Extrahepatic biliary tract 15/5/03 13:49 Page 231

Extrahepatic biliary tract surgery

in the cat: a case series and review
Four cases of extrahepatic biliary tract surgery in the cat are Mayhew and others 2002), acute necrotis-
ing pancreatitis, extra- or intraluminal
described. The causes of the disease were inflammation of the
masses (Barsanti and others 1976, Tangner
gallbladder, distal common bile duct (CBD) or major duodenal and others 1982, Edwards and others
1983, Martin and others 1986), cholelithi-
papilla, and traumatic avulsion of the CBD. Bile peritonitis was
asis (O’Brien and Mitchum 1970, Hirsch
present in two of the cats. Biliary enterostomy was performed in and Doige 1983, Wolf 1984, Mayhew and
others 2002), diaphragmatic herniation
three cats, two of which were euthanased at five weeks and three
(Cornell and others 1993), inflammation
months postsurgery; the third was alive at the time of writing, of adjacent structures (Tangner and others
1982) and liver fluke infestation (Jenkins
four months postsurgery. Cholecystectomy was curative in one cat.
and others 1988, Lewis and others 1991).
A literature review reveals high early mortality following biliary There is evidence that obstructive biliary
disease in the cat is an emerging problem,
diversion, with only 50 per cent of cases surviving more than two
with both an increase in the incidence of
weeks, and 23 per cent surviving more than six months. Surviving predisposing factors such as acute pancreati-
tis (Simpson 2001), and a recent case series
cats had repeated intermittent vomiting and anorexia that
describing the pathogenesis and clinical out-
responded to antibiotics. No postoperative mortality was seen come of complete obstruction (Mayhew and
others 2002). This report reviews previously
when biliary diversion was avoided. Whenever biliary enterostomy
published cases of surgical correction of
or temporary diversion methods are performed, a poorer prognosis biliary tract disease in the cat, and describes
four additional cases presented to The
should be offered due to the increased likelihood of postoperative
Queen’s Veterinary School Hospital, Univer-
complications and mortality. sity of Cambridge, between 2000 and 2002.

N. J. BACON AND R. A. S. WHITE
Journal of Small Animal Practice (2003)
44, 231–235
The Queen’s Veterinary School
Hospital, University of Cambridge,
Madingley Road, Cambridge
CB3 0ES
INTRODUCTION
Diseases of the biliary system are relatively
uncommon in small animals. Importantly,
there is little information on morbidity or
survival rates following extrahepatic biliary
tract surgery in the cat. Reviews of extra-
hepatic biliary disease rarely include the
feline condition, and draw conclusions
from publications concerning humans or
dogs. Differences in feline anatomy,
disease incidence and aetiology warrant
specific comparisons with the dog.
Indications for surgical intervention
include bile leakage or biliary obstruction
(Bjorling 1991). Leakage and subsequent
chemical peritonitis is usually traumatic in
origin (Ludwig and others 1997) but may
also result from prolonged obstruction.
Causes of obstruction of the biliary tract in
cats include cholangiohepatitis, with or
without inspissation of bile (Kelly and
others 1975, Zawie and Shaker 1989,
CASE HISTORIES
Case 1
A six-year-old, male neutered domestic
shorthaired cat was presented with a
four-day history of progressive lethargy,
anorexia, vomiting and jaundice. A similar
episode had occurred two years previously
and the cat had responded promptly to
intravenous fluid and antibiotic therapy.
The cat was found to be profoundly jaun-
diced with a painful, distended abdomen.
This was accompanied by pyrexia (41°C),
dullness and dehydration.
Haematological examination demon-
strated moderate neutrophilia (19109/
litre [reference range 2·5 to 12·5109/
litre]) with a slight left shift; mild lympho-
penia (1·13109/litre [1·5 to 7·0109/
litre]) and normocytic-normochromic
anaemia (0·23 litre/litre [0·26 to 0·45 litre/
litre]). Biochemical abnormalities included
mild azotaemia and elevations in alkaline
phosphatase (119 IU/litre [16 to 68 IU/litre)

JOURNAL OF SMALL ANIMAL PRACTICE • VOL 44 • MAY 2003 231

Extrahepatic biliary tract 15/5/03 13:49
and alanine aminotransferase (190 IU/litre
[16 to 44 IU/ litre). Total bilirubin (104
mol/litre [0 to 15mol/ litre]) was raised.
