Case ReportCholedochotomy for Obstructive Choledocholithiasis inTwo Dogs

Christian Folk and Cassie Lux

The University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee, USA

Correspondence should be addressed to Christian Folk; cfolk@utk.edu

Received 29 April 2019; Revised 5 July 2019; Accepted 11 July 2019; Published 24 July 2019

Academic Editor: Sheila C. Rahal

Copyright © 2019 Christian Folk andCassie Lux.This is an open access article distributed under theCreativeCommonsAttributionLicense,whichpermits unrestricteduse, distribution, and reproduction in anymedium, provided the original work is properly cited.

Two geriatric (> 9 years old) dogs presented for vomiting, lethargy, and anorexia. Obstructive choledocholithiasis was diagnosedbased on analysis of a serum biochemical analysis and abdominal radiographs and ultrasonography. In both dogs, choledocholithswere removed from the common bile duct via a choledochotomy without a cholecystectomy, and survival without recurrenceoccurred in both dogs for more than 1 year.

1. Introduction

Choledocholithiasis is an uncommon disease process indogs, which can result in life-threatening extrahepatic biliaryobstruction. Cholecystectomy has previously been consid-ered the treatment of choice for obstructive cholelithiasiswhen the choleliths are predominantly within the gallbladder.When cholelithiasis is present throughout the biliary tree,it is less obvious which surgical treatment is ideal to alle-viate the biliary obstruction [1–8]. The cases presented heredescribe choledochotomy and biliary stent placement alonefor treatment of extrahepatic biliary obstruction, which haspreviously been unreported.

2. Case 1

Anine-year-old 7-kg (15.4-lb) spayed femalemixed breed dog(dog one) was examined for a 4 day history of vomiting,lethargy, and anorexia. On initial physical examination, agrade III/VI systolic heart murmur was detected with maxi-mum intensity over the mitral valve region. A complete bloodcount (CBC) revealed unremarkable findings. A serum bio-chemical analysis revealed a normal total bilirubin (0.5mg/dL; reference range 0.1-0.6 mg/dL) and elevations inalkaline phosphate (ALP) (435 U/L; reference range 13-240U/L), alanine transferase (ALT) (1259 U/L; reference range18-100 U/L) and cholesterol (375 mg/dL; reference range 130-354 mg/dL).

The patient underwent standard three-view abdominalradiography, which revealed a 1.1 cm x 0.6 cm oval-shapedmineral opacity in the right cranial abdomen superimposedwith the proximal descending duodenum (Figure 1). Trans-abdominal ultrasonographywas also performed, and findingsincludedmultiple hyperechoic structures with acoustic shad-owing within the common bile duct (CBD) at the distal-mostaspect adjacent to the major duodenal papilla with the largestone measuring approximately 1 cm in diameter. The CBDwas found to be markedly distended along its entire length,measuring up to 8 mm in diameter. The average diameter ofthe normal canine CBD is 3 mm [9]. The gallbladder (GB)was markedly distended and the wall appeared thick andirregular. The canine GB wall typically measures 2-3 mm inthickness and wall thickening of the GB is diagnosed whenthe wall is thicker than 3-3.5 mm [10]. The GB lumencontained a large amount of variably echogenic debris. Themajority of the debris was non-organized and collected inthe dependent portion while some appeared adhered to thewall and was partially organized suggestive of early mucoceleformation.

Based on clinical signs, clinicopathologic findings, andresults of diagnostic imaging, the primary differential diag-nosis was partial obstruction of the extrahepatic biliarytract due to choledocholithiasis [1, 2]. The dog's clinicalsigns improved with supportive care of intravenous fluidtherapy,maropitant (1mg/kg, IV, q 24 hr), and buprenorphine(0.02 mg/kg, IV, q 8 hr), and an abdominal ultrasound was

HindawiCase Reports in Veterinary MedicineVolume 2019, Article ID 4748194, 5 pageshttps://doi.org/10.1155/2019/4748194

2 Case Reports in Veterinary Medicine

Figure 1: Ventrodorsal radiograph of the abdomen. Note the oval-shaped radiopaque calculi in the right cranial abdomen (whitearrow).

performed the following day revealing the common bile ductto be slightly less distended measuring 4-5 mm in diameterwith the previously described choledocholiths in a similarlocation. The dog was discharged with medical managementincluding ursodeoxycholic acid (7.7 mg/kg, PO, q 12 hr),amoxicillin-clavulanic acid (16 mg/kg, PO, q 12 hr), tramadol(6.5 mg/kg, PO, q 8-12 hours) and s-adenosylmethionine andsilybin (30 mg/kg, PO, q 24 hr).

