Ascites after a Bob Martin wormer?

Re: Ascites after a Bob Martin wormer?

Tom Ward — Wed, 05 Feb 2014 16:54:07 GMT

[quote user="Anthony Todd"]

[quote user="Tom Ward"]I convinced the owner to take bloods, which are as follows:[/quote]

Wouldn't/shouldn't the abdo fluid be the first thing to look at? A quick and easy abdo tap gives you so much info.?

[/quote]

perhaps, though I've had a lot of cases of 'modified transudates' that come with a very long list of differentials. In hindsight, it would have saved time to do them both together!

Re: Ascites after a Bob Martin wormer?

Anthony Todd — Wed, 05 Feb 2014 06:33:21 GMT

[quote user="Tom Ward"]I convinced the owner to take bloods, which are as follows:[/quote]

Wouldn't/shouldn't the abdo fluid be the first thing to look at? A quick and easy abdo tap gives you so much info.?

Re: Ascites after a Bob Martin wormer?

Tom Ward — Tue, 04 Feb 2014 13:14:54 GMT

Doesn't look good I'm afraid... going to ring the o this afternoon and discuss FIP :(

Total nucleated cell count 1.02 x10^9/L
red cell count 0.01 x10^12/L
total protein 69 g/L
Albumin 14.5 g/L
Neuts 62%
Lymphocytes 10%
Monocytes/macrophages 25%
Mesothelial 3%
No neoplastic cells seen

Re: Ascites after a Bob Martin wormer?

Christopher Saul — Mon, 03 Feb 2014 00:03:37 GMT

[quote user="Kishor Mahind"]What is your opinion on BAST?[/quote]

Hi Kishor

I believe the BAST to be useful, but it has its limitations, as do many (all?) tests,and one needs to be aware of these limitations when interpreting the test.

Rather than thinking of a BAST as a direct measure of liver function, I find it helpful to think of it as essentially an interrogation of a patient's enterohepatic circulation....

CCK stimulates gallbladder contraction which should cause BA release into the GI tract. These BAs are readily absorbed by the ileum where they are transported back into the portal circulation, from where they should (assuming normal hepatic function) be scavenged by the liver extremely effectively (98% on first pass) and returned to the gallbladder. Thus, BAs should not enter the systemic circulation in any significant quantities.

High post prandial BA tells us that enterohepatic circulation is disrupted, so either

-there is biliary obstruction OR

-the liver is failing to properly remove BAs from the portal circulation OR

-there is portosystemic shunting.

So. If there is a situation where enterohepatic circulation is impaired and we know why - for instance bile duct obstruction, in which case a patient will be jaundiced - then the BAST will be high but it doesn't add anything because WE ALREADY KNOW that the enterohepatic circulation is impaired by virtue of the fact that the patient is jaundiced and the fact we can see the distended common bile duct.

Now imagine we have a patient with liver failure and jaundice because of the liver failure, we do an ultrasound and find no evidence of biliary stasis. So we've already identified hepatic jaundice. The BAST would be high but it wouldn't tell us anything new because WE ALREADY KNOW that enterohepatic circulation is impaired by virtue of the fact the patient is jaundiced.

So - limitation 1. The BAST adds nothing when a patient is jaundiced ( now I know the cat in this thread had a slightly high TBil, but this one only had a very slight elevation in TBil. I'm talking moderate or large elevations in TBil here). Of course, a patient could become jaundiced owing to IMHA, but we should be able to eliminate that before we get as far as a BAST.

This brings me onto the strength of the BAST. BAST will become elevated before TBil, so BAST IS MORE SENSITIVE THAN TBIL for liver disease.

Limitation 2. Reactive (secondary) hepatopathies can cause moderate elevations in post prandial BA. Typically a reactive hepatopathy will cause a pp BA of as much as 50 or 60. Given that normal is <10, this means that there is a very large 'grey zone' where you would say that the BAST is abnormal but you cannot say that there is a significant primary loss of liver function. BAs of 50 or 60 can be hard to interpret.

