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Liver Disease in Dogs
Hepatic microvascular dysplasia
Liver Fibrosis treatment - monitoring use of ursidiol in a dog with no gallbladder
Liver disease in Shiba Inu
Abnormal liver in Shiba Inu
Liver problems in Min Pin
Liver failure in Siberian Husky
Dietary recommendations for liver disease
Liver, gallbladder problems in min Schnauzer
Liver disease in Labs
Liver enzyme levels in Westie
Liver values - Rimadyl
Liver Disease
Liver disease - Hepatitis, Leptospirosis, copper toxicity
Necrolytic migratory erythema (NME)
Liver Toxicity
Vomiting with increased liver values
Suspected Liver Disease
also see Cirrhosis
also see Elevated Alk phos
also see Hepatic nodular hyperplasia
also see Liver tests
also see Gallbladder
also see Liver Shunts
also see Renal Problems
also see Rimadyl
also see Neurological Problems
also see Hepatic Encephalopathy
also see Hepatitis
Hepatic microvascular dysplasiaQuestion: DEAR DOC, MY 8 MONTH OLD TOY FOX TERRIER HAS BEEN DIAGNOSED WITH MICROVASCULAR DYSPLASIA. COULD YOU PLEASE GIVE ME ANY INFO YOU HAVE ON TX, ALTERED LIFE EXPECTANCY, ETC. THANKS, DONNA
Answer: Donna-Hepatic microvascular dysplasia is a condition in which there is mixing of venous blood and arterial blood at the microscopic levels in the liver. If you search for information on this condition, it is also called hepatoportal microvascular dysplasia so you may find information using either name. This condition has been recognized in a number of small dog breeds but seems especially prevalent in Cairn terriers and Yorkshire terriers.
It is likely that most dogs with this condition have no readily apparent clinical signs associated with the microvascular dysplasia and are diagnosed when bile acid response testing is done to rule out liver disease for some reason. Unfortunately, some dogs with this condition do have clinical signs, which can include seizures or other central nervous system disorders, gastrointestinal problems or urinary tract disease associated with ammonium biurate crystals in the urinary tract, which form due to the liver problems.
Abnormal bile acid response testing usually provides the initial suspicion that this disease is present. High bile acid levels can occur with portosystemic shunts, as well. It is necessary to rule out that possibility when considering the possibility of hepatic microvascular dysplasia. Liver biopsy adds further evidence for the presence of this condition, in part by ruling out other liver diseases.
When dogs have microvascular dysplasia without clinical signs, their prognosis is very good. In many instances there is not a need for therapy. In dogs that are diagnosed because they have clinical signs, it is often possible to manage the signs through the use of dietary therapy and medications. The dietary therapy is aimed at reducing excess protein in the diet and the medications, including lactulose and antibiotics such as neomycin or metronidazole, which are used to lower ammonia levels in the digestive tract and thus in the body. The prognosis is variable for patients who have clinical signs from hepatoportal microvascular dysplasia. Some dogs do well with therapy and live normal, or nearly normal, life spans. Others have worsening of the clinical signs over time. I do not know of a method for predicting how well an individual patient will do.
There are a number of reduced protein diets that might be helpful, including Hills k/d (tm) and l/d (tm) diets, Purina's NF diet and others. Lactulose dosage is adjusted to individual patient's needs by using it to obtain a soft but formed stool. Neomycin is usually given at a dosage of 22mg/kg of body weight twice a day and metronidazole at 7.5mg/kg twice a day. This is a lower metronidazole dosage than is used for many other conditions. I have seen recommendations for the use of other antibiotics but these two are the most commonly mentioned ones.
I hope that this is helpful.
Mike Richards, DVM
9/14/2001
Liver Fibrosis treatment - monitoring use of ursidiol in a dog with no gallbladder
Question: Hello Dr. Richards,
My standard poodle, Angel 16 months appears active and healthy aside from
some itching and rapid breathing-all she has had since we owned her at 3
months. We found out she has some form of Liver Disease when she was spayed.
She had elevated Liver enzymes. She has been seen by University of
Wisconsin(and currently still in contact with) but questions seem to arise.
It was decided after liver biopsies and removal of her gallbladder (which was
abnormal) to start her on ursidiol and colchicine,Vit E(water soluble).
