March 31, 2023

#89: Live recording: The jaundiced cat, and rethinking liver diagnostics. With Prof Jill Maddison.

#89: Live recording: The jaundiced cat, and rethinking liver diagnostics. With Prof Jill Maddison.
Apple Podcasts podcast player icon Spotify podcast player icon RSS Feed podcast player icon
Apple Podcasts podcast player icon Spotify podcast player icon RSS Feed podcast player icon
Season 1

This episode from our clinical series is brought to you by Elanco, makers of the broadest range of parasiticides including Advocate, Milbemax, Seresto and Credelio Plus.

 

"The question about the biochemistry is really interesting, because what your question now is, is 'what is it, and where is it?' And the problem that we have is that the liver enzymes aren't gonna tell us, because it's really hard to separate hepatic from post-hepatic on bloods. ALP is very insensitive in the cat and will go up with both hepatic and post-hepatic. ALT will go up with hepatic and post-hepatic. Bilirubin will be up. So what?!"

 

We recorded this case-based interactive session about how to work up the jaundiced cat with one of the world's leading Small Animal Medicine specialists and teachers, ⁠Prof Jill Maddison⁠ at session our live event in 2022.

Prof Jill Jill Maddison, BVSc, DipVetClinStud, PhD, SFHEA, MRCVS, is a professor of general practice, the director of professional development, and the BVetMed and CertAVP course director at Royal Veterinary College. She is also a coordinator for London Vet Show and is a consultant at a local veterinary practice and at Beaumont Sainsbury Animal Hospital in London. Dr Maddison is the senior editor of the second edition of Small Animal Clinical Pharmacology and the senior editor of Clinical Reasoning in Small Animal Practice. She has lectured worldwide on clinical problem-solving, small animal internal medicine, and clinical pharmacology. 

In this session she helps us reason through a case of jaundice in a cat to create a deeper understanding, rather than a simple list of facts. She also shifts some long-standing beliefs around diagnostic testing in liver disease in both dogs and cats.

 

Topic list:

5:07 Where to begin your workup.

6:05 Defining the problem and localising the problem: Pre-hepatic, hepatic or post-hepatic?

9:17 How much does dehydration actually affect PCV?

10:43 Bilirubin - how useful is it?

"It’s the most over-interpreted test I reckon. I have so many vets tell me, “Oh, the bilirubin is 16, it has to have a problem with its liver…” No, it probably just has inflammatory disease."

13:14 Dd’s for hepatic disease in cats.

14:20 Dd’s for post-hepatic causes of jaundice.

16:04 Biochem in jaundice: ALP, ALT, GGT.

"The problem that we have is that the liver enzymes aren't going to tell us."

19:51 Why bile acids are useless in the diagnosis of liver disease.

"The bile acids don't tell you anything more than you already know. There is no relationship between the level of bile acids and the prognosis or reversibility of the lesion."

24:25 Can't I just trial-treat?

26:16 Ultrasound.

28:27 Signalment: how useful is it?

29:36 Cholesterol and liver disease.

30:52 Pancreatic lipase and pancreatitis in cats.

"What we found was that we had 24% false negatives. So we had a quarter of our cats who had what seemed to be pancreatitis that did not have an increased Pli."

36:54 Hepatic lipidosis.

 

For more world-class specialists in an easy-to-consume format join our community of Vet Vault Nerds at vvn.supercast.com.

Visit thevetvault.com for the show notes for this episode.

Join us in at Vets on Tour in Wanaka, New Zealand on 13 - 18 August 2023 for great CE, more live podcasting and snow... lots of snow!

 

 

 

