Clinical and Prognostic Findings in Dogs with Suspected Extrahepatic Biliary Obstruction and Pancreatitis

ABSTRACT Pancreatitis in dogs may lead to extrahepatic bile duct obstruction as a result of local inflammation. Medical records of 45 client-owned dogs with clinical suspicion of extrahepatic bile duct obstruction secondary to pancreatitis were reviewed to determine clinical findings, outcome, and factors associated with survival. Survival times were determined using the Kaplan-Meier product limit method. Cox multivariable survival methods were employed to determine factors associated with survival time following diagnosis. The median survival time was 241 days (95% confidence interval [CI] 25–631), with 34 of 45 dogs (76%) surviving to discharge. Dogs 9 yr of age or older with azotemia at presentation had a 9.9 greater hazard for death (95% CI 2.5–38.1; P = .001) compared with dogs younger than 9 yr old without azotemia at presentation. Dogs without subjective ultrasonographic gallbladder distension had a 4.4 greater hazard for death (95% CI 1.3–15.4; P = .018) compared with dogs with subjective gallbladder distension. Dogs with a body temperature ≥102.5°F at admission had a 3.1 greater hazard for death (95% CI 1.3–7.7; P = .013) than dogs with a body temperature <102.5°F at admission. This information may help clinicians discuss prognosis with owners of affected dogs.

SCORE SYSTEM FOR ERCP INDICATING IN EXTRAHEPATIC BILE DUCT OBSTRUCTION

Abstracts. Aim: to objectify indications for urgent/emergency ERCP in patients with extrahepatic biliary tract obstruction (EBTO) by using the score system Matherials and Methods. The score is used by summing the points: hyperthermia ≥ 37.3 ° C (1 point); one of three hematological points — leukocytosis ≥ 9×109/l or stab neutrophils ≥ 7% or the ratio of the number of segmented and stab neutrophils <10 (1 point); two biochemical — serum bilirubin ≥ 70 μmol / l (1 point), hyperamylasemia (1 point); thickening of the gallbladder wall ≥ 4 mm or shrunken gallbladder (1 point); the main pancreatic duct dilatation (1 point); in the presence of a periampular tumor or signs of chronic pancreatitis, one point is subtracted (- 1 point). The scale was tested on 171 patients with EBTO. Results. The threshold value of the scale was ≥3 points (p <0.001). The number of points (3, ≥4) correlated with the severity of acute cholangitis and acute biliary pancreatitis (p <0.01). Conclusions. In patients with confirmed OEDB in case of ≤2 points of the score system — urgent/emergency ERCP is not indicated; in case of ≥3 points — urgent ERCP is indicated; in case of ≥4 points emergency ERCP should be performed.

Placement of a temporary cholecystostomy tube to relieve pancreatic EHBDO in a dog

A 12-year-old male neutered labrador retriever was treated for extrahepatic bile duct obstruction (EHBDO) secondary to acute pancreatitis. Supportive care was provided for 14 days, but despite treatment the dog’s clinical condition worsened. A temporary cholecystostomy tube was placed via minilaparotomy to provide extracorporeal diversion of bile until patency of the common bile duct was spontaneously re-established. Within 24 hours of tube placement, marked improvement in total bilirubin was noted and the dog could be managed as an outpatient. Clinical signs resolved rapidly, and despite complications with the external tubing necessitating replacement after 48 hours the procedure and tube were well tolerated. Patency of the common bile duct was spontaneously re-established three weeks after tube placement, and the cholecystostomy tube was removed percutaneously. No recurrence of EHBDO was noted in the 13 months following removal of the cholecystostomy tube.

Recent advances in understanding biliary atresia

Biliary atresia (BA) is a neonatal liver disease characterized by progressive obstruction and fibrosis of the extrahepatic biliary tree as well as fibrosis and inflammation of the liver parenchyma. Recent studies found that infants who will go on to develop BA have elevated direct bilirubin levels in the first few days of life, suggesting that the disease starts in utero. The etiology and pathogenesis of BA, however, remain unknown. Here, we discuss recent studies examining potential pathogenetic mechanisms of BA, including genetic susceptibility, involvement of the immune system, and environmental insults such as viruses and toxins, although it is possible that there is not a single etiological agent but rather a large group of injurious insults that result in a final common pathway of extrahepatic bile duct obstruction and liver fibrosis. The management and diagnosis of BA have not advanced significantly in the past decade, but given recent advances in understanding the timing and potential pathogenesis of BA, we are hopeful that the next decade will bring early diagnostics and novel therapeutics.

An Improved Method of Percutaneous Transhepatic Biliary Drainage Combining Ultrasound-Guided Bile Duct Puncture with Metal Stent Implantation by Fluoroscopic Guidance and Endoscopic Visualization as a One-Step Procedure: A Retrospective Cohort Study

Aims In recently published comparative studies, it is reported that percutaneous transhepatic biliary drainage (PTBD) is less successful, causes more adverse events, and needs more re-interventions than endoscopic ultrasound-guided biliary drainage (EUS-BD) in patients with malignant extrahepatic bile duct obstruction when endoscopic retrograde cholangiopancreatography (ERCP) fails. Could an improved technique of PTBD produce better results to use this technique for further comparative studies with EUSBD? Methods In our tertiary referral hospital, 116 prospectively documented, and retrospectively analyzed PTBDs with ultrasound guided ductal puncture were performed. In 16 of 30 PTBDs with metal stent implantation in malignant diseases, metal stent was inserted as a one-step procedure by endoscopic luminal guidance in the first session. Results Fifteen of 16 (94%) or 14/16 (88%) of PTBDs with primary metal stent implantation were technically or clinically successful. Mainly the left liver was used as access route for PTBD. Procedure time was 68.1 minutes (25–118), fluoroscopic time: 18.6 minutes (3–46), and patient radiation exposure: 5957 μGy/m2 (471–17,569). In 2/16 (12.5%) patients, adverse events (1 × mild and 1 × moderate grade of severity) were documented. One re-intervention was necessary (0.1/patient) in the observation time of 6 months. The mean overall survival time was 163.2 (7–864) days after PTBD. Conclusions PTBD with ultrasound-guided ductal puncture and primary metal implantation by endoscopic luminal guidance in patients with malignant extrahepatic bile duct obstruction showed good technical and clinical success and low adverse event and reintervention rates in our retrospective cohort study. Clinical Trial Registration: ClinicalTrials.gov ID: NCT03541590.