Condition upon arrival at The COVE: Hattie was BAR and vitals were WNLs. On physical examination, the following abnormalities were noted: Grade 2/6 holosystolic heart murmur, missing OS (previous enucleation), cranial abdominal organomegaly, 5-7cm lateral thoracic SQ mass.  

Diagnostics: Abdominal U/S revealed a hypoechoic, diffusely nodular liver parenchyma, a distended gall bladder with hyperechoic debris radiating from the outer wall to the center, normal extrahepatic biliary parameters, hyperechoic foci along the capsule of the spleen, some loss of renal corticomedullary distinction and small cortical cysts in the right kidney. All else was found to be unremarkable (WNLs). A cardiac consult with Dr. Small, DVM, DACVIM (Cardiology), revealed well-compensated mitral and tricuspid insufficiencies due to early endocardiosis. PT and PTT were WNLs. An FNA of the liver was obtained at the time of the U/S evaluation and submitted for cytological evaluation. Results revealed mixed suppurative and lymphoplasmacytic inflammation with a histiocytic component, mild to moderate vacuolar change and extramedullary hematopoiesis.

Assessment: Upon completion of Dr. Nobles' evaluation, the following assessments were made: Suspicion of chronic active hepatopathy; emerging gall bladder mucocele; early, compensated valvular heart disease. Based on the liver enzyme elevations, U/S  and cytological findings, Dr. Nobles recommended laparoscopic liver biopsies and cholecystectomy due to concern for future mucocele development. A consult with Dr. Stallings, DVM, DACVS, for an evaluation and discussion of surgical options was subsequently arranged for Hattie and Mrs. Edwards.

Surgical assessment and recommendations: Based on the lab work, U/S, and cytological findings, Dr. Stallings recommended laparoscopic abdominal exploration, cholecystectomy, multiple hepatic biopsies with histopathology, C&S and quantitative copper analysis. Mrs. Edwards elected to proceed.

Preoperative evaluation: A coagulation profile, blood type, cross-match, CBC, biochemical profile, U/A, T4, BP, and 2 view thoracic radiographs were done. Aside from Hattie's historical CBC and biochemical abnormalities, the results were WNLs. Hattie was also hyposthenuric (USG - 1.018).

Surgery: A 5-port laparoscopic array was established in standard fashion for the procedure. The liver was cobble-stone appearing and extremely irregular on the surface with a diffusely mottled appearance. Additionally, there were multiple small (2-4 mm diam.), irregular, raised lesions noted on the diaphragm. The gallbladder appeared distended and was determined to be softer proximally and firmer distally. The spleen, stomach, pancreas, and intestines appeared grossly normal. Multiple representative hepatic biopsies were obtained and submitted for histopathology, C&S and quantitative copper analysis. The diaphragmatic lesions were biopsied and submitted as well. A cholecystectomy was then done. The gall bladder was removed from the abdomen in a specimen bag and submitted for histopathology. A sample of bile was submitted for C&S. After irrigation, the instrumentation was removed, and the abdomen was desufflated. The portal sites were closed.

Post-operative course: After surgery, Hattie was transferred back to Dr. Nobles and the ER for recovery monitoring and individualized pain management. Hattie was eating and drinking within 12 hours of surgery. She did regurgitate once, the morning after surgery. Post-operative lab work revealed an increase in hepatic enzyme elevations, most likely secondary to the multiple biopsies and surgical manipulation. Hattie was felt to be doing well enough to be discharged the day after surgery. She was sent home with Denamarin, metaclopromide, Tylenol #3, and gabapentin. Hattie was scheduled for a re-check two weeks post operatively for incisional evaluation and lab work. 

Results: Histopathology: Gall bladder - cystic mucinous hyperplasia; Liver - marked diffuse nonzonal vacuolar degeneration, nodular hyperplasia, multifocal parenchymal collapse, mild ductal reaction and suspected bridging fibrosis; Diaphragm - mild mesothelial hyperplasia, chronic hemorrhage, mild lymphohistiocytic inflammation. Bile C&S - no growth; Hepatic parenchymal C&S - no growth. 

Follow-up: Hattie continued to do well at home. In a phone communication four days post discharge, Mrs. Edwards reported that Hattie seemed to be "back to normal." Hattie experienced a mild delay in her incisional healing due to owner non-compliance, which resolved following client re-education and another week of healing (verified at re-check 10/15/18). Lab work revealed continued hepatic enzyme elevations consistent with the diagnosis of chronic active hepatopathy. Regular follow-up re-checks and lab work with Dr. Lewis was recommended. During a recent phone re-check (11/28/18), Mrs. Edwards reported that Hattie was doing very well clinically and seemed to be back to her normal self. Mrs. Edwards has chosen not to follow recommendations with regard to follow-up lab work, etc.