Abdominal radiographs demonstrated a
generalised loss of serosal detail. Ultra-
sonography showed a large gallbladder
with a dilated and tortuous common bile
duct (CBD) that contained discrete miner-
alised hyperechoic bodies. Ultrasound-
guided abdominocentesis of free peritoneal
fluid revealed bright yellow, non-floccu-
lent, bile-stained fluid.
Stabilisation with intravenous fluid
therapy (Hartmann’s; Aqupharm), metro-
nidazole (Metran; Pharma Mondial) and
clavulanate-potentiated amoxycillin (Aug-
mentin; SmithKlineBeecham) was fol-
lowed by laparotomy. A grossly distended
cystic bile duct was identified with a 5 mm
tear in the fundus of the gallbladder, which
appeared necrotic. A choledocholith was
flushed into the duodenum and cholecyst-
ectomy was performed, with the cystic
duct being oversewn with 1·5 M
polyglactin 910 (Vicryl; Ethicon). Abdom-
inal lavage was carried out.
Postoperative analgesia was achieved
with tactical buprenorphine (Vetergesic;
Alstoe Animal Health). The cat was main-
tained on intravenous fluids for three days
as it was reluctant to eat voluntarily. Urea,
creatinine and total bilirubin were normal
after six days. Antibiotic therapy was main-
tained for a total of two weeks after surgery.
Stone analysis revealed that the cholelith
was composed of calcium carbonate (86 per
cent), oxalate (10 per cent), phosphate (2
per cent), and magnesium (2 per cent). Fol-
low-up examinations at two and seven
months found no recurrence of the signs.aa
Case 2
A two-year-old, female neutered domestic
shorthaired cat presented to the referring clin-
ician following a road traffic accident, and
was discharged after two days of supportive
care. The cat deteriorated over the next three
days and became dull, anorexic, depressed
and jaundiced, with a painful abdomen.
Radiographs demonstrated reduced abdomi-
nal serosal detail. Biochemistry showed eleva-
232
Page 232
tions in alanine aminotransferase (995
IU/litre [16 to 44 IU/litre) and total bilirubin
(155 mol/ litre [0 to 15 mol/litre).
Ultrasonography showed a full gallblad-
der surrounded by free fluid, with a hyper-
echoic area caudal to the duodenum, in the
region of the CBD. Abdominocentesis
produced thick greenish-yellow bile-
stained fluid. The cat was stabilised prior
to surgery, as in case 1.
At laparotomy, bile peritonitis was con-
firmed and an avulsion of the CBD was
identified 4 mm from the duodenum.
Attempts to re-anastomose the duct were
unsuccessful and a cholecystoduodenos-
tomy was performed. The avulsed ends of
the CBD were ligated with 1·5 M poly-
glactin 910 (Vicryl), and 1 cm incisions
were made in the gallbladder and descend-
ing duodenum. These were apposed using
a continuous appositional suture pattern
of 1·5 M polyglactin 910. Abdominal
lavage was performed.
Postoperative analgesia was achieved
with tactical buprenorphine (Vetergesic).
The cat was maintained on intravenous
fluids for a further five days as it was inap-
petent postoperatively. Urea and creatinine
were elevated for six days after surgery, but
total bilirubin was only mildly elevated
after 48 hours (23 mol/litre [0 to 15
µmol/litre) and was normal by six days
postsurgery (13 µmol/litre). Antibiotic
therapy postsurgery was as in case 1.
Bouts of pyrexia, two and three months
after discharge, responded promptly to
short courses of antibiotics. At four
months, the cat became anorexic and dull,
did not respond to symptomatic therapy
and was euthanased. Postmortem exami-
nation was not performed.
Case 3
A three-year-old, male neutered Siamese
cat presented with a three-month history
of weight loss and vomiting. The cat was
found to be jaundiced and dull.