The dog represented to the emergency service 3 dayslater for icterus, anorexia, and lethargy. On physical examina-tion, the dog now exhibited generalized icterus and markeddiscomfort was elicited on deep palpation of the abdomen.A serum chemical analysis revealed elevations in ALP (903U/L; reference range 13-240 U/L), ALT (1250 U/L; referencerange 18-100 U/L), aspartate aminotransferase (AST) (80U/L; reference range 9-63 U/L), cholesterol (557 mg/dL;reference range 130-354 mg/dL), and total bilirubin (7.6mg/dL; reference range 0.1-0.6 mg/dL).

Transabdominal ultrasonography revealed the GB andCBD to be markedly distended with the CBD measuring upto 8 mm in diameter. Several choledocholiths were notedwithin the lumen of the cystic duct and CBD (Figure 2).The wall of the distal CBD was markedly thickened andhyperechoic, measuring up to 3 mm in thickness. Thewall of the canine CBD is often partially visualized withultrasonography and should not exceed 1 mm in thickness[11]. In addition, mild dilation of several intrahepatic bileducts with intraluminal choleliths was noted. The variablyechogenic, partially organized, and adhered debris within theGB lumen was unchanged compared to the transabdominalultrasound performed 3 days prior. The decision was madeto perform an immediate exploratory laparotomy due to thesuspicion of complete extrahepatic biliary tract obstructionfrom choledocholithiasis. Echocardiography demonstratedmildmitral and tricuspid regurgitation with normal chamber

Figure 2: Abdominal ultrasonography. Note the 1.06 cm choledo-cholith (white crosshairs) obstructing the entrance of the commonbile duct into the duodenum resulting inmarked bile duct distension(white arrows).

sizes and a normal left ventricular systolic function. Acoagulation panel consisting of prothrombin time (PT) andpartial prothrombin time (PTT) was done prior to surgeryand both values were within normal reference ranges.

General anesthesia was induced with administration offentanyl (5.0 mcg/kg, IV), ketamine (2 mg/kg, IV), andpropofol (4 mg/kg, IV) to effect. An endotracheal tube wasplaced, and anesthesia was maintained with delivery ofsevoflurane in oxygen, with a constant rate infusion (CRI)of fentanyl (3 to 5 mcg/kg/hr, IV) and lidocaine (25 to50 mcg/kg/min, IV) for analgesia. After standard asepticpreparation for surgery, and with the patient positioned indorsal recumbency, a ventral midline incision was madefor exploratory celiotomy. An enlarged liver, a moderatelydistended GB, and markedly dilated CBD were noted duringabdominal exploration.

Multiple stones were palpated within the lumen of thecommon bile duct. An antimesenteric duodenal incisionmeasuring 2 cm in length was made with a #11 blade distalto the externally visible junction of the CBD and duodenum,and the major duodenal papilla was visualized. The largestcholedocholith was isolated within the lumen of the commonbile duct, and a #11 bladewas used tomake a 1 cm incision intothe CBD over the choledocholith. The 1 cm in length chole-docholith was removed and the CBD was gently compresseddislodging multiple stones for evacuation. A five Frenchred rubber catheter (Covidien Dover Rob-Nel, MedtronicCovidien, Minneapolis, MN 55432) was placed through themajor duodenal papilla, bypassing the choledochotomy, andthe cystic and intrahepatic bile ducts were flushed copiouslywith sterile saline. This process was repeated multiple timesalongside massaging the GB, cystic ducts, and intrahepaticbile ducts to dislodge and remove any remaining biliarysludge and stones. The CBD incision was closed with a singlelayer closure using monofilament absorbable suture (size 4-0 polydioxanone (PDS II, Ethicon, Johnson and Johnson,Somerville, NJ 08876)) in a simple continuous pattern. Thered rubber catheter was then sutured to the lumen of the

