Hepatobiliary Disorders

Questions on case #6

1. Maggie’s total serum bilirubin was increased at 1.1 mg/dl. Why weren’t we able to detect jaundice on her physical examination?

a. The total serum bilirubin was too low
b. Serum bilirubin must be greater than 10.0 mg/dl to detect on physical examination
c. We just missed the finding on our examination

2. Based on the biochemical findings, would you characterize Mattie’s liver disease as a predominantly cholestatic or hepatocellular pattern ?

a. Cholestatic
b. Hepatocellular

3. Why was Mattie hypokalemic?

a. Anorexia (lack of intake)
b. Vomiting
c. 2º to excess fluid therapy
d. More than one of the above

4. Does a normal hepatic ultrasound exam rule-out the possibility of hepatic disease?

a. Yes
b. No

5. What do the rhodanine positive granules in the liver biopsy represent?

a. Aluminum
b. Lead
c. Zinc
d. Copper
e. None of the above

6. What is the cause of the increased hepatic copper in Maggie’s liver?

a. The copper is probably normal
b. Excess dietary copper and zinc
c. Copper accumulation 2º to chronic hepatitis
d. Hereditary copper excretion disorder

7. At what level does hepatic copper become toxic to hepatocytes?

a. > 400 ppm
b. > 1000 ppm
c. > 2000 ppm

8. What drug is indicated to treat hepatic copper accumulation in Maggie?

a. Actigall
b. Penicillamine (or D-penicillamine)
c. Corticosteroids
d. Milk thistle

9. If Mattie is not treated, what hepatic disorder will eventually result (after months to years)?

a. Hepatic cirrhosis
b. Hepatic neoplasia
c. Common bile duct obstruction

10. Which of the following is NOT one of the "Big Four" liver diseases that causes jaundice in cats?

a. Hepatic lidosis
b. Cholangiohepatitis
c. FIP
d. Congenital portosystemic shunt
e. FeLV-related neoplasia

11. What clinical finding made idiopathic hepatic lipidosis a less likely consideration in Sam?

a. She was not anorexic
b. She is too old to be at risk
c. Her temperature was normal
d. She is clinically icteric

12. After finding jaundice on the physical examination, what lab test would you want to run immediately to determine whether jaundice was caused by a prehepatic (hemolytic) mechanism?

a. Urinalysis
b. PCV
c. Total bilirubin
d. T4
e. FeLV/FIV test

13. Is bilirubin ever a normal finding in cat urine?

a. No
b. Yes

14. What non-invasive imaging technique is helpful to differentiate intrahepatic from extrahepatic biliary obstruction?

a. Survey abdominal radiographs
b. Upper GI contrast study
c. Abdominal ultrasound
d. None of the above

15. What medical therapy is indicated for treatment of Sam's cholangiohepatitis after the surgery?

a. Antibiotics
b. Ursodiol
c. Penicillamine
d. a and c
e. a and b

16. What was the cause of Murphy's neurologic signs?

a. Hookworms
b. Lead toxicity
c. Hepatic encephalopathy
d. a and b
e. b and c

17. At the time of examination, Murphy’s neurologic examination was within normal limits. Which of the following characteristics are more likely with a metabolic encephalopathy (like hepatic encephalopathy) versus a structural disorder?

a. Waxing and waning signs
b. Persistent neurologic deficits

18. Which of the following is (are) a cause of microcytosis (decreased MCV) in dogs?

a. Iron deficiency
b. Portosystemic shunting
c. Regenerative anemia
d. a and b
e. a and c

19. An increase in which two biochemical parameters could be a normal age-related change in a young dog?

a. Bilirubin and phosphorus
b. Bile acids and alkaline phosphatase
c. Calcium and bile acids
d. Phosphorus and alkaline phosphatase

20. What is your diagnosis based on the portogram?

a. Normal portogram
b. Patent ductus venosus
c. Multiple portosystemic shunts
d. Single extrahepatic shunt

21. What is the treatment of choice for this disorder?

a. Medical management
b. Surgical occlusion

22. Medical management of hepatic encephalopathy consists of all of the following except?

a. Restricted protein diet
b. Neomycin
c. Benzodiazepines (Valium®)
d. Lactulose
e. Increase dietary fiber

23. What histologic change would be most likely on Murphy’s liver biopsy?

a. Hepatocellular necrosis
b. Severe cholestasis
c. Lobular atrophy
d. Moderate hepatic fibrosis
e. Cirrhosis

24. What is the etiologic cause of Sunshine’s pulmonary disease and hepatomegaly?

a. Protothecosis
b. Histoplasmosis
c. Blastomycosis
d. Coccidioidomycosis
e. Cryptococcosis

25. Sunshine had marked hepatomegaly on abdominal radiographs. Which of the following disorders DO NOT cause hepatomegaly?

a. Congenital portosystemic shunt
b. Corticosteroid-induced hepatopathy
c. Complete bile duct obstruction
d. Hepatic infiltration (inflammation, neoplasia)
e. Hepatic congestion

26. On Sunshine’s biochemical profile, her liver enzymes are only mildly elevated. Does this mean her liver function is only mildly abnormal?

a. No
b. Yes

27. Would performing a serum bile acid test be indicated in the initial work-up to evaluate Sunshine's hepatic function?

a. Yes
b. No

28. Sunshine has hypoalbuminemia on the profile (2.8 gm/dl). All of the following could be a cause of hypoalbuminemia in dogs EXCEPT:

a. Protein-losing nephropathy
b. Protein-losing enteropathy
c. Dehydration
d. Hepatic disease
e. GI blood loss

29. All of the following drugs might be indicated for treatment of Sunshine’s disease EXCEPT:

a. Enrofloxacin
b. Amphotericin B
c. Ketoconazole
d. Itraconazole

30. Why did the owners only recognize that Beau was sick in this past week, when the cirrhosis must have been present for weeks to months (pick the best answer)?

a. The owners don't pay any attention to Beau
b. The liver has a large functional reserve capacity so clinical signs may not be obvious until the end stage.

31. How would you characterize Beau's anemia?

a. Regenerative anemia
b. Non-regenerative anemia

32. Potential mechanisms for Beau's GI blood loss are:

a. Gastric or duodenal ulcer
b. Coagulopathy
c. Thrombocytopenia
d. a and b
e. a and c

33. Which of the following is the most likely underlying mechanism for ascites formation in Beau's case?

a. Pancreatitis
b. Portal hypertension
c. Hypoalbuminemia
d. Hypoglobulinemia
e. b and c

34. Hypoalbuminemia is most likely due to:

a. Lack of hepatic production of albumin
b. Protein-losing nephropathy
c. GI blood loss
d. a and b
e. a and c

35. The presence of free abdominal fluid makes it easier to see the liver on abdominal radiographs.

a. True
b. False

36. The presence of free abdominal fluid makes it easier to see the liver on abdominal ultrasound.

a. True
b. False

37. If an ultrasound guided liver biopsy were to be performed in Beau, the most likely complication would be bleeding from the biopsy site.

a. True
b. False

38. If Beau were to be treated all of the following would be indicated except:

a. Famotidine
b. Hetastarch transfusion
c. Furosemide
d. Sucralfate
e. 0.9% saline fluids

39. Known causes of hepatic cirrhosis in dogs include:

a. Chronic anticonvulsant therapy
b. Hepatic copper accumulation
c. 2º to chronic hepatitis
d. All of the above