high pre BA stim, low post BA stim

Re: high pre BA stim, low post BA stim

Christopher Saul — Fri, 12 Nov 2010 19:07:04 GMT

Regarding the bile acid results:

Both James and Micheal's explanations are possible; mixing up of the samples would explain it but so would premature gall bladder contraction. The basis if of the bile acid stimulation test is essentially that it tests gall bladder emptying and enterohepatic recicrulation. The purpose of feeding them is to cause a postprandial cholecystokinin surge and thus stimulate gall bladder contraction; but this does not necessarily actually occur post feeding - as James says, it may have already happened before the food was given.

However I don't think it is worth losing sleep over; the bile acid stimulaton test doesn't really add anything in this case anyway. The reason behind doing post prandial bile acids is that these improve the sensitivity of bile acids to detect hepatic or bilary problems.

In a jaundiced patient in which you have eliminated pre-hepic causes ( I assume you have - PCV?), you already know that enterohepatic circulation is interrupted and there must be either a hepatic or cholestatic problem anyway. so the BAST is not really necessary, it doesnt help distinguish heptaic from post hepatic jaundice.

I'm sorry that doesn't help much!

With regards case management:

ideally you need to get good images of the bilary tract and pancreas, could you refer to a radiologist? If the patient declines clinically, then I would consider referral to a surgeon ( if it is obstructed it may need a stent, and if it isnt then you may ultimately need a liver biopsy to get a diagnoisis).

If referral isn't an option and so long as the patient is improving with your treatment, your treatment plan seems fine. (word of caution, destolit is relatively contraindicated in bilary obstruction so if you repeat the ultrasound and the bilary tree looks more distended may be worth stopping it). From your initial results, this does seem suspicious for a posthepatic case, as you say pancratitis is a differential.

I'm sorry I can't help more!

Chris

Re: high pre BA stim, low post BA stim

HMC — Fri, 12 Nov 2010 18:33:47 GMT

I was just about to say my opinion but Laurence just said it all for me!

Re: high pre BA stim, low post BA stim

Laurence Webb — Fri, 12 Nov 2010 17:59:40 GMT

One of the main reasons for doing a BA stim test rather than a random one is as a quality control to ensure that you are seeing peak levels rather than trough levels or somewhere in between. Premature contraction of the GB is probably the reason for the reversed BA levels unless the sample order was mixed up. Lipaemia in the post sample is one way of checking that the sample order was correct. Not being fully starved or spotaneous GB contraction may be reasons for this

As the BA pattern is reversed you can't be sure whether the 93 is the true peak or if it was falling from a higher level. It doesn't really matter though as you've got a sufficiently high 1st sample anyway. Personally, if the dog is icteric, I wouldn't bother with a BA stim as you know bilirubin is elevated so by default the BAs will be up.

Re: high pre BA stim, low post BA stim

Kate Richardson — Fri, 12 Nov 2010 17:55:45 GMT

As a slight aside, recent cpd at TDDS advised when doing bile acid stim tests, just to give a small meal of normal food and not to add any fat/oil; normal food will cause GB contraction. Adding oil often leads to very lipaemic sample which can falsely elevate bile acid levels and cause +++ artefacts. That doesn't explain your lower post prandial result tho, sorry!

Re: high pre BA stim, low post BA stim

sophia guymer — Fri, 12 Nov 2010 17:53:17 GMT

Just a little question in between, would you worry if you got a high BA level back on a health check bloods in a dog without symptoms?

Re: high pre BA stim, low post BA stim

jonathan harte — Fri, 12 Nov 2010 16:27:26 GMT

was done in house, so couldn't have got mixed up?

Also thought it was odd that the gall bladder was still full 2hrs after fatty meal? Don't know if this has anything to do with it, but thought there would still hjave been high BAs post stim if there was an obstruction?

Planning to rpt bile acids later today...so i'll see what they show now...

Re: high pre BA stim, low post BA stim

Martin Atkinson — Fri, 12 Nov 2010 15:41:12 GMT

[quote user="James Allsop"]

I was told that a post BA lower than the Pre BA suggested that you had premature GB contraction - this is often caused by the animal getting a smell or inkling that food will soon be available and the GB contracts - eg the nurses got everything ready for the 1st sample, including putting the food out next to the kennel.

[/quote]

I can't see how that would, surely work bile acids aren't that labile unless you prepared the food the day before. Michael's explanation is what I would have suggested but when do you start or stop trusting labs unless it was done on an in-house analyser which may be inaccurate?

Re: high pre BA stim, low post BA stim

Michael Woodhouse — Fri, 12 Nov 2010 14:19:42 GMT

Could the lab have mixed the samples up?

Re: high pre BA stim, low post BA stim

James Allsop — Fri, 12 Nov 2010 13:21:12 GMT

Re: high pre BA stim, low post BA stim

Martin Atkinson — Fri, 12 Nov 2010 13:14:38 GMT

I can't explain the drop in BA post prandial unless you initiated therapy before the second sample. However I went to a lecture recently (can't remember where - I've been to so many and my memory is fading ) and the lecturer inferred that recurrently sludging gall bladders are common and not necessarily related to bile duct obstruction, and patients did very much better if the gall blader was removed. Can't say I'd have the courage to do that but the surgery is apparently relatively easy!