921062

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Journal of Feline Medicine and SurgeryDeJesus et al

Case Series

Journal of Feline Medicine and Surgery

Ultrasonographic evaluation of 1­–9

© The Author(s) 2020
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DOI: 10.1177/1098612X20921062
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Antonia A DeJesus1 , Dominique G Penninck1,2

and Cynthia RL Webster3

Abstract
Case series summary This case series describes the postoperative ultrasonographic findings in six cats that
underwent a cholecystoduodenostomy as treatment for extrahepatic biliary obstruction. The surgery site was
identified in all six cats, most often within the right cranial abdomen as a thick-walled gall bladder, with a broad-
based connection to the descending duodenum. Postoperatively, the biliary tree often remained distended, similar to
its preoperative appearance. Recurrent extrahepatic biliary obstruction was suspected in three cats with worsening
hyperbilirubinemia. Common bile duct distension was progressive in one of these cats and unchanged in another,
but improved in the third. Intrahepatic bile duct distension resolved in one cat following surgery but reappeared
with suspected recurrent biliary obstruction. In two cats, progressive echogenic biliary contents were associated
with locally aggressive cholangiocarcinoma. Our findings suggest that in cats with cholecystoduodenostomy and
progressive increases in hyperbilirubinemia following surgery, progressive or recurrent biliary distension and/or
progressive echogenic biliary contents should prompt further investigation.
Relevance and novel information Biliary diversion surgery in cats is associated with high morbidity and mortality.
The ultrasonographic appearance of a postoperative cholecystoduodenostomy site has not been described,
making differentiation of the expected appearance from postoperative abnormalities difficult. The goal of this study
was to determine the expected ultrasonographic appearance, in order to assist in managing cats with recurrent,
persistent or worsening clinical signs and biochemical abnormalities following surgery.

Keywords: Cholecystoduodenostomy; extrahepatic biliary obstruction; ultrasound; histopathology

Accepted: 28 March 2020

Introduction
The most common causes of extrahepatic biliary obstruc- case series is to describe the ultrasonographic features of
tion (EHBO) in the cat include neoplasia or inflamma- postoperative cholecystoduodenostomy sites in order to
tion of the hepatobiliary system, pancreas and/or aid in differentiation of the expected appearance from
duodenum, and cholelithiasis.1–4 Biliary decompression
is key to treatment and biliary diversion via cholecys-
toduodenostomy is the surgical treatment of choice 1Diagnostic Imaging, Tufts University Cummings School of
when patency of the common bile duct (CBD) cannot be Veterinary Medicine, North Grafton, MA, USA
2Department of Clinical Sciences, Cummings School of Veterinary
re-established.1,4 Unfortunately, this procedure is associ-
Medicine at Tufts University, North Grafton, MA, USA
ated with a high perioperative and postoperative 3Internal Medicine, Tufts University Cummings School of

morbidity and mortality.1,2,4 Veterinary Medicine, North Grafton, MA, USA

Abdominal ultrasonography is instrumental in the
Corresponding author:
diagnosis of EHBO,2,5 and could be equally important
Antonia A DeJesus DVM, Diagnostic Imaging, Tufts University
for evaluation of cats with recurrent, persistent or wors- Cummings School of Veterinary Medicine, 200 Westboro Road,
ening clinical signs and biochemical abnormalities North Grafton, MA 01536-1828, USA
following cholecystoduodenostomy. The goal of this Email: [email protected]
Licensed to Bruno Henrique Ribeiro Pereira - [email protected]

2 Journal of Feline Medicine and Surgery 

abnormal findings. The ultrasound examinations of At a routine recheck, 83 days postoperatively, the
six cats presented to the Foster Animal Hospital at cat was doing well clinically, and serum bilirubin and
Cummings School of Veterinary Medicine at Tufts liver enzyme activity were normal. On ultrasound,
University from 2014 to 2019 were reviewed. The signal- the CBD remained tortuous but with reduced diame-
ment, presentation and outcome for each case is sum- ter (4.5 mm, previously 5.8 mm; normal <5 mm)5 and
marized in Table 1. Table 2 provides a timeline of major contained anechoic bile and small choledocholiths.
postoperative ultrasound examination findings, as well There was persistent intrahepatic bile duct distension.
as changes in serum total bilirubin for each case. The cholecystoduodenostomy site was identified
in the right cranial abdomen as a triangular viscus
Case series description with a thick (3.2 mm; normal <1 mm),6 hypoechoic
Case 1 wall and a broad-based attachment to the proximal
A 14-year-old spayed female domestic longhair cat was descending duodenum (Figure 1). The GB contained a
diagnosed with EHBO based on acutely progressive small amount of echogenic fluid and gas, associated
hyperbilirubinemia and ultrasound findings consistent with reverberation artifact. The adjacent duodenal
with obstructive choledocholithiasis. An exploratory wall was normal. The connection at the surgical site
laparotomy was performed, and the CBD was flushed of was approximately 11 mm in height. Similar to previ-
stones and sludge via a choledochotomy. A cholecys- ous reports, suture material or fibrous scarring associ-
toduodenostomy was performed to prevent recurrent ated with suture material was seen at the junction of
obstruction by intrahepatic choleliths. Biopsy of the liver the GB and duodenum as tiny hyperechoic foci with-
and gall bladder (GB) at the time of surgery showed a out artifact.7,8
severe, subacute-to-chronic cholangiohepatitis with bile About 1 year (383 days) postoperatively, the cat had
duct hyperplasia and periductal fibrosis and chronic an ultrasound evaluation for acute-on-chronic kidney
neutrophilic cholecystitis. Bile culture was positive for disease. The surgery site was again identified. The GB
Escherichia coli. contained a small amount of echogenic fluid and gas;