Haematology demonstrated neutrophilia
(33·8109/litre [2·5 to 12·5109/litre])
and lymphopenia (1·33109/litre [1·5 to
7·0109/litre]). Biochemistry showed ele-
JOURNAL OF SMALL ANIMAL PRACTICE
vations in alkaline phosphatase (78 IU/ litre
[16 to 68 IU/litre]), alanine transferase (307
IU/litre [16 to 44 IU/litre]) and creatinine
kinase (701 IU/litre [49 to 151 IU/litre]).
Total bilirubin (22 mol/ litre [0 to 15
mol/litre]) was raised. Ultrasonography
revealed a hugely dilated tortuous CBD,
indicative of severe biliary obstruction.
Dilation of biliary ducts suggestive of intra-
hepatic cholestasis was detected.
A 1 cm, pale, hardened area within the
lumen of the CBD, close to the duode-
num, was found at laparotomy. Fine nee-
dle aspiration of this area revealed evidence
of chronic inflammation. A cholecysto-
duodenostomy was performed, as in case
2, with a 2 cm stoma. The anastomosis was
omentalised and the abdomen lavaged.
Antibiotic therapy postsurgery was as in
case 1. The cat remained inappetent for two
days but improved rapidly thereafter. Postop-
erative analgesia was achieved with tactical
buprenorphine (Vetergesic). The jaundice
had resolved by three days after surgery.
Normal eating and behaviour continued
for three weeks but bilious vomiting and
anorexia returned. The cat was euthanased
five weeks postoperatively. Postmortem
examination was not performed.
Case 4
An eight-year-old, female neutered domes-
tic shorthaired cat was presented to the
referring clinician with pyrexia, lethargy,
inappetence and weight loss. Ultrasonog-
raphy demonstrated a periduodenal com-
pression of the CBD, and at laparotomy
and cholecystotomy the CBD was cannu-
lated and lavaged and full patency was
restored. A duodenal biopsy revealed
chronic plasmacytic-lymphocytic infiltra-
tion, although such changes are commonly
found at this site in the normal cat (Weiss
and others 1996). Low dose prednisolone
and antibiotic therapy was instigated.
One year later, clinical signs recurred
while the cat was on medical therapy. Bio-
chemistry and haematology showed elevated
aspartate aminotransferase (42 IU/litre [0 to
32 IU/litre]), mild non-regenerative anaemia
(packed cell volume 0·24 litre/litre [26 to 45
• VOL 44 • MAY 2003
Extrahepatic biliary tract 15/5/03 13:49
litre/litre]) and mature neutrophilia (29·1
109/litre [2·5 to 12·5 109/litre]). Radio-
logical findings were unremarkable, but
ultrasonography revealed a mass in the distal
CBD merging with the duodenal wall, a dis-
tended CBD and a thick-walled gallbladder.
At laparotomy, clinical inspection
showed the mass in the bile duct to be a
recurrence of the duodenal inflammation
involving the papilla. A cholecystojejun-
ostomy was performed to avoid biliary
enterostomy with inflamed small intestine.
This was performed following the same
principles as in case 2, with a 2 cm stoma. A
gastrostomy tube was placed into the fun-
dus. The anastomosis and gastrostomy were
omentalised and the abdomen lavaged. A
liver biopsy revealed multifocal, moderate,
portal plasmacytic-lymphocytic cholangio-
hepatitis with mild fibrosis and a diffuse
neutrophilic hepatitis, consistent with a sub-
acute ascending portal cholangiohepatitis.aa
Postoperative antibiotic therapy was as
for case 1, and the preoperative pred-
nisolone was continued. Analgesia was
achieved with tactical buprenorphine (Vet-
ergesic). The cat proved difficult to med-
icate and so was fed and medicated via the
gastrostomy tube for three days. It was dis-
charged five days after surgery with the
tube in situ. Ten days later, the cat became
anorexic and markedly anaemic (packed
cell volume 0·12 litre/litre [26 to 45
litre/litre]). Haemobartonella felis infection
was diagnosed, which responded to tetra-
cycline treatment over three weeks. During
this time, feeding was supplemented via
the gastrostomy tube; once the packed cell
volume was normal, the tube was removed.