Case Reports in Veterinary Medicine 3

duodenum with a simple interrupted pattern of monofil-ament absorbable suture (size 3-0 polydioxanone (PDS II,Ethicon, Johnson and Johnson, Somerville, NJ 08876)) to actas a stent. The duodenal incision was closed with a modifiedGambee pattern using monofilament absorbable suture (size4-0 polydioxanone (PDS II, Ethicon, Johnson and Johnson,Somerville, NJ 08876)). A guillotine biopsy of the left medialliver lobe was collected and submitted for histopathologicexamination. Choleliths and liver tissue were submitted foraerobic and anaerobic culture. Several of the choledocholithswere submitted for quantitative analysis. The abdomen wasthen copiously lavaged with sterile saline and then closedroutinely. Postoperatively, the dogwas treated with ampicillin(30 mg/kg, IV, q 8 hr) for 3 days for suspected cholecystitis.Pain was managed postoperatively with a fentanyl CRI (2-5mcg/kg/hr, IV) that was tapered over 72 hours of hospitaliza-tion.

Histopathological examination of the liver revealed mod-eratemultifocal hepatic glycogenosiswith biliary hyperplasia.No organisms were detected with aerobic and anaerobiccultures of the liver and gallbladder. Composite analysis ofthe collected gallstones revealed the largest calculus to havea surface layer composed of 100% calcium carbonate with ahomogeneous interior composed of 100% bilirubin.

Four days postoperative, a serum biochemical analysisrevealed persistent but improved elevations in ALP (440U/L; reference range 13-240 U/L) and ALT (330 U/L; ref-erence range 18-100 U/L). The dog’s hypercholesteremia,hyperbilirubinemia, and elevated AST had resolved, but thealbumin had decreased (1.6 g/dL; reference range 3.2-4.3g/dL). The dog was transitioned from intravenous to oralanalgesics which included acetaminophen (10 mg/kg, PO, q8 hr) and codeine (1.5 mg/kg, PO, q 8 hr). The clinical signsat presentation had resolved, the dog was eating and subse-quently was discharged on day 4 postoperatively. Follow upinformation was obtained from a phone conversation withthe dog's owners. The owners did not report any return ofclinical signs related to biliary obstruction in the 16 monthssince surgery.

3. Case 2

A thirteen-year-old 5.0-kg (11-lb) spayed female Shih Tzu(dog two) was referred for evaluation of a 7 day historyof vomiting, lethargy, and anorexia. On initial examination,the dog's sclera were icteric and marked discomfort waselicited on deep palpation of the abdomen. A CBC revealedunremarkable findings. Alkaline phosphate (3788 U/L; ref-erence range 13-240 U/L), ALT (3851 U/L; reference range18-100 U/L), AST (247 U/L; reference range 9-63 U/L), totalbilirubin (4.3mg/dL; reference range 0.1-0.6mg/dL), gamma-glutamyltransferase (GGT) (81 mg/dL; reference range 0-5mg/dL), and cholesterol (499 mg/dL; reference range 130-354mg/dL) were elevated.

Abdominal radiographywas performed revealing numer-ous, pinpoint, round mineral opaque foci within the rightcranioventral aspect of the liver, and four approximately 0.5cm in diameter mineral opaque structures were noted withinthemid cranial abdomen superimposed with the gastric body

and liver. Transabdominal ultrasonography revealed severalintrahepatic ducts to be markedly distended with multiplesmall tomoderately sized hyperechoic structures up to 0.5 cmin diameter. The gallbladder was markedly distended with athickened and irregular wall. The CBD was markedly dilated(around 1 cm in diameter) with thickened and irregular wallsand contained echogenic sediment and multiple hyperechoicstructures consistent with choledocholiths. The largest chole-docholith was just proximal to the major duodenal papilla.