Table 1 General patient information

Case Age at Sex Breed Presenting complaint Duration Time from Cause of EHBO
presentation of clinical surgery to
(years) abnormalities death (days)

1 14 FS DLH Vomiting, anorexia 1 day 383 Cholelith lodged in duodenal

papilla, concurrent chronic
cholangiohepatitis
2 12 FS DSH Elevated liver enzymes 5 months At least 169* Hyperplastic nodule within
distal common bile duct
at the duodenal papilla
(possible lymphocytic
infiltrate on cytology)
with some evidence of
hepatocellular injury
3 11 FS DSH Elevated liver enzymes 6 months 22 Extrahepatic
~6 months; intermittent cholangiocellular carcinoma
vomiting, icterus, of the distal common
anorexia bile duct, concurrent
cholangiohepatitis
4 9 FS Maine Progressive lethargy 2 days 25 Extrahepatic
Coon and inappetence, cholangiocellular
elevated liver enzymes, carcinoma of the common
increased frequency of bile duct, concurrent
vomiting cholangiohepatitis
5 10 FS DSH Lethargy, anorexia, 2 days 39 Pancreatic carcinoma,
vomiting and discolored concurrent
urine cholangiohepatitis
6 10 FS Egyptian Hyporexia, vomited 1 day 1083 Extrahepatic
Mau once cholangiocellular carcinoma
of the distal common bile
duct as initial cause of
EHBO, concurrent mild
hepatitis†

*The patient was discharged with a plan to euthanize but was lost to follow-up
†Concurrent pancreatic neuroendocrine tumor diagnosed at necropsy

EHBO = extrahepatic biliary obstruction; FS = female spayed; DLH = domestic longhair; DSH = domestic shorthair
Licensed to Bruno Henrique Ribeiro Pereira - [email protected]

DeJesus et al 3

Table 2 Timeline of ultrasound findings and serum total bilirubin values

Patient Days GB wall CBD maximal Intrahepatic Presumed cause of EHBO Serum total
postoperatively thickness internal bile duct (when suspected) bilirubin
(mm)* diameter (mm)† distension (Y/N) (mg/dl)‡

Case 1 0§ 1.5 5.8 Y Cholelith lodged within the 18.3

duodenal papilla
83 3.2 4.5 Y NA 0.1
383 2.5 4.8 Y NA 0.1
Case 2 0¶ NA¶ NA¶ NA¶ NA¶ 1.8
5 3.6 10.2 Y NA 1.3
21 3.3 12 Y NA 0.6
Case 3 0§ 2 12 N Nodular thickening of distal 20.4
CBD
5 4.5 13 N NA 10.9
14 2 16 N NA 19.3
22 2.6 19 N Tissue/debris filling CBD 20.2
Case 4 0§ 1.2 5.8 Y Amorphous tissue focally 7
obscuring the lumen of the
distal CBD
4 2.8 5.8 N NA 8.9
7 2.2 NA NA NA 11.7
10 2.6 NA N NA 11.4
17 2.8 NA Y Echogenic mass filling 11.8
the GB
Case 5 0§ 2.2 14 N Pancreatic nodule near 21.3
duodenal papilla
22 2.6 8 N NA 3.5
39 2.3 5.8 N Progressive pancreatic 8
nodule
Case 6 0§ 1.4 6.9 N Echogenic CBD contents 13.4
13 4.0 6.2 N NA 3.7
41 6.7 13 Y NA 2.4
80 NA 16 Y NA 2.6
95 4.7 15 Y NA 3.6
130 4.3 16 Y NA 3.4
178 4.7 19 Y NA 1.6
273 NA 19 Y NA 0.8
357 3.8 23 Y NA 0.4
See below∞ 4.5–4.9 25–35 Y NA 0.2–1