At the time of writing, four months after
surgery, intermittent vomiting was still
occurring and therapy with prednisolone
(Prednidale; Arnolds) 5 mg orally, once
daily, and ampycillin (Amfipen; Intervet) 50
mg orally twice daily) was being continued.
DISCUSSION
The primary goals in the surgical treatment
of biliary disease are to establish an accurate
JOURNAL OF SMALL ANIMAL PRACTICE • VOL 44 • MAY 2003
Page 233
diagnosis, to prevent leakage of bile into the
abdomen and to provide a patent conduit
for bile into the gastrointestinal tract
(Bjorling 1991). Diagnosis is dependent on
a combination of clinical signs and appropri-
ate laboratory and imaging techniques.
Anatomical variations are noteworthy
in the cat. The major pancreatic duct usu-
ally joins the CBD before it enters the duo-
denum, but occasionally they share an
opening (Bjorling 1991). The duct(s) cross
the serosal surface of the duodenum at the
mesenteric wall, approximately 3 cm distal
to the pylorus, travel through the muscu-
laris and empty obliquely into the duode-
num at the major duodenal papilla
(Halpert 1932). In dogs, the major pancre-
atic duct is small, drains only the left limb
and is rarely fused with the CBD.
The feline accessory pancreatic duct,
which empties into the duodenum at the
minor duodenal papilla, 2 cm distal to the
major one, is small and occurs in only 20
per cent of cats (Schummer and others
1979), whereas in dogs it is the larger, pre-
dominant duct. Pancreatitis in the cat may
therefore concurrently obstruct the CBD,
whereas this is less likely to occur in the
dog, where the more significant accessory
pancreatic duct is distant from the CBD.
Thirty-eight cases of extrahepatic biliary
tract surgery have been described in the cat
(Naus and Jones 1978, Tangner and others
1982, Edwards and others 1983, Wolf 1984,
Martin and others 1986, Jorgensen and oth-
ers 1987, Jenkins and others 1988, Lewis
and others 1991, Cornell and others 1993,
Ludwig and others 1997, Elwood and others
2001, Mayhew and others 2002). Of these
cases, 26 (68 per cent) were domestic short-
haired cats and seven (19 per cent) were
Siamese. Anecdotally, the prevalence of
pancreatitis and cholangiohepatitis is high
among Siamese cats and this may predispose
them to pathological changes leading to bil-
iary obstruction. The sex distribution was
balanced, with 20 males and 18 females. The
mean age, where recorded, was 7·6 years.
Clinically apparent jaundice was the
most common sign, although it was not
consistently seen. Most signs were vague and
non-specific, such as vomiting, anorexia,
depression and weight loss. Acholic faeces
may occur following biliary tract obstruction
(Blass 1983, Martin 1993a) and, although
invariably seen following experimental liga-
tion of the CBD in cats (Center and others
1983), none of the 38 cases reported had
acholic faeces. The mean duration of clinical
signs following chronic enteritis, cholangio-
hepatic, pancreatic or neoplastic obstructive
disease was 54 days, compared to four days
in three cats with biliary tract trauma.
In all three trauma cases, injury to the
biliary system alone was reported, with sur-
rounding structures remaining unharmed, a
phenomenon not uncommon in humans
and dogs (Thompson 1981, Hunt and
Gofton 1984). Mild biliary leakage and
injury may resolve spontaneously (Robins
and others 1977), but severe leakage causes
intense local inflammation (Hunt and
Gofton 1984). Four cats presented with bil-
iary tract rupture, two with CBD avulsion
from gunshot wounds (Ludwig and others
1997) and a road traffic accident (case 2 of
the present series) and two with gallbladder
rupture from gunshot wounds (Ludwig and
others 1997) and cholecystitis (case 1). As in
the dog, the poorly vascularised fundus of
the feline gallbladder appears to be predis-
posed to rupture secondary to inflamma-
tion (case 1), suggesting that focal ischaemia
may be aetiologically important (Ludwig
and others 1997).
