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Veterinary Ultrasound Society

10-year- old male castrated Bull Terrier

July 1, 2023
Samantha Soltau, DVM; Diagnostic Imaging Resident, Schwarzman Animal Medical Center, NYC
Antonia DeJesus, DVM, DACVR, Schwarzman Animal Medical Center, NYC

Referred for a suspected gallbladder mucocele

Sagittal ultrasound image of the gallbladder caption

10 year-old male castrated Bull Terrier presented to the Emergency Department at the Schwarzman Animal Medical Center (AMC) for a suspected gallbladder mucocele. The patient initially presented to the referring emergency hospital the day prior for anorexia, vomiting and abnormal behavior. The patient was febrile and initial complete blood count and serum biochemistry revealed a leukocytosis (WBC 27.8 K/uL, Neutrophils 25.3 K/uL), mixed liver enzyme elevations (AST 271 U/L, ALT 399 U/L, ALP 1290 U/L, GGT 17 U/L), and hyperbilirubinemia (total bilirubin 4.2 mg/dL).

Findings on an abdominal ultrasound were concerning for a gallbladder mucocele (hyperechoic debris with a few linear projections that extend to the periphery). The patient was then transferred to the AMC for continued medical management /- surgical intervention

On presentation, the patient was bright, alert and responsive and tense on abdominal palpation. Recheck CBC/Chemistry revealed mildly improved hepatic enzyme elevations (ALT 153 U/L, ALP 1210 U/L, AST 35 U/L, GGT16 U/L) and hyperbilirubinemia (0.3mg/dL). An abdominal ultrasound was recommended for reevaluation.

 

1. Multiple hyperechoic striations create a septated appearance of the gallbladder, separating it into smaller, round, interconnected compartments. All compartments contain anechoic bile with a small amount of gravity dependent echogenic, nonshadowing debris. The wall of the apex of the gallbladder is minimally thickened (2.2 mm) compared to the remaining normal appearing wall (0.9 mm).

2. No intrahepatic or extrahepatic biliary duct dilation is present. The major duodenal papilla cannot be identified, the evaluation limited by the patient’s deep-chested conformation.

3. The liver is mildly enlarged, diffusely hyperechoic and coarsely echotextured.

 

1. Multi-septate gallbladder likely represents a congenital anomaly, previously reported in this breed (Lange, 2018). The mild thickening of the apical aspect of the gallbladder in conjunction with gallbladder debris is supportive of cholecystitis (e.g. inflammatory, infectious etiologies) given reported serum biochemistry findings. A gallbladder mucocele is not identified.

2. Mild diffuse hepatopathy. Consider hepatitis given above. A vacuolar hepatopathy is also possible.

Malformations of the gallbladder in dogs are rare with abnormal gallbladder positioning and agenesis being previously documented. Septation of the gallbladder is a very rare malformation in humans. The etiology was previously hypothesized to be a vacuolation anomaly of the gallbladder which occurs during embryonic development. The anomaly is described sonographically as echogenic bands or septa which are fine and linear, bridging the lumen and joining the opposite wall of the gallbladder, giving a “honeycomb appearance”. The orientation of the septa can be vertical or horizontal and can be present throughout the gallbladder or within a portion of it.

Differential diagnoses include a mucocele, a particular kind of emphysematous cholecystitis or a previously reported pseudodiverticula. 44 human cases have been documented, only 12 being asymptomatic (27%). Clinical signs of the symptomatic patients included vomiting, nausea and cranial abdominal pain. Humans have also been shown to demonstrate a prolonged asymptomatic phase. The appearance of symptoms may be associated with the presence of cholecystolithiasis and cholecystitis, suggesting that the clinical phase is linked to the occurrence of biliary complications. The clinical signs of symptomatic patients resolved with surgical intervention (cholecystectomy) (1, 3).

The only case report of a septated gallbladder in dogs documented six, 2-month-old, bull terrier puppies (the same breed as our case) that had abdominal ultrasounds performed for a health screening. The paper described abnormal hyperechoic septa going from the gallbladder wall towards the center. The length of the septa varied between the puppies with the gallbladder walls and common bile ducts were otherwise normal. Two of the puppies with the largest septa had echogenic content within their gallbladders. No hepatic abnormalities were identified. Since all puppies had a degree of septation, which was different in each puppy, the etiology was suspected to be an abnormal embryological development during embryogenesis (metabolic, toxic, infectious origin) rather than a genetic anomaly.

The only follow up in this case series was at 15 months, one puppy with the largest septa remained asymptomatic and had no changes in the appearance of the gallbladder. The same dog presented at the age of 5-years-old for exhaustion, weakness, anorexia and vomiting and hyperthermia. Physical exam revealed abdominal pain and a heart murmur. The patient had a mild neutrophilia however the serum biochemistry (including liver values) was normal. An abdominal ultrasound revealed persistent gallbladder septa, echogenic bile, two cholecystoliths, and hypoechoic areas with the discretely echogenic edges in the liver parenchyma close to the bile duct. Cholecystitis and a gallbladder abscess were suspected. At surgery (cholecystectomy) the gallbladder contents were purulent and the cholecystoliths were identified. Cytology of the liver confirmed infectious neutrophilic hepatitis (presumed due to ascending infection) with cholestasis.

Case Follow-up

Additional diagnostics: An ultrasound guided cholecystocentesis and fine needle aspirates of the liver were performed. No cytologic abnormalities were detected and the bile culture was negative.

The owners elected for outpatient care and the patient was discharged with enrofloxacin, clavamox, denamarin and ursodiol. No other follow up has been documented since discharge.

 

  1. Lange, E., and C. Beaudu-Lange. “Canine Multi-Septate Gall Bladders in Bull Terrier Puppies: First Description and Follow up of the Most Affected One.” Revue Vétérinaire Clinique, vol. 53, no. 4, 2018, pp. 129–133., https://doi.org/10.1016/j.anicom.2018.10.001.
  2. Sato, K., et al. “Gallbladder Agenesis in 17 Dogs: 2006-2016.” Journal of Veterinary Internal Medicine, vol. 32, no. 1, 2018, pp. 188–194., https://doi.org/10.1111/jvim.15034.
  3. Karaca, Turgut, et al. “Diagnosis and Treatment of Multiseptate Gallbladder with Recurrent Abdominal Pain.” Case Reports in Medicine, vol. 2011, 2011, pp. 1–2., https://doi.org/10.1155/2011/162853.