*Normal <1 mm
†Normal <5 mm
‡Reference interval 0.1–0.3 mg/dl
§0 indicates the immediately preoperative ultrasound examination
¶This information is not available as there was a large gap of time between the preoperative ultrasound examination and surgery
∞Ultrasound examinations following the first year after surgery (from 416 days postoperatively to 1078 postoperatively) have been summarized

GB = gall bladder; CBD = common bile duct; Y = yes; N = no; EHBO = extrahepatic biliary obstruction; NA = not available

its wall was moderately echogenic and remained thick- Case 2

ened (2.5 mm). The CBD remained tortuous and rela- A 12-year-old spayed female domestic shorthair (DSH)
tively unchanged in size (4.8 mm) with echogenic fluid cat was referred for surgical liver biopsies to investigate
and choledocholiths. Intrahepatic bile duct distension increased serum liver enzyme activity. Prior to referral,
was again seen. Total serum bilirubin and liver enzyme percutaneous ultrasound-guided liver biopsy was per-
values were normal at this time. formed, but biopsy material was of poor diagnostic
The cat was euthanized 383 days after surgery for quality and surgical liver biopsies were recommended.
reasons unrelated to hepatobiliary disease. A necropsy There was no ultrasonographic evidence of EHBO at
was not performed. that time.
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4 Journal of Feline Medicine and Surgery 

relatively unchanged and the regional fat was no longer

hyperechoic. Intrahepatic bile duct distension persisted.
Given continued anorexia and repeated esophagos-
tomy tube complications the patient was discharged
with the plan to euthanize within a few days. The cat
was lost to follow-up after 169 days following surgery.

Case 3
An 11-year-old spayed female DSH cat presented for
progressively increased serum liver enzyme activity and
hyperbilirubinemia. On abdominal ultrasound, EHBO
was suspected secondary to a nodular thickening of the
CBD near the duodenal papilla. Additional findings of
GB wall thickening and a hypoechoic pancreas were
suggestive of cholecystitis and pancreatitis.
At exploratory laparotomy the CBD was severely dis-
Figure 1 Sonogram of the cholecystoduodenostomy site of case
1. The liver is seen cranially, to the left of the image (L). The gall
tended and tortuous with a firm thickening near the
bladder (large arrowheads) has a thickened wall and contains duodenal papilla. Although the duodenal papilla was
a mixture of echogenic fluid and gas. The attached duodenum patent, due to the thick nature of the bile and difficulty
(arrows) maintains normal wall layering. Suture/fibrous scar flushing the CBD, a cholecystoduodenostomy was per-
tissue (small arrowheads) is seen at the surgical site formed. Hepatic biopsy specimens showed moderate-
to-severe, chronic, lymphocytic cholangiohepatitis with
For unknown reasons, surgical biopsy was delayed vacu­olar change, biliary hyperplasia, and portal and
for 4 months. At this time the cat was hyperbilirubine- peridu­­ctal fibrosis. The GB/CBD biopsy showed cystic
mic. An ultrasound examination was not performed. At mucosal hyperplasia.
exploratory laparotomy the CBD was dilated and the In the first 3 days postoperatively, serum liver
GB was non-expressible. A firm thickening occluded the enzyme activity and hyperbilirubinemia improved, but
CBD at the level of the duodenal papilla. A cholecys- on the fourth day, it abruptly worsened (from 9.4 mg/dl
toduodenostomy was performed. Histopathologic eval- to 10.9 mg/dl; reference interval [RI] 0.1–0.3 mg/dl).
uation of the liver biopsy showed vacuolar change, mild The cat became febrile (103ºF [39.4ºC]; RI 99.5–102.5ºF
lymphoplasmacytic hepatitis, periportal hepatocellular [37.5–39.2ºC]). An abdominal ultrasound (day 5)
necrosis, biliary hyperplasia, and sinusoidal and peri- showed that the CBD remained distended (13 mm, pre-
ductal fibrosis. Fine-needle aspiration of the lesion viously 12 mm) and tortuous, with anechoic contents
within the CBD showed a mildly atypical epithelial and thickened, nodular walls. The cholecystoduodenos-
population, most consistent with hyperplasia; however, tomy site was identified in the right cranial abdomen.
a well-differentiated neoplasm could not be ruled out. The GB contained a small volume of anechoic fluid; its
Five days postoperatively the cat was presented for walls were echogenic and irregularly thickened (up to
anorexia, vomiting and lethargy. Bloodwork at this time 4.5 mm). The duodenum maintained normal wall layer-
showed persistently elevated but improved hyperbiliru- ing but was thickened (3.7 mm; RI 1.78–2.51 mm).9
binemia and serum liver enzyme activity. On ultrasound, Suture material/fibrous scarring was seen. The regional
there was distension of the intrahepatic ducts, the cystic fat was markedly hyperechoic and beam-attenuating.
duct (4 mm) and the CBD (10.2 mm). The CBD contained Persistent pancreatitis was suspected. There was mod-
echogenic fluid/material; its wall was echogenic and erate, slightly echogenic peritoneal effusion. An abdom-
thickened. The cholecystoduodenostomy site was iden- inocentesis was performed revealing a neutrophilic
tified. The GB was collapsed, and its wall was thickened inflammation; a culture was not performed.
(3.6 mm) and echogenic. The connection of the surgical At recheck (day 11) the cat was lethargic, persistently
site was estimated to measure 14 mm. Suture material/ inappetent and only tolerating small-volume feedings via
fibrous scarring was seen. The adjacent duodenal wall the esophagostomy tube. Bloodwork showed progressive
was normal. The regional fat was slightly hyperechoic. increases in serum liver enzyme activity and hyperbiliru-
The cat remained intermittently inappetent with occa- binemia (19.3 mg/dl; RI 0.1–0.3 mg/dl). On abdominal
sional vomiting and progressive weight loss. At 21 days ultrasound (14 days postoperatively), the cholecysto­
after surgery, hyperbilirubinemia and elevated serum duodenostomy site was identified. The GB contained
liver enzyme activity persisted but continued to improve. heterogeneously echogenic, multicystic, and irregularly
A recheck ultrasound showed slightly progressive CBD marginated, vascular tissue. The CBD was progressively
distension to a diameter of 12 mm. The surgery site was distended (16 mm) with echogenic contents. The adjacent
Licensed to Bruno Henrique Ribeiro Pereira - [email protected]

