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Cushing's disease and elevated liver enzymes
Cushing's and elevated liver enzymes
Liver enzyme levels in Westie
also see liver problems
also see Cushing's disease
Hyperadrenocorticism (Cushing's disease, HAC) and elevated liver enzymes
Question: Dr. Richards, I am a Vetinfo subscriber.
I am very concerned about my 13-year old border collie, Dixie. Last
summer, Dixie spent the day at my vet's office for routine geriatric
bloodwork and vaccinations. Her bloodwork was normal except for
slightly elevated liver enzymes - ALKP 403,ALT 102. Five days later she
came down with kennel cough which she must have picked up at the vet's
as he works with the humane society on their "rescue" animals. She was
treated with Depomedrol injection and an antibiotic. Three days later
she was not responding and was given another anitibiotic. This resolved
the kennel cough, but three weeks later she had massive diarrhea and a
trip to the vet revealed a small perianal tumor. She was very thin and
looked awful. Pre-surgery bloodwork before the tumor removal put a stop
to surgery plans because her liver enzymes were through the roof, ALKP
1208, ALT 268. We were referred to an internal medicine specialist
(Dallas Ft Worth) who performed an ultrasound and then biopsy with the
results being regenerative liver changes. An ACTH test came back
negative. In the meantime, Dixie began having nosebleeds, and a
rhinoscopy showed an infection which was cleared up with antibiotics.
We finally took off the perinal tumor and it was benign. Because of a
since-deceased dog's bout with cancer, I asked for a mini-consultation
with a veterinary cancer specialist I know, who suggested a follow-up
Cushings test in 6 months because of a link between Cushing's and
perianal tumors in female dogs. Since the summer scare, I have had her
bloodwork re-run three times, and the liver enzymes are still really
high. Today ALKP 1065, ALT 315. Dixie has had treatment for arthritis
in the past, Adequan injections in 1997, Rimadyl in 1998, lately I was
using a glucosamine product which I took her off of in October to see if
the liver would improve. She has a better appetite now than she ever
has, but could that be because she gets almost exclusively canned
Science Diet Senior rather than dry? She seems to produce a lot of
urine, but I rarely see her at the water bowl. Her membranes are nice
and pink, but a slight heart murmur was discovered during the liver
diagnostic process and has since worsened despite being on Enacard 10mg
daily. She has no chest congestion and is not coughing. She seems
happy and looks healthy with no coat or skin problems.
All of this history finally gets me to the question - are we on the
right track looking for Cushing's? Are there other tests I should
request? We see the internal medicine specialist day after tomorrow.
Thanks for your help, and thanks for the great web resource.
Answer: C-
There are enough signs of hyperadrenocorticism (Cushing's disease, HAC)
that I think it would be best to check again for it. Sometimes it is even
necessary to go ahead and consider treatment even if the labwork doesn't
really support the diagnosis, but that should be a last resort.Diagnosis of hyperadrenocorticism is sometimes very frustrating. We have
had two or three patients who had obvious symptoms of this disorder and
normal lab work through two or even three tests prior to finally having lab
work that supported the diagnosis. In addition, the signs are indistinct
enough that it is often necessary to rule out several other conditions,
such as diabetes mellitus (easy to rule out), diabetes insipidus (hard to
rule out), hypothyroidism, pheochromocytoma other hormonal illnesses and
even kidney or liver disease.The other problem with this condition is that it occurs primarily in older
dogs, who often have more than one problem, making the diagnostic challenge
even a little harder. Getting the opinion of an internal medicine
specialist is a good idea in situations like yours.There are a couple of studies that show a link between HAC and perianal
adenomas in female dogs so this does seem like it might be a hint that HAC
may be present.Nosebleeds sometimes occur due to hypertension (high blood pressure), which
can occur with Cushing's disease. Also, dogs with Cushing's disease tend to
get infections more easily and a nasal passage infection is possible, too.