Colchicine as I understand is to minimize fibrosis thereby minimizing
cirrhosis. The ursidiol I'm not sure I understand -I think it's a good bile
acid. Her liver enzymes are all coming down, I don't have them currently.
So the thought is the colchicine is working. However her Bile acid test
which had been a high normal before starting ursidiol is now 300 pre and 125
post. (These are approximate numbers) The strange thing is they are the
reverse-high pre and lower post. I am told this is a phenomena when the
gallbladder is removed. The Dr. at Madison is trying to talk with some
Clinical Pathologist at Cornell about her Bile acid test. Is the Bile acid
test effected by ursidiol and or no gallbladder? You made reference in
response 7/26/2000 Vet info digest to monitor use of ursidiol in a dog with
no gallbladder. How do you monitor it? Her tests have us stumped because
the Liver enzymes are lowest ever, while the Bile Acid is high. Bleeding
time, NH3, Bilirubin remain normal. The albumin has dropped slightly to 2,
so we have added 1/2 c. cottage cheese to her current LD diet. Any
information would be greatly appreciated. My vet and the vets at the
University are excellent, but I am finding that Liver disease in dogs is
difficult to understand and manage. Meanwhile, Angel plays alot, loves to
swim, eats heartily- and appears normal. I'm trying to keep it this way. Do
you have any info on Sam-E and Milk weed extract? Why do dogs get Liver
fibrosis?(I feel she was born with it)Thank you, Kim
Answer: Kim-
Ursodiol (Actigal Rx) is a naturally occurring bile acid, although I think
that the pharmaceutical is a synthetically produced duplicate. I do not
understand the exact mechanism for why it is beneficial when some other
bile acids are considered to be harmful. However, it lowers cholesterol in
the bile by decreased synthesis of it in the liver and absorption of it in
the intestines. This helps keep the bile flowing. In addition to this
effect, ursodiol seems to have a direct stimulatory effect on bile flow and
to protect liver cells from the detrimental effects of bile salts which are
also a component of bile. These are all beneficial effects that help both
dogs and cats when they have chronic liver disease.Ursodiol is a bile acid, so it does contribute to the measured levels of
bile acids when a bile acid test is performed. For this reason, it is
recommended that it be discontinued about 3 days prior to performing a bile
acid response test or measuring serum bile acid levels. I do not know if
anyone has developed a formula for compensating for ursodiol administration
so that it could be continued despite testing but it is possible that this
has been done or will be done in the future. I know of no problems with the
use of ursodiol in patients without a gall bladder. Since bile flows
continuously in this case (no storage facility for it), it makes sense that
free flow would continue to be important but that is just my own logic, not
something I have found in the literature.SAM-e (Denosyl SD4 tm) is S-adenosylmethionine. This is also a naturally
occurring compound that can be synthesized for pharmaceutical use. It is
supposed to help stabilize liver cell membranes and when broken down also
provides essential nutrients for repair and maintenance of the liver. It
seems to be very safe. Several of the leading experts on liver disease in
the US have been endorsing the use of this medication for liver disease and
there are now a small number of studies that also support its use. The
tablets should not be broken, so if the 20mg/kg dose doesn't match the
tablet size it is best to round the dosage up to the next whole tablet dosage.Milk thistle contains a compound, silymarin, that also seems to help
protect liver cells and to stimulate cell healing. This compound is an
anti-oxidant and that may be part of its effect but I am not sure what the
mechanism for the whole effect is. Milk thistle can be overdosed, so it has
to be used in a appropriate manner. There are many available formulations
so giving exact dosing information is difficult. One approach is to use
about 1/4th of the adult human dosage for a 50lb dog and to adjust that up
or down some based on the size of the dog that the milk thistle is being
given to. I have not seen any reports of incompatibility with other liver
medications.I think that I understand how bile acid measurement works enough to explain
what might be happening. Bile acids are contained in the biliary system
(the bile ducts and the gall bladder) most of the time. They are released
into the intestine when the gall bladder is stimulated to contract by the
presence of food or liquid in the intestine. They are absorbed from the
intestinal tract into the blood stream where they can be measured and the
liver recaptures them. So, bile acids are normally low when the gall
bladder has not contracted and when the liver is functioning properly.