DeJesus et al 5

duodenum maintained normal wall layering and was

now reduced in thickness (2.6 mm). The connection at the
surgical site was estimated to be 8 mm. Suture material/
fibrous scarring was identified. Regional peripancreatic
fat was slightly hyperechoic and hypoechoic nodules
within it were concerning for carcinomatosis. Fine-needle
aspiration of the tissue within the GB was consistent with
mild inflammatory infiltration.
The cat was presented 6 days later for continued
clinical deterioration. Bloodwork showed progressively
increased serum liver enzyme activity and hyperbiliru-
binemia (20.2 mg/dl; RI 0.1–0.3 mg/dl). On abdominal
ultrasound (22 days postoperatively), the previously
described tissue within the GB filled its lumen and
extended through the cholecystoduodenostomy site into
the proximal duodenum, resulting in a mechanical ileus
(Figure 2). It was difficult to delineate this tissue from
wall of the GB, which was approximately 2.6 mm in
thickness. The CBD was again filled with echogenic
material and was mildly progressively distended
Figure 2 Sonogram of the cholecystoduodenostomy site in
(19 mm). Recurrent EHBO was also suspected. Nodules case 3. Cranial is to the left and caudal is to the right. A large,
within regional fat were again seen, in addition to sev- heterogeneous and multicystic mass fills and distends the
eral serosal nodules, consistent with progressive gall bladder and cystic duct (long arrows). There is extension
carcinomatosis. of the mass into the duodenum (asterisk), which resulted in
The owners elected humane euthanasia 22 days fol- a mechanical ileus in this patient. Suture/fibrous scar tissue
lowing surgery. A necropsy was not performed but a (short arrow) is seen at the surgical site. Histopathology of the
mass was consistent with extrahepatic cholangiocarcinoma
review of the original GB/CBD biopsy samples was
consistent with extrahepatic cholangiocarcinoma.

Case 4 descending duodenum, just proximal to the duodenal

A 9-year-old spayed female Maine Coon cat was pre- papilla. The GB was moderately distended with echo-
sented for a 2-day history of progressive lethargy and genic fluid, as well as rounded (approximately 11 mm in
inappetence, elevated serum liver enzyme activity, diameter) echogenic tissue in the region of the GB neck
hyperbilirubinemia and vomiting. On ultrasound exam- extending into and distending the cystic duct. This tissue
ination, EHBO was suspected secondary to amorphous was initially suspected to represent hematoma or granu-
tissue focally obscuring the lumen of the dilated CBD. lation tissue. Color flow Doppler evaluation was not
At surgery, the GB and CBD were severely distended performed. The surgical site connection was estimated
and diffuse thickening of the CBD wall was noted. A to be up to 8 mm. Suture material/fibrous scarring was
catheter could not be advanced into the GB. A cholecys- seen. Similar to the preoperative examination, the CBD
toduodenostomy was performed. Histopathology of the had thickened, echogenic walls and a focal loss of visu-
biopsy from the distal CBD was initially reported as alization of the lumen. Evidence of gastric ileus and pan-
severe, chronic eosinophilic cholangitis. Hepatic biop- creatitis with regional steatitis were noted.
sies were consistent with severe, diffuse, chronic lym- Follow-up ultrasound examinations were performed
phoplasmacytic and neutrophilic cholangiohepatitis at 7, 10 and 17 days postoperatively to evaluate persis-
with periductal fibrosis and bile duct ectasia. GB histo- tently decreased appetite and progressive worsening
pathology showed mild fibrosis and mucosal necrosis. of biochemical changes. At each ultrasound examination,
Bile culture revealed a multidrug-resistant Enterococcus the intraluminal GB tissue progressed in size (from
species. 22 mm in diameter to 29 mm) to eventually fill the GB,
On the fourth day postoperatively, the cat vomited becoming a partly cavitated, moderately vascular, echo-
multiple times and abdominal distension was noted. A genic mass. Intrahepatic bile duct distension recurred.
repeat abdominal ultrasound revealed that intrahepatic In the last two studies, the wall of the GB developed a
bile duct distension seen preoperatively had resolved. layered appearance. Recurrent EHBO secondary to the
The cholecystoduodenostomy site was identified in the mass within the GB was suspected and 19 days posto­
cranial abdomen, to the right of midline. The GB had peratively an exploratory laparotomy and cholecy­stotomy
thick (2.8 mm), echogenic walls and was attached to the was performed. At surgery, the CBD was described as
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6 Journal of Feline Medicine and Surgery 

