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The curious case of beany with notes
- 1. THE CURIOUS CASE OF BEANY: THE TROUBLESOME TRIAD By Brandon Cohen
- 2. SCENE eany is a 13 year old MN Siamese Cat presented with a 4 day history of anorexia and 2 episodes of vomiting M are pale, tacky, and icteric /9 BCS despite recent weight loss associated with anorexia
- 3. CLUES!!
- 9. ROLL ON DETECTIVE! epatic lipidosis is typically associated with obese, anorectic cats asically the fuel usage switches to primarily fatty acids elivered to the liver in the form of Triglycerides by lipolysis his accumulation leads to hepatic dysfunction and cholestasis norexic due to stress or secondary disease…. Hmmmmm…
- 10. HELP US OUT WATSON n HL we see elevated ALP, normal GGT and elevated bilirubin UT Beany has elevated ALP, GGT, ALT, AST, Cholesterol, and Bilirubin
- 11. ELEMENTARY!!! e will see elevated ALP and GGT together when there is a cholestasis of some sort (cholangitis, cholangiohepatitis, bile duct obstruction) holesterol will be elevated with bile duct obstruction (thus cholestasis) as well LT and AST will be elevated with hepatocellular damage, which can occur with HL, cholestasis, cholangitis, cholangiohepatitis…
- 12. WAIT…..WHAT? UT you may also see an elevated GGT, Cholesterol, and Amylase in another condition commonly seen in cats..PANCREATITIS!!
- 13. IN FLAMES?? eukocytosis with a neutrophilia, monocytosis ormocytic, normochromic, non-regenerative anemia he changes we see in the hematology are consistent with SOME type of Inflammation
- 14. NOW WHAT? e know there is evidence of inflammation and pancreatitis from Beany’s bloodwork ancreatitis can cause a post hepatic or obstructive jaundice. (Extrahepatic biliary obstruction) and elevated GGT, AST and cholesterol support this
- 16. ALL I DO IS WIN!
- 17. WELL….
- 18. WE GOTS WHAT YOU NEED n order to confirm our theory…. S of liver and pancreas iver Biopsy ile Acid Stimulation Test to determine pre-hepatic, hepatic, or post hepatic origin of jaundice
- 19. SUSPICIOUS STILL
- 20. THE FINAL STRETCH nflammation of the small intestine or IBD is a definite possibility in Beany’s case e have an inflammatory picture, and a non-regenerative anemia which are also often seen with IBD mylase is also elevated in the presence of bowel inflammation BD and can cause mild pancreatitis!!!
- 21. THE TRIAD ATTACKS riaditis is an inflammatory process that involves the liver, pancreas, and small intestine. eany may have 2/3 of these conditions….. OES HE HAVE THE THIRD?!? eed to look for inflammation on US eed a biopsy to confirm
- 23. REFERENCES iello, Susan E. The Merck Veterinary Manual Online 10th Edition. 2012 ttinger, Stephen J., Feldman, Edward C. TextBook of Veterinary Internal Medicine 6th Edition Chapters on Feline Liver Disease, Feline Pancreatitis and IBD th Year lecture notes
Editor's Notes
- Mention decided to try and make this fun. The title reminds me of an Old Black and White detective movie so that is where I go the inspiration for the layout and some of the pictures.
- Mention the long standing fracture Beany has but not how it is not brought up in this case as it does not serve the pathology of the case due to the injury being 10 years old and the pathology we are discussing has nothing to do with the injury, with the exception that if the cat was in pain all of the sudden due to the fracture, then perhaps it has been unlikely to walk to the food bowl or eat. This is very unlikely though due to the how old the injury is and no actual signs of lameness.
- Just like every good detective novel, clues need to be found. Luckily in the case of Beany, I had everything I needed to put the pieces together and build an image in my head as to what was going on with Beany.
- Interpretation: WBC is elevated=Leukocytosis Elevated Segmented/Mature Neutrophils=Neutrophilia Mildly Elevated Monocytes=Monocytosis Red Blood Cell Picture=Normocytic, Normochromic none regenerative anemia (mild) Elevated Platelets=Thrombocytosis Possible Reasons for changes=Inflammation, specifically chronic inflammation, can cause all of these signs. In addition, an inflammatory condition such as Irritable Bowel Disease would fit the possible cause for inflammation and the mild anemia as well as some of the clinical signs Beany presented with. There are still other conditions such as Hepatic Lipidosis, or other GI conditions that could present in this matter so we need to evaluate the other clues.