After a meal, the bile acid levels increase temporarily due to the release
of bile containing them from the gall bladder and biliary system. This
means that in a "normal" bile acid response test, the levels of bile acids
should be higher in the sample taken after feeding a small meal, rather
than the sample taken after a twelve-hour fast prior to the test.
Unfortunately, it is not possible to stop the dog from secreting liquid
from the stomach into the small intestine or from stimulating gall bladder
contractions for other reasons. So in about 25 to 35% of the bile acid
response tests the pre-feeding sample is higher than the post-feeding
sample. Usually both samples are pretty close in value in this case but not
always.In the case of a dog without a gall bladder, there is no place to store the
bile and so a big release of bile and bile acids after feeding doesn't
occur like it would in a dog with a gall bladder. I am actually not sure if
there is a great deal of value in doing pre and post feeding blood tests in
a dog without a gall bladder for this reason but that is probably something
that should be determined by testing a number of dogs without gall bladders
and if that work has been done I couldn't find it.In any case, values in both the 125 and 300 range do indicate a decrease in
liver function. However, as you are discovering, this doesn't always
translate into serious clinical signs. Some dogs with really serious liver
failure still feel great and act like normal dogs. By doing the things you
are doing to slow the progression of this disease, hopefully Angel will be
able to feel good for a long time.Mike Richards, DVM
7/20/2001
Question: Dear Dr. Richards,
I am a new subscriber, and I emailed you a week ago tomorrow about my 3
year old Shiba Inu. I am not sure if you are going to reply to my email address
or put your answer on the website (or both). In any case, there is now
more information on Sasi's condition which somewhat outdates my original
questions. SaSi has now had some bloodwork done which indicates that she
probably has some sort of liver disease. They took a blood sample after
fasting, fed her some puppy food (because of the high protein content) and
took a second blood sample. I don't have the numbers but I understand they
were very high. Our vet said the results were likely indicative of liver
disease, and if not, then inflammatory bowel disease. We are booked to
have an ultrasound in a specialist clinic Feb.2.
My questions remain along the same lines. What might the ultrasound tell
us? And what happens next? There is also talk of doing a liver biopsy
depending on the results of the ultrasound. What does the liver biopsy
tell us?
Thank you. DianneAnswer: Dianne-
Ultrasound examination can sometimes detect portosystemic shunts, gall
bladder stones, bile obstructions and tumors in the liver (and probably
some other things that aren't coming to mind right now). Liver biopsy
allows specific diagnosis of conditions that affect most of the liver, such
as cholangiohepatitis and chronic active hepatitis. In addition, biopsy can
allow a specific diagnosis of the type of tumor present if there is liver
cancer (not too likely in your dog). Very high bile acid levels are most
commonly associated with portosystemic shunts (where blood flow that should
go through the liver bypasses it instead) but can occur with any liver
condition in which liver function is significantly decreased.The advantage of ultrasound exam is that it is less invasive than
exploratory surgery and it allows guided biopsy, in which the operator can
aim for a structure showing in the ultrasound picture. The disadvantages
are additional cost is surgery is necessary later, anyway and smaller
sample size when doing needle biopsies, which can make it hard for the
pathologist to be sure of the problem, in some cases. We send some patients
for ultrasound and do exploratory surgery on others, based on how we feel
about the odds for successful anesthesia and surgery and how the client
feels about surgery versus ultrasound (do they wish to avoid surgery or is
cost more important?)We see many instances of liver disease that are acute insults to the liver,
such as bacterial infections, blood clots, trauma or toxin exposure. In
these cases there is usually a good recovery, so even when liver related
blood values seem really bad we try to keep on treating until we either
have a definite diagnosis that discourages us or until it is obvious that
the problem is not going to clear up and the patient is becoming
debilitated.Good luck with this.
Mike Richards, DVM
4/4/2001
Question: Dear Dr. Richards,
SaSi's ultrasound showed a smaller than normal liver, (so small the
internist said he would not be able to do a biopsy under ultrasound), and
some evidence of scar tissue, but otherwise normal. (I believe he said that
the liver was about the size of thumbnail. Is this possible?) He did a
very thorough exam and checked out all the other organs and everything
seemed normal. Since that time SaSi has stabilized on a low protein
hypoallergenic diet, (the Canadian VMD MediCal), and has even gained two
pounds. Our veterinarian is planning to retest SaSi's liver function in a
month or so, and probably proceed with a liver biopsy if the enzymes are
elevated again. I guess my problem is I am trying to avoid the trauma of
both the liver enzyme test and the biopsy, hoping to get a diagnosis, or at
least rule out some possibilities, from behavioral clues.