stenotic and fibrotic. A vascular mass was removed of the duodenal papilla and deviated the course of the
from the GB. The cystic duct could not be catheterized, duodenum. The pancreaticoduodenal (PD) lymph node
but the stoma of the cholecystoduodenostomy site was hypoechoic but normal in size.
was patent. Histopathology of the mass confirmed Over the next few weeks the cat showed progressive
extrahepatic cholangiocarcinoma. Review of the initial decline at home with worsening of liver enzyme activity
surgical CBD biopsy was also consistent with and hyperbilirubinemia. On recheck ultrasound exami-
cholangiocarcinoma. nation (39 days postoperatively), the hepatobiliary
The cat clinically declined 4 days following the sec- system and surgery site appeared unchanged. The pan-
ond surgery owing to septic peritonitis and was eutha- creatic nodule (23 mm) and hypoechoic PD lymph node
nized (25 days following the initial surgery). A necropsy were larger (4.3 × 8 mm). The cat was euthanized owing
was not performed. to poor quality of life.
At necropsy, the pancreatic mass effaced a large por-
Case 5 tion of the pancreas and surrounded the CBD and pan-
A 10-year-old spayed female DSH cat was presented for creatic duct at the level of the duodenal papilla. Bile flow
further evaluation of progressive hyperbilirubinemia into the duodenum was obstructed at both the duodenal
and elevated serum liver enzyme activity. Initial ultra- papilla and the surgical site. The GB contained purulent
sound showed hyperechoic hepatomegaly and a dupli- fluid. Histopathological evaluation of the pancreas con-
cated GB with two separate cystic ducts that converged firmed pancreatic adenocarcinoma with intravascular,
on a single CBD. A pancreatic nodule was seen near hepatic and splenic metastases. Review of the initial
the duodenal papilla. The cat was treated medically pancreatic biopsy was consistent with pancreatic
but, owing to continued inappetence, returned 4 days adenocarcinoma.
later. A percutaneous ultrasound-guided needle biopsy
of the liver showed mild lymphoplasmacytic portal Case 6
hepatitis and cholangitis with lipidosis and periductal A 10-year-old female spayed Egyptian Mau cross cat
fibrosis. was evaluated for hyporexia, vomiting and icterus.
The cat remained lethargic and inappetent, with pro- Bloodwork showed an inflammatory leukogram, hyper-
gressive hyperbilirubinemia. A recheck ultrasound was bilirubinemia and increased serum liver enzyme activity.
consistent with EHBO secondary to extension of the pre- Ultrasound findings were consistent with EHBO sec-
viously seen pancreatic nodule into the distal CBD. ondary to echogenic contents within the distal CBD. An
A cholecystoduodenostomy was performed. During exploratory laparotomy was performed. The GB and
surgery, the pancreas was noted to be firm, enlarged and CBD were both subjectively severely distended and a
occluded the CBD. Pancreatic biopsies were initially focal (approximately 10 mm in length) thickening of the
interpreted as marked, diffuse, chronic, neutrophilic distal CBD was present immediately adjacent to the duo-
pancreatitis with atrophy and fibrosis. Hepatic histopa- denal papilla. A choledochotomy was performed con-
thology showed moderate, chronic, neutrophilic cholan- firming a focally thickened wall, which was biopsied.
gitis with bile duct dilation and periductal fibrosis. Owing to concern for patency of the CBD, a cholecys-
The cat was discharged 9 days postoperatively. toduodenostomy was performed. Surgical biopsies con-
Hyperbilirubinemia improved; however, the cat firmed extrahepatic cholangiocarcinoma of the CBD, as
remained lethargic and inappetent. A recheck ultra- well as mild, neutrophilic and lymphoplasmacytic hepa-
sound was performed 22 days postoperatively. Given titis with mild lipidosis, biliary hyperplasia and peri-
that the GB was duplicated, the unmodified GB ductal fibrosis. The cat was discharged after 5 days.
appeared to persist within the liver and was filled with Thirteen days postoperatively, at routine recheck, the
echogenic debris; its walls were hypoechoic and thick- cat appeared nauseous and serum liver enzyme activity
ened (1.3 mm). Immediately caudal to this, the surgical and hyperbilirubinemia persisted. On abdominal ultra-
site was identified. The GB had heterogeneously hypo- sound, the cholecystoduodenostomy site was identified.
echoic and thickened walls (2.6 mm). The connection The GB contained a small volume of echogenic fluid and
between the GB and duodenum was estimated to meas- gas. Its wall was hypoechoic, irregular and thickened
ure 4.5 mm. Suture material/scarring fibrosis was seen. (4 mm). The surgical connection was estimated to be
The regional abdominal fat was hyperechoic. The cystic 3.5 mm. Suture material/scarring fibrosis was seen. The
ducts and CBD remained tortuous with echogenic con- abdominal fat in the region of the surgical site was mildly
tents, but the CBD diameter had decreased from 14 mm hyperechoic. The CBD remained distended (6.2 mm, pre-
to 8 mm. Gas was noted within the biliary tree and viously 6.9 mm) with anechoic fluid and a thickened
rerouted GB. The previously described pancreatic nod- wall (2 mm). The previously described obstructive tissue/
ule was larger (19 mm; previously 11 mm) and had a thickening was not seen. The adjacent duodenum
hypoechoic to anechoic center; it obscured visualization appeared normal.
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DeJesus et al 7

