Knowledge Lab

Welcome to Tails from the Lab, where an ever optimistic veterinarian and slightly salty technician entertain listeners with true stories and tall tales revolving around laboratory diagnostics.

Names have been changed to protect the innocent, but the lab work is real.

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Each episode we hope to leave you a little smarter, a little brighter, and feeling more empowered in the lab.

Welcome to today’s Tale from the Lab. Snickers. Belly full of trouble.

I like to brag about that.

I forgot.

I’m Jessica.

And I’m Holly.

And it’s been a hot minute.

It’s been a bit.

But we are back in our pod closet.

We’re back in the pod closet like good old times.

But it’s so dark in here.

But it’s not hot.

No, it’s not. Not like that. The bone booth that we were in, that was awful. So it has been a bit. I have a wonderful update.

Yeah.

I have a new dog, Mr. Opie James. He was in a crate along the side of the road with his siblings. And I’ll post a picture of Opie on Instagram because he’s just so stinking cute.

And they are awesome little dogs. Um, Opie has in like just merged into our family. He’s brought new life to both Tank and Ruger. They’re running around and playing, I mean, and snuggling.

There are so many snuggling pictures that I have. They’re just ridiculous. Yeah, so that’s my, my great update. Yeah.

So I guess let’s talk about a case that I think really highlights how we work together. So Snickers, 13 year old male, neutered domestic, short hair. Snickers came in for second opinion for intermittent inappetence.

And he had been to his rdbm. He had started to show signs about a month ago and he had been hospitalized for several days prior to coming to our hospital.

And the RDVM had sent him home with antibiotics and an anti vomiting medication but he had still not been eating. So his owners came to our hospital for a second opinion.

His physical exam showed no abnormalities other than muscle wasting, but they did note a fluid wave in his abdomen and so they collected some ascites. So not only was there a fluid sample in the lab that we’re going to talk extensively about, but there was also a blood sample.

So we had a CBC and a chemistry and we’ll let Dr. Brown take over that portion.

Okay. So in looking at the CBC and starting in the erythrogram or the red blood cells. We see that Snickers does have a marginal anemia, right? And the young red blood cells or reticulocytes are at the low end of the reference interval.

So this is consistent with a non regenerative anemia. And the most common reason we see a non regenerative anemia is because it’s secondary to other chronic or inflammatory disease. And in Snicker’s case, we see that indeed we do have support for that inflammation.

As we look at that leukogram, there are increased white blood cells characterized by a neutrophilia and a monocytosis. And those both being increased support most likely at chronic inflammatory condition, especially in a cat.

And we notice the lymphocytes and eosinophils are at the low end of the reference interval. And that’s most likely because of increased glucocorticoids or stress lipid leukogram, right. Superimposed on that inflammatory leukogram in the chemistry.

The most significant changes we see are within some of our liver values. So as far as liver enzymes, the alt, right, that is increased twice the high end of the reference interval.

It matters when we’re looking at the liver enzymes where our patient value lies relative to the high end of the reference interval. And really we don’t consider it significant in a CAT until it’s over twice the high end of the reference interval.

And that’s just about where we are now. ALT is a liver damage enzyme, meaning that there’s been damage to the liver cells or the hepatocytes and that has leaked out the alt, the enzyme activity is because it’s come from within the hepatocytes that have been damaged.

So we’re thinking about some destructive process, right, that’s irritated or necrosed the hepatocytes. And then the alkaline phosphatase, that’s an inducible enzyme and that is within the reference interval. But the GGT is increased.

So the third enzyme that we see in this profile, the ggt, is increased. And this comes from backup, it comes from the biliary cells. And it is also an inducible enzyme.

And it means that those biliary cells have become crowded or irritated. It’s on the membrane associated on the, on the biliary epithelial cells. And so often we see this or most commonly see it when there’s backup in the biliary tree, when there’s some cholestasis or bile stasis.

So that sort of means that we’re thinking now when it comes to imaging, we’re going to be focusing on the biliary tree and whether that’s from the gallbladder itself or through different parts of the liver where the different sinusoids are the total bilirubin.

Now we’re talking about a liver function test, right? And so when bilirubin is high, it’s either because the liver is not functioning well, right, which is a hepatic cause of hyperbilirubinemia.

There are prehepatic causes which happen from a lot of red cell lysis, which we didn’t have evidence for here. And there’s a post hepatic cause for the bilirubin being high.

And that is because we’ve had some obstructive disease somewhere in the biliary tree that it’s backing up again. When we see that elevated, we first want to exclude a prehepatic cause.

Do we have any evidence for a regenerative anemia and red cell lysis, like an IMHA case, which we did not have here? And so now we’re concerned about liver function, given this elevation of these other enzymes as well, or an obstructive disease somewhere in the biliary tree.

So I think that’s a great segue back to our fluids because we have. We have a couple of different things going on with this cat.

And I’m not sure what’s happening in that fluid. As we have said, it’s a wonderful little window into what’s going on inside of the patient. And so it’s so important to collect whatever we can, whether that’s a drop, whether we can fill our purple and our white tops.

In this case, they were able to. And we’re going to run it through our hematology analyzer.

