Emphysematous hepatitis in a Bloodhound
Earlier I showed some images of consolidated lung with just a few air bubbles in the bronchi. At first glance, through an intercostal space, I thought this was going to be the same scenario….
A middle-aged Bloodhound is presented with acute anorexia and pyrexia (T40+). Bloods are relatively unremarkable. Specific physical signs are lacking. And so to ultrasound.
This is a longitudinal plane view from close to the ventral midline:
Obviously there is an effusion around the spleen (which looks otherwise fairly unremarkable). This gives us something to go at -we tapped the effusion and, on cytology, it duly turned out to be full of bacterial rods and cocci.
However, it gets more interesting -and we still need a source for this septic peritonitis. This is a transverse plane view from under the xiphisternum angled to the right.
The gallbladder is clearly visible. The right medial liver lobe is unremarkable but, in contrast, the right lateral lobe contains a pattern of highly echogenic gas-densities. There is an irregular lesion centrally and then gas-densities can also be seen running up and down some of the vessels.
A little more detail of the largest lesion:
And an oblique view through a right intercostal space of a non-emphysematous part of the right lateral lobe. There is a scatter of discrete hypoechoic lesions and one which could be classified as a ‘target’ lesion (centre hyperechoic, hypoechoic rim):
This is obviously a bit unusual to say the least. Emphysematous hepatitisor cholecystitis is occasionally reported in the literature. In my experience neoplasia is the commonest primary underlying cause. The fact that changes are confined to one lobe and that there is a ‘target’ lesion reinforce this suspicion. I did wonder whether a liver lobe torsion was possible -however, on power Doppler there is clearly at least least some flow in right lobe vessels:
At the time I thought the outlook was pretty bleak: it seemed likely that the liver was the most likely source of the septic peritonitis -which is obviously very serious in its own right, and I was concerned that there was a significant possibility of neoplasia. However, his owners were keen to give him every chance so treatment with intravenous co-amoxyclav and metronidazole was instigated…….and he improved a lot over subsequent days to the point where the septic peritonitis was in abeyance. A core biopsy of the affected lobe was performed at this point and yielded a diagnosis (in summary) of ‘necrotising hepatitis with microthrombi in many vessels’.
It will likely remain unproven but my suspicion is that this may have been an episode of self-correcting liver lobe torsion which left a legacy of hepatic ischaemic necrosis and secondary emphysematous hepatitis. The possibility of neoplasia remains and will not recede for some months yet. Fingers crossed.
