Diagnostic and surgical treatment for traumatic bile peritonitis in dogs and cats

Heath W. McAlexander Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX

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Janet A. Grimes Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA

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Sharon L. Ullman SAGE Veterinary Centers, Redwood City, CA

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Grace Pei-Chun Lai Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong

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Megan Davis Blue Pearl Downtown Seattle, Seattle, WA

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Brett G. Darrow Capital Veterinary Specialists, Jacksonville, FL

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Vanna M. Dickerson Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX

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Abstract

OBJECTIVE

To describe short-term outcomes of dogs and cats undergoing surgery for traumatic bile peritonitis.

ANIMALS

13 dogs and 4 cats.

METHODS

Multi-institutional, retrospective study. Medical records from 6 institutions were reviewed for cases of traumatic bile peritonitis between 2006 and 2022. Clinical presentation, additional injuries, surgical treatment, and outcome were recorded.

RESULTS

Trauma occurred a median of 2 (range, 1 to 22) and 4 (range, 1 to 22) days prior to presentation in dogs and cats, respectively. Total bilirubin was increased in 11 of 13 dogs and 2 of 4 cats. Rupture occurred at the common bile duct (CBD) in 10 dogs and 1 cat, gallbladder in 3 dogs, cystic duct in 2 cats, and hepatic duct in 1 dog and 1 cat. The most common surgeries were cholecystoduodenostomy and CBD repair in dogs and cholecystectomy in cats. Eleven of 13 dogs and all cats survived to hospital discharge (88.2% overall survival). Median follow-up in surviving dogs and cats was 35 days (range, 14 to 401) and 30 days (range, 14 to 90), respectively. One dog that underwent cholecystectomy experienced recurrent bile peritonitis 20 days postoperatively. Short-term survival following surgical treatment of traumatic bile peritonitis was excellent and recurrence appears uncommon. The most frequent site of rupture was the CBD in dogs and the cystic duct in cats.

CLINICAL RELEVANCE

Measurement of peritoneal bilirubin should be considered in dogs and cats with peritoneal effusion following trauma. Surgeons should be prepared to identify and address ruptures in locations other than the gallbladder.

Abstract

OBJECTIVE

To describe short-term outcomes of dogs and cats undergoing surgery for traumatic bile peritonitis.

ANIMALS

13 dogs and 4 cats.

METHODS

Multi-institutional, retrospective study. Medical records from 6 institutions were reviewed for cases of traumatic bile peritonitis between 2006 and 2022. Clinical presentation, additional injuries, surgical treatment, and outcome were recorded.

RESULTS

Trauma occurred a median of 2 (range, 1 to 22) and 4 (range, 1 to 22) days prior to presentation in dogs and cats, respectively. Total bilirubin was increased in 11 of 13 dogs and 2 of 4 cats. Rupture occurred at the common bile duct (CBD) in 10 dogs and 1 cat, gallbladder in 3 dogs, cystic duct in 2 cats, and hepatic duct in 1 dog and 1 cat. The most common surgeries were cholecystoduodenostomy and CBD repair in dogs and cholecystectomy in cats. Eleven of 13 dogs and all cats survived to hospital discharge (88.2% overall survival). Median follow-up in surviving dogs and cats was 35 days (range, 14 to 401) and 30 days (range, 14 to 90), respectively. One dog that underwent cholecystectomy experienced recurrent bile peritonitis 20 days postoperatively. Short-term survival following surgical treatment of traumatic bile peritonitis was excellent and recurrence appears uncommon. The most frequent site of rupture was the CBD in dogs and the cystic duct in cats.

CLINICAL RELEVANCE

Measurement of peritoneal bilirubin should be considered in dogs and cats with peritoneal effusion following trauma. Surgeons should be prepared to identify and address ruptures in locations other than the gallbladder.