Can I interject first, just to tag on to how important this is? Because in this cat, we know he’s got a significant disease, right? There’s a chronicity to it, and inflammation is part of it.

The liver is involved. The biliary tree appears to be involved. And. But he could have anything from a pancreatitis to a septic abdomen to heart failure to a liver mass.

Right. Like all of those things are all lymphoma. I mean, anything could contribute to this. And so what an opportunity, right, to get a window into what processes might be happening by tapping that.

So we are going to run our purple top through our hematology analyzer.

So the total nucleated cell count was 9.2, 9,000 per microliter. And the total protein was 5.8.

Increased nucleated cell count over, you know, 2,000, 2,500. And then protein over 2.5 grams per deciliter. Right. So, yep. Both high cellular, high protein. Sounds like an exudate.

So now I’m excited because these are my favorite fluids because there’s something to look at.

These inflammatory ones we often do, whether it’s because it’s pancreatitis or it’s septic like it was for Mac.

Yep. So now I’m. Now I’m looking.

Going to do my 100 cell count differential. I’m going to look around, kind of have a mixed bag. We have some neutrophils in there. There are large mononuclear cells that have these blue inclusions in them.

It’s not across all of the large mononuclear cells.

And so I took several cell phone images and sent a text message to Holly and said, hey, do you have a second? Can I send you some images? She said, sure.

I said, here. Here’s what I’m seeing. I told.

I told her the. The total protein.

I was going to check the T, Billy, because there were spots in the slide that I thought I saw white bile, but didn’t feel confident enough about it. I didn’t know what that pigment was in some of those larger cells.

That was my only other question.

The one with the most that you showed me, I think might be hemosiderin, but it’s hard to know. Right. Also another blue pigment inside of cells. The tbili in the blood.

Right. Was high. So especially with checking. Especially if you think there may be some white bile, too.

So after the reassurance of what I saw, I had already known that that’s what I was supposed to be doing.

Run the TV on the effusion.

Correct. And compare it to what we are seeing in the blood. So I actually really like this article. It’s analysis of canine peritoneal fluid analysis.

Interesting.

That’s funny. Two analysis in the same title.

And it was. It’s an article from 2017,

and it goes through and kind of creates algorithms for fluids. One of the last things that it talks about is additional testing. And one of the items is for bioperitonitis.

If the fluid bilirubin is greater than the serum bilirubin, that’s indicative of bioperatonitis.

Right. With the idea being that the bilirubin had to come from someplace. Right. And so normally the chemical constituents of the effusion have come from the blood are that of the blood or a dialysis.

Right. Of a dilution of what was in the blood. So when these values are higher in the fluid than they are in the blood, then we think there’s been some breach of that system.

Right. And so, like again, with pancreatitis, it’s if the lipase is higher in the fluid than is in the blood, it’s likely because the lipase is leaking out of the pancreatic cells.

Right. And so in this case, to say, well, the bilirubin is higher in the fluid than it is in the blood, there must be some breach of the.

Biliary tree, which for me,

I,

I haven’t ever seen a cat with bioperitonitis.

I mean, we don’t see it very often in dogs and I don’t, I don’t think I’ve ever looked at one in a cat.

Cats are weird.

Cats are weird. So to remind everybody, the bilirubin in the blood was 4.2 mixed per deciliter.

Yep.

And we are using the same analyzer to measure the bilirubin in the fluid. So we’re going out of that white top. So we’re not going out of our purple top. That’s for our slides.

Because EDTA helps preserve the cells and we can have issues with our biochemistry analysis using an EDTA tube. So we want to use that white top that doesn’t have an additive in it.

And the total bilirubin in the fluid was 32.2 milligrams per deciliter.

So just a bit higher in the fluid.

Just a smidge. So I go to the doctor and I say, here’s what I found on the fluid, here’s what I see. I compared the bilirubin’s. Something is going on in the biliary system and I really.

We need to ultrasound the cat.

Yeah, it’s leaking.

Correct. So they performed an ultrasound and it was, unfortunately for the cat, a mess in there. So there was a large cavitated structure in the cranial abdomen. There were multifocal cavity fluid filled structures throughout the central and caudal abdomen and numerous enlarged lymph nodes.

So owners were presented with a couple options. We can sample the mass, we can go to surgery and see, or you can do palliative care, or we can talk end of life based on quality of life.

And the owners elected to take him home for palliative care.

He’s still in game.

Yeah.

And they still assess him having a quality of life.

Okay. So what are our take home points?

Understanding a little bit about liver enzymes the take home of understanding your liver damage enzymes Understanding looking at them relative to the reference interval Understanding when GGT specifically rises that we’re talking about the biliary epithelium as being the source of that largely and then the importance of a fusion analysis.

Correct. And that there are biochemical tests that you can do to help you confirm your diagnosis. And as a technician like this would be a great journal article to snip that little box out and have that in your lab so that that way you could remember, hey, if we have a suspected biopyrotinitis,

here’s something that we can do. So it’s just another little tool in your toolbox and hopefully you will be using it for your fluid analysis.

Thank you for listening.

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Bye.