09 | The complete guide to caring for cats with inflammatory liver disease
Today we’re chatting about another very common feline liver disease - inflammatory liver disease, or feline cholangitis/cholangiohepatitis syndrome.
This is actually the second most common liver disease we see in cats, and our patients can present with a range of signs from mild inappetence and pyrexia, to marked jaundice.
There’s lots to think about when nursing them - including nutrition, managing nausea and pain, fluid therapy and preventing hypotension - and with this, comes lots of nursing skills we can put to good use.
So if you want to know exactly what cholangitis/cholagiohepatitis complex is, why it happens, the consequences for our patients, and the treatment and nursing care these patients benefit from, I’ve got you covered in today’s episode.
So what is feline cholangitis/cholangiohepatitis syndrome (CCHS)?
Cholangitis is the inflammation primarily of the intrahepatic biliary system - specifically of the portal regions of the liver, with infiltration into the bile duct epithelium or lumen of the bile ducts.
Cholangiohepatitis is the inflammation of not just the bile ducts or portal regions of the liver, but also the surrounding hepatocytes.
Why do cats get CCHS?
In order to look at why cats in particular are at risk of CCHS we need to loop back to episode 4, and the anatomy and structure of the liver.
Cats have unique differences in the anatomy of the biliary and pancreatic ducts compared with other species. Their pancreatic duct fuses with the common bile duct before it enters the duodenum at the level of the major duodenal papilla.
This is unlike dogs, where the pancreatic ducts enters the duodenum separately to the common bile duct.
This difference means that in many cats, conditions affecting the biliary tree (+/- liver) also affect the pancreas - for example in conditions like triaditis, which is a combination of cholangiohepatitis/cholangitis, inflammatory enteropathy and pancreatitis.
Let’s look at CCHS in more detail…
There are two forms of CCHS we see in cats - neutrophilic CCHS (aka suppurative CCHS, where neutrophils are the inflammatory infiltrate within the biliary tree +/- hepatocytes) and lymphoplasmocytic CCHS (aka nonsuppurative CCHS, where lymphocytes and plasma cells are the inflammatory infiltrates seen).
Neutrophilic inflammation is typically associated with ascending infections from the intestine up the biliary system (and commonly also up the pancreas via the pancreatic duct).
The cause of lymphoplasmacytic CCHS is unknown, but an immune-mediated mechanism is suspected.
What signs do we see in CCHS patients?
Clinical signs associated with CCHS in cats can be variable and acute or chronic in onset.
Neutrophilic cholangitis causes the most overt clinical illness, and usually is more acute onset. It often presents with signs such as:
Pyrexia
Lethargy
Dehydration
Inappetence
Abdominal pain
Vomiting
Variable jaundice
Abdominal pain (which can be hard to spot on exam)
Hepatomegaly may be palpable
Lymphplasmacytic CCHS usually causes intermittent diarrhoea and vomiting, and episodic hyporexia or anorexia, and self-resolving jaundice. Hepatomegaly is common on exam. Complications of chronic liver disease like portal hypertension and acquired shunts are rare.
Evidence of bruising or bleeding ma be apparent if concurrent coagulopathies are present - especially if they have a destructive cholangitis, where small bile ducts become destroyed as part of their disease process.
How is it diagnosed?
Like most of our other liver diseases, CCHS is diagnosed via a combination of bloodwork, imaging and liver sampling +/- a bile aspirate.
On our biochemistry, we tend to see marked increases in our hepatocellular enzymes - ALT and AST with less marked increases in ALP and GGT. Hyperbilirubinaemia is also common, alongside other changes such as hyperglobulinaemia and azotaemia.
On haematology, we often see a neutrophilia with a left shift, and evidence of toxic changes on a smear review. Poikilocytosis and Heinz bodies may also be seen, alongside a non-regenerative anaemia in many cases.
Abdominal ultrasound allows us to examine the hepatic parenchyma in detail and guides sample collection. It also enables assessment of the biliary tree, alongside the pancreas and small intestine, looking for the presence of concurrent pancreatitis or chronic enteropathy.
Definitive diagnosis is achieved via a hepatic biopsy, and bile sampling in most cases. Liver tissue should be submitted for histology and aerobic/anaerobic culture, and bile should be collected for cytology and culture.
And what about treatment and nursing care?
Now we’ve got our diagnosis, it’s time to talk treatment! The main treatment for CCHS depends on whether our patient has the neutrophilic or lymphoplasmacytic form - neutrophilic cases are treated with extended courses of antibiotics (based on culture results), whereas lymphoplasmacytic CCHS is treated mostly with glucocorticoids.
Alongside this, supportive treatments including antioxidants, antiemetics, analgesia, appetite stimulants and choleretics are commonly used, accompanied by intravenous fluid therapy, electrolyte and B-vitamin supplementation.
Nursing considerations for these patients are vast, and include things like montioring, nutrition, hydration and analgesia alongside supportive nursing care.
There are plenty of nursing skills we can use with CCHS patients - including assisting with oesophagostomy tube placement, supporting clients with at-home feeding tube use, calculating and formulating nutritional plans, calculating and administering electrolyte supplemented fluid therapy, pain assessment and intensive monitoring to name just a few!
Did you enjoy this episode? If so, I’d love to hear what you thought - screenshot it and tag me on instagram (@vetinternalmedicinenursing) so I can give you a shout out, and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Resources
Center, SA. 2023. Acquired portosystemic shunts in small animals [Online] Available from: https://www.msdvetmanual.com/digestive-system/hepatic-diseases-of-small-animals/acquired-portosystemic-shunts-in-small-animals
Jenkins, H and Haskey, E. 2013. Nursing the portosystemic shunt patient [Online] Available from: https://www.theveterinarynurse.com/content/clinical/nursing-the-portosystemic-shunt-patient/
Konstantinidis, A. et al. 2023. Congenital portosystemic shunts in dogs and cats: Treatment, complications and prognosis [Online] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10223741/
Merrill, L. 2012. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Iowa: Wiley-Blackwell.
Mullins, RA. et al. 2021. Postattenuation neurologic signs after surgical attenuation of congenital portosystemic shunts in dogs: A review [Online] Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/vsu.13729
Purina Institute, undated. Portosystemic shunts and hepatic encephalopathy [Online] Available from: https://www.purinainstitute.com/centresquare/therapeutic-nutrition/portosystemic-shunts-and-hepatic-encephalopathy
Tobias, KM. 2015. Portosystemic Shunts [Online] Available from: https://vetmed.illinois.edu/wp-content/uploads/2015/09/54.-Portosystemic-Shunts.pdf
