Cholagiohepatitis and Hepatitis in Cats

Lymphocytic Periportal Hepatitis - Holistic herbal treatment

Question: Dear Dr. Richards:

My cat, Max, is 8 years old and has been diagnosed with Chronic Lymphocytic Periportal Hepatitis.

Max had some blood work done on May 18, 2000 and the following were the results:

ALT (SGPT) 1462 (H)

ALK PHOS 317 (H)

ALBUMIN 3.9

CHOLESTEROL 462 (H)

The following are blood results for Max on June 13, 2000:

ALT (SGPT) 885 (H)

ALK PHOS 137 (H)

ALBUMIN 4.0 (H)

CHOLESTEROL 364 (H)

Max is on the following medications:

Metronidazde, 50 mg., 2 times a day Ursodiol, 40 mg., 1 time a day Prednisone, 10 mg., 1 time a day

I was recommended the following holistic medications for Max:

Cytozyme LV, 1/2, twice a day Gu Ben Wan, 3, twice a day Shu Gan Wan, 3, twice a day Prozine

My question to you doctor, are these holistic medications that I have listed above okay to give my cat? Will they harm him in any way? Will they help his condition?

Any information that you can give me would be greatly appreciated.

Thank you, Karen

Answer: Karen-

I found a site tonight on the internet that listed the formulation of some of these things. The URL is copied below:

http://www.cathayherbal.com/library/TCM_Feature_Articles/Ginseng_Formulas/Gu _Ben_Wan/gu_ben_wan.htm

Ginseng & Rehmannia Formula (Gu Ben Wa): there are no listed contraindications to using either of these medications in the PDR for Herbal Medicines for liver disease but ginseng has to be used cautiously in diabetics, when high blood pressure is present and if diuretics are being taken at the same time.

Chai Hu Shu Gan Wan (from: http://www.barefootdoctors.com/chiherb.html) Historical use in China: stress, cold hands and feet, regulate menses Contents: Buplerum Root, White Peony Root, Aurantium Fruit, Licorice, Ligusticum, Cyperus Label Instructions: 8 pills three times daily

From PDR-- I found information on licorice. It is indicated for treatment of some forms of hepatitis (viral hepatitis in humans) and should not be used at the same time as diuretics because both can cause low potassium.

Cytozyme LV is neonatal calf liver in a concentrated form according to this web site: http://www.naturmedicine.com/vitaminc.htm There is no information on this product other than this web site that I was able to find.

According to this web site: http://www.thriveonline.com/health/Library/drug/drug339.html , Prozine is a brand name for chlorpromazine or Largactil. If this is the case, I am not sure why it is being used. It is sometimes used in vomiting patients for its anti-emetic effect. There is also the strong possibility that there is another product named Prozine but this is the only one I found. Chlorpromazine is a phenothiazine tranquilizer. This is a good web site for information on this compound in humans: http://pharminfo.com/drugfaq/thor_faq.html There is not a lot of use of chlorpromazine in pets and I am not aware of any studies of long term use.

I found most of these sites using the search engine at http://www.google.com It works pretty well for medical stuff. All of the information is based on humans. As I mentioned previously, I could not find references for use of these medications in pets.

Mike Richards, DVM 6/28/2000

Bacterial hepatitis/suppurative cholangiohepatitis

Question: My name is Kathy, on approx 2/28 I wrote about my cat Lil Bit having a strong urine odor. You were kind enough to reply letting me know my cat may have a real problem. I don't want to use up your valuable time, but I thought you might find interesting what happened.

On 3/6 I came home at noon and Lil Bit was acting ill, he also threw up. Later that night he was still acting like he didn't feel well but being affectionate so I didn't worry too much but thought that if it persists until morning I'll take him to the vet. Then I noticed him loose his balance. Very odd for a cat. I live in a small town, there are no 24 vet hospitals around here so it had to wait until morning. In the a.m. Lil Bit shook his head and fell completely over. I was panic stricken. I got him to the vet and had to wait a gruelling 24 hours for blood and urine results. I am told he has bacterial hepatitis. We took him home on the 8th and he was a new cat. He's on antibiotics, vit K, and liponal. He's doing very well.

I am having a difficult time finding out about it. The veteranarian claimed it was not uncommon.

Thank you again for your time.

Kathy

Answer: Kathy-

Bacterial hepatitis in cats is often referred to as suppurative hepatitis, suppurative cholangiohepatitis and sometimes cholangitis (if the infection primarily affects the bile ducts, rather than the liver itself). You might want to search under those terms, too.

