The liver contains very small bile channels (tubes) called canaliculi that collect bile from the liver cells. These ducts join larger and larger ducts that ultimately terminate in 3 to 5 visible ducts that empty bile into the gallbladder. The common bile duct (technically called the “bile duct”) is the final stretch of tubing that delivers bile into the first part of the small intestine.
The gallbladder is nestled between two liver lobes on the right side of the liver. Bile, which is concentrated by the gallbladder, serves as a vehicle for fat absorption. Cholecystokinin, a hormone that is released from the pancreas when food is consumed, causes the gallbladder to contract and expel its contents into the intestine via the bile duct.
Cause of gallbladder mucoceles
Historically, gallbladder diseases were rarely diagnosed in dogs and cats. With the advent of advanced imaging tools such as ultrasound, the diagnosis of gallbladder disease is commonly recognized in dogs and cats. Unlike humans, dogs and cats rarely develop stones in the gallbladder. A mucocele is the most common condition that afflicts the gallbladder. By definition, a mucocele is an accumulation of thick mucus within the gallbladder. Infection is infrequently associated with a mucocele. This condition occurs as a result of excessive proliferation of the mucus-producing cells within the lining of the gallbladder. Thick mucus cannot be expelled from the gallbladder. As the gallbladder becomes distended, its blood supply is impaired and it subsequently is prone to rupturing. Once ruptured, bile will leak into the abdomen from the gallbladder and cause the patient to become severely ill.
Gallbladder mucocele is more prevalent in mid-aged to older medium-sized breeds of dogs such as Cocker Spaniels, Miniature Schnauzers and Shetland Sheepdogs. Most dogs with a mucocele have nonspecific signs such as vomiting, loss of appetite and lethargy. Other signs that may be found on a physical examination include abdominal pain, jaundice, elevated respiratory rate, fever and elevated heart rate.
Bloodwork commonly will frequently show elevation of liver enzymes with this condition. With rupture of the gallbladder, liver enzymes are usually very elevated and the white blood cell counts are mild to markedly elevated. Ultrasound is the “gold standard” to diagnose the problem and commonly reveals a “kiwi” appearance of the gallbladder (see photo).
The day of surgery
Emergency surgery will be recommended if the gallbladder is ruptured. If the patient is stable and the gallbladder is still intact, surgery may be scheduled the next day. If your companion has elective gallbladder surgery, make sure that your companion has been fasted prior to surgery and that the prescribed dose of Pepcid AC has been administered on the morning of the procedure. The surgeon will contact you after the surgery to give you a progress report after the surgery. Our anesthesia and surgical team will prescribe a pain management program, both during and after surgery that will keep your companion comfortable. This will include a combination of general anesthesia, injectable analgesics, and oral analgesics.
Medical therapy may be recommended in select cases; however, surgery is typically needed in most cases. Surgical removal of the gallbladder is the treatment of choice. In some cases, a stent (rubber tube) may be placed in the common bile duct, to ensure continued flow of bile. Following surgery, the patient will receive pain-relieving medication to ensure a comfortable recovery. Intravenous fluids will be administered to ensure that your companion remains hydrated after surgery. Blood testing will be performed after surgery to monitor your companion’s recovery.
The perioperative mortality ranges from 22 to 32%; however, rupture of the gallbladder has been shown to worsen the prognosis when infection is present. Long-term survival of patients that have undergone gallbladder removal is excellent. Liver enzymes remain elevated in most patients, but these values usually are much lower after the healing process is completed.
At home, the incision should be checked for signs of infection. Your companion should not lick the incision, as this could open the incision or cause infection. If necessary, an Elizabethan collar can be placed on your companion to prevent licking and chewing at the surgical site. A low fat diet may be recommended in some patients; however, a regular diet may be tolerated. Antibiotics may be prescribed after the surgery if bacterial infection is suspected or confirmed by culture results. Exercise should be restricted for about 3 weeks after surgery to allow uncomplicated healing of the incision.
- Aguire AL, Center SA, Randolph JF, et al. Gallbladder disease in Shetland Sheepdogs: 38 cases (1995–2005). J Am Vet Med Assoc 231:79–88, 2007.
- Amellem PM, Seim HB, MacPhail CM, et al. Long-term survival and risk factors associated with biliary surgery in dogs: 34 cases (1994–2004). J Am Vet Med Assoc 229:1451–1457, 2006.
