June 2013, Issue 56
What’s New at AMVS!
|Jim Perry, DVM, PhD, DACVIM
Oncology Specialist and Surgical Resident
As of July 12th 2013, Jim Perry, our Surgical Resident and Oncology Specialist, will have finished his surgical residency at Aspen Meadow Veterinary Specialists. He will be moving to join his family in Seattle, Washington.
After careful selection we are excited to announce that Brooke Fowler, DVM, DACVIM Oncology will start with us on August 5th 2013. For the 3 week period before Dr. Fowler joins us, Dr. Dana Dietrich, Board Eligible Criticalist, will be continuing the care for Dr. Perry’s current cases. On August 5th they will transfer over to Dr. Fowler. To ensure the best of care, Dr. Perry will be available via phone to consult on his cases with Dr. Dietrich. Dr. Fowler will also be available for phone consultations during this 3 week period until starting with us on August 5th.
It has been a pleasure working with Dr. Jim Perry and we are all going to miss him very much. He has been a great doctor, co-worker and friend to us here. We are excited for him to settle in with his family in Seattle.
We look forward to continuing to provide you and your clients with the same excellent standard of care that Dr. Perry has exemplified for the last 3 years. We will be sending out more information on Dr. Fowler in the upcoming weeks. If you have any questions please call Dr. Matthew Rooney or Christine Kjeell at 303.678.8844.
We regret to inform you that Sacha Mace, BA, DVM, DACVIM our Internal Medicine Specialist at our Alpenglow location located at 3640 Walnut St. Boulder, CO 80503 will be moving on in her Internal Medicine career starting July 3rd, 2013.
While it is sad to see her go, please join us in welcoming our new Internists Drs Kelly Monaghan and Benjamin Nolan who will start practice at Alpenglow and Aspen Meadow in July. We will be sending more information regarding Dr. Nolan and Dr. Monaghan soon.
|Sacha Mace, BA, DVM, DACVIM
Internal Medicine Specialist
News from our Internal Medicine Service:
Aspen Meadow Veterinary Specialist’s
Internal Medicine Department will be moving from their normal schedule of Monday through Thursday and will be available Monday through Friday beginning on the dates listed below.
At the Aspen Meadow Veterinary Specialists location:
104 South Main St. Longmont CO 80501
Starting August, 19th 2013
At the Alpenglow Veterinary Specialty + Emergency Center location:
3640 Walnut St. Boulder, CO 80301
Starting July, 29th 2013
Should you have any questions please call
AMVS at 303.678.8844
or our Alpenglow location at 303.443.4569
Wendy Yaphe, DVM, DACVIM our Internal Medicine Specialist will be on vacation starting July 15th 2013 and will be returning August 5th 2013. While Dr. Yaphe’s is on vacation her cases will be seen by Dana Dietrich, DVM, our Board Eligible Criticalist.
Dr. Dana Dietrich, Board Eligible Criticalist
Attendees were given a brief lecture on the basics of first aid and then shown how to obtain vitals and place a bandage. It was definitely one of our more interactive presentations and everyone was pretty engaged.
Thank you Dr. Dana Dietrich, and her nurses Holly and Kelsey for helping pull off an amazing event.
Located on Main Street in Longmont, CO
If you would like to schedule a lunch and learn continuing education course please call Catherine Hillier at 303.678.8844
By Wendy Yaphe, DVM, Dipl ACVIM
Internal Medicine Specialist
1. A gallbladder mucocele is characterized by inspissated mucinous secretions within the gallbladder lumen that can predispose to gallbladder rupture and bile peritonitis.
2. Abdominal ultrasound is critical in evaluating patients with unexplained increases in liver enzymes to screen for the presence of a gallbladder mucocele.
3. Secondary bacterial infection occurs in some patients with gallbladder mucocele.
4. Cholecystectomy (surgical removal of the GB) is the treatment of choice in symptomatic patients with a gallbladder mucocele.
5. Medical management of the asymptomatic patient with a gallbladder mucocele remains controversial.
Sheltie: breed predisposed to gallbladder mucocele
What is a gallbladder mucocele?
A gallbladder mucocele is a pathologic condition of the gallbladder characterized by cystic mucinous hyperplasia of the gallbladder wall. There is associated production and accumulation of thick, inspissated mucinous secretions that congeal within the gallbladder. Secondary bacterial infection occurs in some cases with more common isolates including Escherichia coli, Enterobacter, Enterococcus, and Clostridium spp. Mucoceles are frequently associated with enlargement of the gallbladder, compromise of the gallbladder wall (cholecystitis), and as disease progresses, a higher likelihood of gallbladder obstruction or rupture. Gallbladder rupture and secondary bile peritonitis if not identified and treated may result in death. Gallbladder mucoceles are found more often in small breed and older dogs (mean age of 10 years in one study) with an increased incidence noted in the Cocker Spaniel and Sheltie. Risk factors for development include underlying endocrine disease (Cushing’s, hypothyroidism, diabetes), hyperlipidemia, and high fat diets. Some authors have suggested a link between steroidogenic hormones and gallbladder dysmotility, or steroidogenic hormones and dysfunction of mucus-secreting cells within the gallbladder.
What are the clinical signs of a gallbladder mucocele?