So: BAST is useful but remember:-

*no point in doing it on a jaundiced patient (or in patients you know by ultrasound have either biliary obstruction or a portosystemic shunt) because it doesn't tell you anything you don't already know

*there's quite a large grey zone where reactive hepatopathies, with no significant loss of function, can result in fairly largish elevations in BAs (often 50 odd) - so an elevation of this degree is hard to interpret.

If you use the BAST carefully and remember its limitations, it is a useful test.

Just my 2 pence

Hope this helps

Chris

Re: Ascites after a Bob Martin wormer?

Kate Richardson — Sun, 02 Feb 2014 12:48:52 GMT

[quote user="Christopher Saul"] I agree with the others that this poor cat is screaming FIP[/quote]

+ another 1. Sadly. Suspect cat already had ascites it just got REALLY obvious.

Re: Ascites after a Bob Martin wormer?

Tom Ward — Sat, 01 Feb 2014 22:26:59 GMT

Thanks so much for your replies, especially Chris - I think I'll be filing that response too for future reference. I shall let you know what I get from the abdominocentesis on Monday!

Re: Ascites after a Bob Martin wormer?

Linda Filshie — Sat, 01 Feb 2014 20:47:19 GMT

[quote user="Richard Carter"]

A trick for FIP/ high protein transudates vs exudates is to shake the syringe with some air and if it remains persistently foamy, the protein content is high.

[/quote]

And this works with urine too :)

Re: Ascites after a Bob Martin wormer?

Richard Carter — Sat, 01 Feb 2014 19:14:54 GMT

A trick for FIP/ high protein transudates vs exudates is to shake the syringe with some air and if it remains persistently foamy, the protein content is high.

Re: Ascites after a Bob Martin wormer?

Kishor Mahind — Sat, 01 Feb 2014 13:49:03 GMT

Hi Chris,

Thank you for such simple yet detailed explanation for interpretation of free abdominal fluid. Very useful, I'm going to print this off and save it for future reference!.

[quote user="Christopher Saul"]

Might be an idea to do a BAST to look at liver function.

[/quote]

What is your opinion on BAST? At London Vet Show last year, one of the speaker mentioned that he was not a big fan of the test. I have always struggled a bit to interpret the results and sometimes I feel that it doesn't add a lot to what I already know after performing a detailed serum biochemistry study.

Thank you

Kishor

Re: Ascites after a Bob Martin wormer?

ChrisBVSc — Sat, 01 Feb 2014 13:22:52 GMT

My input is nothing compared to the post above but I did read that & instantly think "FIP" too!

Re: Ascites after a Bob Martin wormer?

Christopher Saul — Sat, 01 Feb 2014 10:53:44 GMT

Firstly, I agree with the others that this poor cat is screaming FIP, and that other causes are less likely. That said, though unlikely, there are other potential causes and we might consider; for (God forbid this ever happens) if my cat came down with this clinical picture I should like a little more evidence before waving him goodbye. Could this be one of those weird foreign bodies which hasn't vomited ? heart failure? Liver disease?

So it may help if we have a little review of the potential causes of ascites. These definitions are pretty wooly and there is some overlap between them - they are only a rough guide and must not be considered to be 'gold standard' (I'm also doing this off the top of my head whist waiting for a train, and don't have my notes to hand!)

-Pure transudate (generally SpG <1.016 or so, total solids <25g/l) mainly hypoalbuminaemia

[quote user="Thomas Ward"] The albumin level doesn't really seem low enough? [/quote]

Agree. usually don't get a transudate until you get down to 14 or so

-Modified Transudate (generally SpG 1.016-1.025 or so, total solids 25-50g/l) - essentially portal hypertension - so right sided heart failure, hepatic vascular disorders, liver disease etc - and neoplasia.