- Mehler SJ, Mayhew PD, Drobatz KJ and Holt DE. Variables associated with outcome in dogs undergoing extrahepatic biliary surgery: 60 Cases (1988–2002). Veterinary Surgery 33:644–649, 2004.
- Pike FS, Berg J, King NW, et al. Gallbladder mucocele in dogs: 30 cases (2000–2002). J Am Vet Med Assoc 224:1615–1622, 2004.
- Worley, DR, Hottinger Lawrence HJ. Surgical management of gallbladder mucoceles in dogs: 22 cases (1999–2003). J Am Vet Med Assoc 225:1418–1422, 2004.
- Neer TM. A Review of disorders of the gallbladder and extrahepatic biliary Tract in the dog and cat. Journal of Veterinary Internal Medicine 6:186-192,1992.
Frequently Asked Questions After Surgery
When should my dog have the first bowel movement after surgery?
- Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
- Reasons that a dog will not have regular bowel movements after surgery include:
- The dog has been fasted prior to surgery
- Dogs do not eat well during the hospital stay
- They frequently do not eat well when they go home
- They are fed highly digestible food that produces little stool
- Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
- If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
- Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable
My pet had surgery and will not eat. What can be done?
- Most pets will not eat their regular dog food after surgery, especially if it is kibble.
- Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source. The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked). The carbohydrate can be pasta, potato or white rice.
- Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
- Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
- Try Hill's A/D diet available at most veterinary hospitals
- Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
- Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
- Remember that most pets will not eat the first day or two after they get home from surgery
- Offer smelly foods that contain fish such as tuna or smelly cat foods
- Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
- Hand feeding: with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
- Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
- Some cats will only eat dry food, try kibble if your cat normally has been fed that food
- Petting and stroking your cat frequently will help to stimulate appetite
- Remember that most pets will not eat the first day or two after they get home from surgery
- Appetite stimulants such as cyproheptadine may be helpful
- If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop
My pet is vomiting. What can be done?
- The first thing for you to discern is whether your pet is vomiting or regurgitating. Both will result in fluid or food being brought up. Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus. Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled. Usually the regurgited material will be clear or brown colored fluid.
- Next is to identify the cause of the vomiting or regurgitation.
- Causes and treatment of vomiting after surgery
- When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
- Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery. In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart. Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to. The antibiotic in some cases may be changed to a different one, or may be discontinued.
- Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days.
- An uncommon cause of vomiting after surgery is internal organ failure. Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
- If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present. Do not ignore this sign.
- Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days. In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days. Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats. You should always consult a veterinary healthcare professional before administering medication.
- Causes and treatment of regurgitation after surgery
- The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia. Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis. This results in poor motility of the esophagus, therefore water and food will accumulate in this structure. In most cases, esphagitis is self-eliminating and will resolve within two or three days.
- If the esophagitis is severe the esophagus may develop one or more strictures. A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week. This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope). If an esophageal stricture is chronic surgery is needed.
- Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other). Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.
How do I know that my dog is in pain following surgery?
- Signs of pain include
- biting if you get near the surgical site
- grimacing (lips are pulled back and the the dog looks anxious)
- tragic facial expression
- restlessness and unable to sleep; pacing
- if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
- the worst pain will be for the first 2 to 3 days after surgery
What can I do to control my dog's pain?
- Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
- Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
- If an orthopedic surgery has been done cold packing the surgical site may be helpful
- A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack. An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern. Cooling the surgical site helps to numb the area.
How do I know that my cat is in pain following surgery?
- Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
- Signs of pain in a cat include the following:
- biting if you get near the surgical site
- growling or deep cry
- not wanting to eat
- hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)
What can be done for pain at home for my cat?
- Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
- Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
- Anti-inflammatories can be used, but the dose is much less than dogs
Is it okay for my pet to lick the incision?
- If a dog licks the incision, the healing process may be delayed.
- Licking can remove stitches and cause the incision to open
- Licking can become a severe habit that is difficult to break
- Licking can cause infection as the mouth has many bacteria
- Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
- To stop your pet from licking the following can be tried:
- Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
- Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
- A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
- A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
- Bitter apple can be applied around the incision; many dogs will continue to lick after application of this topical
- Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
- Antipsychotic medication in some cases is needed