She was put on the low protein diet about three days after she
was fed the puppy food to get the blood test showing the elevated enzymes. For about
six weeks after that her stools were very yellow and formed but very soft,
and she continued to have an odor that I noticed when she was so sick at
Christmas, kind of an acrid smell from her breath. Then overnight and for
no apparent reason her stools became a more normal brown colour and held
their shape when I picked them up. This lasted for about a week and I
noticed that the disturbing odor was gone, and even briefly noticed her
breath was back to a normal not unpleasant slightly sweet doggie breath.
But now we seem to be deteriorating again and also for no apparent reason.
Her stools are softening up, and are a mixture of brown and yellow. She
does not show any sign of wanting to vomit but the last two or three days
she has wanted to eat grass, usually a sign that her tummy is upset. During
all this time I have been watching her very carefully and do not think she
has been able to eat too much crap on our walks, although I cannot say for
sure that she hasn't picked up some tidbits.
So are these yellow stools and acrid breath indicative of liver
disease?
And does the fact that both are normal at times mean anything? If the liver
is really small already, won't taking a biopsy compound the problem? If we
were to assume that she had a liver shunt (at the cellular level) could we
treat her with some of the drugs you have recommended in your emails to see
what effect they have and perhaps gather more information that way leading
to a diagnosis? There is no heartworm disease where we live but we plan to
travel across the continent this summer and will be wanting to protect her
from fleas and ticks and heartworm. Should we be concerned about any
detrimental effect of these medications on a weak liver and are there
alternatives? And for dogs with liver disease, is it important to minimize
stress. (SaSi is aggressive with other dogs so I take her walking with
other dogs and she gets very anxious at first. We also do agility training
and I am not sure she is crazy about that either!)
There are two other issues I am not sure are related. Sasi never
seems to need to drink water. She likes to drink it outside in muddy puddles but
from her bowl in the house almost never unless she has been running hard.
Also she seems to do an abnormal amount of licking her chops and slurping
and gulping. Our veterinarian has checked her mouth and throat and they
seem normal. Are either of these behaviors potentially indicative of
anything in particular?
Thank you very much for your support. Regards, DianneAnswer: Dianne-
I have to think that the description of the liver as being as big as a
thumbnail would have to be an exaggeration. Livers can be pretty small in
some cases, though.There does seem to be a correlation between liver function and breath odor.
Several of my clients have mentioned this and have even been able to use
this symptom to evaluate how treatment was going to some degree. The
buildup of toxins in the blood stream is probably responsible for this
effect. A lot of dogs with liver disease lick their lips a lot and I have
always assumed that this probably related to the taste or feeling of the
toxins that build up, as well.It is usually necessary for me to track liver enzymes or to do periodic
bile acid response testing in order to feel really comfortable about when
to make changes in liver therapy. There is some evidence that low protein
diets are not optimal when the liver disease is compensated (when the
patient is doing well), so choosing when to stick with a low protein diet
is part of the reason that we try to monitor patients as time goes on. When
liver values are not good, we also try to add lactulose and neomycin or
metronidazole to the treatment effort, so it is important to know when
things are going well and when they are not. Once we reach a point where
we know that the liver function is going to remain depressed, we often opt
to cut back on the lab work and monitor just when clinical signs seem to
indicate a need.Biopsy of the liver is often the only way to be really certain what is
happening with the liver. It is most important to have a diagnosis when
something treatable seems like it is a strong possibility. Your vet has to
make that judgment based on the lab work, the physical exam findings and a
subjective opinion about how SaSi feels, based on your opinion and your
vet's experience with her in the office. It is hard to decide whether or
not to pursue a biopsy in a patient whose liver is very small, because the
odds of discovering something that will change that situation are not very
good but it is the best test available.If you are going to travel into heartworm endemic areas you should use
heartworm prevention. It is important to remember that the monthly
heartworm prevention medications are not time release. They do not protect
for the month AFTER administration of the pills, they kill heartworms that
have been acquired in the month BEFORE administration. It is really
important to give 1 heartworm preventative pill at least a month after the
last possible exposure to heartworms. We have used these medications in a
number of dogs with liver disease, since we live in a heartworm endemic
area and so far, we have not been able to detect problems with either
ivermectin (Heartgard 30 Rx) or milbemycin (Interceptor or Sentinel Rx).Some dogs with small livers do very well with medical management so I hope
that is your experience with SaSi, as well.Mike Richards, DVM
4/4/2001
Question: Dear Dr. Richards,
I have a beautiful little Min Pin who will be two years old on December 26th. She has always been a very fun and energetic dog to say the least. She is very well taken care of because she is hard of hearing in one ear. Because of that she is always walked on a lead.