-Exudate (generally SpG >1.025, though total solids can be as low as 30 or 40 with lots of cells instead so there is overlap with modified transudate) - septic peritonitis, vasculitis (mainly FIP), bile, blood, chyle, urine, some neoplasia. Pancreatitis can cause an exudate too

so:

Abdominal radiography is likely to be unrewarding. Thoracic radiography worth a look (in case of any mediastinal masses etc or gross cardiomegaly). Ultrasound is more likely to be helpful, as may be able to visualise things like acquired portosystemic shunts or gross changes to the liver parenchyma, or large masses, or gastrointestinal lesions. Also you might see granulomas within the lymph nodes - I have seen this with FIP.

If ultrasound either unrewarding or not an option then:-

First thing is to get hold of a sample of the fluid and get it analysed. You can quickly eliminate blood, chyle, urine in this way. If you can't or don't want to wait for the lab report then you could do a refractometer reading and microscopy in house, if there is lots of degenerate neutrophils with intracellular bacteria etc then that would point to sepsis, also you can compare glucose of the fluid with that of the serum - if the fluid glucose is lower then that also points to sepsis.

Obviously if this is a septic exudate then ex lap is indicated.

Might be an idea to do a BAST to look at liver function.

By this stage, most of the other differentials (sepsis, liver failure etc) will likely have been ruled out but if you're still drawing a blank then I would recommend sending some fluid and blood to Glasgow Uni path lab for their 'FIP profile' which includes FCoV tire, AGP, amongst others. Could also send blood for ProBNP to look for evidence of congestive heart failure, or even refer for cardiac and abdominal ultrasound (though I'm guessing uninsured if owner felt that the best way to fix her cat's abdominal distension was to useBob Martin's, but perhaps I'm being prejudiced here)

Just a few thoughts. I'm sorry this has (yet again) just turned into one of my rambles.......

Chris

Re: Ascites after a Bob Martin wormer?

Bob Russell — Sat, 01 Feb 2014 10:02:47 GMT

Pretty sure BM spot on wormer contains praziquantel so side effects will be in line with the data sheet for droncit spot on. Clearly pretty unlikely to be the cause!

FIP until proven otherwise (if you can!).

Re: Ascites after a Bob Martin wormer?

Suzanne Kelly — Fri, 31 Jan 2014 22:44:28 GMT

+1 FIP. Your blood picture very supportive of FIP with the hyperglobulinaemia. Also in the early stages ascites would look like a wormy belly.

Re: Ascites after a Bob Martin wormer?

Yantha Smyth — Fri, 31 Jan 2014 19:56:14 GMT

+1 for FIP- several supportive changes- the fluid would be high protein too...I remember looking up some info on www.catvirus.com re FIP and as well as it having a very complicated diagram and simpler check list for FIP, it also had this simple cheap test you could do on the effusion using water and white vinegar that was a pretty reliable indicator ( prob related to protein content )

Re: Ascites after a Bob Martin wormer?

Francisco Gomez — Fri, 31 Jan 2014 18:58:21 GMT

[quote user="Thomas Ward"]

A bugger to pin down though!

[/quote]

Definitely, and with a client that's already blaming something else.. you've got a lot of work to do... Good idea to exhaust the wormer side effect possibility to get the client on-board I think...

Re: Ascites after a Bob Martin wormer?

Tom Ward — Fri, 31 Jan 2014 18:55:53 GMT

[quote user="Francisco Gomez"]

multi-house cat, hyperproteinemia, possibly non regenerative anaemia, ascities and weight loss...

FIP?

[/quote]

Yep, that's towards the top of my list too. A bugger to pin down though!

Re: Ascites after a Bob Martin wormer?

Francisco Gomez — Fri, 31 Jan 2014 18:31:45 GMT

multi-house cat, hyperproteinemia, possibly non regenerative anaemia, ascities and weight loss...

FIP?

Re: Ascites after a Bob Martin wormer?

Francisco Gomez — Fri, 31 Jan 2014 18:23:34 GMT

I have encountered a number of occasions when the owner has first giving the wormer to the cat because it was unwell. 'Oh! He/she may just need a wormer'. When realised that the cat doesn't improve/worsen, it is taken to the practice. I'm not saying this is what happened to your patient, but I would be very careful before dismissing this possibility completely.