Suppurative cholangiohepatitis may be the initial form of chronic cholangiohepatitis in cats, which is a fairly common disorder, especially in older cats. If the problem can be caught in the stage in which bacterial infection is just starting response to treatment can be very good. It is sometimes necessary to continue antibiotics for a month or more in order to eliminate the bacterial infection in the bile ducts. It can be helpful to use a medication such as Actigall (Rx) to help with bile flow, as well. This problem can occur in conjuction with inflammatory bowel disease (IBD) and pancreatitis to produce a syndrome that is currently referred to as "triad syndrome" and "triaditis". I am hoping a better name comes along but that is the one I see used most often to describe cats affected with all three of these conditions at one time. The major reason for including this syndrome in this note is that it is likely to be a chronic or recurring problem if the other disorders are present. Persistent vomiting and weight loss are the most prevalent signs associated with triad syndrome and also with both IBD and pancreatitis in cats.

Hopefully the success of treatment so far will hold up and you won't have to worry about these other possibilities.

Mike Richards, DVM 3/13/2000

Cholangiohepatitis and Cholecystojejunostomy

Q: Dear Dr. Richards:

In October of 1989, we adopted a male cat, about two to three months old, from an animal shelter. Sammy was sickly and at first tested positive for the feline leukemia virus. We force fed him and he grew stronger and later had him tested again for the feline leukemia virus, and the Vet said he tested negative. In about March of 1999, we started noticing that Sammy, a ten and one-half year-old male neutered tabby cat, started drinking increased amounts of water and had abnormally large amounts of urine in his litter box, as well as diarrhea (like pudding). On approximately April 9, we started noticing Sammy was coughing up small amounts of clear liquid, seemed to be uncomfortable around his head, particularly his ears, and just seemed to not feel well. On April 12, we took him to the Vet and told him about the increase in water drinking, the large amounts of urine, diarrhea, and holding his head funny. The Vet found that he had a temperature, which he said ruled out diabetes, but, upon examination, found Sammy had fluid in his lungs and an ear infection. The Vet gave Sammy an antibiotic corticosteriod IMSQ shot and sent us home with some antibiotics (Amoxi drops 15ml). After a few days, Sammy improved, but the increased water drinking, excessive urine and diarrhea continued. On April 21, we took Sammy to get his annual shots (feline FVRCP, feline leukemia and rabies) and again informed the Vet of his increase in drinking water and urine. We also told the Vet about Sammy coming from an animal shelter and that he first tested positive for feline leukemia, then negative. The Vet had to sedate Sammy, but tested him again for feline leukemia, and he tested negative. About a month later, I noticed Sammy was going to his litter box frequently, with no results. Through all of this, his appetite was increasing a small amount. I took Sammy to the Vet and told him about him sitting in the litter box and that he still had the increase in drinking water and increased urine and increase in appetite. The Vet could get no urine to test for bladder infection, so he sent us home with a special type of litter to get a sample urine. When we got home, Sammy immediately went to use the litter box to urinate and his urine definitely had blood in it. The Vet tested his urine and said there was definitely blood in his urine, and again sent us home with antibiotics (CEFA - Drops (15ml)). On approximately June 16, we were still noticing that Sammy was drinking large amounts of water and the increase in urine and that he had diarrhea and the Vet suggested doing some blood work on him. He again had to be sedated to get the blood and while he was out, the Vet cleaned his teeth, which he said were bad, in fact, some of the front teeth should be pulled, but that they were in the jaw bone region and he was afraid that he might break his jaw bone if he pulled them. I did not get a copy of the blood tests results, but the Vet said that he showed no signs of thyroid problem, no problems with his liver and kidneys and blood sugar was within normal range and suggested I put him on some special food to help with him with the diarrhea (CNM EN Formula). Sammy would not eat much of the special food, but it appeared to not help his diarrhea. On approximately July 30, we started to notice that Sammy was lethargic and had stopped eating and drinking water. Sammy would go up to the food bowl like he was starving and sniff around, but would not eat. On August 2, we took Sammy to the Vet and the Vet said Sammy had a temperature and upon removal of the thermometer, there was blood in his feces. Sammy was also dehydrated. The Vet wanted to do some more blood work, for which Sammy did not have to be sedated, as he was feeling so bad. The Vet also put Sammy on liquids for dehydration. He gave Sammy a shot of antibiotic corticosteriod IMSQ. The Vet called a few days later to tell us that Sammy's blood work showed negative on Feline Infectious Peritonitis, Feline Toxoplasma Titer, but that his liver enzymes were elevated and that he had bile in his urine ( I'm not sure this last part is right, but I believe he said that he was showing signs of toxicity in his urine). He also said his blood sugar was elevated. The Vet referred us to a specialists, who did a battery of tests (more blood work, ultrasound, x-rays, and a liver biopsy). She said his liver enzymes and bilirubin were elevated, his blood sugar had come down and that he had bile in his urine the consistency of which was muddy. She found no bacterial growth and the gall bladder did not appear to be enlarged. Her ultimate diagnosis is CHOLANGIOHEPATITIS AND CHOLESTASIS. She advised us that Sammy needed a feeding tube and also wanted to surgically take out his gall bladder. We talked her into letting us to try to force feed him at home on Hill's Feline A/D diet (one 5-1/2 oz. can mixed with same amount of water) at 40 ml. six times a day and give him the antibiotic CEAPHALEXIN (or CEPHALEXIN I don't know which spelling is correct) (250mg) one-half tablet twice daily.

