C09985262 / invoice 10000

Reason: UltrasoundMedicine revisit summaryBoba presents for investigation into recent development of vomiting Previous diagnosis:- Biliary mucocele - removed 7/1/25 with histo showing neutrophillic cholangitis but culture negative - had received antibiotics in the 24 hours prior to surgery. Course extended to 4 weeks on amoxiclav post op. Concurrent Inflammatory changes on hepatic biopsies (neutrophillic + LP) along with some fibrosis. Plausibly attributable to mucocele and concurrent cholangitis but LP inflammatory changes and fibrosis couldalso indicate a more chronic inflammatory hepatopathy (LP hepatitis). Copper WNL. Some eosinophils so path comment re potential for GI disease. Copper quantification WNL and minimal staining- Repeated hepatic biopsies April due to persistent ALT increases - Multifocal, mild to moderate, chronic neutrophilic and lymphoplasmacytic cholangiohepatitis with mild to moderate portal fibrosis, mild peribiliary fibrosis, mild centrilobular fibrosis, bile duct hyperplasia and hepatocyte vacuolar change. Microvascular structrures normal, portal veins identifiable in most areas. Culture negative. Consistent with chronic active hepatitis. Commenced cyclosporine April 2025 (5mg/kg/day) and within 4 months of therapy at 25mg SID ALT had normalised - When tapered to EOD treatment however liver values increased again (ALT 1151 - similar to pre-treatment) so increased to SID in September 2025 with slow improvement in ALT (753 by 7 weeks on therapy)At last visit though, ALT 597 whilst receiving cyclosporine 25mg PO q 24 hour. Active concern was recent GI episode (vomiting, diarrhoea) mid-January, which had resolved, but Boba's vomiting re-developed last weekInitial plan following documented failure of ALT to improve was to increase cyclosporine to 25mg q 12 hour, however, given active GI signs instead have commenced novel protein diet trial (kangaroo) and antiemeticsUltrasound today to make sure no structural GI or hepatobiliary changes + cortisol assessment Current medications:- Cyclosporine 25mg q 24 hour - Ondansetron 2mg q 12 hour up until Recent history:Thursday started to react quite significantly - crying when touched and crying when touched by companion dog at the park Friday jittery and anxious, didn't want to be touched - went to local vet, no obvious pain but perhaps some cranial abdominal discomfort Over the weekend returned to his more normal behaviour Vomiting had improved but relapsed when ondansetron was stopped Physical examination:Demeanour - Bright and alert - very anxious Vital signs - MM pink, CRT<2s, HR 160  bpm, RR pant  bpm, T 39.0  CCardiovascular - Cardiac auscultation normal, pulses strong and synchronousRespiratory - Effort normal, bronchovesicular sounds audible all quadrantsAbdomen - No abnormalities on palpation - tense but no overt pain response Head / neck - Moderate calculus, pink and moist gums Musculoskeletal - Normal gait, no pain identifiedIntegumentary - No abnormalities identifiedGenitourinary - No abnormalities identifiedLymph nodes - Peripheral lymphadenopathy not detectedBCS  6/9. Body weight 4.68 (was 5.4)kg.Laboratory: Note - stressed on blood collection CBC: Mild reticulocytosis without anaemia, HCT 0.55Biochem: Glucose 9 (stress), ALT 135, ALP 103, PO4 0.6 (L)Cortisol - 276Ammonia: 24 (WNL)Procedures:Trazodone 50mg PO  IVC placedSedation: Butorphanol 0.2mg/kg IV, medetomidine 3mcg/kg followed by a further 3mcg/kg Alfaxan 0.25mg/kg IV for portal pressures assessment Reversed (50%) with atipamezole Imaging reportFindings:The liver is diffusely reduced in size with normal echotexture and echogenicity. The portal vein at theporta hepatis it is reduced in size with a portal vein to aorta ratio of 0.52 (normal 0.7-1.25). Theextrahepatic portal veins within the abdomen are normal. The portal vein velocity is reduced with amaximal speed of 9.7cm/s (normal 10-20cm/s) and there is normal laminar flow in the portal vein.There are no visualised acquired portosystemic shunts. The gallbladder is absent and the cystic ducthas a bulbus margin at the suture site and is mildly dilated and tapers appropriately with a normalcommon bile duct.Difffusely throughout the small intestinal mucosa are hyperechoic striations. The small intestinesmaintain normal thickness and overall layering. The adrenal glands, pancreas, spleen, prostate,urinary bladder, abdominal lymph nodes and remaining abdominal vasculature are normal.Conclusion- Small portal vein and borderline portal hypertension- this is likely congenital portalhypoplasia. An occult PSS cannot be entirely excluded though is less likely.- Small liver- congenital hypoplasia is most likely and concurrent chronic hepatitis- No complications with previous cholecystectomy- Hyperechoic intestinal mucosal striations may indicate enteritisProblem list: - Vomiting - Crying when touched at home (pain vs anxiety) - Weight loss - Chronic active hepatitis - Concern for progressive fibrosis - no baseline for comparison but small portal vein + portal hypertension concerning Assessment:Treatment:Plan:Client communication:Vet communication:    Vital Signs    Weight: 4.68;