On the other hand, the most common cause of nasal bleeding in older dogs is
probably nasal tumors. Make sure that you mention this problem in the
history when you see the specialist. In fact, the best thing to do is to
write the history of Dixie's problems down and bring the information with
you. I like to send the whole medical record along with patients I refer,
so you might ask your vet to do that, too. Sometimes there is something in
the record that doesn't seem too important to me that turns out to be
important to the specialist.We see rises in the alkaline phosphatase levels with HAC very frequently
but it is much less common to have significant rises in the ALT that are
actually due to HAC. It does seem to happen sometimes, though. It would
not be uncommon for an older dog to have liver disease and HAC at the same
time.I hope that the specialist is able to help you sort all this out. I do
think that you have to keep Cushing's disease high on the list of
differentials at this point and make another effort to rule it out by
testing again.Mike Richards, DVM
3/8/2000
Question: Dear Dr. Mike,
My question is regarding our dog, Angus. He is a 7 ½ year old West
Highland White Terrier. The condition I am enquiring about has become
noticeable in the past year. We live in Toronto, Canada and last winter
to avoid the ugly winter weather we rented a little house in Naples,
Florida. It was great, except for Angus - the flea situation was
something we were unprepared for. They were overwhelming. We took quick
action and visited a very helpful vet there and he put Angus on a stronger
flea medication than we had given him - he still took his heartworm / flea
medication and the doctor changed him to a stronger flea / tick version of
"Frontline". That got the fleas under control, but sadly Angus who has
never taken well to hot weather, couldn't take the skin irritation and we
had to resort to Prednisone to calm down the cycle of scratching and
further irritation. The 20 day cycle of Prednisone was all it took to
calm down his skin troubles. When we returned to Toronto Angus went
through another itching flea bite related cycle and we had to use
Prednisone once again in early summer and yet again in late summer. All
his life - even in puppyhood - he has had a difficult time with hot
weather and it shows in itching, lethargy and a lack of appetite. Our vet
here in Toronto had us give Angus blood tests because of Prednisone - to
check that the drugs weren't hurting him and we found his enzyme levels
high...we thought that we should wait another month and check again since
the Prednisone supposedly can take quite a while to wear off. Well, that
test proved to be bad news again, we gave him another test where he fasted
for at least 12 hours, had a blood test, then they force-fed him (like
that was hard!!) high protein, high fat food and tested his blood a few
hours later and that test was deemed inconclusive. The vet started
talking Cushing's disease, but Angus doesn't show any of the classic signs
- his water consumption is not unusual, he's perky, energetic and he
doesn't have the pot belly or the blue vein
conference with another vet they are now thinking Chronic active Hepatitis
or Copper Toxicity. They want to give him an ultrasound and a biopsy -
that means general anaesthetic which I am not excited about. My husband
is convinced that he's heard somewhere that white dogs do not react well
to anaesthetic. I'd love to hear what you think. A couple of other
things to throw into the mix, Angus has suffered off and on for a few
years with a gurgly stomach for a day at a time, sometimes often and
sometimes not for quite a while. Sometimes with that he gets a retch
thing going and vomits up frothy yellowish bile. When we mentioned the
gurgly stomach to our vet he suggested that Angus had developed a
sensitivity to the green beans and carrots we have always added to his
food - we stopped the vegetables, but the gurgles returned as they always
have.Sorry this note is so long, but I really want a second opinion and as long
as I am writing someone is listening. I like our vet, but he's sometimes
a bit too busy to listen to everything. I wonder if these things are
connected and he's not tying them together.Warm regards, Ann
Answer: Ann-
Your vet has reason to be concerned about liver enzyme level rises in a
Westie. There is a chance of copper accumulation in the liver leading to
toxic changes. This is a treatable condition in which it is possible to
reduce copper levels and slow the future accumulation of copper. The only
good way to diagnose this is a liver biopsy and it usually takes enough
liver tissue that an ultrasound guided biopsy using a specialized biopsy
needle or a surgically obtained biopsy is necessary. Anesthesia is a
concern but there are anesthetics that can be used with reasonable safety
even when liver disease is present. Since your vet knows there is a problem
I'm sure he will plan carefully to avoid complicating that problem.Cushing's disease can cause rises in liver enzyme levels, so testing for it
is reasonable. However, if you have to choose between tests you should ask
your vet how seriously he takes this possibility since there is a lack of
other clinical signs.The rises in alkaline phosphatase levels associated with cortisone use
normally drop reasonably quickly once medication is withdrawn and it is
unlikely that this would be a contributing factor after waiting the month
between tests.Flea allergy or hypersensitivity does seem common in Westies, as are other
allergies. Hot weather always makes skin conditions worse, so it is not
unusual that you would have more problems in Florida and in the warmer
summer months. In Southern climates it is usually best to treat with
Frontline (TM), Advantage (TM) or Revolution (Rx) all year if a dog is
sensitive to fleas. I don't know the necessity of this where you are.I know of no special sensitivity to anesthesia in white dogs and we have
anesthetized a lot of Westies over the years without any significant
problems (nothing bad enough I can remember it). I think that white dogs
have more skin disease but am not actually sure that is true.I really wish I knew why some dogs have excessive intestinal or gastric
gurgling. This is a problem that people write to me about fairly
frequently and I don't have a really good answer for. There are a number of
causes of this problem and some dogs that really seem to be reacting to
stress or to have gas for reasons that do not show up in lab work.I do really think that it is a good idea to consider pursuing a diagnosis
and medication for this condition if it is recurrent, even if it does get
better each time. Food allergies are a possible problem and food trial for
allergies would be worth considering. Testing for other causes of colitis
is worthwhile, too. If you elect to have a surgical biopsy of the liver, it
would be worthwhile to get intestinal biopsy samples at the same time. If
you have ultrasound guided biopsy for the liver disease, it might be best
to see if there is a treatable problem and then see if treating it reduces
the intestinal problems prior to doing a lot of additional testing for the
bowel disorder.One other thing to consider, as if there wasn't enough else going on, is
that megaesophagus can be a cause of gurgling noises in dogs. Fluid
accumulates in the distended esophagus with this condition and it is a
cause of retching, too. Plain X-rays of the chest sometimes show this
condition and X-rays with barium dye show it very well, usually. I'm not
sure whether or not this would be a serious consideration in Angus' case
but your vet can tell you that.I hope this helps some. Please feel free to write back for clarification of
any parts that you need.Mike Richards, DVM
2/25/2000
Last edited 01/30/05