For about two weeks we have been feeding him Hills Prescription A/D and Science Diet Maintenance Light which is the food he was on to begin with. At first, he had to be force fed the Prescription A/D (mixed in a blender with water). After a few days, he appeared to want to eat on his own and, after consulting the specialist, we let him eat Science Diet Light (both dry and can) and continued to force feed the Prescription A/D. His attitude and appetite are showing marked improvement, and he appears to be getting back a lot of his strength. We are taking him for follow up blood work today, and will not get the results back until sometime next week.

Since Sammy's diagnosis, we have tried to obtain as much information on cholangiohepatitis and cholestasis as we can, including reviewing a number of pet manuals that we have, searching the Internet (this is how we found you and why we have just subscribed to the VetInfo Digest) and purchasing the current edition of the Merck Veterinary Manual. We know the importance of getting Sammy to eat, and appear to be successful in this (he does eat on his own now, in addition to force feeding). What we do not understand is why the specialist suggested removing his gall bladder. I understand that vomiting is a symptom of gall bladder disease, but vomiting has never been a symptom of Sammy's except when he had fluid in his lungs as I stated earlier. I asked her if she was absolutely certain that the problem was with his gall bladder, and she said she was not certain. Although we found plenty of information on cholangiohepatitis and cholestasis, we were not able to find anything on the need or benefit of removing the gall bladder. We did find one brief reference to the use of Actigall as an aid in treating cholangiohepatitis, which the specialist has not mentioned.

We are writing to you for insight on why this procedure was suggested, and if it is a common practice, as well as any other observations that you might have in this area. Also, is it possible for blood tests taken within a few weeks of each other to show substantial differences as Sammy's has? Although Sammy appears to be doing better, no underlying cause has been found for his cholangiohepatitis and cholestasis, and we are trying to determine if his gall bladder might be the source of his problem, and its removal a solution.

We would really appreciate a prompt response from you, if possible, since we may have to make a decision on the surgery next week. If you need more information (such as blood work results), we can email or fax them to you.

We found your responses to other writers in this area to be very helpful, and will deeply appreciate any information that you can provide.

Sincerely,

Mike & Shirley

A: Mike and Shirley-

At the present time, I am not aware of a strong indication for removing the gall bladder in the cats with cholangiohepatitis. In some cats with this condition the common bile duct from gall bladder to the intestine becomes inflamed or scarred to the point that it is not functional and it is recommended that the gall bladder be directly connected to the small intestine in a surgery referred to as "cholecystojejunostomy". In most cases, medical treatment is probably sufficient, though. Corticosteroids are sometimes used to control inflammation and a medication whose brand name is Actigal is sometimes used to "thin" the bile and allow it to flow through the liver better.

Cats can have infections involving the gall bladder that do sometimes require removal of the gall bladder to control. In other instances the gall bladder may become necrotic due to gall stones, infection or progression of the cholangiohepatitis and that may require removal. It wouldn't surprise me if the specialist was less enthused about removing the gall bladder with the improvements you have seen, though. It is not considered to be an easy surgery and complications such as bile peritonitis can be difficult to treat, so even a lot of surgeons try to avoid gall bladder removal in cats when other treatments appear to be working. Your specialist may feel that one of the conditions that make it necessary to remove the gall bladder is present. But it is worth reviewing the reasoning and need for surgery again with her.