Hello, vit valtor's and welcome back.It's been a wee while between episodes, but I have an excuse.I was learning and I was live broadcasting.See, last week was the Vex Spring Symposium up in Port Douglas.And I was there as the vet felt to do some live interviews.
And to stuff my brain, full of some incredible quality critical kce.I had the privilege of sitting down with some very smart people to dig for highlights and key takeaways and to get some questions answered about the jokes.And did I ever have Some questions.
If you are a VIXX members are that's the Veterinary emergency and critical cases Aya tea or one of our clinical subscribers, you should check your inbox for an invite to the space where the video recordings of these sessions are currently residing.All for our clinical subscribers.Hold tight, we'll be releasing the audio as podcasts on the ECC stream over the coming weeks and months.
Here's a little teaser.It was the General consensus amongst the dorian's of critical care that we probably don't have to put animals.Is that have ingested potential?Never toxins on preventative IV fluids?Yes, we're talking about those damn grape and raised in ingestions who sit in your hospitals, for two days on fluids barking.
The heads of a driving, everybody crazy.We'll let you know when that episode goes live, but I'm super excited.I also had the privilege to meet many of you.Haven't felt this in person and can I just say that I am in awe of how cool you all are and inspired by your support and feedback?
I really do feel privileged to be a part of such a dynamic and passionate group of people, and I'm pumped to keep using the red felt as a tool for further connection and growth for all of us.Sincerely, thank you, speaking of conferences, and dorian's at the end of 2022, we had our first ever vid V live event, with the Dorian's of small is medicine and endocrinology prep Jill medicine and prof.
David church and of course we had the recording equipment switched on to capture the wisdom that just pours out of these two speakers like blood pause from an ear laceration is on the walls and on the floor and just everywhere.This recording was one of my personal highlights because the joint is cat case can seem so bloody vague and prep, Jill made it.
So bloody simple in the session while also completely shifting.Some of my very long-standing beliefs Our liver enzymes and liver testing in both dogs and cats.I also loved it because we did the session as a sort of a live broadcast style Q&A / case discussion session which gave us a lot of audience participation and unearth some real gold Way Beyond, just a list of facts.
Now it is a live recording so it's not studio quality audio, but I think it is perfectly clear and we're just not, I've done some magical post editing or sometimes recorded myself asking some of the questions from From the audience, where they were a little bit hard to hear, to make sure that you can hear what they said.
We shared this episode on our subscriber clinical podcasts.In while ago, along with a bunch of other stuff from the conference.If you don't know about a clinical series, then check it out and Vivi in for red belt Network or they dwelt nerds dot super cars.com.So that's v v in that super cars.com or click the link in the show description wherever you listening to this.
And if you do know about it and you haven't subscribed yet, Then like Lara.Bingle said, where the bloody hell?Are you?Sorry inside was a joke.But seriously, you are missing out.Now we bringing this recording to all of you with the support of elanco Australia, who are also sponsors for our conference last year.
So those of you who are there, can thank you, lanco, for some of those wonderful meals and if you thinking, I know the name.But I can't think what elanco cells, they the makers of products like Advocate will be Max sarastro and Cordelia plus.So, basically, The stuff that keeps your patients, parasite, free and healthy, so that you don't have to deal with too many weird, vector-borne diseases.
So shout out and thank you to a Lancome, Australia.Okay, let's get into it with proof.Jill medicine and bezel the jaundiced cat.The jaundice catco bezel and he's a twelve-year-old muted.
Domestic short-haired cat.He's got a three-week history of anorexia hasn't wanted to eat.He intermittently.Vomits vile, Stone material, he's quite depressed.On physical exam, he's thin.He's got a dull, ill-kempt coat.
He's depressed and lethargic.He's got jaundice, sclera and mucous membranes.He's about five percent dehydrated.He's got a heart rate of a hundred sixty and his Pyrex if he's got a temperature of 39.7.So and a normal thoracic auscultation.
So that's the cat that presents two years.He's not insured, but the okay to invest in him, but they want to know what their money is going to get them.That gives philosophical the person you were talking this morning about thinking and you talk about fishing instead of targeted going after something.
Yeah, because I've what we do more and more is fishing with dynamite that way.Yes.So this is everything and he's gonna get it blood for blood blood guess.That's me Ascend the ladder off, get an ultrasound Yeah.And what are you going to say?So on the owner and I'll say, well, that's great.But you now about to charge me and I'm going to sew has, is it possible that he's got anything treatable?
What's the prognosis for the options that he has?You know, should I just kill him now?Like literally is every other is every possible option and nasty option in which case let's have a conversation about that, or is it possible that he's got something that we can think about now with him, if you want to patent recognize him, that's absolutely fine.
But you've got to know your differentials.So there aren't that.Many things that will cause jaundice in an elderly cat.But you have to know your differentials.You have to know what the prognosis is for those, and you have to know how to diagnose them.So, should we Define?What do we think of we're going to Define this problem?Let's start.