The decision was made to perform an exploratory celi-otomy because of presumptive complete extrahepatic biliaryobstruction due to choledocholithiasis. A coagulation panelconsisting of PT and PTTwas done prior to surgery revealingvalues within normal reference ranges. General anesthesiawas induced with administration of butorphanol (0.3 mg/kg,IV), dexmedetomidine (2 mcg/kg, IV), ketamine (2 mg/kg,IV), and propofol (4 mg/kg, IV) to effect. Anesthesia wasmaintainedwith delivery of sevoflurane in oxygen, with aCRIof fentanyl (3 to 5 mcg/kg/hr, IV) and a CRI of lidocaine (25-50 mcg/kg/min, IV).

An exploratory celiotomy was performed via a ventralmidline incision. A markedly dilated common bile ductwas noted and a #11 blade was used to make a 1 cm longcholedochotomy. Multiple small, green, spiculated choledo-choliths were expelled along with a 1 cm in length chole-docholith. The CBD was gently compressed starting distallyand moving proximally which dislodged multiple stones forremoval. A duodenotomy was performed with a #11 blade onthe antimesenteric border to visualize the major duodenalpapilla. A five French red rubber catheter (Covidien DoverRob-Nel, Medtronic Covidien, Minneapolis, MN 55432) wasplaced through the papilla bypassing the choledochotomy,and the bile ducts were flushed copiously with sterile salinewhile massaging the biliary tree to dislodge and remove anyremaining biliary sludge and stones within the intrahepaticducts, gallbladder, and CBD. The red rubber catheter (Covi-dien Dover Rob-Nel, Medtronic Covidien, Minneapolis, MN55432) was sutured to the lumen of the duodenum withmonofilament absorbable suture (4-0 polydioxanone (PDSII, Ethicon, Johnson and Johnson, Somerville, NJ 08876))in a simple interrupted pattern to perform as a stent. Thecholedochotomywas closed with a simple continuous patternusing monofilament absorbable suture (4-0 polydioxanone(PDS II, Ethicon, Johnson and Johnson, Somerville, NJ08876)). The duodenal incision was closed with a simpleinterrupted pattern using monofilament absorbable suture(4-0 polydioxanone (PDS II, Ethicon, Johnson and Johnson,Somerville, NJ 08876)). A guillotine biopsy of the left medialliver lobe was collected and submitted for histopathologicexamination. Tissue samples of the liver were collectedaseptically and submitted for culture.The abdomen was thencopiously lavaged with sterile saline and closed routinely.Pain was managed postoperatively with a fentanyl CRI (2-5mcg/kg/hr, IV) that was tapered over a 24-hour period andtransitioned to buprenorphine (0.03 mg/kg, IV, q 4-6 hr) forthe remainder of hospitalization.

Histopathological examination of the liver revealed find-ings suggestive of microvascular dysplasia. No organismswere detected with aerobic and anaerobic cultures of the liver.

4 Case Reports in Veterinary Medicine

Collected gallstones were not submitted for compositeanalysis.

One day postoperative, a serum biochemical analysisrevealed persistent but improved elevations inALP (1433U/L;reference range 13-240U/L), GGT (27U/L; reference range 0-5 U/L), and ALT (897 U/L; reference range 18-100 U/L). Thedog’s hypercholesteremia, hyperbilirubinemia, and elevatedAST had resolved, though the albumin had decreased (1.7g/dL; reference range 3.2-4.3 g/dL).The dog was transitionedfrom intravenous to oral analgesics which included tramadol(5 mg/kg, PO, q 8 hr) and gabapentin (10 mg/kg, PO, q8 hr). The clinical signs at presentation had resolved, thedog was eating and subsequently was discharged on day 3postoperatively. Follow up information was obtained froma phone conversation with the dog’s owners. The ownersdid not report any return of clinical signs related to biliaryobstruction in the 14 months since surgery.

4. Discussion

Cholelithiasis in dogs is an uncommon cause of a clinicallysevere disease, where most affected dogs do not exhibitclinical signs [1–8]. Medical dissolution generally involvesursodeoxycholic acid and broad-spectrum antibiotics butin most cases is not successful. Clinical signs associatedwith obstructive cholelithiasis are usually non-specific andinclude anorexia, vomiting, diarrhea, lethargy, icterus, andabdominal pain and distension as seen in both dogs [6, 7].Biochemical and hematological abnormalities are indicativeof biliary obstruction, but not specific to cholelithiasis. In thecase of complete extrahepatic bile duct obstruction (EHBDO)due to cholelithiasis, emergency surgery is warranted.