It is possible for liver values to change quite dramatically in a very short amount of time. The half life of the enzymes tested for is not long and it is theoretically possible for the values to change by as much as 50% in one to two days. In addition, there is often variation even in a normal patient in the liver enzyme values that can often be 40 or 50 units between two blood samples for alkaline phosphatase and ALT enzyme levels. But it is still a good sign when the liver enzyme levels are falling.

It is important to evaluate how the patient feels when thinking of what lab values mean. This is particularly important with liver disease. Lots of times we see patients who are clinically much improved before the liver values start to fall -- and the clinical improvement (increased appetite, activity, etc.) usually is a reliable sign. Not always, but usually.

I think that it would be be best to find out if the specialist was actually referring to a cholecystojujenostomy, whether she continues to feel that gall bladder removal is necessary in the face of the improvements seen and whether or not a medication like Actigal or prednisone might be called for at this time. Also, the new liver diet from Hills (l/d) might be beneficial. An exploratory surgery, including liver biopsy, may be worthwhile, even with some improvement. Knowing for sure what is going on can really help with long term planning. Balancing that need against the risk and expense of surgery is always hard but it is useful enough that it should be considered.

It is usually a good idea to test a cat that has been positive for feline leukemia again for this disease when severe illness occurs. Unfortunately, the current thinking is that cats stay infected but that many can adequately suppress the virus and stay well -- but severe stress can reactivate the problem. This sort of illness is obviously a severe stress. I am glad that Sammy did not show positive but you will have to consider that possibility again in the future if he has further episodes of severe illness.

I am in favor of getting bad teeth out, so when you have the liver problems under control it would be good to consider removing the teeth at a future time. If your vet is uncomfortable doing that he or she may be able to refer you to a veterinary dentist.

Good luck with this.

Mike Richards, DVM 8/22/99

Cholangitis or Cholagiohepatitis in 6 year old Siamese and continuing treatment

Q: Dear Dr. Richards,

Thank you for replying. I'm sorry if I wasn't clear on the eye condition and cholangitis. The eye condition has been cleared up and has not been a problem since 12/97. However, in the process of trying to get it cleared up, bloodwork revealed high ALT levels which lead to the diagnosis of cholangitis, which is now part of his problem, although the exact nature of his problem is still an enigma.

It just has us all stumped. I was hoping that with your experience you may have come across something like this and be able to offer some clues and suggestions...although I think we've pretty much done all we can and are continuing to do so...just treat the symptoms as they occur. The vet has ruled out FeLV, FIV, toxoplasmosis, parasites and thyroid problems. Possibilities are FIP, but he says that the symptoms aren't following the course of a normal case of FIP, and lymphosarcoma, but nothing has shown this to be positive so far.

The odd thing is that my cat doesn't seem to feel bad, although there are days he isn't as perky as others. His appetite is good, he is mostly frisky, however he does have very loose stools, but this began after we started his medicine (clindamycin and bile salts). He was also prescribed baytril, which he couldn't tolerate. He has finished the clindamycin and bile salts (6 wks regimen) and is now on a 6 wk regimen of clavamox. The latest test (4/3/98) revealed ALT of 500 and elevated kidney readings (don't know exactly what) and elevated WBC. My vet says he is not sure what could be causing it, but put him on the clavamox. If it would be of any help, the following is a history of tests and results since 1/98 and I'm hoping that they might give you a clue for any further suggestions? I'm sorry this is so long. I think I am grasping at straws now to help my pet and it's frustrating that a cause and cure can't seem to be found. Thanks so much for your input and especially patience in reading all of this...please read the following:

The following is a recap of the tests and results done so far:

ALT RANGES:

1/29/98 - 205; 2/13/98 1,628; 3/4/98 - 195; and 3/18/98 - 536.

LIVER BIOPSY:

"Hepatic punch; the liver parenchyma contains multiple accumulations of small numbers of neutrophils and hyperchromatic debris scattered in multiple foci throughout the specimen. In several foci there are clusters of a few hepatocytes which have vacuolar degeneration of the cytoplasm. Brown to slightly green pigment is present within hepatocyte cytoplasm and within Kupffer's cells. This pigment is negative for iron therefore it is likely to be bile, which has accumulated as a result of bile statis.