Well, he's easy because he's chose the darkness to me, is lovely, because it goes where we absolutely her down to absolutely free the liver, the liver posted.Exactly.So you say, do I have pre hepatic disease?Could he be joined us?Because he's got hemolytic, anemia.Do I have a paddock disease?
Do I have posed to predict disease?So what is your problem list would be?Good choice.Good, most localizing problem.Yeah, but what else is on your problem?All we go through week history, pyrexia.It was going through the survey, and in order of importance, come on.
There's no room bones.I've got dull lethargy.Yeah, history of inhabitants of reduced, appetite weight loss dehydration.But we need a lot of it's really not necessarily localizing.It's just ill.Yep.So there, what we would call nonspecific robots, the, but One of those problems we need to definitely make a note of, because I think we probably all agree.
If we explain why he is doing this while I was vomiting.The pyrexia is probably something we need to keep their because it may limit might, or might not limit our differentials.So we need to create our problem list with all the problems on it, to make sure that we don't miss something.
That is because we've got so focused on the joiners.The other question we're going to ask is, do you think on the balance of probability is that all of the problems on that problem lists are do?Due to the same 21 disorder, do you think on the balance of probabilities with this cat very possible?Yes, exactly.
Very possible if he came in with, you know, cats as they say, go shopping for diseases, he might have some changes on his, you know, if he was pu PD, we might say, has he got other diseases going on as well?But that's one decision that we make.Is I think on the balance of probabilities, it's likely one disorder, which means, if I solve the vomiting, I'll solve the rest of them, and the pyrexia becomes a problem that Is there as some background information?
That's probably going to help me when I'm thinking about differentials and now so testing, no no no, I've been Benedict's a plan fluid, you can do realize he's got fluid okay he's got he's through with it.
So you want to test but why?Well, what do you want to spend my money?Okay.Well, what I would love to do very simple straight to and I'm going to put myself on the line.Yeah.And I figured I'd love to just do a piece of ETP and a blood smear and watch that, because I need to see whether he's Hema lysing is a yellow because his livers and trouble.
Exactly, exactly.So our first question was, does he have Priya Paddock a political post herpetic disease and the easy ones to separate out from the pack is the pre Paddock.So absolutely want to do a PCV.That's great.PCB, would you expect him to be if it was pretty emphatic.
It'd be a pretty significant, it should be it.Yeah, I mean, he might have a mild vis-à-vis, decrease if he's got a name of inflammatory disease or something, but for him to be joined as like that, you'd expect it to be a significant.It may or may not be regenerative.That depends on and also depends of course on the cause of it.
It doesn't have to be me and mediated.It could be parasitic blah blah blah blah blah.Yeah.But that's the first key question.That's because once you do that And let's say he comes back with a PCV.That's pretty normal, which we'll see in a moment.Then your question is, does he have a paddock or poster Paddock disease?
And that's where you say, okay?What are you going to do to try and sort that one step backwards?Let's say we swipers and dehydrated, right?Could you think of anything then have like a slightly elevated PCB?Which then maybe was 12 or 13 PCB but now it's 18 or something like that.
Well it depends on do the math so he's five percent dehydrated.How much is is pcv going to go up?I've never thought of it that way much like to meet ya.So if you do the math, then that means that if he had a PCV of 18 and he's five percent dehydrated, And it's only going to go down about point.
Nine of a, it's not going to go down by very much when he's rehydrated, what?I'll say to you now, is that, okay, so let's just say we've done.You've done your PCV and let's just say, you've decided he doesn't have pretty Patty.Okay.All right, and now you want to do some tests but now you've got it.
Now, you've got to think about your differentials.Now, you've got a, I want to know as a client.What are the options now?You can patent recognize, he doesn't matter because now we're just talking about a paddock post herpetic disease.So what are the options?For this cat.Because that's what's going to drive, what you're going to spend your money on.
You just talked about differentiating between a paddock and post a paddock and I know he used to set a lot of store by congregating on quantitative bilirubin, but we don't do that anymore.Is that correct?So it really doesn't help at all.So, and in fact, a lot of labs now won't even measure it.So, you might have the occasional animal that's fully conjugated and hardly any unconjugated, which means it's probably post a paddock and you might have the really, really unusual case where it's pretty all unconjugated and therefore its prophetic but because bilirubin is such as Sort of Damages, the liver, most of them have a mixture and it really isn't enough of a differentiation quick Side Track before we go for the case.
That's not as obviously yellow, there you go.Little bit tinge.Am I right in saying bilirubin should be up with it.Yellow blue ribbon should?Yeah, if I do, if I think I yell out we ran blood.So when I believe ribbon and it's normal to go, okay, you're not yelling.
Yeah, but so just as a little aside, one of the things that so the bilirubin reference range is about not to 15, they don't get jaundice until it gets to 45 so you can have an elevated bilirubin and the not be jaundiced and they can.
An elevated bilirubin and not be joined us for non Priya Paddock to Paddock post herpetic reasons, so they can have it.If they have inflammatory disease in cats quite significant in people, they can have it with fever.We don't really know where that happens in cats in horses.