Results of laboratory investigations are
subtle and non-specific. The mild non-
regenerative anaemia seen in 13 cats has
been previously reported in five out of six
cats following experimental extrahepatic
biliary tract obstruction (Center and others
1983), and also in a clinical case in a dog
(Hunt and Gofton 1984), and appears to be
an anaemia of chronic disease. The associa-
tion of clinical coagulopathy with biliary
tract disease, as seen in humans (Neer
1992), has rarely been reported as a prob-
lem in cats, despite one-stage prothrombin
time being elevated in eight of 18 cats in
one study (Mayhew and others 2002). Ele-
vations in total bilirubin and liver enzyme
levels were common, with increases in ala-
233
Extrahepatic biliary tract 15/5/03 13:49
nine aminotransferase usually being greater
than alkaline phosphatase. This concurs
with findings following experimental CBD
ligation in the cat, where alanine amino-
transferase increased to 20 times the base-
line level (Center and others 1983), whereas
alkaline phosphatase increased to only 4·0
to 7·6 times the baseline level (McLain and
others 1978, Center and others 1983).
Ultrasonography is used as the primary
imaging modality for the biliary tract in
humans (Rosenthal and others 1990). It
was used in all four cats in this report to
identify lesions such as dilation and tortu-
ousity of the CBD, and distended gallblad-
der. Ultrasonography has previously been
used to diagnose gallbladder disease, CBD
distension and obstruction in cats,
although the precise level of obstruction is
often not identifiable (Lévéillé and others
1996, Hittmair and others 2001).
Nine different surgical procedures for
management of biliary tract disease have
been described in the cat: cholecystoduo-
denostomy (17 cats); cholecystojejunostomy
(six cats); choledochojejunostomy (two
cats); choledochotomy, with or without T-
tube stenting (four cats); duodenotomy with
CBD lavage or cholecystotomy (two cats);
tube cholecystostomy (two cats); primary
gallbladder repair (one cat); and cholecystec-
tomy (three cats). Biliary enterostomy in the
cat and dog differs from that in humans.
Choledochoduodenostomy is the procedure
of choice in humans, but the small size of the
normal bile duct in the cat (2 to 2·5 mm)
and dog (3 mm) compared to the human
bile duct (10 mm) makes choledochoenteric
anastomosis difficult in veterinary patients
(Martin 1993b), so cholecystoenterostomy
is therefore performed more frequently.
Recommendations for biliary enteros-
tomy in humans have been adapted by
Tangner and others (1982) for veterinary
patients as follows:
 Stoma size should be a minimum of 2 to
2·5 cm long;
 An ellipse of mucosa should be excised
before anastomosis;
 Mucosal surfaces must be accurately
apposed to avoid stricture formation;
234
Page 234
 Create a tension-free anastomosis;
 Use synthetic absorbable suture materi-
als to reduce inflammation; and
 Suture omentum over the anastomosis
site.
Where possible, primary suturing or
anastomosis of traumatic injury should be
performed, but gallbladder perforation
secondary to necrotising cholecystitis war-
rants cholecystectomy, rather than repair
(Church and Matthiesen 1988, Brömel
and others 1998).
Despite careful surgical technique,
gastrointestinal signs such as vomiting and
anorexia are common following biliary
enterostomy. This has been attributed to
surgical trauma to the pancreas, duodenum
and gallbladder, but enterobiliary reflux
causing cholangitis has also been incrimi-
nated (Tangner 1984). Recurrent cholangi-
tis and/or cholecystitis after cholecysto-
duodenostomy has been reported in cats,
humans and dogs (Tangner and others
1982). Postoperative cholangitis is believed
to be descending rather than ascending, and
is caused by stricture at the anastomotic site.
In humans this may be avoided by creating
a large stoma (2 to 2·5 cm) at the anastomo-
sis (Johnson and Stevens 1969) and this
principle has been extended to animal
patients. Retrospectively, the 1 cm stoma in
case 2 was too small and the effect this may
have had on the case outcome is unknown.
Subsequently, a larger (2 cm) stoma in cases
3 and 4 was created, as described in humans
(Johnson and Stevens 1969), although cre-
ating an even larger stoma (2·5 to 4 cm) has
been advocated in the dog (Matthiesen and
Rosin 1986).