Dx: Hepatitis, suppurative, subacute, multifocal, mild with bile statis."

THYROID TESTS:

T4 RIA = 19

TOXOPLASMOSIS TITER:

Specimen: serum Test: Toxo titer Method: Latex agglut. Results: <1:16 (neg.)

ABDOMINAL ULTRASOUND: (These are the abnormal findings - other organs were "normal")

Spleen - Mild difuse enlargement

Left kidney - Diffusely hyperechoic; patchy hyperechoic change medulla, mineralized renal pelvis, enlarged (L-4.5 cm) and elevated vascular resistance (RI=0.76)

Left adrenal - Mineralized cranial pole (0.2 by 0.7 cm) Stomach - Mineralized or hyperechoic submucosa (3mm)

Liver - Rounded, enlarged, diffusely hyperechoic; decreased velocity of portal flow intrahepatic (velocity=0.7 m/s) which suggests portal hypertension

Right kidney - Similar to left kidney but smaller (L=4.0cm) RI = 0.88)

Pancreas - Diffusely hyperchoic, normal size bocy = 0.6 infarct in caudal pole cm

CHEST AND ABDOMINAL X-RAYS:

The heart and major thoracic vessels are within normal limits. The pulmonary parenchyma shows a diffuse increase in bronchointerstitial opacity. The differential diagnosis should include allergic lung disease (feline asthma) as well as other infectious or inflammatory conditions of the lung. Radiographs of the abdomen show small foci of mineralization in the renal pelves. There is considerable digesta in the colon. Other abdominal viscera are within normal limits. There is no radiographic evidence of fluid or generalized inflammation in the abdomen.

Impression: Diffuse bronchointerstitial opacity in the lungs; small mineralized foci in the renal pelves bilaterally.

PARASITE TESTS: All came back negative (lungworm, roundworm, heartworm)

The only other significant thing I was told was that his eosinophills were elevated:

1/29/98 - 4; 2/13/98 - 1; 3/4/98 - 26; and 3/18/98 - 23.

Sincerely, Alice

A: Dear Alice-

I have to say first off that I do not have extensive experience in treating cholangitis or cholangioheptatis in cats. We have treated cats with these problems in our clinic over the years but have no special expertise. I think that your vet has done an excellent job of selecting appropriate tests in order to rule out the most likely underlying problems and you appear to be well informed, so I have to assume that he or she is also communicating well with you.

Cholangitis is inflammation of the bile ducts, primarily. Cholangioheptatis is inflammation of the bile ducts and liver. I think that the results of your cat's tests probably indicate cholangiohepatitis.

Suppurative cholangiohepatitis is diagnosed by the prevalence of neutrophils among the white blood cells present in the biopsy. Neutrophils are present when there are bacterial, viral or parasitic causes, usually.

The virus most commonly implicated in this condition is feline infectious peritonitis virus (FIP). Feline leukemia virus may be able to cause this condition as well or at least cause enough secondary problems to indirectly affect the liver. FIP is hard to test for accurately, even by biopsy. Testing serologically for antibodies to FIP is controversial. Many cats have positive titers to FIP who are not infected with the virus. Perhaps as many as 80% of cats may be positive on this test. Some severely ill cats with FIP test negative for antibodies to the virus. Due to these problems many vets feel the test is worthless. On the other hand, I attended a continuing education seminar in which Dr. Greene, a infectious disease specialist from the University of Georgia stated that the test has some value in helping to determine how likely FIP infection is because a very high titer in the presence of clinical signs was a big hint that the problem is FIP. Of course, specialists usually worry a little less about spending people's money than general practitioners. The bottom line in all of this is that FIP is a definite possibility and it is difficult to rule out. Most cats die within a couple of months of signs associated with FIP, though, so the clinical course isn't typical.

The two most common parasitic conditions leading to suppurative cholangiohepatitis are fluke infestations and toxoplasmosis. Liver flukes are somewhat common in Florida and uncommon every where else, as far as I know. Toxoplasmosis is common all over the U.S. A negative titer is a good sign, though. Clindamycin (Antirobe Rx) is the treatment of choice for toxoplasmosis, which is probably why your vet is using it.