Of course, the most common cause of jaundice is anorexia, maybe in cats, their balloon goes up, but they don't get jaundice.But it's the inflammatory septic cat or dog that can have an increased bilirubin that isn't jaundice, but it doesn't mean that, That they've got a paddock disease and it's the most over-interpreted test.
I reckon I have so many vets.Tell me all the bilirubin 16 it has to have a problem with it sleeve up.No probably it's just got inflammatory disease.The rate-limiting step for bilirubin.Excretion is the actual excretion from being conjugated and then going into the gallbladder and the enzymes and Transporters that do that are affected by inflammatory mediators infected possibly by fever and the anorexia probably changes those mediators as well.
So whether it is an intimate and And fasting.And I would find it hard to believe that just because the gallbladder wasn't Contracting, that would increase it.But I absolutely agree.You've got a bilirubin of 25 that can be all sorts of things that it is and you need to hunt for it could still could be living.
So if my cat's got her Panic disease, what are some of the causes of hepatic disease and the cat that will cause jaundice.Okay, so at this point, our audio wasn't all that fantastic so I might interrupt every now and again and tell you what they audience said, so the first answer here was cholangitis.
What kind jaundice is a pathological term.So what type of college itís, you're right.But what type of color because they're a different times just yet.So we can have, we can have lymphocytic close my city, or we can have neutrophilic so there too and treated very differently.
So what else?Lymphoma absolutely hepatic lipid doses.Yeah, absolutely.Especially when a cat that's got a three-week history of any recent viral causes and well if I pecan he's probably in the wrong.For, if I pee, but the fop definitely can Triad itís will try it.
Itís is going to be a comedy so he could have.So he could have cholangitis, as well as have pancreatitis, as well as have whatever we do there.What there aren't that many other but they've going to be potentially different prognosis.So that's me.That's me.Hepatic.
Then what about the poster Patty?What are some options for poster Paddock, while duct obstruction, but Jeter, what so pancreatitis is one Carlos.Yep.Could be often subclinical but, you know possible.Yeah.It would be a really, I mean, you could get a foreign body getting up there for him when he's sitting right at the outlet of the of the bile duct because remember in cats have a CO pancreatic and bile duct opening.
So, and you can have if you have pathology right at that duodenum it could cause definitely could cause it yep, Jarvis had the pleasure of neoplasia of something along the biliary tract or is the pancreas.The pancreas just wants to hang out with the liver.
Just got foam.I really bad.So just hangs out with a liver and anything that happens to all the fact deliver is not a dog.So it's not going to have a concealed.They can get sort of bacterial infection, the gallbladder.That's probably it all you could get you know a rupture but you probably is not presenting like a rupture.
My point is that you need to know that to be able to say to me the client.So some of that's very true nibble and some of its not so treatable some of it is will be easily treatable.So I was treated Paul, but it's more expensive and it's longer some of it as got a better prognosis and some of it doesn't.
But also it might, it might influence what test you want to do.So the question is, if you do so blood count, absolutely right?You need to know what this cat's PCV is because you'll keep question is, could he be Priya Paddock?But once that goes, you've also the blood count would be useful, because it may give you information that he's got significant Flemish, read Aziz, he might be leukemic, it might be whatever.
The question about the biochemistry is really interesting because what your question now is, and this is why we think about them together is, what is it, and where is it?Because it's really hard to separate them on Bloods.So to separate a paddock from poster padding.So that's why we have to think about the knowledge.
He's and think about well, how am I going to find that out?And the problem that we have is that the liver enzymes aren't going to tell us a or p is very insensitive in the cat and we'll go up with both the paddock and post herpetic alt will Go up padding and post herpetic, Billy room.
Yeah.So what so the Alp in the cat has got a really short half-life, it's got a half-life of six hours compared to 72 hours and the dog which means that it's a quite an insensitive enzyme.It's also they hardly make any of it.And so in the cat alkaline phosphatase goes up with cholestasis but it may not.
And so you can have lots of cats that will have.You would never get that pattern of enzymes in a dog with a joined us dog.If you got that, Pattern of enzyme, not the aisle to so much and maybe you'd get if they're really Advance this erotic but usually in a jaundice dog, you would expect the alkaline phosphatase to be up because it's actually a more sensitive marker of cholestasis than bilirubin is.
But in the cat, it's got a short half-life, they don't make very much of it.And so in the cat, unlike in the dog, there's very few things that will put up the Alp, which is not primary have had a biliary disease, so pancreatitis will.
But I Call it.It have had a biliary disease hyperthyroidism will, but it's probably the bone Alp not deliver Alp that goes up in hypothyroidism and then not much else, doesn't go up.The steroids doesn't go with Santa Barbara tone, doesn't go up with all the things that it goes up within dogs.
So, what else could we maybe do and see, just wanted to go back to dips over the stuff that we learned about the patterns of LPG, alt, and that helps to do to differentiate their product.The ptosis.Yeah, the only continent helps with liver doses if the, because in caps, the gamma GT should be higher than the Alp.
