NorthStar VETS Cool Case Mollie

The team at NorthStar VETS is doing innovative and amazing things every day as they work to advance the level of care available to your pet. This series of posts highlights cool cases at NorthStar VETS and the types of things done to save pets and improve their quality of life. These are cases using innovative and cutting-edge medical techniques, and/or stories of pets beating the odds. This is the story of Mollie, a patient of Dr. Kelly Kraus of our Surgery team.

About Mollie
Mollie is a thirteen year old cat who came to see the Internal Medicine department about 6 months ago for increased drinking, urinating, an episode of vomiting, and elevated liver enzymes noted on her veterinarian’s bloodwork. She had an abdominal ultrasound, which revealed evidence of pancreatic inflammation. She also had additional bloodwork that indicated possible diabetes. Mollie was started on oral medications and initially improved.

Mollie’s Condition
However, she was rechecked several weeks later and her appetite was declining. She had an esophageal feeding tube placed to assist with her nutrition. Recheck bloodwork several weeks later revealed that despite treatment with medications and nutrition, her liver values were continuing to climb drastically. In particular, her total bilirubin was elevated greater than 28 mg/dL (the high end of normal bilirubin in a cat is 0.9 mg/dL.) Bilirubin is a normal product produced in the body that is processed by the liver and excreted into the intestine by the gallbladder and biliary tract. Bile contains bilirubin, and is useful for digesting fats. Mollie’s recheck abdominal ultrasound at the time of her extremely elevated bilirubin now demonstrated that her biliary tract was markedly distended.

In a normal animal (Figure 1), bile processed in the liver travels into the gallbladder via hepatic ducts (small bile ducts within each liver lobe.) When the gallbladder contracts in response to the presence of food in the stomach, bile flows through the cystic (gallbladder) duct into the common bile duct, and then enters the intestine through an area in the duodenum called the duodenal papilla. Problems in many locations of the biliary “tree” (gallbladder, hepatic ducts, cystic duct, common bile duct, or entrance into the intestine) can cause elevations in the bilirubin and cause illness (Fig. 2 – see situations 1 and 2.) The liver itself can have trouble processing bilirubin, or blockages in many locations of the “tree” or at the intestinal entrance can prevent bile from traveling into the intestine, where it should be.

The exact treatment required to allow bile to flow into the intestine in a normal pattern depends upon the location of the blockage or problem.

Mollie’s Treatment
Due to Mollie’s progressively elevating bilirubin, her significantly dilated common bile duct, and the fact that she remained sick despite treatment, an abdominal exploratory surgery was recommended. Mollie was placed under anesthesia. During her exploratory surgery, it was found that Mollie had blockages at both the end of the common bile duct/duodenal papilla AND the base of the gallbladder (see Fig. 3, 1st image.) The multiple locations of blockages left only one option for repair, which was a choledochoduodenostomy (Fig. 3, 2nd image, in which the open end of the common bile duct is connected to the intestine in a healthy location.)

This is a relatively uncommon surgery to do, as there are usually other options for re-routing the flow of bile, such as using the gallbladder itself, which is a larger organ than the bile duct and easier to stitch to the intestinal wall ( Fig 4). For comparison, the gallbladder is usually the size of a large fig in a cat, whereas the common bile duct can be anywhere from the size of a strand of spaghetti to the diameter of a #2 pencil. It is a much smaller, more delicate portion of the biliary tree. Mollie’s multi-level obstruction precluded any other surgery, and a new opening was created by attaching the bile duct to the intestine.

This surgery can be associated with multiple complications, including failure of healing, infections ascending into the liver, or stricture (scarring) of the new opening which can cause another obstruction.

How Things Went for Mollie
Luckily, Mollie recovered exceptionally well, healed her surgery site, and began eating soon after surgery. Biopsies that had been obtained at surgery to rule out cancer as a cause of the gallbladder and bile duct obstructions revealed scar tissue only. Her bilirubin quickly returned to normal. We think the most likely cause of Mollie’s biliary problems was scarring and inflammation due to her pancreatitis. Referring to figure 1, it is notable that the pancreatic duct system is extremely closely associated to the bile duct system, especially in a cat. Therefore, inflammation occurring in the pancreatic system, intestines, or gallbladder can cause a triad of problems.

Mollie’s feeding tube was removed and she enjoyed a cuddle with her care team at her last recheck (photograph 1.) Everyone at NorthStar VETS was so happy Mollie was able to recover from such a severe illness and continue to enjoy her life with her owner.

Learn more about the Surgery service at NorthStar VETS

Kelly Kraus, VMD, DACVS
Dr. Kraus is originally from Connecticut. She obtained a Bachelor of Science degree from Loyola University in Baltimore, Maryland in 2003 before moving to Philadelphia, where she did molecular genetics research for two years at the University of Pennsylvania. Dr. Kraus then completed veterinary school at the University of Pennsylvania in 2009. After graduating, she completed a rotating internship at Oradell Animal Hospital in Paramus, NJ. She then moved to Texas to complete a one-year internship in surgery at Gulf Coast Veterinary Specialists. She was fortunate to then move back to New Jersey for a three-year residency in surgery at Red Bank Veterinary Hospital, which she completed in 2014.

She is excited to be part of the surgery team at NorthStar Vets. Her special surgical interests include, but are not limited to, wound management and reconstructive surgery, surgical oncology, cardiothoracic surgery, and hepatobiliary surgery. Dr. Kraus also enjoys management of orthopedic conditions. She is trained in the tibial plateau leveling osteotomy (TPLO) for cranial cruciate ligament disease. Outside of work, Dr. Kraus enjoys spending time with her family, cooking, traveling, and helping her local SPCA.

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