- Interpretation: Total Protein is slightly decreased=Hypoproteinemia however, it is important to note that both albumin and globulin are within normal limits on their own. Decreased sodium=hyponatremia Decreased chloride=hypochloremia Decreased Anion Gap=Could be explained from the hyponatremia and hypochloremia. Could be a result of metabolic acidosis from GI upset, vomiting, etc Elevated Billirubin=bilirubinemia Elevated ALP, GGT=together these could be elevated due to cholestasis of some sort, pancreatitis, or cholangiohepatitis Elevated ALT, AST=indicative of hepatocellular damage, and elevated ALT can be seen in pancreatitis as well. Elevated Cholesterol=seen with hepatic disease as well as concurrent pancreatitis or bile duct obstruction Elevated Amylase=This can be associated with kidney or bowel inflammation, and is fairly high in cases of pancreatitis though it is not accurate measurement of pancreatitis in those cases. Urinalysis: 3+ Bilirubin and the presence of Bilirubin crystals is indicative of hepatic lipidosis So looking at hematology and biochemistry we can determine there is an inflammatory process occurring and possible causes seem to be hepatic lipidosis, IBD, pancreatitis, cholangiohepatitis, or a combination of more than one of these. The clinical signs Beany presented with also fit these differentials.
- The darker color of the urine is a sign of bilirubin present in the urine, which matches the differential of hepatic lipidosis.
- Fine Needle Aspirate from the liver: We can clearly see the presence of red blood cells, neutrophils, and fat cells on the sample. The fat sells are infiltrating the hepatocyte population. This is the classic picture we see with hepatic lipidosis.
- Obviously this is a “Curly Case” so there must be more at hand. Given some of the results of the hematology and biochemistry then I am sure something else is also going on along with the obvious hepatic lipidosis.
- This is very similar to how Beany has presented. We know Beany is anorexic as well, but we are unsure of the exact cause of that.
- If we follow the clues, they tell us something else is going on with Beany.
- It seems that besides the hepatic lipidosis we may have some sort of factor causing a cholestasis. Our differentials for that could be cholangitis, cholangiohepatitis, bile duct obstruction.
- This is an important point to make. You need to not only interpret the clues, but also remember the species you are working with along with the presenting signs. Beany has presented with the initial clinical signs of pancreatitis, and it could also possibly be the cause of his anorexia if that is the case.
- As explained earlier, we know that there is some type of inflammation going on, this could be explained by the presence of pancreatitis or another inflammatory disorder in the GI system like IBD which I mentioned earlier. At the moment, pancreatitis seems like a likely culprit.
- By putting the clues together, we can make decisions about what could be ailing Beany. The clues are pointing us to a hepatic lipidosis that could possibly be secondary to pancreatitis. It also possible the pancreatitis caused an anorexia which would lead to hepatic lipidosis. Either way, this helps to explain the changes in the bloods that are consistent with hepatic lipidosis as well as pancreatitis.
- An interesting point to make is that the pancreas of the cat has a duct that joins the common bile duct just before the opening into the duodenum. This means that a pancreatitis could affect the bile ducts, it also means a problem in the bile ducts could cause a pancreatitis. This also ties into one of our other differentials in this case, Irritable Bowel Disease. Inflammation of the bowel at this opening could easily cause problems in the pancreas, bile ducts and possibly the liver.
- So in theory, my detective work has paid off and we now have a diagnosis!!!
- Well…..not true. We still need some tests to be done in order to obtain a solid diagnosis for Beany. Though some of the clues point to pancreatitis, we need to perform the gold standard tests for identifying pancreatits or any other problems in the liver or GI system.
- By using the tools at our disposal, we will be able to get a solid diagnosis as to what is wrong with Beany. These tests will cover all of our basis, help to confirm any other hepatic disease, cholestasis, and pancreatitis.
- I was not quite settled with the possibility of Beany having just a HL and pancreatitis. I felt like something else that has been at the back of my differentials could possibly still be lurking within Beany’s system and it was my job to eliminate that differential……IBD
- IBD has been on our list this whole time, and though it was further down, without the appropriate tests we can not eliminate it. After some further research, it became evident that IBD could definitely be a major culprit in Beany’s illness, and further more it could have been the starting point for everything!
- We can safely assume Beany definitely has 2/3 of the conditions we see with Triaditis. In order to rule out the third, US of the intestine must be done, and biopsies must be taken. Without these results we can not rule out IBD, and being that Triaditis is an inflammatory process we see specifically in cats, it is worth the investigation. We owe it to BEANY!!
- I hope you all enjoyed the story I laid out for you and I hope I did not bore you too badly. Thank you for your attention.