015esavs-貓病專題ii-9肝膽疾病黃色hepatobiliary diseases

FelineHepatobiliary?TheYellowDr.StefanUntererDiplomateECVIM FelineHepatobiliaryNJaundiceduetoelevatedNDifferentialdiagnosesIncreasedproduction/hemolysis生成增加/LivercellBiliaryobstructionFelineHepatobiliaryDisease貓的肝膽疾病原因Hepaticlipidosis脂肪肝Inflammatoryliverdisease肝炎Lymphoma淋巴瘤FIPAcute(Toxins,drugs ，藥物FelineHepatobiliaryDiseaseEnzymepatternscangiveNALT>>ALP:Livercelldestruction(poss.Nalt>>alp:肝細(xì)胞破壞( 的可能性NALP,GGTincreased:Nalp,ggt升高：膽汁淤NExceptionALP>>GGT:hepaticALP>>GGT:Enzymepatternsarenon-specific酶譜沒(méi)有特異性NFNAlymphomalipidosis細(xì)針抽吸(淋巴瘤，脂肪沉積)NBiopsy(cholangiohepatitis,…)(膽管肝炎)HepaticLipidosis脂肪Progressiveliverfailureduetomassivelipidstorageithinhepatocytes肝細(xì)胞內(nèi)的大量脂 導(dǎo)致的進(jìn)行性的肝功能衰Excitingcauses:Stress,otherillness+anorexia,speciallyinobesecats誘因：緊張，其他疾病+厭食，特別在肥Symptoms:Lethargy,jaundice,anorexia,weightHepaticLipidosisClassichistory經(jīng)典的病NObesecatstopseating(WhyotherillnessNWeightloss體重減輕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約60千卡/公斤/N200–300HepaticLipidosisSupportivemeasures支持治NAntiemetics(Metoclopramid0.25mg/kgBID-NAminoacids–necessaryforhepaticNArginine精氨酸(1000NTaurine?；撬?500NL-Carnithine左旋肉堿(250-500NVitamins plexBNVitaminK維生素NVitaminE維生素NS-Adenosylmethionine 苷甲硫氨酸(抗氧化劑SignalementSiamese暹羅貓11years11歲Male雄性HistoryNMorequietforthelastNLethargicandanorecticforacoupleofNVomitingforacoupleofNFoundseizuringPhysicalexaminationLateralrecumbency側(cè)躺Statusepilepticus持續(xù)癲癇Heartrate80/min80/分CRTnotmeasurablehypothermicEmergency Emergency 2xDiazepam0,5mg/kgi.v1minapart2x0.5mg/kg1stopsseizuringAtropine0,4mli.v.0.4mlheartrateincreasesto150/min心律升到150/Glucosemeasurement:1mmol/l血糖測(cè)量：1glucosei.v4mlof25%glucose25%葡萄糖Schockinfusion20ml/kgin10min在10分鐘內(nèi)完成抗休克輸液20ml/kgExternalheat外部加熱Physicalexaminationafter穩(wěn)定后的臨床mucusmembranes:pale-pinkslightlysticky黏膜：白-CRT:<2sec毛細(xì)血管再充盈時(shí)間：<2秒 Bodycondition:gaunt HR RR 呼吸：15/Auscultationlungs Palpationabdomen腹部觸診soft,hartfecesincaudalabdomen,bladder y柔軟腹腔后部有硬的糞 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–