And for some reason in the ptosis it's reversed.So the Alp is higher than the GT.So that's a reason to do the enzymes, but you must include a GT.Elevated IEP versus able to elevate a team.This is that working dogs in dolls.
Yeah, they're like an LPS will likely to be raised in a called letter obstruction, you know, not always might see Emily?No not in the cat.So mlas is absolutely useless in the cat.
They hardly produce any of it.So amylase and lipase that we have in a normal bike chemistry profile doesn't help us at all.So we might want to do feel and pancreatic lipase.So what I'm what I'm going to do is what I'll do.So we want to do feel in pancreatic like house, we want to do some enzymes, we might want to do some Imaging because we've said that might help us all of.
That's, absolutely fine.So why don't I show you what the results are and then see what questions that brings up.So we did that path results is piece of it was 25.It's a bit.Dehydrated will go down to about 24 but really not enough to say that he's got him living there.
Mia.So he's mild anemia once.Righted and fairly happy doesn't have pretty Paddock.He had a moderate inflammatory but not a sceptic.Luca G.He had increased alt was 300 reference range up to 60.He had bilirubin emia no surprise there.
He had a normal.Alp, he had a normal ceiling pancreatic lipase.He had a normal amylase bile acids work requested and on Imaging.He had no ultrasonographic abnormalities.So he said well acid wasn't wasn't asked for it.
So we don't know.We don't know what his bile acids are.Because why would we want to do by license?They won't tell us anything that we do.I already know you're gonna go back to the by license please and you said that there was no point doing them.Yeah, there's the cap.Bilirubin was increased.
Yep.And it's because you would get a false result because it's not false, their incredible.Yeah.Okay, so the reason why we do buy less isn't because of liver function.So this is this is a, this is a bone of contention.So bile acids, absolutely are produced in the liver and in one way, a measure of her, Addict function except that.
I have huge fights with people about this.So they produced in the liver.If they were a true measure of hepatic function, then should be like our women.They should go down with the paddock disease Paddock failure.But they don't they go up and the reason why they go up in a paddock disease is because the ability of the liver to extract.
The bile acid becomes decreased but they can also go up when we've got a shunt and they're going up because of the shunt not because the livers failing and they also go up When they can't be excreted properly.So there's three ways.Bile acids go up, they go up.If they're coming from the gut and then they go bypass the liver and they don't go through the liver.
So that's a shunt, got nothing to do with function.They can go up, if the liver is dysfunctional and that's got to do with extraction problems, not with synthesis problems.So, unlike our human and unlike coagulation factors which are synthesized in the liver and go down, when the liver is in advance, failure, they go up because the extraction doesn't happen.
Do they go up?Because you've got cholestasis within the liver or outside of the liver.So, slowing down of the bottle.Now, once you've got bilirubin, increase, you know that you've got cholestasis.So, the bile acids don't tell you anything more than you already know.
There is no relationship between the level of bile acids and the prognosis or reversibility of the lesion.The only time you would want to do bile acids in a jaundice cat or dog would be, if you were concerned, they They had hemolytic anemia and that was why they were jaundiced because they may give you some idea about the liver or in a septic patient.
That's joined us because it septic which is incredibly uncommon.But most of the time 99% of the time in a jaundice animal, they're not going to tell you anything that you don't already know.They're not going to quantify the degree of problem.They're not going to tell you what the reversibility is.They're not going to tell you what the prognosis is.
I get that and I'm still confused because this cat could still have extraction from student would have issues there in the liver.Yes.Yeah, but the, but I know that but I already know that I know that because the bilirubin's increase, I've got a jaundice cat, it has to have a paddock or post herpetic disease.
So I think the two reasons I do bile acids would be one hunting a shunt.Absolutely for sure.And then if I was hunting liver disease and wasn't yet convinced that The enzymes were telling me enough that it had liver disease, so that clinical science fits the enzymes are mmm.
You know, then they're five times elevated, something like that.And I'm going, is that secondary?Or is it primary?Then then balus is for sure.I can show you some data that we did in some cats and dogs because one of the messages about bile acids is that not so much in the cat and you don't seem to get full false positives and the cat or we didn't, you can get false positives in the dog easily.
So other things put it up like conjugation of bile acids in the intestine by bacteria.And so the reference range for bile acids.You know, they talk about not 225, and if it's above 25, you got a problem.Well, really in a dog, it's probably up to about 40 or 50 before you can be sure it's definitely liver in the cat.
They don't tend to get false positive, but what was really interesting in?Both the dog and the cat.We've got a bunch and the numbers are there.I can't quite remember Listen.But something like, 15% of our cats and dogs who had card-carrying liver disease, card-carrying biopsy, proven shunt, proven whatever, liver disease, who had normal bile acids.
So, one of the messages about by licenses, they can't rule out liver disease, which is really important in particular in cats, because cats just the enzymes, a weird, you know, the lt's got a shorter Half-Life as well, it doesn't go up as high, you know, they just don't like to kill the blood, there's something wrong.