Introduction

Bile peritonitis refers to peritoneal inflammation in response to free bile within the peritoneal cavity. In dogs, the most common sources of bile peritonitis are ruptured gallbladder mucoceles, necrotizing cholecystitis, and trauma.14 In cats, bile peritonitis is rare and may be secondary to trauma or iatrogenic in nature following procedures such as cholecystocentesis or needle core liver biopsy.1,59 Diagnosis of bile peritonitis is confirmed when the measurement of total bilirubin in abdominal fluid exceeds peripheral serum bilirubin concentrations.10 Mucinous material on cytologic examination may also be present and support the diagnosis of bile peritonitis.11

Traumatic biliary rupture is described within several veterinary reports discussing bile peritonitis, though no recent reports focus specifically on traumatic bile peritonitis. A 1983 case series described primary repair of traumatic bile duct rupture in 7 dogs, with all dogs surviving to hospital discharge.12 A 1997 report described surgical treatment of bile peritonitis in 24 dogs and 2 cats that was secondary to trauma in 13 animals.1 Cholecystectomy (12 dogs) and open abdominal drainage (10 dogs) were the most common surgical treatments in this report overall with a survival to discharge rate of 50%, though details related to the trauma cases were not separated from other causes. In a previous study13 of 60 dogs undergoing extrahepatic biliary surgery with 4 being secondary to trauma, dogs with septic bile peritonitis, immediate postoperative hypotension, and preoperative increased creatinine concentration were associated with poor clinical outcome. Another study14 assessed long-term survival and risk factors associated with biliary surgery in 34 dogs, of which 3 were secondary to trauma. The 2-year survival rate in this study was 66%, with a worse prognosis in patients that underwent cholecystoenterostomy.

A case series focused specifically on traumatic bile peritonitis in dogs and cats has not been performed to date. The purpose of the present study was to describe the signalment, clinical presentation, perioperative/postoperative diagnostic results, surgical procedure(s), and short-term outcomes of dogs and cats undergoing extrahepatic biliary surgery following the diagnosis of traumatic bile peritonitis.

Methods

Criteria for inclusion

A call for cases was sent to the Society of Veterinary Soft Tissue Surgery email listserv. Medical records were reviewed of canine and feline patients with a diagnosis of traumatic bile peritonitis between January 2006 and July 2022 at Texas A&M University College of Veterinary Medicine and Biomedical Sciences, University of Georgia College of Veterinary Medicine, SAGE Veterinary Centers, City University of Hong Kong, Blue Pearl Downtown Seattle, and Capital Veterinary Specialists. Only cases suspected or confirmed to be due to trauma were included; presence and type of trauma were based on owner-reported case history. Dogs and cats with a definitive diagnosis of bile peritonitis via exploratory laparotomy were included. Patients with a known nontrauma source of biliary leakage, such as gallbladder mucocele rupture with common bile duct (CBD) obstruction or biliary neoplasia, were excluded. Animals not treated surgically were excluded.

Information collected from each record included signalment, clinical presentation, history including the date and type of any known trauma, perioperative diagnostic imaging reports, perioperative hematologic and biochemical testing, and perioperative peritoneal effusion cytology reports. The surgery report was reviewed for the date of surgery in relation to known trauma, confirmation of bile peritonitis, location of biliary tree rupture, type of surgical procedure performed, and whether an abdominal drain was placed. Histopathology, bacterial cultures, and antimicrobial therapies were evaluated when available. Postoperative hematologic and biochemical testing, duration of hospitalization, hypotension, outcomes, and whether repeat surgical interventions were performed were recorded. Hypotension was defined as a systolic arterial pressure < 90 mm Hg or a mean arterial pressure < 60 mm Hg.

Statistical analysis

Statistical analysis was performed in Prism version 9.0.0 (GraphPad Software LLC). Median (range) was reported for all data.

Results

Dogs

A total of 13 dogs were identified, including 7 females (2 intact, 5 spayed) and 6 males (3 intact, 3 neutered). Median age was 1.5 years (range, 3 months to 14 years). Median weight was 16.9 kg (range, 2.9 to 27.5 kg). Reported trauma occurred a median of 3 days (range, 1 to 22 days) prior to hospital presentation. Source of injury consisted of vehicular trauma in 6 dogs, fall from a height in 5 dogs, falling down a flight of stairs in 1 dog, and iatrogenic injury during foreign body removal surgery in 1 dog. Clinical signs reported on presentation included abdominal distension in 8 dogs, anorexia in 6 dogs, vomiting in 4 dogs, icterus in 2 dogs, and diarrhea in 1 dog. Nine dogs had concurrent injuries including hemoperitoneum in 4 dogs, pneumothorax in 3 dogs, pulmonary contusions in 3 dogs, traumatic brain injury in 2 dogs, and 1 dog each with multiple rib fractures, hemothorax, superficial abrasions, carpal laxity, degloving injuries to the limbs, a laceration on the ventral abdomen, and right hip luxation. Reported preoperative medications included ampicillin/sulbactam in 5 dogs, and 1 dog each received enrofloxacin, ursodiol, SAMe, and vitamin K. Drug doses were not recorded.

