Review Article
Comprehensive Review of Biliary Peritonitis

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Abstract

Biliary peritonitis is a growing concern in the canine patient and a thorough understanding of the disease will lead to better treatment outcomes. This article reviews the human and veterinary literature pertaining to biliary peritonitis including both scientific reviews and original publications. Compared to human medicine, biliary peritonitis can be difficult to diagnose preoperatively. Multiple risk factors exist increasing the likelihood of development of biliary peritonitis. Treatment recommendations center on stabilization, surgical cholecystectomy, and postoperative supportive care. Clinically, further studies on treatment and prevention in veterinary medicine are warranted.

Introduction

Biliary peritonitis, a severe inflammatory process from direct contact of the peritoneal surface with bile, is the most severe sequelae of the ruptured gallbladder. As awareness of gallbladder mucoceles increases in veterinary medicine, due to increased utilization of advanced imaging techniques, the treatment and management of biliary peritonitis has been an increasing concern. Cases of biliary peritonitis have been reported in dogs as early as 19491 and continue to carry a guarded prognosis despite studies focused on goal directed therapies. Rupture secondary to complications from development of a gallbladder mucocele, an inappropriate accumulation of mucus leading to distention of the gallbladder, is the most commonly reported cause of biliary peritonitis.2,3 Additionally, ruptures have been described as a result of neoplasia, trauma, obstruction of the common bile duct by choleliths, necrosis of the gallbladder wall, and cholecystitis; the majority of these occur independently of a mucocele.2,3 Biliary peritonitis is widely reported in human medicine, most commonly in infants due to congenital anomalies, but is also seen with calculi, cysts, diverticula, and idiopathic perforations.4 Due to the more limited information currently published in veterinary medicine, we may be able to adapt information from human research to aid in diagnosis and treatment of biliary peritonitis.

Section snippets

Pathogenesis

Biliary peritonitis occurs when the peritoneal surface is directly exposed to bile salts and other gallbladder contents. The most common cause of this is secondary to complications arising from the obstruction of normal bile excretion due to the development of a gallbladder mucocele. It is not completely understood how mucoceles form. However, the most widely accepted theory is from hyperplasia and dysfunction of the mucus secreting glands in the gallbladder. As with the respiratory,

Risk Factors

As biliary peritonitis is a sequela of gallbladder or common bile duct rupture and subsequent leakage of contents, the risk factors are associated with those underlying conditions. Multiple veterinary studies have tried to assess the prevalence of biliary rupture with gallbladder mucoceles and have yielded varying results ranging from 21.4% (41/197) to 22.7% (5/22) to 60.9% (14/23).8,36,45 Gallbladder mucoceles have well established risk factors while many other extrahepatic biliary

Clinical Presentation & Diagnosis

With blunt force trauma, it may be more difficult to assess for biliary leakage into the abdomen at presentation, as it can be a gradual process. Within a week of the initial trauma, changes such as icterus, pyrexia and pale feces may occur.26,43 Signs of shock and development of peritonitis will also likely be appreciated at this time.26

The most common presenting complaints associated with gallbladder mucoceles and extrahepatic biliary obstructions are anorexia, vomiting, diarrhea, weight

Treatment

The definitive treatment for biliary peritonitis is laparotomy for decontamination and resolution of the underlying cause. This section will go into detail on the preoperative and postoperative stabilization of the patient with biliary peritonitis. The specific details pertaining to the surgical approaches of gallbladder diseases can be found elsewhere.

Prognosis

The prognosis of biliary peritonitis is dependent on multiple variables including the time to an accurate diagnosis, other comorbidities, preoperative stabilization and septic status.19,24,33,44,75 In humans, gallbladder rupture has a survival as low as 58%83,84,85 and in veterinary medicine as low as 45%.19 Reports in veterinary medicine consistently give survival rates of 22%-40% in the immediate postoperative period following emergency cholecystectomy, but do not always specify survival

Prevention

Since the largest cause of biliary peritonitis is secondary to gallbladder mucocele rupture, medical management of forming intact mucoceles could help prevent progression of disease and rupture. Medical treatment often includes antibiotics, ursodeoxycholic acid (UDCA), S-adenosyl-L-methionine (SAMe), and serial ultrasound monitoring for any evidence of rupture.14 UDCA is a cytoprotective bile acid. Although its entire function is not fully understood it does offer cytoprotection through

Conclusion

There is still limited information on biliary peritonitis in veterinary medicine. Further evaluation for more effective definitive diagnosis may help patients receive surgical therapy more quickly. Identifying tests that are more accessible to clinicians on an emergency basis, like serum to effusion bilirubin concentration ratio, may aid in more aggressive, timely therapy.

Further understanding of why mucoceles develop and therapies to support normal gallbladder function may aid in decreased

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