Bacterial infections are the last group of infectious causes for suppurative cholangiohepatitis. Most bacterial infections probably are acquired through infection of the bile ducts but a few probably come from blood borne bacteria that settle in the liver. Chronic pancreatitis is thought to be a more common cause of the infection than vets recognize, probably because pancreatitis is pretty hard to diagnose in cats. The inflammation associated with the pancreatitis leads to bile statis and this makes it easier for infectious agents to invade the bile ducts and then the liver. Inflammatory bowel disease may also lead to cholangioheptatis for the same reason. Bad luck is probably the next most likely reason for the bile ducts to get infected.

The bacterial infection is best diagnosed by culturing the bile or culturing the liver during biopsy (or a biopsy specimen after biopsy but this means taking more than one sample). In all honesty I think that obtaining and interpreting cultures is daunting enough that many vets won't try, but I could be wrong about that. I know that I don't do it very often. So I use the antibiotics most likely to be effective in a liver infection, which are usually considered to be amoxicillin/clavulanic acid combinations (Clavamox Rx), cephalosporins (Keflex Rx), fluoroquinolones (Baytril Rx, Orbax Rx) and metronidazole (Flagyl Rx). Metronidazole only works for anerobic infections. Many vets use metronidazole in combination with amoxicillin or fluoroquinolones to try to cover the possibility of both aeorobic and anerobic infections. Other antibiotics may be deemed better based on culture and sensitivity results and aminoglycosides, which have more toxic side effects than most antibiotics, can be used when the situation warrants it. Your vet has been using the antibiotics that are likely to be effective. Helicobacter (of the ulcer fame) is thought to be involved in some cases of inflammatory bowel disease leading to secondary suppurative cholangiohepatitis in cats. It is best diagnosed by endoscopic exam and biopsy.

Chronic pancreatitis in cats is hard to diagnose but the ultrasound exam may point to a problem here based on the infarct seen. Serum trypsin-like substance testing is currently thought to be the most accurate test for pancreatitis in cats, I think. I recently read something about diagnosing pancreatitis in cats and can't remember what it was or where I read it. I will continue to try to remember this and let you know if I find it again. It is sometimes necessary to use parenteral (intravenous or at least not oral) feeding of cats in order to allow the pancreas to heal. This is not something that most veterinary hospitals are experienced at. If this seems like a strong possibility after testing, it may be necessary to ask your vet about referral to veterinary school or specialist in your area who has experience with this.

Corticosteroids, usually prednisone, are another possible medical treatment to consider. Their use is very controversial for suppurative hepatitis because they are immunosuppressive which can make it easier for the bacteria to survive antibiotics or even to gain the upper hand and lead to worsening of the infection. On the other hand, getting rid of inflammation, which prednisone does well, can sometimes allow the antibiotics to work better and stop the stasis of bile that leads to a lot of the problems. I'd place them in the "if nothing else is working, consider this" category and hold off use as long as possible but not rule them out totally. Definitely wait until after long term use of antibiotics, generally at least 8 weeks.

The best way to monitor the progress of hepatic illness in cats is repeating the biopsies as frequently as seems necessary. Determining how frequently is tricky. I think that the overall attitude of the affected cat is the best way to judge when to consider doing further biopsies. If there is obvious improvement and a long course of antibiotics (at least 8 weeks) is over, then consider follow-up biopsy after treatment. If the cat is obviously not doing well or is losing weight continuously, consider earlier biopsy. Liver enzyme levels (ALT, ALKP) may stay elevated when the disease is resolving so they are a little less helpful in deciding when to stop treatment but should still be monitored regularly.

I don't know if this information will help. I do think it is very good that your cat's overall attitude is good. We have had cats in our practice who lived a long time, in reasonable comfort, despite having elevated serum liver enzyme levels throughout much of their adult lives.

Good luck with this.

Mike Richards, DVM

Cholagiohepatitis

Q: Our cat is 2 1/2 years old and eats a little here and there - some times vomits (4 x month) and is quite thin - male cat. I rarely see him drink water. He had two ticks we removed from his neck area last year ( I am not sure this means anything). His bilirubin is 1.7, I understand normal is .5. His other liver function tests where elevated as well. He was diagnosed with choliangiohepatitis. What is this disease and is it preventable? The cat is now taking DAP.

A: Patricia- Cholangiohepatitis is a descriptive term for inflammation of the bile ducts and subsequent damage to the liver. Cholangitis (bile duct inflammation or infection) can occur without liver damage but due to the importance of the bile ducts to liver function there is usually a secondary hepatitis There are actually several causes of this condition in cats but they fall into three broad categories --

1) suppurative (usually bacterial infection) cholangitis/cholangiohepatitis

2) chronic lymphocytic cholangitis/cholangiohepatitis

3) lots of other primary diseases that can lead to secondary cholangiohepatitis or cause it as part of the overall disease process. These include toxoplasmosis, Tyzzer's disease, Hepatozoon protozoal infections, kidney failure and possibly immune mediated disease.