Twelve dogs underwent preoperative abdominal ultrasound, in which scant to moderate volume of peritoneal effusion was identified in all dogs. A description of the gallbladder was available in 8 dogs and was described to have wall edema in 3 dogs, a normal appearance in 3 dogs, a wall defect in 1 dog, and a previously undiagnosed gallbladder mucocele without evidence of CBD distension in 1 dog that had fallen down several flights of stairs. One dog underwent abdominal CT, which described laceration of the left medial and quadrate liver.

Results of serum chemistry and CBC data are summarized in Table 1. All dogs had a preoperative serum chemistry panel performed. Total bilirubin was above the reference range in 11 dogs. Peritoneal total bilirubin was available in 8 dogs with a median of 28.0 mg/dL (range, 7.9 to 74 mg/dL [no reference range]). The median ratio of peritoneal bilirubin to peripheral bilirubin was 5.4 (range, 1.3 to 22.7). Alanine transferase was increased above the reference range in all dogs, ALP was increased in 11 dogs, and GGT was increased in 1 dog. Serum creatinine was increased in 3 dogs. Preoperative CBCs were available in 12 dogs. Three dogs were anemic. No significant alterations in the WBC count were noted.

Table 1

Select serum biochemistry and CBC values from 13 dogs and 4 cats diagnosed with traumatic bile peritonitis. Median, range, and reference range are reported.

Hct (%) WBCs (X 103/µL) ALP (U/L) ALT (U/L) GGT (U/L) Total serum bilirubin (mg/dL) Creatinine (mg/dL)
Dogs (n = 13)
  Median 38.4 19.9 1323 596 5.5 2.0 0.9
  Range 25–59 8–23.8 55–2,417 155–4,002 0–31 0.1–21.7 0.3–2.6
  Reference range 37–56 6–17 24–147 3–114 0–25 0–0.8 0.5–1.5
Cats (n = 4)
  Median 26.3 13.3 74.5 412 0.5 0.7 1.3
  Range 16.7–36.3 9.9–28.7 33–223 107–622 0–6 0.2–3.1 1.1–3.4
  Reference range 24–45 5.5–19.5 20–109 3–83 0–12 0–0.6 0–1.5

Intraoperative findings—Surgery was performed via an open exploratory laparotomy, with free peritoneal bile confirmed in all cases. Anesthesia records were available for 9 dogs, with a median anesthesia duration of 215 minutes (range, 103 to 300 minutes) and median surgery duration of 90 minutes (range, 48 to 180 minutes). Duration of hypotension under anesthesia was available for 6 dogs and occurred for a median of 15 minutes (range, 0 to 50 minutes). The rupture location was determined by direct visualization to be the CBD in 10 dogs (Supplementary Video S1), the gallbladder in 3 dogs, and both the CBD and a hepatic duct in 1 dog. Trauma to the left medial and quadrate liver lobes was also identified in 1 dog. Individual case data describing rupture location paired with surgical treatment and outcome are available in Supplementary Table S1.

Surgical treatment included cholecystoduodenostomy (n = 4), primary repair of the CBD alone (2), and cholecystectomy combined with CBD repair (2) and 1 dog each had CBD repair with placement of a cholecystostomy tube, cholecystectomy alone, cholecystectomy with CBD stent placement, and primary repair of the gallbladder with quadrate lobe liver lobectomy. One dog with a history of trauma 14 days earlier and a CBD rupture proximal to the major duodenal papilla was euthanized intraoperatively due to severity of adhesions. The location of each dog’s rupture along with the repair(s) performed is presented in Table 1. One dog had a splenectomy for suspect infarction. Jackson-Pratt closed suction drains were placed in the abdominal cavity of 8 dogs and remained in place for a median of 3 days (range, 1 to 7 days). Bacterial culture of the abdominal cavity was performed in 8 dogs; 2 dogs had positive cultures, with one dog having a multidrug–resistant Staphylococcus pseudintermedius and the other an Escherichia coli. The dog that cultured positive for E coli had a previously undiagnosed gallbladder mucocele at the time of traumatic gallbladder rupture.

