameroidconstrictor动脉缩窄-urinarystone-liverbiopsyclinically肝酶活性-什么与临床有关liverfunctionNliverfunction–laboratoryparameters肝功能 NliverfunctiontestsNbileacidsNammoniumtolerancetestNcoagulationliversizechronicityofenzymeactivityLiversizesmalllivershuntlivercirrhosishypoplasticconnectionbetweenportalandsystemicvascularsystembloodfromGItractreachessystemiccirculationunfilteredcongenitalPSSmostlysingularsecondaryPSSmostlymultiplextrahepatic肝mostlyconnectedtoabdominalV.cavacaudalis

rareconnectiontoV.rareconnectiontoV.cavantrahepatic肝shuntscaudaltobranchingV.portaewithinliverCongenitalportosystemicshuntintrahepaticleft-sided≅patentDuctusvenosus(fetalconnectionbetweV.cava&portalvein) causesNpathologyofvascularwallintrahepaticshuntmorelikelyinlargebreeddogRetriever,IrishWolfhound肝内的分流在大型犬中CongenitalportosystemicshuntN„intestinaltoxins“(ammonium,otherCNStoxbacteria,endotoxins)directlyreachCNSNlackoftrophicfactors&O2inportalhepatocytegrowth&CongenitalportosystemicshuntNvarietyofclinicalsymptomsNgastrointestinalsymptoms(anorexia,diarrhea,vomiting)(厌食，腹泻 Nsignsofurinarytractdisease (dysuria,hematuria,PU/PD,urateuroliths) Nneurologicsymptoms(suporousbehaviour,behaviouralchanges,Anfälle,ptyalismincats!!,„quiet“dog!!) ，行为改变，癫痫，猫的流涎!!犬的”安静Nmiscellaneous:retardedgrowth,intermittentfever,anestheticcomplicationsCongenitalportosystemicshuntNvarietyofclinicalsymptomsNmostlyyoungeranimals(<2Nalsoseeninolderpatients(>10也在老年动物中发生(>10岁Nneurologicsymptoms神经症Nothercongenitaldefects(cryptorchism,heart Nbilateralrenomegaly双侧肾脏肿大Ncopper-colourediris赤褐色虹膜CongenitalportosystemicshuntNdiagnostictests:labwork诊断测试 Nliverenzymeactivityelevation(inmostN50%„subtle“signsofdecreasedliverfunction(hypoalbuminemia,hypoglycemia,lowBUN)Nbileacids&ammonium胆汁酸&highlysensitivetest(80%–100%)todiagnoseorexcludePSSNdiagnostictests:rads诊断测试：X光N60%100%smallliveronrads在X光片中60%-100%combinationofNsmallliverNrenomegalyNuroliths100%diagnosticforPSS100Congenitalportosystemicshuntdiagnostictests:ultrasound诊断测试：BNdependson“radiologist’s”Nquickuninvasivemethod快速，Nvisualizationofshuntingvessel&shunt-associatedchanges(liversize,vascularization,renomegaly,uroliths)N可见分 Ndistinctionbetweenintra&extra-hepatic可以辨别肝内&Nportalbloodflow(portalhypertension门静脉血(门静脉CongenitalportosystemicshuntNdiagnostictests:mesentericNgoldstandardforvisualizationNdoneincombinationwithsurgicalligation&portalpressuremeasurementNtocheckdegreeofligationpostCongenitalportosystemicshuntNdiagnostictests:advancedN诊断测试：先进的影像Nportalscintigraphyyes/noanswerregarding-fractionofshuntingNCT-,MR-angiography arterial&venousvesselCongenitalportosystemicshuntNtherapySurgicalligationormedicalmanagementHowtodecidefirst:exclusionof首先排microvascualrdysplasia(medical)小血管发育不良(药物治疗)arterioportalfistula(surgical/medical(手术/药物治疗congenitalidiopathicnon-cirrhoticportalhypertension(medical)aquiredmultiplesecondaryshuntsduetoportalhypertensionCongenitalportosystemicshuntNmicrovasculardysplasiaNdisseminatedshuntingbetweenterminalportalNbreedpredisposition,symptoms,andlabchangeslikePSS(exception:nomicrocytosis) 相似(除了：没有小红细胞)Nliver&kidneysizemostlynormal;livercouldbeNonlymedicalmanagement,nosurgical只能用药物治疗，没有手术治疗的可能NacquiredmultiplesecondaryNsecondarytoportalhypertension继发于肝门静脉高压Nmostlyduetolivercirrhosis大多源于肝硬化Nmultipleshunts多灶分流Nsurgicalcorrectionnotpossible手术治疗不可行

AV

aquPSS体分 fistula静脉 PSS门体分 rare少见 typical典型 typical典型undicerare少见

rare少 typical典Congenitalportosystemicshunt primaryhepatopathy,疑 Nsignsforprotalflownotvisiblewith 流在影像学不可biopsy肝脏活CongenitalportosystemicshuntNtherapeuticoptionsSurgicalclosureormedicalmanagement药物治疗Howtodecide怎样决定surgicalmanagementNstabilizationpre-operativelyNasymptomaticpatientsbetterprognosisaftersurgicalproteinrestricteddiet,antibiotics,crudefiber,anticonvulsivetherapy(phenobarbital,K- dependingonalbumin&coagulation基于白蛋白&usebloodproducts(wholeblood,CongenitalportosystemicshuntNclosureofextrahepaticPSSNinitiallycompleteclosurenotpossible(portalhypertension最初完全关闭不可能(肝门静脉高压)NsignsofportalhypertensionNriseofportalpressureNincreasedperistalsisNcongestionofabdominalveinsNdeclineofcentralvenous CongenitalportosystemicshuntclosureofextrahepaticPSSNavoidanceofabruptportal避免突发门静脉高Npartialclosure部分闭-inapp.50%completeclosureafter6先闭合50%，6月后完全关-app.30%-50%still差不多30%-50%仍然有症Ncompleteclosureoftenafter6通常6个月后能够完Nstep-wiseclosurewithameroidconstrictorCongenitalportosystemicshuntstep-wiseclosureofextrahepaticdeath MehlML,JAVMACongenitalportosystemicshuntNclosurePSSincats猫的门体分流闭N90%extrahepaticanomalies90Ncompleteclosureonlyin1/3(portal只有1/3能够完全闭合(肝门静脉高压Nafterpartialligationapp.50%Nevenwithstep-wiseclosurep