Clinical signs can be non-specific. Affected patients may present with depression, loss of appetite, abdominal discomfort, vomiting, and in some cases icterus. Some patients may be asymptomatic with the mucocele identified as an incidental finding during abdominal ultrasound. In patients with GB rupture, pain on abdominal palpation, icterus, tachycardia, tachypnea and fever may be present.
What lab abnormalities are noted with a gallbladder mucocele?
Lab findings can be variable. The most common abnormalities include leukocytosis, elevated SAP, GGT, ALT, and bilirubin. Elevations can be mild to profound. Secondary elevations in BUN, amylase, lipase, globulin and BUN may occur. In some patients, elevations in liver enzymes may be mild and serum bilirubin levels may be normal.
How is the diagnosis made?
Ultrasound appearance: Gallbladder Mucocele
Abdominal ultrasound is critical in diagnosing this disease. Ultrasound reveals an enlarged gallbladder with consolidated hyperechoic luminal contents surrounded by anechoic material.
The inspissated secretions often form tentacles that are tightly adherent to inner surface of gallbladder wall (giving the GB a “kiwi” or “stellate” appearance). A hallmark feature of a mucocele on ultrasound exam is the inability to get intraluminal contents to move with agitation. Not all mucoceles are classic in appearance and transitionary forms can occur (partial mucoceles). The common bile duct may be normal or dilated suggestive of obstruction. Associated hypoechoic thickening of the GB wall suggests concurrent cholecystitis. Hyperechoic mesentery adjacent to the GB wall with pockets of associated anechoic fluid is suggestive of focal GB leakage. Free fluid in the abdomen in association with a mucocele may be suggestive of bile peritonitis due to gallbladder rupture. Analysis of the peritoneal fluid and measurement of bilirubin in comparison to serum levels can be used to confirm biliary rupture.
What is the treatment of choice for a GB mucocele?
Surgical removal of the GB (cholecystectomy) is the treatment of choice in symptomatic patients with a gallbladder mucocele. Until surgical removal, the patient remains at high risk of spontaneous GB rupture and life-threatening bile peritonitis. The time course to leakage or rupture is unpredictable. Gallbladder mucoceles are the most common cause of gallbladder perforation.Most agree that morbidity and mortality rates for patients undergoing emergency cholecystectomy due to gall bladder rupture are higher than for patients undergoing elective cholecystectomy prior to gallbladder rupture.
Supportive therapy for the patient undergoing cholecystectomy should include intravenous antibiotics (within one hour of surgery), and vitamin K1 therapy (1 mg/kg SQ BID x 3 doses) prior to surgery if possible. Other peri-operative supportive measures may include anti-nausea medications, gastric protectants, pain medications, fluids, and oncotic support. Placement of a feeding tube should be considered pre-emptively in patients that are more debilitated and less likely to eat after surgery. Hepatic biopsies as well as gallbladder and liver cultures should be obtained during surgery. Post-operative care consists of long term antibiotics (4-6 weeks) for concurrent bacterial cholangiohepatitis. Combination therapy with a potentiated penicillin, fluoroquinolone, and metronidazole has been recommended by one respected author. Other supportive measures include a hepatoprotectant (such as Denosyl), and Ursodiol (Actigall: 15 mg/kg PO q24h). These latter two medications are continued longterm (months to lifelong)
Medical management of the asymptomatic patient with a gallbladder mucocele remains controversial, although there is a published study of success: “Nonsurgical resolution of gallbladder mucocele in two dogs” JAVMA June 2008; 232(11.). If medical treatment is elected, owners should be informed of the risk of spontaneous GB rupture and life-threatening bile peritonitis. Such patients should be meticulously monitored with serial labwork and ultrasound exam to monitor for progression of mucocele. Management consists of long term antibiotics (as above) and long term to lifelong treatment with a hepatoprotectant and Actigall. Actigall decreases bile viscosity, has anti-inflammatory and immunomodulatory effects on hepatocytes/biliary epithelium, and upregulates phospholipid transporters in bile canaliculi that may help resolve mucoceles. A fat restricted diet should be considered in patients with concurrent hypercholesterolemia or hyperlipidemia.
What is the overall prognosis in patients with GB mucocele?
Factors that contribute to a more favorable outcome include early surgical intervention in the otherwise stable patient, with minimal inflammation of the GB wall and mesentery noted on ultrasound exam. Patients with co-morbid conditions, debilitation, or biliary rupture prior to surgery tend to experience more complications. Potential complications include bile peritonitis, vasculitis, hypoproteinemia, ileus and septic peritonitis. Mortality rates of approximately 20% are reported with cholecystectomy, but numbers vary amongst different studies. With successful recovery from surgery and post-operative time period, the long term prognosis is excellent.
Gallbladder mucoceles are characterized by inspissated mucinous secretions within the GB lumen. Associated inflammation and infection of the gallbladder wall may be present. Affected patients typically present with systemic signs of illness and elevated liver enzymes and bilirubin. Ultrasound is critical in establishing a diagnosis. The treatment of choice in most patients is cholecystectomy.
Thank you for your continued support!
-Aspen Meadow Veterinary Specialists
104 S. Main Street
Longmont, CO 80501