Postoperative findings—Postoperatively, all surviving dogs received opioids for analgesia, including fentanyl (n = 8), methadone (2), and tramadol (2). Additional postoperative medications included maropitant (n = 10), ampicillin/sulbactam (8), ondansetron (6), metoclopramide (5), carprofen (3), enrofloxacin (2), metronidazole (1), ceftiofur (1), and ursodiol (1). Drug doses were not recorded. Postoperative hypotension was reported in 5 dogs. Three dogs received vasopressor therapy including dopamine (n = 2), norepinephrine (2), and/or dobutamine (1), while 2 dogs received fluid boluses only. All but 1 dog were reported to respond to treatment.

Eleven dogs survived to discharge from the hospital. One dog (a 14-year-old Miniature Poodle that underwent cholecystectomy with CBD stent placement following a fall down a flight of stairs) experienced cardiac arrest on day 3 postoperatively; this dog had persistent hypotension following surgery (cholecystectomy with CBD stenting) with a poor response to vasopressor therapy. Necropsy examination was not performed; however, the dog was not prophylactically treated with antibiotics while awaiting culture results and the intraoperative culture was positive for E coli. The dog also had a previously undiagnosed gallbladder mucocele on preoperative ultrasound. Median duration of hospitalization in surviving dogs was 4 days (range, 1 to 12 days). Two of these dogs had prolonged hospitalization times of 10 and 12 days; this was impacted by the need for daily bandage changes for degloving injuries and cholecystostomy tube maintenance, respectively. The cholecystostomy tube was removed at day 17.

Final outcome—Dogs that survived to hospital discharge were lost to follow-up at a median of 35 days (range, 14 to 401 days). One dog (a 1.5-year-old Husky that underwent cholecystectomy alone following a fall from a cliff) presented 20 days postoperatively for weight loss and vomiting; the dog had undergone cholecystectomy alone for gallbladder tear at the initial surgery. Repeat abdominal exploration revealed approximately 10 mL/kg of serosanguinous fluid with severe adhesions encasing the abdominal organs. The severity of the adhesions prevented complete exploration, and the dog was euthanized intraoperatively. A yellow appearance to the right side of the abdomen was suspicious for leakage from within the biliary tree; however, necropsy examination was not performed. Recurrence of bile peritonitis was not reported in the remaining dogs. Another dog (an 8-month-old Miniature Australian Shepherd that underwent cholecystoduodenostomy to address iatrogenic biliary trauma during a prior surgery) presented 68 days postoperatively with ascites; repeat abdominal exploration revealed multiple acquired portosystemic shunts with suspicion for microvascular dysplasia on biopsy. This dog returned for periodic abdominocentesis and was lost to follow-up after a second abdominal exploration.

Cats

Preoperative findings—Four cats were identified, including 2 intact males, 1 intact female, and 1 spayed female. Median age was 1.5 years (range, 10 months to 6 years). Median weight was 3.7 kg (range, 2.6 to 4.4 kg). Reported trauma occurred a median of 4 days (range, 1 to 11 days) prior to hospital presentation. Trauma consisted of a high-rise fall in 2 cats, crushing injury in a garage door in 1 cat, and unknown trauma after 1 cat was missing for 1 week. Clinical signs reported on presentation included anorexia in 2 cats, vomiting in 1 cat, and abdominal distension in 1 cat. One cat also sustained right tarsal luxation, otherwise no concurrent injuries were reported. All cats received antibiotic therapy prior to surgical treatment for an unknown duration, including ampicillin/sulbactam in 2 cats, enrofloxacin in 1 cat, and cefazolin in 1 cat.