Suppurative cholangiohepatitis is probably the result of infectious agents such as E. coli invading the bile ducts from the digestive tract. Since this isn't a common occurrence it is possible that the body's natural defense mechanisms may be deficient in some way or that some pre-existing liver disease may be present making infection easier. This form of cholangiohepatitis usually has fever, inappetance, weight loss, depression, and sometimes jaundice associated with it. It is less likely to be an intermittent problem than lymphocytic cholangiohepatitis.

Chronic lymphocytic cholangiohepatitis causes weightloss, may cause an increase in appetite or less commonly a decrease in appetite, weight loss, fever, ascites (fluid accumulation in the abdomen), jaundice and sometimes neurologic signs. It is often an intermittent problem with a "waxing and waning" course.

Obviously, the signs of these disorders overlap since the damage that occurs is similar. It is probably impossible to tell them apart without a liver biopsy. Bloodwork, including checking liver values and white blood cell counts helps to identify the presence of cholangiohepatitis. Liver biopsy makes it possible to tell which type is present. In some instances biopsy of the liver doesn't look like a good idea after doing the labwork.

If suppurative cholangiohepatitis is present it is necessary to treat with antibiotics to control the infectious agent. It may take several months of antibiotics to eliminate the infection. At the same time it is necessary to support the liver function. If inappetance is present, using appetite stimulants may be necessary. Dehydrocholic acid (Decholin Rx) is used in cholangiohepatitis to help control the inflammation. Surgery may be necessary to correct bile duct obstruction in some patients.

If the diagnosis is chronic lymphocytic cholangiohepatitis it may be responsive to prednisone or other corticosteroids. Since the use of cortisones could be a problem if infectious agents are present it is pretty important to rule out suppurative cholangiohepatitis prior to using prednisone, if possible. If ascites is severe enough, diuretics may be necessary to control it or even drainage of the accumulated fluid (this must be done cautiously). Supportive care is necessary for this type of cholangiohepatitis as well.

Mike Richards, DVM

Hepatitis and IBD - can people catch

Q: Our cat, a Himalyian female, age 18 seemed to be very thin. We took it into the vet who said that it was severly dehyrdrated, after he took a look at it, but he then did a complete blood panel, an x ray, an ultrasound and then begain an intravenous feeding to try to get liquid and some minerals into the Cat. The cat then died - trouble breathing followed by heart stopping. A biopsy of the liver had also been taken, before death, because the doctor thought the cat had liver cancer because of readings on the blood panel and because the x ray showed an enlarged liver and the ultrasound sound showed abnormalities on the liver. The doctor then concluded from the biopsy that the cat had IBD which in turn caused hepatitis.

1- Assuming the vet is right, can people get IBD and hepatitis from cats? 2- Can a cat get IBD from people? 3- Given the age of the cat, were the number of procedures- completed in 6 hours too much for any cat, causing shock and death? 4- Ought we to do anything special with the cat's feeding dish, sleeping place and litter box? 5- Is it safe to give the items above after cleaning them to a cat shelter?

A: I do not know of any infectious agents causing IBD in older cats which would be infectious to people so I don't think that should be a major concern. The hepatitis that normally occurs in conjunction with IBD is hepatic lipidosis. This is not an infectious condition, either. The reverse is true, too === I don't know of any transmission of IBD from humans to cats.

It is always hard to decide how hard to push for a diagnosis with a severely ill cat. You want to know what is wrong to initiate proper treatment but it is important not to push too hard and cause undue stress. The procedures you describe are not normally excessively stressful (even the liver biopsy in most instances) and I can see a purpose for each one. So I think your vet was doing his or her best to help your cat despite the outcome.

It would be a good idea to disinfect the food bowls, litterpan, etc. just because it is good practice, even though it is pretty unlikely your cat had an infectious disease. Just using dilute chlorine bleach (1:30 dilution) to rinse these after a good cleaning should be sufficient. I am sure an animal shelter would be grateful for the donation.

I am sorry to hear about your cat. It is always hard to lose a friend of eighteen years.

Mike Richards, DVM

Last edited 04/20/04