A very sweet 9 year old spayed female Oriental Shorthair was seen by a colleague at the practice in June for an upper respiratory infection. She was rescued only a few years ago by a nice couple, who are excellent pet owners. Some cats have chronic nasal discharge from infections when they were young kittens. This seems to happen more in the cats that have spent some time in shelters.
I saw her about 3 weeks later because she wasn't improving on the antibiotics. She also had an ear infection. We put her on ear meds and switched the oral antibiotic. Blood work done on her that day was non-remarkable (this included a complete blood cell count, chemistry panel - liver, kidney, pancreatic, etc values , and a thyroid test). The only "blip" was an elevation in her amylase, which we most often associate with the pancreas but it is not exclusively produced by it.
She came back in another 3 weeks and was seen by one of the owners of the practice. This time her ear problem had worsened, so she was sedated and found to have a ruptured ear drum. She was given a steroid injection locally in the swollen ear tissue and the owner was told to discontinue the topical meds until we could re-exam her.
I saw her for a recheck in another 2 weeks and she was doing great! She was feeling better and her ear was on the mend.
In another 2 weeks, she came back because she was not doing well but in a different way. She wouldn't eat and was lethargic. She was 7lbs 4oz when this first started. On this date she was now 1 lb lighter. This is NOT good for a cat - think about the percentage of weight loss that this represents.
We put her on an appetite stimulant and ran some additional blood work. Again, nothing major going on there. Her Amylase was elevated a bit more than previously. As as side note, her lipase was never elevated AND these are both not often even elevated in cats with raging pancreatitis!
We spoke with the owner a few days later who felt she was not doing better AND they had trouble giving her the appetite stimulant (it's a pill). She came back the next day for a "touch" of IV valium (a wonderful magical instantaneous appetite stimulant in cats), fluids and an lateral abdominal radiograph. Just know that her abdomen palpated normally and wasn't really painful. Below is the xray:
I was VERY surprised by this. In 13+years of practice I have never seen anything like this. It had to be her gallbladder (her stomach has gas in it - black - seen just behind the bright white defined "mass"). The only other thing possible would be some sort of calcified mass in her liver but I took another view (with kitty on her back) and confirmed it was her gallbladder.
It looked like someone had injected contrast into her gallbladder versus stones. Weird and very interesting! She needed an abdominal ultrasound to get more info on what exactly was going on here, but the vet that does those was out that day. We put her on a different antibiotic (one we use for liver and GI issues). A few days later she did get the ultrasound and they found a shadow in that area (usually indicative of a stone) and bile duct distension.
We referred her to a surgeon in the Lehigh Valley. We all thought they'd take her gallbladder out but they did not. They didn't find any stones, just a lot of sludge in her gallbladder and a blocked common bile duct, which they flushed and unblocked. They elected to not remove her GB because they said it appeared healthy otherwise. They did do cultures of it and also found a small pancreatic nodule that they biopsied. They also biopsied her liver but everything else appeared normal.
The pathology on all these samples did not show any cancer and her gallbladder was simply "chronic cholecystitis." They did say she could potentially have future episodes. Cats can have cholangiohepatitis (GB and liver inflammation) for various reasons, so we will be monitoring her closely.
There are several comments I'd like to make on this case:
1. The upper respiratory and ear issue had nothing to do with her gallbladder issue but she was in and out of the practice a lot over the summer. That happens in veterinary medicine. Fortunately these pet owners didn't try to link it all together as some do. Many times what we see are coincidental issues or 2 or 3 problems in the same patient. None of the medications she was ever put on would cause this to happen and it was likely happening for quite a while before we even saw her for her "cold."
2. These owners are very dedicated. All of this did cost them a lot of money. So what if they couldn't go forward? In some cases, we can do things in general practice, like offer to do a procedure we may not have as much or any experience on for a much reduced cost as long as the owner is made FULLY aware of that and I'd say (in this day and age) signs a consent saying such. I would've done it for them. Since we have specialists nearby, we have to always offer referral. Back in the day (and I see this as both a good and bad thing) we just had to do it ourselves - figure it out, be creative, etc.
3. This cat's blood work was normal. You'd be amazed at how many times blood work is normal and something BAD is going on. This is why we recommend further diagnostics. But some of us do know that even then if things are normal, something could still be wrong!
4. I KNOW how it felt when I had this issue for 6 months! I wonder what SHE was feeling and too bad she couldn't tell us! But hey, at least she didn't have to go through 6 months of pain . THIS part of her medical history started on 8/11/2011. Her surgery was on 8/23/2011!! I think she wouldn't have lasted too much longer anyhow, because eventually she would've gone off food and become icteric (yellow)...there's a saying in vet medicine "Yellow cat, dead cat" and it is usually true.
5. Even though cholangiohepatitis is common in cats (often as part of what we call triad diease - the other two being pancreatitis and inflammatory bowel disease), THIS radiograph is NOT how it usually appears. In fact, they are usually completely normal! It's usually found by doing blood work and abdominal ultrasonography +/- biopsies.
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