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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–腹部超聲“Whatisyour你的解釋是什么腹部超聲腹部超聲InflammatoryLiver(WSAVALiverStandardisationInflammatoryLiverDisease肝炎分類NAcuteMostcommonbileductdiseaseInfiltrationofportalareawith+acuteNAnorexia,weightloss,lethargy,vomiting,厭食，體重減輕，昏睡 ，發(fā)Cause:mostlikelyascendingbacterialinfectionthrobileductsEspeciallyinyoungtomiddleold急性嗜中性粒細(xì)胞膽管MostlikelybacteriaIntestinalNE.coli,Enterococcus,NBacteroides,Clostridia,NStaphylococcus,StreptococcusNHelicobacterspp.CharacteristichistopathologicNNeutrophilsinwallsandlumenofbileNBacteriamightbevisibleNBileductdegenerationandnecrosisNPosthepaticlesionsNibd炎性腸NClinicalpresentation臨床表現(xiàn)NMiddleoldtooldercats終年到老年貓NAcutesymptoms急性癥狀NNDiarrhea腹瀉NAnorexia厭食NLethargyNPhysicalexamNFeverNJaundiceNPainfulabdomenDiagnosisNIncreasedliverenzymeactivityNIncreasedbilirubin膽紅素上升NLeukocytosis白細(xì)胞增多NEnlargedbileduct5NThickenedgallbladderwall1DiagnosisNLiverbiopsyNCytologyliver/bile(fineneedle肝/膽管細(xì)胞學(xué)(細(xì)針抽吸NBacterialculture(bile/liver細(xì)菌培養(yǎng)(膽管/肝臟組織Ncave:注意CheckcoagulationbeforeliverGiveVitaminK(1mg/kgBIDscTherapyN4-6,maybeeven8-10NCulture/sensitivity培養(yǎng)/NAmoxicillin/Clavulanicacid阿莫西林/NIfpatientstableandculturependingN3067%sensitivetoAmoxicillinFluorquinolonesN80sensitivetoCiprofloxacin1超過(guò)80%Enrofloxacin+Amoxicillin/Clavulanic沙星+阿莫西林/克拉維酸NIfpatientnotstable,intensiveantibiotictherapyNEnrofloxacinmax.5mg/kg/day(retinal5mg/Kg/(視網(wǎng)膜退形Metronidazol甲硝NAnaerobicbacteriaofteninvolved(Clostridiaspp,BacteroidesNIfanaerobicbacteria ed(gasingallbladder,non-responsiveto TherapyNNutritionalsupport,especiallyenergyrequirements(hep營(yíng)養(yǎng)支持，尤其是對(duì)能量的需要(脂肪肝NHigh-proteincontentNTube-feedingNCholeretics(Ursodesoxycholicacid)利膽劑(熊去氧膽NAntioxidants:VitaminE,SAMe, gesics止NInfiltrationwithlymphocytes,plasmacellsandneutrophilsportalareaandaroundbileducts在肝門區(qū)和膽管周圍的淋巴細(xì)胞，漿細(xì)胞和嗜中性粒細(xì)胞NSignsofchronicity慢性的標(biāo)志NBileductproliferation膽管增生NFibrosis纖維化NEtiologyunclearNChroniccourseofacute急性膽管性肝炎的慢性表NIndependentimmunemediated自主免疫系統(tǒng)疾Medianage9years平均發(fā)病 Clinicalpresentation臨床表現(xiàn)NNon-specific,waxingandwaning沒(méi)有特異性， Clinicalpathology臨床病理NIncreasedbilirubinandliverenzymeNCholelithiasis(rare) (罕見(jiàn)NLong-termantibioticsNConsiderPrednisoloneafter2weeksofantibioticsStartingdose:2mg/kg/day 開(kāi)始劑量：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開(kāi)始劑量：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?幽門螺旋桿菌Therapy

NImmunsuppressivetreatmentN NNotalwayseffectiveNChlorambucilNInadditiontoPrednisolone NSmallcats 1mg/cat2xper小貓：1毫克/2NLarge 2mg/cat2xper大貓：2毫克/2NLong-termtreatmentNRescuewithMethotrexatenfiltrationwithlymphocytesandplasmacellsinportalareaductsnotaffected在門管區(qū)的淋巴細(xì)胞和漿細(xì)胞浸潤(rùn)-膽管不受影Commonhistopathologicdiagnosisinold在老貓中常見(jiàn)的組織病理學(xué)診80%ofcats>1010%ofcats<10

