a 4-year - old male neutered domestic shorthair cat was referred for investigation of jaundice .
sequential serum biochemistry demonstrated increasing plasma bilirubin concentrations ; abdominal ultrasonography revealed ongoing pancreatitis and apparent extrahepatic obstruction of the common bile duct .
exploratory laparotomy identified constriction of the common bile duct with foreign material ( cat hair ) .
postsurgical quality of life is excellent with chronic treatment of tylosin , omeprazole and ursodeoxycholic acid .
to our knowledge , this is the first reported case of extrahepatic biliary duct obstruction resulting from the intra - abdominal migration of a foreign body , in this case , hair shafts .
the mechanism by which this occurred was likely a combination of physical constriction by the hair shafts and subsequent foreign body reaction surrounding this .
a 4-year - old male neutered domestic shorthair cat , weighing 5.7 kg was referred for investigation and management of jaundice .
one week prior to presentation at eastside veterinary emergency and specialists , the cat presented to the referring veterinarian when the owner discovered a 23 cm skin laceration adjacent to the xyphoid process of the sternum ( cause unknown ) .
the cat was allowed to roam freely outdoors ; it had been involved in territorial aggression in the past .
the laceration was closed and the cat treated with amoxicillin - clavulanate ( amoxyclav ; apex laboratories ) 17.5 mg / kg , po , q12h for 1 week .
the cat s mucous membranes were jaundiced and there was abdominal discomfort noted on palpation .
marked bruising was identified on the right abdominal wall at the level of the caudal rib margins .
immune - mediated haemolysis ( secondary to tissue damage or medications ) and traumatic pancreatitis leading to extrahepatic biliary duct obstruction ( ehbdo ) were considered the most likely differential diagnoses .
serum biochemistry , haematology and an abdominal ultrasound were undertaken to help differentiate between these causes .
the results of serum biochemistry analysis ( idexx catalyst dx chemistry analyser ) are presented in table 1 .
abnormalities included a marked elevation in alanine transaminase ( alt ) , a moderate hyperbilirubinaemia and mild elevations in alkaline phosphatase and -glutamyl transpeptidase ( ggt ) .
haematology results were within the reference intervals ( ri ; idexx procyte dx haematology analyser ) ; specifically , the haematocrit was 32.1% ( ri 30.352.3% ) .
citrated prothrombin time was 18 s ( coag dx analyzer ) and within the ri ( 1222 s ) .
feline immunodeficiency virus and feline leukaemia virus serology was negative ( idexx snap fiv and felv combo test ) .
urine concentration was adequate ( > 1.050 ) and bilirubin crystalluria the only abnormality noted on urine sediment examination .
serial serum biochemistry observations ri = reference interval ; alp = alkaline phosphatase ; alt = alanine transaminase ; ggt = -glutamyl transpeptidase abdominal ultrasound identified a hypoechoic pancreas surrounded by hyperechoic mesentery . the gall bladder was moderately distended , as was the proximal common bile duct ( figure 1 ) .
ultrasound image of the liver , gall bladder and common bile duct ( 4.3 mm ) .
sonographically , a diagnosis of extrahepatic biliary duct obstruction can be made in cats when the bile duct diameter exceeds 5 mm supportive treatment included intravenous fluids ( 5 ml / kg / h , hartmann s compound sodium lactate ; baxter viaflex ) , maropitant citrate ( 1.0 mg / kg sc q24h , cerenia ; zoetis ) , buprenorphine ( 10 g / kg sc q8h , temgesic ; rackitt benckiser ) , mirtazapine ( 0.7 mg / kg po q3d , axit ; alphapharm ) and amoxicillin  clavulanate ( 17.5 mg / kg po q12h ) was continued .
initial improvement in demeanour in the first 24 h was attributed to correction of dehydration , as anorexia , vomiting and abdominal pain persisted .
clavulanate was substituted for a combination of clindamycin ( 8.7 mg / kg po q12h , clinacin ; intervet ) and marbofloxacin ( 4.4 mg / kg po q24h , zeniquin ; zoetis ) .
a lincosamide and fluoroquinolone were chosen based on the high frequency of escherichia coli and/or streptococcus species ( 35% ) identified using fluorescence in situ hybridisation from pancreatic sections of confirmed cases of pancreatitis in one report .
prednisolone ( 0.4 mg / kg , po , q24h , microlone ; mavlab ) was administered to reduce pancreatic inflammation . by the following day , there was marked improvement , the cat was eating well and appeared comfortable .
it did well for 7 days at which time its appetite reduced rapidly and the owner noticed that it was icteric .
repeat abdominal ultrasound revealed marked dilation of the gall bladder and distension of the entire common bile duct ( figure 2 ) .
a small amount of free fluid was present around the common bile duct ( figure 3 ) .
