Yesterday I had a few ultrasound reports to review, one is of a patient of mine whose had some liver enzyme changes that so far are not causing any clinical signs of diarrhea, vomiting or reduced appetite. After following the liver enzymes for some time, I offered the owners an abdominal ultrasound. There is a liver enzyme called alkaline phosphatase, which is an enzyme that has a few different forms, and I usually tell owners that it is not specific for liver disease. It can be elevated due to primary liver disease, gastrointestinal issues like inflammatory bowel disease, pancreatitis, gallbladder disease, or the adrenal glands because of an increase in glucocorticoid production that we usually say is steroid induction of the ALP.
What did I say about work-life balance?! Sometimes it just does not happen in our profession! You know what I’m doing while having my morning coffee? Looking up gallbladder mucocele surgery.
Again, the case presentation should always start with a signalment. I have a 13-year-old MN mixed breed (medium sized spaniel-type dog) who was diagnosed with hypothyroidism with the previous veterinarian and started on levothyroxine. I saw him first for a skin infection of his tail head. Over time the ALP has been elevated in the 400 range, with good appetite, no vomiting or diarrhea. A test for Cushing's or hyperadrenocorticism was negative. On physical he is moderately overweight, the skin crusting resolved with treatment with Cephalexin and 4% chlorhexidine shampoo spot cleaning daily.
The ultrasound was performed on Friday after I had left for the day. I came in on Monday to read the report. The radiologist goes through the findings in medical jargon, and a summary of differential diagnoses of the findings. Then there is a blurb about the recommendations. On ultrasound, we see some old age changes to the liver, spleen and pancreas. There was a small nodule on the cranial pole of the adrenal gland. In the gallbladder was a structure that was incomplete with striations of hyperechoic material most consistent with a partial mucocele.
Then, as the general practice veterinarian we have to take the medical jargon from a specialist’s report and translate it to language that the owner can understand. Complete transparency for the owners is a skill that veterinarians also need to hone. You want the owner to have options, to be able to make an informed decision and not push them to make a decision based on fear or have them forced into a situation that they are not clear of what is going on. The art of veterinary medicine falls on your ability to properly communicate to owners. How you word things is so important. When it comes to transparency, if it is a new situation for me, I will tell the owners. I am fortunate that in the clinics that I have worked in, I have strong seasoned veterinarians to assist me. I also live in Toronto where there are board-certified surgeons and internal medicine specialists within 20 minutes drive from me. If you are honest and have integrity, this will take you farther than the attitude of fake it ’til you make it. You need to be aware of your own limitations.
So back to gallbladder mucoceles, the board-certified veterinary surgeons recommend to NOT take a wait and see approach with gallbladder mucoceles. What happens with the mucous build up in the gallbladder is it can cause increased pressure inside this little balloon, that then can lead to rupture of the gallbladder. Sounds painful, but then its peritonitis and septic shock leading to death. So, before we get to the rupture, its suggested to remove the gallbladder. I have known a few people that have had gall stones and gallbladder pain, and these people had their gallbladders removed. When you see a gallbladder mucocele on ultrasound, the best case scenario is having it removed prior to them becoming systemic unstable with inflammation and peritonitis already occurring. There are a few cases reported that have undergone medical management and the sludge in the gallbladder resolved, but most cases of gallbladder mucoceles are found after they are already unstable patients.
My medical director is a seasoned veterinarian. I asked him what his thoughts were on gallbladder surgery. I was willing to perform the surgery, alternatively, we refer the patient to a boarded surgeon to perform. I sent information to the owners via email, because I wanted them to have some time to think about it. Then I plan to give them a call once I am back in the office to answer any questions or concerns they may have. I'll keep you posted on the outcome!