On November 3rd Callie had her first episode of lethargic behavior. I had never seen this with her before. She was fine in the morning but by 5pm she was depressed with no appetite. By the next day though she was better. 5 days later we were going out of town and decided not to bring Callie since she seemed depressed again. We left her for the weekend at the vets. I really have great confidence in our vet. Callie boards there when we travel and they are very familiar with Callie's normal behavior. They ran blood work and everything looked normal except one of her liver enzymes were slightly elevated. By the time we got back two days later she was back to her happy self. But 5 days later, she had a bad episode of throwing up, not eating, etc. On Saturday morning we brought her back to the vet and she saw the Jr vet. With Callie's history of allergies he said it sounded like that could be the culprit. She got a cortisone shot and we changed her diet to z/d. She was fine all of Saturday, eating etc. but by Monday she was bad again so we left her at the vets for more blood work. Her liver enzymes were off the chart! They put her on an IV with fluids and vitamins. An x-ray showed no signs of any obstructions. Her white blood cell cut was slightly elevated but her billy rubens were normal. By Wednesday she was almost back. Eating l/d and taking an antibiotic. The vet gave her fluids under her skin and sent us home. Callie got better every day--no throwing up and almost back to her crazy hyper self. By Saturday she was back!! Saturday night we were at a friends house and there were a lot of children who had dropped a French fry on the ground and before we could grab her, she had scarfed it down. She was also sniffing around the carpet and probably got a few other tid bits. She was sick by 4am Sunday morning--throwing up, etc. Sunday night we went to the vet and they gave her fluids and send us home. By 10pm she would eat a little. Yesterday they did another set of blood tests which showed one of her enzymes down to 1534 but the other one is still off the charts. Her white blood cells and her billy rubens were normal.
They gave her fluids and sent us back home. Last night was her worst night. By then she had not eaten
anything but a tablespoon of l/d since Saturday night. She was lethargic, in some pain, couldn't even handle the smell of food. All she wanted was to sleep and be held. But like before by 1am she popped up and wanted to go out, At 2am she was hungry--scratching at her dish and sniffing the floor for food. I gave her food and she kept it down. The morning she is better again. She is back at our vets now for a bile acid test and a copper toxicity test. The vet has also put a call into NC State's Vet Hospital. They said that it sounded more routine but they could take her on December 13th. If our vet felt it was an emergency they could take her sooner.
There is a good person in Chesapeake, VA that could do the Ultra sound/biopsy on the liver sooner but can not offer all the services the the hospital can. Callie was weighing 6.4-6.8 pounds. She now weighs 5.8 pounds. My questions are these:1. What could this possibly be in a healthy, two year old dog? It is so hard to understand why she is so
suddenly up and down.
2. Should I decide my self this is an e,emergency and try to get her to Raleigh sooner or should I
take her to Chesapeake for the ultra sound and go from there?
3. Could there be any connection between her partial deafness and her liver problems?
4. Why would the technition at NC State say that her condition sounds routine?
If you need Callie's specific numbers from her blood work I can get them this afternoon. We love this little dog so much. She is loved by everyone who meets her partly because of how friendly and small she is. I want to do the best I can for her. I really appreciate your help.Thank you
Sincerely, Lisa
Answer: Lisa-
1) There are several possible problems.