distension of the common bile duct through to the duodenum ultrasound image shows free fluid around the common bile duct .
free fluid in this region raised a concern of biliary rupture the dilation of the common bile duct suggested biliary obstruction .
owing to the cat s rapidly deteriorating clinical state , an exploratory laparotomy was performed . during surgical exploration of the abdomen
an omental adhesion was identified that surrounded the common bile duct at the level of the duodenal papilla and right pancreatic lobe .
this material was a mass of what appeared to be the cat s own fur .
the hair ( a solid 3 mm wide band of individual hair shafts ) that wrapped around the common bile duct was also removed until the common bile duct could be completely visualised .
in - house microscopy of the peritoneal fluid showed a scant number of non - degenerative neutrophils .
no bacteria were identified ( diff - quik ) . comparative glucose concentration between the free peritoneal fluid and peripheral venous blood ( 9.0 mmol / l and 6.0 mmol / l , respectively ) made septic peritonitis unlikely .
therefore , the non - septic peritoneal effusion was most likely the result of acute and ongoing pancreatic inflammation and/or inflammation secondary to a foreign body .
this was consistent with the gross findings at exploratory laparotomy  specifically , no gastrointestinal perforation was identified .
neoplasm such as teratoma was considered unlikely to be the origin of these hair shafts given that the hair shafts did not appear to germinate from the bile duct itself .
patency of the common bile duct was evaluated by making a 2.5 cm anti - mesenteric incision opposite the duodenal papilla .
a 22 g intravenous catheter was introduced into the duodenal papilla but could not be fed more than 2 cm .
a 5 mm incision into the gall bladder was made and a 5 fr catheter was passed from the gall bladder into the common bile duct but would not pass the obstructed area . to establish biliary patency a cholecystoduodenostomy was performed .
the gall bladder was loosened from the hepatic fossa with blunt dissection . a 2.5 cm incision in the distal end of the gall bladder corresponding to the incision in the duodenum opposite the duodenal papilla was made .
the two mucosal surfaces were approximated and sutured in the form of a stoma with continuous 4/0 polydioxanone ( pds ; ethicon johnson & johnson ) .
the linea alba , subcutaneous tissue and skin was closed in a routine manner . a 14 fr oesophagostomy feeding tube ( canine esophagostomy feeding tube ; mila international )
a diagnosis of ehbdo secondary to migration and entrapment of the common bile duct by autologous hair shafts was made .
it was thought that the hair shafts induced adhesions ( secondary to a foreign body reaction ) , which contributed to biliary duct obstruction .
it was presumed that hair shafts were introduced into the abdomen via the penetrating wound present at the time of presentation to the referring veterinarian .
postsurgical recovery was rapid ; serum bilirubin had normalised and alt concentration had decreased significantly by day 10 ( table 1 ) .
resting energy requirement was calculated at 258 kcal per 24 h , and this was achieved by gradually increasing tube feeding volumes over a 4 day period to reach 290 kcal of hill s a / d .
the cat was discharged 5 days postsurgery on clindamycin ( 8.7 mg / kg po q12h ) , marbofloxacin ( 2.2 mg / kg po q24h ) , transdermal fentanyl ( 12.5 g , duragesic ; janssen - cilag ) , mirtazapine ( 0.7 mg / kg po every 3 days as required ) , ondansetron ( 0.2 mg / kg , po , q12h for 10 days , zofran wafer ; aspen pharmacare ) , omeprazole ( 1.8 mg / kg po q24h , losec ; astrazeneca ) indefinitely and metoclopramide ( 0.4 mg / kg po q68h for 7 days , metomide ; ceva ) .
tylosin ( 13.2 mg / kg , po , q12h , bova compounding ) was introduced to the cat s treatment regimen .
tylosin s beneficial mechanism of action in enteric disease remains unknown . despite this , the rationale of its use in this case is that , anecdotally , tylosin may help modify enteric bacterial populations favourably to reduce the likelihood of ascending bacterial cholangitis , a common complication of cholecystoduodenostomy in cats .
two months following initial presentation the patient was eating well and had gained weight but was having frequent episodes of vomiting .
bilirubin was within ri and alt and ggt were only slightly elevated ( table 1 ) .
ursodeoxycholic acid ( 8.7 mg / kg po q24h ) was added to the treatment regimen ( omeprazole and tylosin ) to improve bile flow and reduce cholesterol saturation of bile . following this ,
two years following initial presentation ( time of writing ) the owners reported occasional vomiting ( every 12 weeks ) ; however , this was roughly the frequency of vomiting prior to initial presentation .
to our knowledge , this is the first suspected case of ehbdo as a result of migration and entrapment of the common bile duct by a foreign body in a cat .