Chemotherapy was started 3 weeks postoperatively. points after surgery. The ultrasonographic features of
The cat presented multiple times for re-evaluation over the cholecystoduodenostomy sites are summarized in
an approximately 2-year period and was reportedly Table 3. The surgery site was identified in all six cats,
doing well at home despite intermittent vomiting, leth- most often within the right cranial abdomen. The GB
argy and inappetence, supported by parenteral feeding had thick, most commonly echogenic walls (median
via an esophagostomy tube. Hyperbilirubinemia was 3.8 mm; range 2–6.7 mm). It was broadly attached to the
persistent but gradually improved (varying between 0.2– descending duodenum, which maintained normal wall
1 mg/dl; RI 0.1–0.3 mg/dl). Recheck ultrasound exami- layering in all cats but was thickened in 4/6 (median
nations were performed approximately every month for 2.4 mm; range 1.5–3.7 mm).
5 months and then every 4–5 months afterwards. The GB was most often collapsed or contained a small
On recheck ultrasound examinations, the cholecys- amount of fluid. The connection between the GB and
toduodenostomy site was identified within the mid-to- duodenum was difficult to evaluate given that the GB
right cranial abdomen. The wall of the GB was initially was often empty. This estimated measurement is there-
echogenic but subjectively decreased in echogenicity fore thought to be unreliable. Gas was intermittently
over time; it was asymmetrically thickened (3.8–6.7 mm) noted within the biliary tree in 50% of the cats. This is
and variably collapsed or contained scant anechoic fluid most consistent with gastrointestinal reflux, which we
and/or gas. The connection at the surgical site was suspect is due to the lack of a sphincter mechanism at the
estimated to measure up to 4.1 mm. Suture material/ site of the rerouted GB. A correlation with progressive
scarring fibrosis was seen. The regional abdominal fat biochemical changes and/or worsening clinical signs
normalized. Over serial examinations, the CBD was pro- was not identified. This finding was therefore not found
gressively distended (from 13 mm to 35 mm) and tortu- to be a clear indicator of infection; however, the possibil-
ous, with progressively organized echogenic contents ity of biliary infection secondary to reflux of gastrointes-
and choleliths. Some similarly echogenic material was tinal contents remains.3
also seen within the intrahepatic biliary tree. An echo- CBD distension was present in 5/6 cats on presurgical
genic nodule within the distal CBD was monitored for ultrasound examinations. In the only cat without disten-
change over time and grew from 6.6 mm in diameter to sion preoperatively (case 2), the ultrasound was not per-
8.2 mm. It never appeared obstructive as it never com- formed immediately before surgery and the prior
pletely filled the lumen. Gas was intermittently noted examination was several months prior to the onset of
throughout the biliary system. The duodenum adjacent icterus. One of the four cats (case 3) with progressive CBD
to the surgery site remained within normal limits. distension postoperatively was suspected to have recur-
The cat presented for an episode of vomiting 415 days rent EHBO. Another cat (case 4) with suspected recurrent
postoperatively. Serum liver enzyme activity and hyper- EHBO had an unchanged CBD distension. Finally, one cat
bilirubinemia were relatively unchanged, but hepato- (case 5) with confirmed recurrent EHBO actually had
megaly was palpated. Fine-needle aspiration of the liver improved CBD distension, despite gradual worsening of
was suspicious for recurrent biliary carcinoma. biochemical changes. Intrahepatic bile duct distension
The patient developed hematemesis and anemia 816 was noted prior to surgery in 2/6 cats. It resolved in one
days postoperatively. A definitive cause was not identi- cat (case 4) following surgery but recurred with suspected
fied. Recurrent episodes of hematemesis and progres- recurrent EHBO. In the other cat (case 1), it persisted,
sive anemia warranted hospitalization and multiple unchanged, despite overall clinical improvement.
blood transfusions. Ultrasound of the hepatobiliary sys- Intrahepatic bile duct distension developed postopera-
tem and serum biochemical changes were otherwise rel- tively in one cat (case 6), despite improved biochemical
atively unchanged. Following presentation for another changes. Based on these findings, persistent biliary dis-
episode of severe anemia the cat was euthanized 1083 tension may be observed in cats following cholecystoduo-
days following surgery. denostomy and changes in biliary distension following
A necropsy was performed revealing a new locally surgery may not always correspond to biochemical
invasive pancreatic neuroendocrine tumor with metasta- changes or the presence of recurrent obstruction.
ses to the liver and GB. No evidence of biliary obstruc- In two cats (cases 3 and 4), the rerouted GB became
tion was described. Within the liver, there was diffuse progressively distended with echogenic and vascular tis-
fibrosis with biliary hyperplasia. Focally extensive chol- sue, which led to a duodenal obstruction with suspected
angiectasia with intraluminal food material at the chole- recurrent EHBO in case 3 and confirmed recurrent EHBO
cystoduodenostomy site was also found. in case 4. In case 4, the echogenic tissue was initially mis-
taken for hematoma formation or granulation tissue.
Discussion Color flow Doppler interrogation was performed on a
In this case series, six cats had a cholecystoduodenos- later examination confirming moderate vascularity. Both
tomy performed to alleviate EHBO and had one or more cats were ultimately diagnosed with extrahepatic cholan-
postoperative ultrasound evaluations at different time giocarcinoma. Therefore, the presence of organized,
Licensed to Bruno Henrique Ribeiro Pereira - [email protected]