Extrahepatic biliary tract disease is historically associ-ated with relatively high morbidity and mortality in dogswith mortality rates reported between 22 to 64% [12–16].Cholecystectomy is considered the treatment of choice forobstructive choledocholithiasis if the choledocholiths canbe massaged into the GB and the CBD is patent. Othersurgical options include cholecystotomy and biliary diversionprocedures such as cholecystoenterostomies to prevent bilepassage through a damaged common bile duct. It has beenfound that dogs that survive the early postoperative periodfollowing biliary surgery generally have a good long-termprognosis unless they have undergone a biliary diversionprocedure [12, 17].

In the cases reported here, it was not attempted tomassage the distal, largest choledocholiths proximally backinto the GB due to worry of damaging and/or rupturingan already inflamed CBD. To prevent iatrogenic traumafrom attempting to massage the distal stones proximally,choledochotomies were performed directly over the distal,largest choledocholiths. Once the largest choledocholithswere removed, all other palpable choleliths were able to beremoved at this site from the GB, cystic duct, and CBDwith gentle manipulation and copious lavage with saline.Given the inability to remove all of the choleliths withinthe intrahepatic biliary ducts, it was elected to perform acholedochotomy without a cholecystectomy in both dogs.This would allow the gallbladder to be available for future

procedures should the remaining intrahepatic cholelithsmigrate and cause recurrent extrahepatic biliary obstruction.Choleliths can initiate within the gallbladder or the biliaryducts due to inflammation, infection, or biliary stasis, andfurther biliary stasis from partial or complete biliary obstruc-tion and potentiate new cholelith formation throughout thebiliary tree [1, 2, 5, 6]. Therefore, it is difficult to determineif the GB is a true source of disease in dogs with suchextensive cholelithiasis. Neither dog had bacterial growthon aerobic or anaerobic bacterial cultures of the GB andliver, nor did they have evidence of inflammation on hepaticbiopsy to aid in the identification of the initiating factor forcholelithiasis. It is a valid consideration to suspect that dueto the chronicity involved in cholelith formation that chronicCBD inflammation and passage or intermittent movement ofsmaller choleliths had been occurring for some time prior toacute obstruction in the cases described.

Some reported complications following choledochotomyinclude postoperative bile leakage, dehiscence, stricture, andadhesion formation [16, 18]. Risks factors for complicationsfollowing choledochotomy have not been proven but aretheorized to include increased tension on the repair, tissuefriability and the presence of infection [14]. Most choledo-chotomies are performed in conjunction with cholecystec-tomy for the treatment of EHBDO and cholelithiasis.

Choledochotomy alone has historically been shown tobe associated with high mortality (100%) and poor long-term prognosis (< 6 months) [6]. One study has shownthat choledochotomy performed with cholecystectomy wasassociated with low perioperative morbidity and nomortalityin a small cohort of cases [18].

To the authors’ knowledge, there are no reported cases ofdogs undergoing choledochotomy without cholecystectomyfor obstructive choledocholithiasis that exhibited low mor-bidity and a long-term prognosis of greater than 6 months.This case report illustrates that a choledochotomy withoutcholecystectomy is a viable surgical treatment option forobstructive choledocholithiasis when choleliths are presentthroughout the biliary tree and removal of the gallblad-der is not possible. Performing choledochotomy alone canminimize the known risks and complications associatedwith performing multiple extrahepatic biliary tract proce-dures, and allow for biliary rerouting procedures involvingthe GB with recurrent biliary obstruction due to cholel-iths.

Abbreviations

ALP: Alkaline phosphateALT: Alanine transferaseAST: Aspartate aminotransferaseCBC: Complete blood countCBD: Common bile ductCRI: Constant rate infusionEHBDO: Extrahepatic bile duct obstructionGB: GallbladderGGT: Gamma-glutamyltransferasePT: Prothrombin timePTT: Partial prothrombin time.

Case Reports in Veterinary Medicine 5

Conflicts of Interest

The authors declare that there are no conflicts of interestingregarding the publication of this article.

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