other reported causes of ehbdo in cats include inflammatory disease , specifically cholecystitis , cholangiohepatitis , pancreatitis , cholelithiasis , hepatic lipidosis and inflammatory bowel disease .
neoplastic causes of ehbdo are also reported , specifically carcinoma of the biliary tract , pancreatic carcinoma , unclassified biliary tract carcinoma , squamous cell carcinoma involving the duodenal papilla , and duodenal lymphoma . finally , a duodenal foreign body , biliary foreign body and platynosomum concinnum are also reported causes of ehbdo in cats . a teratoma arising from the common bile duct has rarely been documented in humans . in humans ,
lesions have been described as a lobulated polypoid mass , which was not evident in this case ; hence , we feel that this differential is unlikely .
another suggestion is that this could represent a form of feline eosinophilic gastrointestinal sclerosing fibroplasia ( fgesf ) due to the foreign body leading to an overzealous fibrous tissue reaction causing biliary duct obstruction .
cases of fgesf often have hyperglobulinaemia or hypereosinophilia , which was not documented at any stage in this case .
it is our opinion that the obstruction was due to a combination of physical constriction from the hair shafts and obstructive adhesions ( induced by a foreign body reaction to the hair shafts )
. we can not exclude concurrent extra and intraluminal inflammation such as cholangitis as a cause of biliary obstruction as cholecystocentesis or hepatic , pancreatic or gastrointestinal biopsies were not collected for culture and susceptibility and histopathological evaluation .
we speculate that this was because inflammation of the surrounding pancreatic and omental tissue made it difficult to delineate these structures .
given the history of recent trauma resulting in a deep laceration , it is likely the abdominal cavity was penetrated and this was not appreciated during the initial surgical exploration .
foreign body migration distant from the original penetration site is well recognised in dogs and cats .
unusual locations of migration are reported , for example in one case report , a grass awn migrated from the neck to the heart in cat leading to fatal endocarditis and myocarditis .
it is therefore not unreasonable to suggest that hair shafts could have migrated from the original laceration site to the common bile duct in this case .
another consideration is that hair was ingested and perforated the gastrointestinal tract ; however , there was no evidence of gastrointestinal damage at exploratory laparotomy .
six month survival in cats after biliary diversion is reportedly poor , ranging from 2767% .
only three cases had biliary diversion surgery performed in the study where 67% ( 2/3 cases ) long - term survival was reported .
long - term complications include reflux of bile into the stomach ( alkaline gastritis ) , cholangitis and stricture or leakage of the anastomosis .
alkaline reactive gastritis is a clinical entity that has been linked to duodenogastric reflux of bile constituents after cholecystectomy in humans . in humans
it is managed with proton pump inhibitors ; hence , omeprazole was used indefinitely in this case .
it is thought that this may be related to stricture at the anastomosis site , resulting in inadequate drainage of the biliary system .
based on previous recommendations to prevent stricture formation , a large ( 2.5 cm ) biliary  intestinal anastomosis was made at the time of surgery and mucosal surfaces were carefully approximated and sutured in the form of a stoma . additionally ,
because recurrent biliary tract infection secondary to enterobiliary reflux has been reported as a complication of biliary diversion surgery , tylosin was administered indefinitely in the hope of favouring the growth of a desirable microflora in the gastrointestinal tract .
to our knowledge , this is the first reported case of intra - abdominal migration of foreign matter ( specifically hair shafts ) contributing to ehbdo through physical constriction and a secondary foreign body reaction causing adhesions surrounding this .
this should be included in the differential diagnosis of a cat with jaundice , particularly following abdominal trauma .
in addition , lacerations over the abdominal cavity need to be explored carefully for evidence of penetration . if present , the abdomen should be explored and flushed thoroughly to prevent complications .
 case summarya 4-year - old male neutered domestic shorthair cat was referred for investigation of jaundice . 
 the cat had a recent history of a skin laceration repair following trauma . 
 sequential serum biochemistry demonstrated increasing plasma bilirubin concentrations ; abdominal ultrasonography revealed ongoing pancreatitis and apparent extrahepatic obstruction of the common bile duct . 
 exploratory laparotomy identified constriction of the common bile duct with foreign material ( cat hair ) . 
 the constricting band of hair was removed surgically ; cholecystoduodenostomy was performed . 
 postsurgical quality of life is excellent with chronic treatment of tylosin , omeprazole and ursodeoxycholic acid.relevance and novel informationto our knowledge , this is the first reported case of extrahepatic biliary duct obstruction resulting from the intra - abdominal migration of a foreign body , in this case , hair shafts . 
 the mechanism by which this occurred was likely a combination of physical constriction by the hair shafts and subsequent foreign body reaction surrounding this . 
 this should be included in the differential diagnosis of a cat with jaundice . 
Case summary
Relevance and novel information
Case description
Discussion
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