Challenging diagnostic work-up of a massive fluid-filled structure in the cranial abdomen of a cat

A 9-year-old female, neutered European shorthair cat was presented with acute vomiting, obvious jaundice and painful enlargement of the abdomen. Icteric skin and mucous membranes in addition to severe bilirubinaemia (mainly direct bilirubin) and a large increase in liver enzyme activities were the main findings at the initial examination. Radio- and ultrasonographic evaluation revealed a massive fluid-filled structure caudal to the liver displacing abdominal organs, in particular the stomach. As this structure with a diameter of 8–10 cm occupied considerable space in the cranioventral abdomen, a detailed ultrasonographic examination of the liver and the gallbladder, and determination of the structure’s association with a particular abdominal organ was initially impossible. Via ultrasound-assisted puncture under general anaesthesia 300 ml of an almost clear fluid could be aspirated. Cytological examination revealed a cyst content-like fluid with cell detritus.Further ultrasonographic and computed tomographic diagnostics followed by abdominal laparotomy finally enabled diagnosis of a cystic dilatation of the entire common bile duct and accumulation of white bile. Histopathological examination after euthanasia (requested by the owner) identified lymphoplasmacytic cholangitis and necrosis of the duodenal papilla. The massive dilatation of the common bile duct complicated its definite diagnosis by diagnostic imaging methods. It was most likely caused by a longer-standing obstruction of the bile flow by lymphoplasmacytic cholangitis with necrosis and granulation tissue formation in the area of the duodenal papilla. An interesting but initially misleading feature was the presence of white bile. The etiology of this extremely rare condition remains obscure but in the described case a manifestation of impaired hepatocyte function secondary to biliary stasis is suspected to be the cause.

White bile in patients with malignant biliary obstruction is an independent factor of poor survival

Background and study aims White bile is defined as a colorless fluid occasionally found in the biliary tract of patients with bile duct obstruction. Its significance is not clearly established. Our objective was to analyze the prognostic value of white bile in a series of patients with biliary obstruction due to biliary or pancreatic cancer. Patients and methods The study was conducted on a series of consecutive patients with malignant obstructive jaundice. They all underwent endoscopic retrograde cholangiopancreatography with collection of bile and biliary stent insertion. White bile was defined as bile duct fluid with bilirubin level < 20 µmol/L. Univariate and multivariate analyses were performed to identify variables associated with overall survival (OS). Results Seventy-three patients were included (32 pancreatic cancers, 41 bile duct cancers). Thirty-nine (53.4 %) had white bile. The mean bile duct bilirubin level in this group was 4.2 ± 5.9 µmol/L vs 991 ± 1039 µmol/L in patients with colored bile (P < 0.0001). In the group of 54 patients not eligible for surgery, the multivariate analysis demonstrated an association between the presence of white bile and reduced OS (HR 2.3, 95 %CI 1.1–4.7; P = 0.02). Other factors independently associated with OS were metastatic extension (HR 2.8, 95 %CI 1.4–5.7) and serum total bilirubin (HR 1.003, 95 %CI 1.001–1.006). There was a significant inverse correlation between serum and bile duct bilirubin levels (r = –0.43, P = 0.0001). Conclusion White bile in patients with inoperable malignant biliary obstruction is an independent factor of poor survival.

Candida albicans cholecystitis with associated hepatitis in a cat

Case summary A 3-year-old male neutered domestic shorthair cat was presented for vomiting, inappetence and icterus. Biochemical results and ultrasonographic findings were consistent with cholestasis and possible biliary obstruction. A diagnosis of Candida albicans cholecystitis with associated hepatitis was made following cytologic examination and fungal culture. Progressive hyperbilirubinemia and hepatic encephalopathy were ultimately fatal. Relevance and novel information To our knowledge, this is the first report of biliary candidiasis diagnosed by cytologic examination of a cholecystocentesis sample in a domestic animal with no evidence of immunodeficiency. Additionally, this is the first reported case of fungal cholecystitis with associated white bile syndrome due to obstructive cholestasis, without an overt gall bladder mucocele.