Presentation
Ginger, an 8-year-old male neutered domestic shorthair cat, was presented to the VES Hospital as an emergency for further investigation of elevated liver enzymes and jaundice. The clients reported a 24-hour history of acute vomiting, inappetence, and lethargy, prompting immediate referral for further evaluation.
Upon arrival, Ginger was bright and alert but exhibited signs of abdominal discomfort and mild dehydration. Our emergency and critical care (ECC) team promptly initiated stabilisation with crystalloid fluids, antiemetics, and opioid analgesia. Bloodwork revealed elevated liver enzymes (ALP, ALT, GGT), elevated total bilirubin, mild neutrophilia, and thrombocytopenia. An AFAST scan showed no evidence of free fluid within the abdomen.
At this stage, what are some of the differentials you would have in mind?
Considering the clinical presentation, the ECC team initially suspected cholangiohepatopathy, pancreatitis/triaditis, or an intestinal obstruction secondary to a foreign body.
Diagnostic Imaging
An abdominal ultrasound performed under sedation by Dr Jose Labrador, our radiologist, revealed a distended hepatic and cystic duct and a hyperechoic structure at the level of the duodenal papilla, indicating a choledocholith. The gastrointestinal tract and pancreas were unremarkable, confirming the biliary obstruction.


Learning point #1: Timely Intervention in Acute Jaundice Cases
The importance of rapid diagnostics and intervention when faced with cases of acute jaundice and elevated liver enzymes cannot be overstated! Early imaging allowed for prompt identification of the choledocholith and confirm biliary obstruction, prompting us to surgically intervene.
Surgical Intervention
Ginger was taken to surgery by our surgeon, Dr Daniele Serrani, where a midline celiotomy confirmed significant distention of the common bile duct. Gentle pressure was applied to dislodge the choledocholith into the duodenum, but this was unsuccessful, requiring a duodenotomy and catheterization of the duodenal papilla. A rigid urinary catheter was used to flush the papilla, allowing the choledocholith to be pushed back into the gall bladder, ensuring patency.
Subsequently, a cholecystectomy was performed. Despite removing the choledocholith and closing the enterotomy, persistent distention of the common bile duct raised concerns. Intraoperative ultrasound confirmed a residual obstruction, necessitating a choledochotomy for further stone removal. The common bile duct was closed with absorbable sutures. An oesophagostomy tube was placed for postoperative nutritional support.
Ginger’s surgery was not as straightforward as we would have hoped for, and intraoperative decision-making was critical in this case. Despite initial attempts to resolve the obstruction, further imaging and surgical exploration were necessary to ensure complete resolution, reinforcing the importance of adaptability during surgery.
Learning point #2 and #3: Biliary Obstruction and O-tubes!
- Choledocholithiasis and Biliary Obstruction:
Biliary obstruction in cats, although relatively uncommon, should be on the differential diagnosis list for patients presenting with elevated liver enzymes, jaundice, and vomiting. Early recognition and surgical management can significantly improve outcomes.
- Role of Oesophagostomy Tube in Postoperative Care:
In gastrointestinal surgery cases, particularly in cats, the placement of an oesophagostomy feeding tube is often recommended. In Ginger’s case, the O-tube provided essential nutritional support, promoting recovery and minimising stress on the digestive system following biliary surgery. Early enteral feeding can be critical in stabilising patients postoperatively.
Postoperative Course
Ginger’s postoperative recovery was smooth, with total bilirubin levels normalizing. However, complications arose as he developed a gallop rhythm and a new heart murmur, with a concerning drop in his packed cell volume (PCV) to 15%.
What are the possible causes of the postoperative anaemia?
The potential causes of Ginger’s anaemia included haemorrhage secondary to vitamin K deficiency, inflammatory consumption, or haemolysis. A blood transfusion was administered, leading to a successful recovery.
Learning point #4: Postoperative Monitoring for Complications
Vigilant postoperative monitoring for complications such as anaemia, haemorrhage, and cardiac abnormalities is crucial. Ginger’s case demonstrated the need for immediate intervention following the detection of a gallop rhythm, heart murmur, and PCV drop.
Outcome
At his two-week follow-up, Ginger had returned to his normal activities and was eating spontaneously. The oesophagostomy tube was removed, and Ginger’s recovery was uneventful. He continues to do well under the care of his owner!
Conclusion
Ginger’s case emphasises the importance of a multidisciplinary approach to diagnosing and managing complex cases such as biliary obstruction. This case highlights the value of collaboration between emergency, surgical, and imaging teams. Coordination between departments ensured comprehensive management, from diagnosis to surgical intervention and postoperative care. With timely intervention, thorough postoperative care, and clear communication with the client, a full recovery was achieved.