Webster, a 5-year-old male-neutered British Blue Shorthair was admitted by his primary care vet Helen, collapsed, vocalising, anaemic (PCV 20%) and hypothermic (35.6°). Helen was initially unable to obtain a blood pressure reading. There had been a history of mild vomiting for just one day previous. Webster was transferred to the primary care vet group ICU where he was stabilised via blood transfusion to allow investigation (and blood typed as rare Type B). His blood count had gone up to 28% and no transfusion reactions were noted. Specialist ultrasonography at the ICU revealed a well-circumscribed hepatic mass, thought to be surgically resectable, which was sampled for cytology. Abdominocentesis of the moderate amount of free fluid in the cranial abdomen confirmed blood. Cytology proved inconclusive and surgery was recommended for removal of the mass (suspected neoplastic). Three-view chest radiographs were performed and were suspicious, but not conclusive for a small pulmonary nodule. Because of the high risk of further bleeding, and given that Webster was a rare blood type and had already received one transfusion, surgery by a specialist was recommended.
Webster and his owner were referred to specialist surgeon Janet Kovak McClaran at London Vet Specialists (LVS) for an initial consultation where the benefits and risks of the procedure were clearly explained to them. Specifically, risks of general anaesthesia, bleeding and infection were discussed. It was explained that surgery would be the next step to get a diagnosis and stop the bleeding but it would not increase Webster’s survival time if a tumour was found and had already spread. A CT scan would be the optimal way to rule out spread of cancer and outline resectability of the tumour, but the owners were keen to move forward with surgery without this step.
Webster then underwent GA, supervised by the LVS residency-trained anaesthetist. ICU monitoring throughout the surgery and in recovery included ECG/NIBP/SpO2/Capno/RR/HR/temp.
Laparotomy revealed the papillary process of the caudate liver lobe was completely abnormal, engorged and twisted at the hilus. Differentials included tumour or torsion or both together. Liver lobectomy was performed by placing a Thoracoabdominal stapling (TA) device across the base of the liver, making sure not to untwist or damage the swollen liver lobe. Luckily, other abnormalities of the abdomen were not observed with the exception of slightly enlarged local lymph nodes. One small hepatic node was removed for histopathology analysis along with the liver lobe.
Webster recovered from his anaesthetic smoothly and spent the night in ICU on fluids. The following day he was stable, bright and comfortable, though nervous and reluctant to eat. Following this remarkably quick recovery, he was discharged on buprenorphine for pain relief and his owner was instructed to limit Webster’s activity for the next 10-14 days.
At his post-operative check at the primary care vet three days later (as his owner felt she would rather not stress him with travel) he was doing very well, was active and had minimal wound swelling. At his 10 day check he was still doing very well, and was reported to be back to his normal, happy self.
Histology of the liver showed necrosis and hemorrhage, multifocal, marked with portal fibrosis, arteriolar duplication and biliary hyperplasia. The extent of the necrosis and distribution was suggestive of an ischaemic event, with torsion the most likely cause. The features were not consistent with hepatocellular neoplasm. Histology of the lymph nodes showed no significant changes bar mildly increased number of neutrophils, likely reflecting necrotic drainage.
Liver lobe torsion is a potentially life threatening event, resulting in obstruction initially of the low-pressure hepatic and portal veins. The liver lobe becomes engorged as arterial perfusion persists, and effusion of red blood cells through the liver capsule explains why a hemoabdomen may follow. As the arterial supply is choked, thrombosis, necrosis of the liver lobe and potential septicemia of the patient follows. When suspected, emergency surgery is indicated.
At 3 months after surgery, chest radiographs were repeated with no evidence of neoplasia noted and Webster was fully back to normal.
The reason for the torsion still remains unknown, but an unwitnessed wrong twist or jump is suspected, which fits in with his owner’s description of him being a keen fence climber. Liver lobe torsion is very rare with only a handful of cases recorded in cats. The cases reported all are due to congenital abnormalities or neoplastic changes. This is the first reported case of a non-neoplastic liver lobe torsion resulting in a haemoabdomen in a cat.
This case illustrated how the very close co-operation of the primary care practitioner, specialist and owner led to a very good outcome for the pet. To help save the owner money, diagnostics tests were not repeated at the specialists; close discussion and a knowledge of the high standards of work carried out at the primary level group meant that LVS could carry on with treatment, trusting that the work-up had been thorough.
Having post-op checks carried out at the primary care clinic meant that distress to the patient, who is a nervous little cat, was minimised. Webster continues to do well.