Signof?oldagewithoutclinicalsymptoms老貓，沒(méi)有臨nsymptomaticcases(liverenzymeactzivity,increasedIndependentimmunemediateddiseaseNBirmaN6months6NmalehistoryNweightloss體重減輕NPUPDN?redcoloredistorylivesin-and vaccination:deworming:physicalproblemlistproblem?redcoloredurine“referencereference--65.5----------------spec.1.015-erythrocytesfurtherexamination ysisbacterialcultureproblemroblemPU/furtherexaminationdiagnosticfurtherexaminationhemogram-MCV37.3fl(range40–平均細(xì)胞容積37.3fl(40–55)-mildneutrophilia輕度嗜中性粒細(xì)胞增furtherexaminationFIV/FeLVSNAPreference0-total57-26-5-0-3.7-reference0-0-furtherexaminationabdominalultrasound-newNmicrocytosis小紅細(xì)problemNBirmaN6months6NmalehistoryNepisodeofdiarrhea(respondedtoNweightloss體重減輕NPUPDN?redcoloredhistoryNlivesinandoutdoorsNdeworming:currentphysical其他正problemlistN?redcoloredurineNPUPDNweightlossNlethargyproblem?redcoloredurine“問(wèn)題“紅色的尿”NhematuriaNhemoglobinuriaNmyoglobinuriareferencereference--65.5----------------spec.1.015-erythrocytesfurtherexamination ysisNbacterialcultureproblemhematuriableeding -thrombocytopenia/-pathy血小板減少/-coagulopathy-vasculopathy血管-local局-kidney-ureter輸尿-

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

PortaliagnosiscongenitalportosystemicsecondaryammoniumurateurinarytreatmentNamoxicilline(12.5mg/kgNphenobarbital(1.5mg/kgBID)(1.5mg/kg一天二次)Nlactulose(2mlBIDp.o.)Nproteinrestricteddietrtherexaminationandportographysurgicaltreatment-ameroidconstrictor動(dòng)脈縮窄-urinarystone-liverbiopsyclinically肝酶活性-什么與臨床有關(guān)liverfunctionNliverfunction–laboratoryparameters肝功能 NliverfunctiontestsNbileacidsNammoniumtolerancetestNcoagulationliversizechronicityofenzymeactivityLiversizesmalllivershuntlivercirrhosishypoplasticconnectionbetweenportalandsystemicvascularsystembloodfromGItractreachessystemiccirculationunfilteredcongenitalPSSmostlysingularsecondaryPSSmostlymultiplextrahepatic肝mostlyconnectedtoabdominalV.cavacaudalis