8 Journal of Feline Medicine and Surgery 

Table 3 Summary of salient ultrasonographic features of cholecystoduodenostomy sites

Case Surgical Location in GB wall GB wall GB contents Duodenal Duodenal Stoma Sutures
site abdomen appearance thickness wall wall visible?
identified* (mm) appearance thickness
(mm)

1 2/2 Right cranial Hypoechoic- 2.5–3.2 Scant Normal 2.9 5.3–1.1 cm Yes
to-moderately echogenic
echogenic fluid and gas
2 2/2 Presumed Echogenic 3.3–3.6 Collapsed/ Normal 2.7 1.4 cm Yes
right cranial† empty
3 3/3 Right cranial Echogenic; 2.2–2.6 Progressively Normal 2.6–3.7 8.2 mm Yes
layered filled with
appearance echogenic,
on latest vascular tissue
examination
4 4/4 Cranial Echogenic 2.2–2.8 Progressively Normal 2.2–2.4 5.3–8.0 mm Yes
abdomen to with a layered distended with
the right of appearance an echogenic
midline on later mass
examinations
5 2/2 Right cranial Heterogeneously 2.3–2.6 Collapsed/ Normal 2.0 4.5 mm Yes
hypoechoic empty
6 12/16 Mid-to-right Echogenic-to- 3.8–6.7 Collapsed/ Normal 1.5–2.7 2–4.1 mm Yes
cranial progressively empty with
abdomen hypoechoic occasional
scant fluid
and gas

*Number of ultrasound studies in which the surgical site was identified out of the total number of postoperative ultrasound examinations
performed
†Location in the abdomen was based on surrounding anatomy, but could not be confirmed due to the lack of an overhead video

