radiographic diagnosis: pericardioperitoneal

RADIOGRAPHIC DIAGNOSIS: PERICARDIOPERITONEAL DIAPHRAGMATIC
HERNIA AND CHOLELITHIASIS IN A DOG
DIANA
S. ROSENSTEIN,
DVM, ULLRICH
REIF,DVM, Russ L. STICKLE,
DVM, GARYWATSON,
DVM,
WILLIAMSCHALL,
DVM, PIERRE
AMSELLEM,
DVM
Veterinary Radiology & Ultrasound, Vol. 42, No. 4, 2001, p p 308-310.
Signalment
Seven year old, neutered, male Shih Tzu
History and Physical Examination
The dog had a history of abdominal pain and vomiting of
five days duration. An umbilical hernia had been surgically
repaired years earlier. The dog was depressed, lethargic, and
had painful palpations of the cranial abdomen. Body temperature (39"C), heart rate (1 10 bpm) and respiratory rate
(44 breathdmin.) were normal. Heart sounds were clearly
audible on the right side and muffled on the left side. There
was a neutrophilia with a left shift (1 5,690 segmented neutrophils/Fl (69%) and 9,100 bands/pl (4%)). Abnormalities
on the serum chemistry profile included elevated values for
liver enzymes (alkaline phosphatase: 562 I U L (1-90 IUL),
aspartate transferase: I90 I U L (10-62 IU/L), alanine transferase: 99 IU/L (1-94 IU/L), hypoalbuminemia of 2.4 g/dl
(3.2-4.7 g/dl) and elevated creatinine kinase: 2862 I U L
(51-529 IUL)). Radiographs of the thorax and abdomen
were obtained (Figs. 1-4).
Radiographic Findings
The cardiac silhouette was enlarged and irregular in
shape. There was incomplete visualization of the diaphragm
and there were only six sternebrae. A spherical object of
mineral opacity was superimposed upon the cardiac silhouette (Fig. 1, 2). The stomach was cranially displaced within
the abdomen (Fig. 3, 4).
Surgical Findings
The right medial liver lobe and the gall bladder were
displaced through a pericardioperitoneal diaphragmatic hernia. The gall bladder was necrotic and it ruptured during
reduction of the hernia. Its contents included purulent bile
and a large cholelith. The common bile duct draining the
remaining liver lobes was intact. The herniated liver lobe
and the gall bladder were resected, the pericardial sac was
lavaged with warm saline (0.09% NaCl) and the diaphragmatic defect was repaired. Enterococcus sp. was isolated
from the gall bladder. Histologically, the gall bladder and
resected liver lobe were characterized by necrotizing, suppurative, and granulating cholecystitis; fibrosing, glissonian
capsulitis; hepatitis with pericapsular hemorrhage, and coalescing bridging portal fibrosis. Antibiotic medication
(cephazolin, 20 m g k g IV, every six hours) was administered during hospitalization. No post-operative complications occurred and the dog was discharged two days after
surgery. Antibiotic therapy (cephalexin, 10 mgkg PO, every eight hours) was continued for seven days. After recovery from surgery the dog's clinical signs resolved. Five
weeks post-operatively the owner noted that even the occasional vomiting, which had been present prior to the acutely
painful episode, had not recurred.
Discussion
Pericardioperitoneal diaphragmatic hernia is an uncommon congenital anomaly in dogs and cats.'-3 It is associated
with other anomalies of the abdominal body wall such as
ventral abdominal hernias and sternal abnormalities. ',* The
dog in this report had a previously repaired, umbilical hernia
and had only six sternebrae. The pericardioperitoneal diaphragmatic hernia may be incidental in some dogs and clinical significance depends on the condition of herniated tissues into the pericardial sac.3
Cholelithiasis is also an uncommon condition in dogs and
cats that may be clinically silent. Clinical signs of cholelithiasis are usually evident when there is an associated cholecystitis, biliary obstruction, or biliary r ~ p t u r e . ~Clinical
.~
signs of cholecystitis include vomiting. anorexia, polyuria,
polydypsia, weight loss, icterus, fever, and abdominal
A cholelith may be visible on abdominal radio-
Radiographic Diagnosis
Congenital pericardioperitoneal diaphragmatic hernia
with displacement of liver into the pericardial sac. Differential diagnoses for the mineralized object included an intraluminal intestinal foreign body or a cholelith within the
gall bladder, herniated into the pericardial sac.