Wrong.So biopsy or something.Then we'll be just try treating that you can.I mean you can definitely try treating bacterial or lymphocytic Pleasant City.You do you 48 hours or whatever?
Antibiotics and disappointing in terms of the things that you can do that 48 hours probably isn't enough?But yep and then if we're not getting any Improvement at certain time then yep.And you give him steroids.Yep.And if you give him steroids so let's say you give him Anybody except nothing but he'll probably look a bit better just because he's got some antibiotics on board.
He might have a bit of encephalopathy going on the antibiotics or sort of effect his gut, but let's just say he doesn't respond to antibiotics so you so you lighting the steroids.Absolutely fine.And he does really well.He starts looking really well.What does that tell you?Does it confirm your diagnosis or because what are the two options if he's really improving on steroids?
So he's either got non-supportive cholangitis or he's got lymphoma and they've got very different prognosis.He's so the point though is that that's the conversation, you have to have with the owner to manage their expectations.So you need to be clear about what the options are.
Not just always got a bit better on steroids and be clear to say this is you know it may be that this is great news it may be that he is going to be responded incredibly well to steroids and it may be because he's got lymphocytic cholangitis and that's going to be great or it might be that this is the start of responding well to lymphoma and He's going to crash and burn or or he might not.
And then the question is, well, maybe she'll throw some chlorine chlorine Brazil in there.You know who knows?So absolutely not saying you have to biopsy.This cat, what I'm saying is you need to be aware of what the options are and what the potential prognosis is and response.
So that you've got a clear discussion with your owner you said that we were still trying to work out whether it was hepatic will post herpetic.But that our ultrasound imaging was normal what sort of causes for postherpetic?Would you still see normal?Imaging results with supposed to Paddock ultrasounds, great supposed to Paddock, really?
Because most of the time you will see what's there.So study that my student did this year, looking at correlating the biopsy results in cads with their ultrasound results for parenchymal disease because the poster Paddock, you know, if their Stones there or there's cholecystitis or there's a mucusy lures is, you know, pancreatitis but not even hungry Titus necessarily but the parenchymal disease is an issue and One of the questions that I've got here is was the ultrasonographer blind.
So in the analysis that we did in these are all caps that had been ultrasound at the IVC.So specialist ultrasonographer is you know all the kids blah blah blah blah.And what we found was that there were two ways that it was analyzed but one was did the officer not refer call that there was pathology there or did they say no and was their pathology, they're based on biopsy or cytology and then if they did call it, did they call it right?
You know.So they gave a range of possibilities.How?Right?Word.They so what it turned out was that they were wrong, a lot of the time, what they called, even if they gave a range of options that would be something else.But but the the main take-home message was that there are all sorts of different types of liver disease.But we analyze the inflammatory in the neoplastic and what it turned out was that if they had near plastic liver disease, then I think one of the cats didn't have ultrasonographic changes but if they had inflammatory disease, if they had cholangitis, then something like 40% of them didn't have ultrasonographic.
Changes.And so the take-home message again is ultra sonography can never rule out liver disease parenchymal disease and particularly.So if it's in, if it's inflammatory at least in calves because cats are more likely other than pancreatitis and if and then in another study we did, the general gist would be that about 20 percent of cats that have pancreatitis will not have an abnormal pancreas and that's where Specialists ultrasonographer it in terms of what process.
Yes, I'm just trying to see what I was thinking.Before you give us the results, neutrophilic cholangitis is more common, in terms of signal meant in a younger cat as opposed to do kneecap and also the history.Like it's a three-week history, whereas neutrophilic cholangitis should be more acute.So nothing is absolute.
In medicines of can't exclude it, but in terms of probability, it will be less likely because of these things, okay?So the little silicon, John is tends to be younger.There's some suggestion is more common in males, and they weirdly will.Present with weight loss despite it normal or an increased appetite.
So they tend to their kind of weird that way.So and they also aren't nearly as frequently Pyrex sick and remember, this cat was poetic, so the fact that you've got a jaundiced Pyrex occult cat.You'll probably neutrophilic cholangitis or lymphoma are sitting up there saying hello, if he was much older, then you'd bring in FIP because it has a bimodal thing or if he was young, then it might be FIP as well.
Jill, sorry.I might have missed this before but whether the other Liver function, model parameters normal, like albumin, glucose cholesterol.His, his albumin was fine.Really?I can't remember his cholesterol is, I never cholesterol.Can go up or down with liver disease.I'm not sure what it tells you really.Okay, yeah, but good question, but looking at the albumen because if his album and had been decreased, then that would absolutely planted firmly in the liver and that's a absolutely, really good point.
Whereas if you had post a paddock disease, you would not expect these a movement to change.If the owners were committed and we've got to that point out the obvious and really it's just biopsy and yeah.And that and the other these are and this is a real case I promise on a real case in general practice.