rareconnectiontoV.rareconnectiontoV.cavantrahepatic肝shuntscaudaltobranchingV.portaewithinliverCongenitalportosystemicshuntintrahepaticleft-sided?patentDuctusvenosus(fetalconnectionbetweV.cava&portalvein) causesNpathologyofvascularwallintrahepaticshuntmorelikelyinlargebreeddogRetriever,IrishWolfhound肝內(nèi)的分流在大型犬中CongenitalportosystemicshuntN?intestinaltoxins“(ammonium,otherCNStoxbacteria,endotoxins)directlyreachCNSNlackoftrophicfactors&O2inportalhepatocytegrowth&CongenitalportosystemicshuntNvarietyofclinicalsymptomsNgastrointestinalsymptoms(anorexia,diarrhea,vomiting)(厭食，腹瀉 Nsignsofurinarytractdisease (dysuria,hematuria,PU/PD,urateuroliths) Nneurologicsymptoms(suporousbehaviour,behaviouralchanges,Anf?lle,ptyalismincats!!,?quiet“dog!!) ，行為改變，癲癇，貓的流涎!!犬的”安靜Nmiscellaneous:retardedgrowth,intermittentfever,anestheticcomplicationsCongenitalportosystemicshuntNvarietyofclinicalsymptomsNmostlyyoungeranimals(<2Nalsoseeninolderpatients(>10也在老年動(dòng)物中發(fā)生(>10歲Nneurologicsymptoms神經(jīng)癥Nothercongenitaldefects(cryptorchism,heart Nbilateralrenomegaly雙側(cè)腎臟腫大Ncopper-colourediris赤褐色虹膜CongenitalportosystemicshuntNdiagnostictests:labwork診斷測(cè)試 Nliverenzymeactivityelevation(inmostN50%?subtle“signsofdecreasedliverfunction(hypoalbuminemia,hypoglycemia,lowBUN)Nbileacids&ammonium膽汁酸&highlysensitivetest(80%–100%)todiagnoseorexcludePSSNdiagnostictests:rads診斷測(cè)試：X光N60%100%smallliveronrads在X光片中60%-100%combinationofNsmallliverNrenomegalyNuroliths100%diagnosticforPSS100Congenitalportosystemicshuntdiagnostictests:ultrasound診斷測(cè)試：BNdependson“radiologist’s”Nquickuninvasivemethod快速，Nvisualizationofshuntingvessel&shunt-associatedchanges(liversize,vascularization,renomegaly,uroliths)N可見(jiàn)分 Ndistinctionbetweenintra&extra-hepatic可以辨別肝內(nèi)&Nportalbloodflow(portalhypertension門靜脈血(門靜脈CongenitalportosystemicshuntNdiagnostictests:mesentericNgoldstandardforvisualizationNdoneincombinationwithsurgicalligation&portalpressuremeasurementNtocheckdegreeofligationpostCongenitalportosystemicshuntNdiagnostictests:advancedN診斷測(cè)試：先進(jìn)的影像Nportalscintigraphyyes/noanswerregarding-fractionofshuntingNCT-,MR-angiography arterial&venousvesselCongenitalportosystemicshuntNtherapySurgicalligationormedicalmanagementHowtodecidefirst:exclusionof首先排microvascualrdysplasia(medical)小血管發(fā)育不良(藥物治療)arterioportalfistula(surgical/medical(手術(shù)/藥物治療congenitalidiopathicnon-cirrhoticportalhypertension(medical)aquiredmultiplesecondaryshuntsduetoportalhypertensionCongenitalportosystemicshuntNmicrovasculardysplasiaNdisseminatedshuntingbetweenterminalportalNbreedpredisposition,symptoms,andlabchangeslikePSS(exception:nomicrocytosis) 相似(除了：沒(méi)有小紅細(xì)胞)Nliver&kidneysizemostlynormal;livercouldbeNonlymedicalmanagement,nosurgical只能用藥物治療，沒(méi)有手術(shù)治療的可能NacquiredmultiplesecondaryNsecondarytoportalhypertension繼發(fā)于肝門靜脈高壓Nmostlyduetolivercirrhosis大多源于肝硬化Nmultipleshunts多灶分流Nsurgicalcorrectionnotpossible手術(shù)治療不可行

AV

aquPSS體分 fistula靜脈 PSS門體分 rare少見(jiàn) typical典型 typical典型undicerare少見(jiàn)

rare少 typical典Congenitalportosystemicshunt primaryhepatopathy,疑 Nsignsforprotalflownotvisiblewith 流在影像學(xué)不可biopsy肝臟活CongenitalportosystemicshuntNtherapeuticoptionsSurgicalclosureormedicalmanagement藥物治療Howtodecide怎樣決定surgicalmanagementNstabilizationpre-operativelyNasymptomaticpatientsbetterprognosisaftersurgicalproteinrestricteddiet,antibiotics,crudefiber,anticonvulsivetherapy(phenobarbital,K- dependingonalbumin&coagulation基于白蛋白&usebloodproducts(wholeblood,CongenitalportosystemicshuntNclosureofextrahepaticPSSNinitiallycompleteclosurenotpossible(portalhypertension最初完全關(guān)閉不可能(肝門靜脈高壓)NsignsofportalhypertensionNriseofportalpressureNincreasedperistalsisNcongestionofabdominalveinsNdeclineofcentralvenous CongenitalportosystemicshuntclosureofextrahepaticPSSNavoidanceofabruptportal避免突發(fā)門靜脈高Npartialclosure部分閉-inapp.50%completeclosureafter6先閉合50%，6月后完全關(guān)-app.30%-50%still差不多30%-50%仍然有癥Ncompleteclosureoftenafter6通常6個(gè)月后能夠完Nstep-wiseclosurewithameroidconstrictorCongenitalportosystemicshuntstep-wiseclosureofextrahepaticdeath MehlML,JAVMACongenitalportosystemicshuntNclosurePSSincats貓的門體分流閉N90%extrahepaticanomalies90Ncompleteclosureonlyin1/3(portal只有1/3能夠完全閉合(肝門靜脈高壓Nafterpartialligationapp.50%Nevenwithstep-wiseclosurep