From the Department of Small Animal Clinical Sciences (Rosenstein,
Reif, Stickle, Schall) and Animal Health Diagnostic Laboratory (Watson),
College of Veterinary Medicine, Michigan State University, East Lansing,
MI 48824- I3 14, and the Small Animal Veterinary Teaching Hospital (Amsellem), Purdue University, West Lafeyette, IN 47907-7403.
Address correspondence and reprint requests to Dr. Rosenstein.
Received November 14, 2000; accepted for publication January 10,
2001.
308
VOL. 42, No. 4
RADIOGRAPHIC
DIAGNOSIS
309
Fig. I . Right lateral radiograph of the thorax. The cardiac silhouette is
enlarged and irregular, the diaphragm is not completely visualized and only
six sternebrae are present. A round, mineral opacity is superimposed upon
the cardiac silhouette.
Fig. 3. Right lateral radiograph of the abdomen. The stomach is cranially displaced in these abdomen and there is incomplete visualization of the
diaphragm.
Fig. 2. Ventrodorsal thoracic radiograph. The mineral opacity is spherical and superimposed on the enlarged cardiac silhouette.
Fig. 4. Ventrodorsal radiograph of the abdomen. The stomach is cranially displaced and there is incomplete visualization of the diaphragm.
310
ROSENSTEIN
ET
graphs although not all choleliths are radiopaque. Pure cholesterol choleliths are radiolucent, pigment stones and
choleliths of mixed contents are variable in opacity and
calcium bilirubinate choleliths are r a d i o p a q ~ e . ~
The
.~
cholelith in this dog was comprised of calcium carbonate. In
this dog, herniation of the gall bladder and liver lobe into the
pericardial sac may have contributed to formation of the
cholelith and was likely associated with the cholecystitis
and hepatitis. Cholecystectomy is indicated for treatment of
cholelithiasis with chole~ystitis.~.~
Microbial culture of bile
or gall bladder tissue is recommended as an underlying
infection is ~ o m m o n .Escherichia
~’~
coli, Streptococcus sp.,
AL.
200 1
Enterococcus sp., and Klebsiella sp. are common bacterial
agents in infectious cholecystitis. Specific antimicrobial
sensitivity should be determined for selection of appropriate
antibacterial medication, however, if this is not available,
then empirical medication may include a first-generation
cephalosporin, fluoroquinolones, or ampicillin!
The dog in this report was unique in that two, potentially
incidental abnormalities, pericardioperitoneal diaphragmatic hernia and cholelithiasis, were present simultaneously
and that both conditions contributed to the dog’s medical
problem. Surgical management by cholecystectomy and
herniorrhaphy led to complete resolution of the clinical signs.
REFERENCES
I . Suter PF. Thoracic radiography: A text atlas of thoracic diseases of
the dog and cat. Wettswil: PF Suter, 1984;194-195.
2. Wallace J, Mullen HS, Lesser MB. A technique for surgical correction of peritoneal pericardial diaphragmatic hernia in dogs and cats. J Am
Anim Hosp Assoc 1992;28:503-510.
3. Evans SM, Biery DN. Congenital peritoneopencardial diaphragmatic
hernia in the dog and cat: a literature review and 17 additional case histones. Vet Radial 1980;21:108-116.
4. Kirpensteijn J, Fingland R, Ulrich T, Sikkema D, Allen S. Cholelithiasis
in dogs: 29 cases (1980-1990). J Am Vet Med Assoc 1993;202:1137-1142.
5. Johnson SE. Cholelithiasis and cholangitis. In: Kirk RW (Ed.), Current Veterinary Therapy X: Small Animal Practice. Philadelphia: WB
Saunders, Co., 1989;884-889.
6. Walshaw R. Liver and biliary system: surgical diseases. In: Slatter
DH (Ed.), Textbook of Small Animal Surgery. Philadelphia: WB Saunders,
Co., 1985;807-812.