All cats had preoperative abdominal ultrasound, which revealed scant free abdominal effusion in 3 cats and moderate effusion in 1 cat. No other abnormalities were reported. All cats had preoperative serum chemistry panels and CBCs, which are summarized in Table 1. Total bilirubin was increased above the reference range in 2 cats. Peripheral compared to peritoneal total bilirubin was available in 1 cat; the peripheral total bilirubin was 3.1 mg/dL and the peritoneal was 30.7 mg/dL. Alanine transferase was increased above the reference range in all cats, whereas ALP and GGT were within the reference range in all cats. Two cats were anemic. One cat had a moderate leukocytosis (28,700 WBCs) with 21,000 neutrophils and bands suspected; the remaining cats had no clinically significant WBC abnormalities.

Intraoperative findings—Surgery was performed via open exploratory laparotomy with free peritoneal bile confirmed in all cats. Median duration of anesthesia was 230 minutes (range, 175 to 300 minutes), and median duration of surgery was 120 minutes (range, 87 to 200 minutes). The rupture was determined by direct visualization to be located at the cystic duct in 2 cats, CBD in 1 cat, and a hepatic duct in 1 cat. Individual case data describing rupture location paired with surgical treatment and outcome are available in Supplementary Table S1. Surgical treatment included cholecystectomy in the 2 cats with cystic duct ruptures, primary repair of the CBD in 1 cat, and cholecystectomy with hepatic duct ligation in 1 cat. The location of each cat’s rupture along with the repair(s) performed is presented in Table 1. Esophagostomy tubes were placed in 3 cats. Jackson-Pratt closed suction drains were placed in the abdominal cavity of 2 cats and remained in place for 5 and 7 days. All cats had intraoperative abdominal cultures performed, with no growth seen in any cat.

Postoperative findings and final outcomes—All cats survived to discharge from the hospital. Median duration of hospitalization was 4.5 days (range, 3 to 7 days). All cats received opioid analgesia including buprenorphine (n = 2), methadone (2), tramadol (1), and fentanyl (1), in addition to ampicillin/sulbactam in the postoperative period. Cats were lost to follow-up a median of 30 days (range, 14 to 90 days) postoperatively. No recurrence of bile peritonitis was reported in any cat within the follow-up period.

Discussion

In this cohort, vehicular trauma and falls were the most common types of trauma precipitating biliary rupture. Serum total bilirubin was not elevated in all animals despite confirmed biliary tree rupture, highlighting the importance of abdominocentesis in animals with peritoneal effusion following trauma. The most common site of biliary tree perforation was the CBD in dogs and the cystic duct in cats, which was not identified on preoperative ultrasound or CT in any case. Common bile duct repair and cholecystoduodenostomy were the most common surgeries performed in dogs, and cholecystectomy was the most common surgery in cats. Short-term outcome was excellent following surgical treatment, though conservative management was not assessed.

Traumatic biliary rupture has been reported to have a more favorable outcome than other causes of bile peritonitis, consistent with the findings in the present study.1,12 This is in contrast to relatively high morbidity and mortality in both dogs and cats undergoing extrahepatic biliary tract surgery for other reasons. Several predictors of poor outcome in biliary surgery have been reported, including septic bile peritonitis, total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, Pomeranian breed, high WBC and neutrophil count, low potassium, increased creatinine concentrations perioperatively, prolonged partial thromboplastin time, pancreatitis, immediate postoperative hypotension, and severe intraoperative hypotension.1318 The patient in this study that survived surgery but did not survive to discharge was advanced in age, had septic bile peritonitis that was not identified or treated in the postoperative period, and had preexisting biliary disease (a gallbladder mucocele). Human patients with sterile biliary effusion may have minimal clinical signs, which can persist an average of 30 days prior to surgical intervention.19 The young median age coupled with lack of preexisting hepatobiliary diseases and sterile bile in the majority of cases likely contributes to the high survival rates of small animals treated for traumatic bile peritonitis.

A recent study20 reported that 40% of 30 dogs with confirmed ruptured biliary tracts had serum bilirubin values within normal reference range. On the basis of results of that study and the findings of the present study, degree of hyperbilirubinemia is not a reliable tool for predicting biliary tree rupture. Additionally, a recent study13 investigated the utility of ultrasonography to identify gallbladder rupture in 219 dogs and concluded that abdominal ultrasonography had low sensitivity (56.1%) for identification of gallbladder rupture. The utility of ultrasound in predicting location of tears elsewhere within the biliary tree has not been reported; however, rupture location was not predicted in any available ultrasound reports in dogs or cats in the current report. Additional studies haves shown that contrast-enhanced ultrasonography may increase the sensitivity of gallbladder rupture to approaching 100%.21,22 When identifying gallbladder perforations in humans, CT is preferred to ultrasonography.23 Future studies evaluating modalities such as contrast-enhanced ultrasound or CT in dogs and cats with traumatic biliary rupture are warranted to determine their utility in localization of the rupture. At present, surgeons must rely on results of abdominocentesis and exploratory laparotomy to confirm bile peritonitis, as well as the location of biliary rupture.

