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tvpjournal.com | September/October 2016 | T O day' S Ve T erinary Prac T ice TH e ye LLOW ca T: dia G n OST ic & TH era P e UT ic ST ra T e G ie S Peer r eviewed 47 to prednisolone therapy, although additional immunosuppressive drugs have also been used. Anecdotal and case reports discuss the addition of cyclosporine (5 mg/kg Q 24 H), chlorambucil (2 mg/cat every 3 days), and mycophenolate mofetil (10 mg/kg Q 12 H) to treatment protocols, especially if prednisolone fails to improve the cat's anemia. 19,20 Feline Leukemia Virus Although immunosuppression in Fe l V positive cats is best avoided, in those patients with clear evidence of IMHA secondary to Fe l V infection, blood transfusions are indicated and, if those fail, prednisolone (2.2 mg/kg Q 12 H) may be used as with primary IMHA patients. 8,21 Erythrocyte PK Deficiency Therapy for erythrocyte PK deficiency is supportive and nonspecific, and outcome depends, in large part, on the severity of presentation and use of transfusions to stabilize critical patients. Selected Hepatic Hyperbilirubinemia Treatment Options Treatment of hepatic causes of hyperbilirubinemia is best guided by histopathology, when possible, or cytology and culture. Hepatic Lipidosis The foundation of treatment for hepatic lipidosis is relatively simple: provide nutrition to the cat. The logistics may be challenging but the advent of esophagostomy tubes (E-tube) makes both nutrition and medication administration easier (Figure 7). Nutrition is critical; therefore, placement of an E-tube should be encouraged early in the disease process if the cat is anorectic. Vitamin K1 (1 mg SC Q 12 H) should be administered prior to E-tube placement if evidence of a coagulopathy is present. Cholangitis Degenerative neutrophils with pleomorphic bacteria from the bile of an acutely ill cat is consistent with acute neutrophilic cholangitis (Figure 8), and treatment is initiated with 2 months of antibiotics aimed at enteric bacteria: cephalosporins, amoxicillin and clavulanic acid (62.5 mg/cat Q 12 H), enrofloxacin (5 mg/kg Q 24 H), and metronidazole (7.5 mg/kg Q 12 H). A mixed population of inflammatory cells or cytology dominated by lymphocytes in a cat presenting with a more chronic history of illness, or failure of initial antibiotic therapy, is consistent with chronic neutrophilic cholangitis or lymphocytic cholangitis, and prednisolone (2 mg/kg Q 24 H initially; taper to 0.5−1 mg/kg Q 48 H) is the foundation of treatment. 22 l ymphocytic cholangitis is believed to be immune- mediated, and treatment includes prednisolone with or without a period of concurrent antibiotics, although other immunosuppressive medications, such as cyclosporine, have been used in these patients. Selected Posthepatic Hyperbilirubinemia Treatment Options Extrahepatic Biliary Obstruction Posthepatic causes, such as EHBO, often require surgical intervention—laparotomy may be the only viable therapeutic option—and carry a poor Figure 8. u ltrasound-guided FNA of the liver of an icteric cat reveals suppurative inflammation. Courtesy Dr. David Twedt Figure 7. Icteric cat with IMHA ready for hospital discharge after placement of an esophagostomy feeding tube.