So the owners were committed and he had biopsy confirmed, neutrophilic suppurative cholangitis and pancreatitis they didn't biopsies gut.And then these are the key questions that I think come from this cat.So why were the liver and pancreas so shy about telling the blood?
There's something wrong.Enzymes are really short lived.They don't like to tell the blood that something wrong.Would it have been helpful to do bile acids.And the answer is, no, it wouldn't have told us anything.And then in particular was so we've talked about Emily's, so, and Liars, really short life, not much of it.
No use Alp, if it's up, take notice of it.But if it's not up, whatever, bile acids.Not a point here pli, we haven't talked about yet and then was the ultrasonographer blind, which is so I guess the thing we haven't talked about is PL.Why so much you sent my dollarz was okay.
And this is based on a study that we did a couple of years ago on 275 cats with pancreatitis.So it's the largest study on cats with pancreatitis looking at pli.Now, the problem with pancreatitis in cats is that being sure that the cat's got pancreatitis is difficult because unlike dogs that do their card-carrying vomiting abdominal pain, blah, blah, blah blah.
They don't do it.So in an ideal world that sort of gold standard, Is biopsy although even that can be challenging and as we know, we're not going to run around boxing, the pancreas in every cat that we think might have pancreatitis.So we used as a criteria that the cats had to have to have confirmed pancreatitis, they had to have clinical signs that were consistent.
Well, that's easy.Because they can have practically anything.They had to have nothing else.That could have explained.Those clinical signs.They needed to have ultrasonographic changes that were consistent with pancreatitis what?Our ultrasonographer said.And for some of them they had biopsy or cytology.
So of the 275 cats with spec, this is one you sent off to the lab.So the reference range is less than 3.5 values.Greater than 5.3 is said to be consistent and there are values in the gray zone.So what we found was and there are studies that will say that the sensitivity.
So in other words, how good is the test at picking up cats with pancreatitis?So in the literature, it's reported to be about 67 percent, which means that about So two cats with pancreatitis will not have an elevator pli.Now, that study was a really good study in that every cat was a study of 28 cats.
Every cat had a biopsy of card-carrying biopsy, but it was only small was 28 in our study of 275 where we diagnose the pancreatitis based on clinical signs, ultrasonographic findings and for some of them on biopsy and no other, no other disease.
That could have explained their clinical signs.What we found was that we had 24% Falls - so we had a quarter of our cats who had what seemed to be pancreatitis, but every other criteria that you could name, did not have an increased pli.
And in fact, because we excluded cats with ultrasound changes and other studies suggest that about 20 percent of cats, at least with pancreatitis have normal ultrasound.We may have, in fact, a higher number of false negatives but the other thing is specificity.
So this is where you say.If the test is positive, is it a true positive?And so if it's increased is that mean?Yep.This cats definitely got pancreatitis and what was found in the literature when the test first came out, it was sort of touted as being close to 100% And then more studies came out.
But again, the lots of not very great study is not very well controlled and it's a problem disease.So there was a sort of suggestion there up to a third posit false positives.We actually found that the false positive rate It was relatively low, it was about 10% and the higher, the value went.
And I think when it got to about so was above 5.3, I think when it got to about 12, the test would show that, you know, the specificity was now like about 99%.So the message in cats is completely different than the Pline dogs were that, which is another story, which is that if the pli is positive, so the spec that gets sent off then you've got a pretty good chance this It has pancreatitis.
I mean there will be some false positives but it's not very high, but if it's negative it doesn't rule out the diagnosis, the SNAP test.It's got a higher sensitivity, there's not really good numbers around about it, but it's a higher sensitivity.So you probably have a slightly less lower false negatives, but it's got a lower specificity.
So you'll have more false positives.How we manage pancreatitis and cats tends to be in flux, you know, we had this little period where where Carolyn Mansfield was saying, for example, I, we think it's bacterial.I think you should treat them with antibiotics, and I've certainly treated a couple with antibiotics and I did really well and then that have gone back saying, oh, no, we don't think so.
Kenny Simpsons saw bacteria and their then maybe it's bacterial.So, in that cat because it's grumbling it on going, I will tend to do it if the owner can afford it.But if I had to, and the problem, it's a sort of Combination.So, the money spent on an ultrasound, I can't rule it out on the ultrasound and I can't rule it out on the test, but probably the combination of both of them is most likely to give me the diagnosis.
And so, so in dogs, it's the complete reverse in that in dogs.When you've got a dog that presents with acute abdomen, you're not going to wait around for a bli, you might do the DP DT, g, whatever.
But the same thing applies and in dogs roughly, It goes roughly that you've got a twenty percent false negative rate in the twenty percent false positive rate roughly and then doll was, if you want to spend your money, what is much more important is that you make sure that that dog does not have an acute abdomen for something else because that's when it's surgical.
