scott@vtx-cpd.com

No problem!

Hope that helps!

Scott 🙂

Hello.

Hope you are safe and well. This is an interesting one. I think that a shunt would still have to be on the list of differentials. If I sent this case to one of my neurology collegues, they would ask me to do a bile cid stimulation before they saw it!

Dogs can definately present later in life with shunts. I must admit, the signs with this dog are a wee bit odd. You would definatley want to keep other neurological differential into consideration too. The best way to move forward would be to do a bile acid stimulation test and then you can more confidently rule it out. The rise in ALP could be non specific and not related as we know.

Hope that helps and keep me posted with the case!

Scott 🙂

Also…

We will provide all the Powerpoint slides as PDF files at the end of the course. This might mean you have to less frantically take notes.

Hope that helps.

Scott 🙂

Hello!

Is it a wee bit sad that I am very excited for you!

Would be interesting to know how the dog gets on. What did you decide diagnostics wise?

Scott 🙂

Hello!

What a great case! I would love to see some images! Would you be able to upload them?

this might be worth publishing!

I would treat like emphysematous cholecystitis. Anaerobes are most commonly isolated and include E. coli and Clostridium perfringens.48 Fluoroquinolones, metronidazole, and chloramphenicol are commonly used as they achieve high concentrations in bile and have strong anaerobic activity.

Hope that helps.

Scott 🙂

This is an interesting question that much better developed in human medicine:

The most common functional disorder of the biliary tract and pancreas relates to the activity of the Sphincter of Oddi. The Sphincter of Oddi is a small smooth muscle sphincter strategically placed at the junction of the bile duct, pancreatic duct, and duodenum. The sphincter controls flow of bile and pancreatic juices into the duodenum and prevents reflux of duodenal content into the ducts. Disorder in its motility is called Sphincter of Oddi dysfunction. Clinically this presents either with recurrent abdominal biliary type pain or episodes of recurrent pancreatitis. Most of these patients present with abdominal pain. Symptomatic treatment comprises treatment of abdominal pain. In patients with a severe episode of either biliary or pancreatic Sphincter of Oddi dysfunction the most appropriate pain medication is parenteral opiates. This is despite the known observation that opiates produce sphincter of Oddi contraction. The rational for their use is that the contraction has already occurred and the opiate is unlikely to aggravate matters further. However, on the other hand opiates are the most effective therapy for pain relief. In order to prevent future episodes in patients who have identified opiates such as codeine to provoke pain avoidance of these medications is recommended. There is no effective pharmaceutical therapy for these patients.

Reflecting on that, I would not withhold methadone/full opioids in cases of abdominal pain. If the rationale is that we are preventing Sphincter of Oddi contraction, it has probably already happened in these cases. In cases of known pancreatitis we would still use opioids, as further contraction will not worsen signs.

The only thing that we may have to be cautious of is long term opioid use, which is not really a thing for our patients:

https://www.gastrojournal.org/article/S0016-5085(13)00507-6/pdf

Hope that helps!

Scott x

Hello.

Thank you again for all of your great questions.

Regarding the analysis of bile. I would definitely consider bile sampling in any symptomatic case where you suspect cholangiohepatitis, both dogs and cats. Sludge is definitely likely to be an insignificant finding in dogs but would increase my index of suspicion of disease in cats.

Regarding chololithiasis. The biggest part of the decision making will depend on whether there is significant/complete obstruction of the biliary system. Complete obstruction would usually require surgical intervention. The problems would also be surgical if there was evidence of bile peritonitis.

I think in cases where you think bilirubin is increased for hepatic and post hepatic reasons, ultrasound is always a good idea.

Never a silly question!

Scott 🙂

Absolutely!

I would definitely add in a product with SAMe and silymarin.

Scott 🙂