A portosystemic shunt could be present. In this condition, blood bypasses the liver because a
connection between the venous blood supply and the arterial blood supply develops (or is present
congenitally). This decreases the functional capacity of the liver significantly. in most cases, signs of
this disorder show up before dogs are a year of age, but sometimes clinical signs wait until later in life
to show up. Dogs with this condition tend to have problems after eating. Surgical correction of the
shunt is usually considered to be the best option for dealing with this problem, when it is present.Microvascular dysplasia is another problem in which the blood supply is not properly routed, but in
this case the shunting occurs at the cellular level. Dogs with microvascular dysplasia may be normal in
appearance most of the time but have intermittent problems when the liver just can't react to an
increased demand on it. Other times, the disorder is evident almost all the time. This problem is
usually dealt with through dietary changes (lowering protein levels) and the use of lactulose and/or
metronidazole or neomycin antibiotics. All of these treatments aim to lower the serum ammonia
levels, which cause the clinical signs associated with the condition. Microvascular dysplasia can be
subtle enough that clinical signs are not noticed until a dog is a young adult or may even be mild
enough that they are never seen.Chronic immune mediated hepatitis or chronic active hepatitis (probably different names for the same
condition) may also be present. This disorder is most common in middle aged female dogs but can
show up earlier than middle age. The only really good way to diagnose this condition is a liver biopsy
and it is a good idea to check for copper accumulation in the biopsy sample, because copper may
not be excreted properly when this disorder is present and can accumulate in the liver. This happens
most commonly in dobermans. I do not know exactly how much correlation there is in problems
between dobermans and miniature pinschers, if any, though.Sometimes inflammatory bowel disease, pancreatitis, intestinal obstruction, gallstones, liver infection,
blood clots or other problems lead to bile duct blockage or a sudden onset of hepatitis and these
problems can occur in any age dog.2) If you are worried about Callie and don't mind the possibility of having to pay for the ultrasound
examination and/or liver biopsy twice, there is no reason not to go ahead and have the ultrasound
done prior to the time it is possible to go to NC State. If it is suggestive of one of the above
problems you may still need to go to the college for scintigraphy or other testing that is usually done
mostly at universities.3) I know of no connection between deafness and liver problems, except that liver disease can cause
central nervous system disorders if they get severe. I haven't really heard of deafness from this
problem, though.4) The liver problems fall into two categories -- chronic conditions for which a couple of weeks of
waiting isn't going to matter and acute conditions that will probably get better, with your usual vet's
help, before you even get to the university. So that is probably why the tech feels that a routine visit is
reasonable in this circumstance. If you feel otherwise, NC State seems reasonable about seeing
patients on an emergency basis, based on our experiences with the school.Good luck with this.
Mike Richards, DVM
12/4/2000
Liver failure in Siberian Husky
Question: Hi Dr Mike,
This is my second letter to you about my Siberian Husky, Cody. I'm in
total confusion now more than ever. She started out with ferocious water
drinking and excessive urination particularly thru the night. My vet checked
her urine for infection and he found a slight evidence of infection and so
was put on anti biotics . She also was put on an acidifier because her ph
level was off. It seemed to work for a while but eventually the problem
returned. He checked for diabedes and found none. So he tested for Cushing's
and he said that's what she's got. I did the 7dys Lysodren 2x/dy. On the 8th
day she wilted and so my vet said to stop. She had a couple days of
prednisone. She did not resume any Lysodren til 6 days later. By then she was
frantic for water again and she got another Lysodren. That week she got a
total of 4 Lysodren and the same the week after. The week after that only 2
and 1/2 pills; then she stopped eating. She also was not drinking or
urinating excessively, either. She was retested and was not overdosed. ( she
was retested a total of 3 additional times after the original diagnosis- she
never was overdosed) She lost 3 lb in 10 dys. This dog is thin and does not
have the pot belly they mention. And she has never been a big eater.