So that's when you need the surgeons and that's when it's important.And so the imaging radiology and ultrasound, not just ultrasound because, you know, intestinal obstruction, that's when you want to spend your money on the Imaging.So I can't.Think of the last time I did a line, a dog but I have done them in cats so you see that you look at it's great.
You're going to do the very Basics so pcv13 be yep.That's going to tell you a lot and then I feel like almost the next most valuable things going to be Imaging to grow, The Outpost the Panic.So make sure that you play zero-sum.Yeah.Yep.
You broke him.Didn't tell and it's if you know if it's if it's Eerie, the bike.Mm.Yeah, I mean I forgot my keys.The only time the by Kim will really be hot.One is the albumin.So, if you've got a lot of argument, then this cats really got a really sick liver and to in the Caps that have a paddock liver doses which is uncommon for sure.
In our study.We had, I don't know, 10 percent of them, had a diagnosis of a paddock with the diocese.Don't get Professor Church started.I can just feel his eyes and boring on me and it just going to leave that for him.But in cars with a paddock liver doses, it has been established that At and this is what we would call.
Well, people refer to as primary have, had it liver disease and other words, they don't have underlying disease other than what triggered their anorexia in the first place.And those ones are the ones that have the higher out faster than the GT, so that might be something.But then have had Italy because Isis is also kind of easy to diagnose on a spirit rather than have needing a biopsy, but yeah.
Imaging.Absolutely.Yeah, you're gonna go for biopsies.Yes boxes.If you're not anemic And there's nothing we had on the scan.I'm gonna do blood tests to be sure there's yeah but and it's reality is that probably if you've got to join us tab, it's not anemic.
You do a scan and it's a good scan and you know what you're doing and there's nothing on the scan, then the chances are, it's got inflammatory disease.But what you don't know is whether it's neutrophilic or lymphocytic but as we said in this cat because of its age because it's Pyrex it's much more likely to be neutrophilic than lymphocytic but if it was younger And if and particularly, if it presented.
So, you know, lymphocytic cat often presents with they can be polyphasic.I don't know why, but they often present with polyphagia, Billy being jaundiced and weight loss.And so they kind of present differently Alvin and give you any more information of than it points to liver.Does it tell you about severity?
Yeah.So, the albumen, obviously, the albumin can go up if they're dehydrated and that can go down if they're losing it in the gut or they losing in the kidneys.But if you're happy, they're not.Is he in the god or the kidney then if you have a animal with liver disease, that is hypoalbuminemia, they have lost 80% of their liver function.
So they are the ones that are also going to have clotting Factor issues as well, both clotting Factor synthesis and clotting Factor Activation, so they're sick.Interestingly another study at one of my students have this year was looking at the differences in clean path.Parameters between dogs, with shunts portacaval, shunt sand cats, were portacaval, shunt and cats were much less likely to Be hypoalbuminemia which I find fascinating.
I've no idea why but much less likely Professor church.Do you want to just comment about the hepatic necrosis?I really don't.David doesn't believe in The Paddock with the doses.Everybody else in the world at least believes that there is a syndrome that cats will get if they have been overweight.
Don't eat for some reason and become and their liver becomes stuffed with fat.And the only way they get better is to feed them, he doesn't believe it exists.I'd like to put a case for the defense here for a second.I didn't say I don't believe it exists.What I said was, I don't think a cat with a swollen liver because of lipid deposits is going to be in evident because of the swollen liver and the liver deposits.
That's what I'm sorry.So what point is?They get fatty liver but that isn't the reason they're not eating so not because triggered by something else.What do we call it a petty Clipper, do some describe to somebody syndrome when it doesn't make any sense, isn't it time you talked about Addison's disease.Has on them.If you like that format and you like the way we ran that session, then you will probably like, what are we going to do later this year at the Vets aren't or Wanaka?
That's New Zealand conference, that we will be doing some more live podcast event.So if you haven't come across it yet, dr.Dave Collins, who is a regular guest on the clinical podcast host, these amazingly fun conferences around the world.That is focused a lot around skiing Young and also some continuing education.
No, I like really good, continuing education, but always in a fantastic location.And this year, from 14th to 18th, August at that 2023, we are going to the Edgewater Resort in one car and I will be going again.As the red fault to do some live broadcasting, with Incredible guests, talking about palliative and hospice care.
And I spoke to one of the people are going to be presenting their that palliative care doesn't have any relevance to be as an emergency vet and she said, know what we Food, emergency vet those end of life conversations.That's all hospice care.I'm suddenly very interested in these sessions talking about ecology and then we are talking about management and Leadership.
So great stations, join us for the CPD.Join us for heaps and heaps of skiing join us for the legendary.Some might say notorious party night that is always happens on red Center.That's 14 to 18 24 August 20 23 it's not even on the website yet so if you do want to get in early contact Dave at vets on tour, At gmail.com.
Or look, for weights, onto her on Facebook.Also, put some links in the show description left to see you there.At gmail.com.Or look, for weights, onto her on Facebook.Also, put some links in the show description left to see you there.

Prof Jill Maddison