In dogs with traumatic bile peritonitis, the CBD has previously been reported to be the most common location of rupture, consistent with the findings in dogs of the present study.1 The proposed pathogenesis of bile duct rupture includes shearing forces applied to the relatively short cystic duct with rapid gallbladder emptying, leading to rupture. Gallbladder rupture itself is more likely to occur in patients with necrotizing cholecystitis and may be more likely to occur in dogs with preexisting biliary pathology.1,24 In the cats of the present study, ruptures occurred at the cystic duct in 2, CBD in 1, and hepatic duct in 1 cat, with no cats having rupture of the gallbladder. While location of biliary rupture has not been compared to clinical outcome, identification of the tear is important in surgical management of the disease. The dog with recurrence in this study likely had a rupture that was not identified at the initial surgery, emphasizing the need to thoroughly examine the entire biliary tree in cases of traumatic bile peritonitis. Intraoperative cholangiography is commonly employed in human medicine and may be a useful tool in referral centers where intraoperative fluoroscopy is available.25 When the gallbladder remains intact, manual expression may help identify bile leakage elsewhere within the biliary tree as well as to confirm integrity of duct repairs. Further research is warranted to identify additional methods of locating biliary ruptures in small animals.

An open approach for exploratory laparotomy was performed in all patients in this study and allowed for diagnosis, identification of the location of rupture, and surgical intervention at the discretion of the clinician. A wide variety of surgical procedures was performed, likely impacted by differences in rupture location, tissue integrity, surgeon experience, and surgeon preference. Reasoning for specific procedure choices (ie, cholecystoenterostomy vs CBD stenting, etc) could not be determined retrospectively. Jackson-Pratt drains were frequently placed to aid in postoperative management of both dogs and cats. Active drains may facilitate monitoring for recurrence of biliary leakage following surgical repair or to aid in drainage of continued leakage if repair was not achieved. Conservative management of small-volume biliary leakage following liver trauma with external drainage alone has been described in human medicine.26 Surgery is likely to be required in cases of complete biliary duct transection or larger-volume leaks in humans.25,26 Case selection for conservative management has not been established in veterinary management. Given the potential for severe adhesions with prolonged exposure to bile in the peritoneal space, as noted in 2 of the cases euthanized in this population, there may be risks associated with allowing time for attempted conservative management.

Several limitations were present in this study. Only a small number of cases were identified despite a wide range of dates and institutions included; thus, data reported are limited to descriptive information only. Differences in quality of data recorded in medical records may impact accuracy of data reported. Though institutions were asked to review records over the entire study period, there may be self-reporting bias, as institutions may be more likely to report successful outcomes. The study also had a very short follow-up period. Particularly given concerns with long-term outcomes following biliary rerouting procedures, future studies assessing long-term outcomes are needed.

The findings of this study suggest that dogs and cats with traumatic bile peritonitis have excellent short-term outcomes following surgical treatment. Additional studies evaluating long-term outcomes are needed. Measurement of peritoneal total bilirubin should be performed in small animals with peritoneal effusion secondary to trauma to determine whether biliary rupture is present. This was performed in 8 dogs in this study, with a median ratio of 5.4. The presence of bacteria within the bile should be ruled out in all cases. Concurrent diseases or traumatic injuries may impact surgical timing and outcome in addition to hospitalization time. Surgeons should be prepared for the need to repair the CBD or perform biliary rerouting in some cases.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org.

Acknowledgments

Presented in abstract form at the Society for Veterinary Soft Tissue Surgery Conference, Jacksonville, Florida, June 2023.

The authors would like to thank the Society of Veterinary Soft Tissue Surgery for their assistance with collecting cases for this study.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.

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