GB = gall bladder

echogenic material within the rerouted GB should be obstruction secondary to cholelithiasis carries a better
considered suspicious for neoplasia. Color flow Doppler prognosis than obstruction owing to either inflammation
can be useful to confirm vascularity of luminal contents. or neoplasia.2 The remainder of the patients were ulti-
Similar to human medicine, differentiation of inflam- mately euthanized due to either a lack of clinical improve-
matory and neoplastic lesions of the bile ducts remains ment (case 2), progression of neoplasia with or without
difficult owing to the fact that these tumors can be well recurrent obstruction (cases 3 and 5) or dehiscence/
differentiated and often accompanied by desmoplastic leakage from the surgical site (case 4).
stroma and inflammation.10 In cases 3, 4 and 5, initial
biopsies of the GB/CBD, GB and pancreas, respectively, Conclusions
were described as inflammatory rather than neoplastic. The cholecystoduodenostomy site was visualized in all
On re-evaluation of the initial biopsies, with necropsy in cats as a thick-walled GB, which was either empty or con-
one case (case 5), all three were diagnosed with malig- tained scant fluid/gas and was broadly attached to the
nant neoplasia (2/3 cholangiocarcinoma and 1/3 pan- descending duodenum. CBD distension persisted in all
creatic adenocarcinoma). This further supports the cases after surgery, often similar to the preoperative
difficulty of accurate histopathologic diagnosis, espe- appearance. Changes to intrahepatic bile duct distension
cially in regard to well-differentiated neoplasms. were variable. Postoperative changes in biliary distension
Consistent with previous studies, there were high did not consistently correlate to the clinical presentation,
postoperative morbidity and mortality rates within this emphasizing the need for evaluation in the light of bio-
study population.1,2,4 The longest survival time follow- chemical parameters. Finally, the development of echo-
ing surgery was for case 6, which is subjectively genic tissue within the biliary tree may represent neoplasia
considered an outlier given that the patient was main- in spite of initial histopathologic results of inflammation.
tained by esophagostomy tube feedings with question-
able clinical improvement. Case 6 excluded, only 1/6 Acknowledgements The authors thank the Pathology
patients (case 1) had a cause of death that was consid- Depart­­ment at the Cummings School of Veterinary Medicine
ered completely unrelated to the previous episode of at Tufts University, especially Cesar Piedra-Mora DVM; Kara
EHBO. Survival time in this patient was 383 days. This is Priest DVM, MS, DACVP; and Francisco O Conrado DVM,
in line with the previous conclusion that biliary MSc, DACVP.
Licensed to Bruno Henrique Ribeiro Pereira - [email protected]

DeJesus et al 9

Conflict of interest The authors declared no potential 2 Gaillot HA, Penninck DG, Webster CRL, et al. Ultrasono-
conflicts of interest with respect to the research, authorship, graphic features of extrahepatic biliary obstruction in 30
and/or publication of this article. cats. Vet Radiol Ultrasound 2007; 48: 439–447.
3 Buote NJ, Mitchell SL, Penninck DG, et al. Cholecystoenter-
Funding The authors received no financial support for the ostomy for treatment of extrahepatic biliary tract obstruc-
research, authorship, and/or publication of this article. tion in cats: 22 cases (1994–2003). J Am Vet Med Assoc 2006;
228: 1376–1382.
4 Mayhew PD and Weisse CW. Treatment of pancreatitis-
Ethical approval This work involved the use of non-exper- associated extrahepatic biliary tract obstruction by chole-
imental animals only (including owned or unowned animals dochal stenting in seven cats. J Small Anim Pract 2008; 49:
and data from prospective or retrospective studies). Established 133–138.
internationally recognised high standards (‘best practice’) of 5 Leveille R, Biller DS and Shiroma JT. Sonographic evalua-
individual veterinary clinical patient care were followed. Ethi- tion of the common bile duct in cats. J Vet Intern Med 1996;
cal approval from a committee was therefore not necessarily 10: 296–299.
required. 6 Hittmair KM, Vielgrader HD and Loupal G. Ultrasono-
graphic evaluation of gallbladder wall thickness in cats.
Informed consent Informed consent (either verbal or Vet Radiol Ultrasound 2001; 42: 149–155.
written) was obtained from the owner or legal custodian of 7 Matthews AR, Penninck DG and Webster CRL. Postopera-
all animal(s) described in this work (either experimental or tive ultrasonographic appearance of uncomplicated enter-
non-experimental animals) for the procedure(s) undertaken otomy or enterectomy sites in dogs. Vet Radiol Ultrasound
(either prospective or retrospective studies). No animals or 2008; 49: 477–483.
humans are identifiable within this publication, and there- 8 Mariano AD, Penninck DG, Sutherland-Smith J, et al. Ultra-
fore additional informed consent for publication was not sonographic evaluation of the canine urinary bladder fol-
required. lowing cystotomy for treatment of urolithiasis. J Am Vet
Med Assoc 2018; 252: 1090–1096.
ORCID iD Antonia A DeJesus https://orcid.org/0000- 9 Di Donato P, Penninck DG, Pietra M, et al. Ultrasono-
0003-0091-5051 graphic measurement of the relative thickness of intesti-
nal wall layers in clinically healthy cats. J Feline Med Surg
References 2013; 16: 333–339.
1 Mayhew PD, Holt DE, McLear RC, et al. Pathogenesis and 10 Kendall T, Verheij J, Gaudio E, et al. Anatomical, histomor-
outcome of extrahepatic biliary obstruction in cats. J Small phological and molecular classification of cholangiocarci-
Anim Pract 2002; 43: 247–253. noma. Liver Int 2019; 39 Suppl 1: 7–18.