Temporary extracorporeal biliary diver-
sion in the cat is uncommon, with only
choledochotomy plus T-tube stenting and
tube cholecystostomy reported. The for-
mer has become associated with increased
patient morbidity in humans (Hunt and
Gofton 1984) and use of the latter has
been precluded by a high incidence of bac-
teria and infection in the drained bile
(Lawrence and others 1992).
Case 1 in this report presented with a
previously unreported triad of cholelithia-
JOURNAL OF SMALL ANIMAL PRACTICE
sis, cholecystitis and gallbladder perfora-
tion, which is equally rare in the dog
(Brömel and others 1998). Cholelithiasis
has been described in another eight
cats, most with obstruction of the CBD
or the major duodenal papilla. Five of the
eight cats were male; conversely, in dogs,
there is an overrepresentation of females
(Kirpensteijn and others 1993). Chole-
lithiasis in cats is not clearly understood,
with some authors considering it to be
associated with cholangitis and/or cholan-
giohepatitis (Zawie and Garvey 1984) and
others believing it to be unassociated with
clinical disease (Wolf 1984). The latter
assumption is questionable, with chole-
lithiasis-associated obstruction or gallblad-
der rupture having reportedly occurred
in five cats (case 1, O’Brien and Mitchum
1970, Naus and Jones 1978, Wolf 1984,
Jorgensen and others 1987).
There is little published survival data for
extrahepatic biliary tract surgery in cats.
Only one series has reported the
outcome of surgery following complete
obstruction (Mayhew and others 2002),
and this study found perioperative mortal-
ity in cats with neoplasia to be 100 per cent,
and in those with non-neoplastic lesions to
be 40 per cent. Previously reported cases
can, however, also be categorised according
to the surgery performed into biliary diver-
sion (n=29) versus non-diversionary groups
(n=9). An early high mortality rate was
recorded following diversion, with only 50
per cent surviving beyond two weeks post-
surgery. Causes of death included clinical
deterioration, enterostomy dehiscence and
cardiopulmonary arrest. All surviving cases
had repeated intermittent bouts of pyrexia,
vomiting and anorexia, every few weeks or
months. These were usually antibiotic-
responsive and transient. Euthanasia due to
such episodes reduced the survival rate to
only 23 per cent beyond six months. Of the
remaining six cases, two were euthanased
(one at 15 and one at 19 months) with the
rest alive at six months, two years (two
cases) and four years. Following non-diver-
sionary techniques, there was a single peri-
operative death due to cardiopulmonary
• VOL 44 • MAY 2003
Extrahepatic biliary tract 15/5/03 13:49
arrest, but no other recorded postoperative
mortality, with follow-up times of six days,
six weeks, three, seven, nine, 12 and 18
months, and six years.
In a large study of 22 cases of canine
extrahepatic biliary surgery, five out of 14
dogs (36 per cent) that underwent biliary
diversion recovered, and six out of eight
(75 per cent) that underwent non-diver-
sion surgery recovered. No follow-up times
were recorded (Fahie and Martin 1995). In
another series of dogs undergoing biliary
diversion, four out of seven cases died
within two weeks of surgery (Martin and
others 1986).
Conclusions
Morbidity and mortality following biliary
tract surgery in the cat is high. Although
comparable to the dog, lack of post-
mortem examination data in the cat limits
confident analysis of the causes. All the
surviving cases of biliary enterostomy had
repeated intermittent bouts of pyrexia,
vomiting and anorexia every few months,
which responded to antibiotics. Mortality
for non-diversionary techniques appears
low, although some follow-up times are
short. It therefore appears that whenever
biliary enterostomy or temporary diversion
methods cannot be avoided, a poorer
prognosis should be offered, due to the
increased likelihood of postoperative com-
plications and mortality.
Acknowledgements
The authors would like to thank Mrs P.
Watson for her help with case 4, and Dr J.
C. Chantrey for providing the pathology
report. N. B. is a BSAVA Petsavers Resi-
dent in Soft Tissue Surgery and is grateful
for the charity’s continued support.
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