I gave her a prednisone if she didn't eat anything by noon and usually
within a couple hours she would eat something. My vet said it was time for a
specialist as he didn't know what to suggest. ( she also has been on
antibiotics most of the time)
The specialist did an ultasound and said everthing looked normal but the
liver looked raggedy. He did a liver function- the two hour test- before and
after food. He came back and said she has liver failure and does not have
Cushing's disease. He said with her numbers from all the retests, she would
be a perfectly balanced Cushing patient and should have a good appetite . I
was totally blown away and can't understand how that could be. Could she have
both? He has put her on Actigal once a day but she's not eating. She's not
drinking too much either, but she does have to go out a couple time at night
and is prone to accidents . Today an hour after taking her pill and eating
two little bites , she threw everything up. so, I gave her another actigal
and did not try to feed her, not that she would eat anyway. It seems like she
wants to eat but just can't bring herself to put it in her mouth. I thought
she might be naseous and my reg vet said to try tagamet. What do you make of
this? Are there any appitite stimulants for dogs that work until the
medication has a chance to work? I'd appreciate any insight you have as my
own vet is also at a loss as to what to do and he even questions the second
diagnosis. Thanks Cody's mom, Carlye
Answer: Carlye-
I think that in most instances in which there is a disagreement between an
internal medicine specialist and a general practitioner about
interpretation of lab results for disorders such as hyperadrenocorticism
(Cushing's disease), the specialist is most likely to be correct because
they deal with these cases much more commonly than most general
practitioners. This has happened in our practice and so far the specialists
were right in all but two cases (based on my memory of events) --- over the
course of twenty years.Many dogs with liver disease have increased drinking and urinating,
sometimes to the degree that it is very suggestive of Cushing's disease.
The increased drinking and urinating are more likely to follow an on again,
off again course with liver disease. Weight loss is a very consistent sign
of chronic liver disease, so that also is highly suggestive.Appetite stimulation does not work as well for dogs as it does for cats.
Prednisone is the most reliable appetite stimulant in dogs. Some forms of
liver disease do respond to prednisone but other types of liver disease can
get worse, so it is best to try to identify the exact cause of the liver
disease, if possible, prior to using prednisone on a regular basis.It can take some patience to get through the initial treatment for liver
disease, since ursodiol (Actigal Rx) can take time to show beneficial
effects. Many times there is a good long term outcome, though.Mike Richards, DVM
10/31/2000
Dietary recommendations for liver diseaseQuestion: I have a soon to be 13 year old Pattern White Australian Shepherd female,
spayed. This past spring at her annual exam the doc noticed her liver enzymes
specifically her ALKP, AST and ALT were slightly elevated, they were last
year but now they were more so. Three months later we had her rechecked and
found them to have risen even more so,,,,,,,,,ALKP 364, Alt 364 and Ast 60.
He referred us to an internist who did an ultrasound and found a slightly
mottled liver, enlarged adrenals and some gall bladder sluggishness. He also
did a ACTH stim test that proved to be borderline high. He recommended we go
through with the Low dex test, where she ended up being 95. A high dose was
not indicated at that time. Last week my vet and the internist conference
called and decided she was early stages of cushings, and that we should not
start any meds at this time, but would redo any blood work in a month and see
what her status is. In the meantime, I am wondering about vitamins, diet,
supplements, water?? anything I can do to take care of her in the best way I
know how. She is currently on Hills Science Diet and has been for three
years. I bought some Milk Thistle to add one capsule to her food because I
heard it will help with her liver. What is everyone else doing. If this is
too cumbersome for the list you can privately email me if you chose, but I
would love information on proper diet, and vitamins/supplements, and also
if it could possibly be something else we are overlooking.
Thanks so much in advance.
LisaAnswer: Lisa-
The typical dietary recommendations for liver disease are to use a low
protein diet that has very good quality protein ingredients so that the
liver doesn't have to do much work to convert the protein into forms the
body can use. There are commercially available diets that help with this,
including Hill's l/d (tm) and k/d (tm), Purina's NF diet and others.Vitamin supplementation with B vitamins is often recommended for patients
with liver disease, since these are important to liver function and because
Vitamin B12 storage partly occurs in the liver. Vitamin K supplementation
may be necessary at some time as liver disease progresses, as it may not be
stored properly and blood clotting problems may develop. Vitamin C is
sometimes recommended for its anti-oxidant properties and Vitamin E is
sometimes recommended due to its anti-inflammatory effects.SAMe (Denosyl SD4 tm) is commonly recommended for liver disease by some of
the leading authorities on liver disease in veterinary medicine. The
recommended dosage is 20mg/kg per day.Ursodiol (Actigal Rx) is recommended to help with bile flow and protect the
liver from the toxic effects of some bile acids. We use this medication
frequently and I believe that it is helpful.Hope this helps some.
Mike Richards, DVM
8/13/2000
Liver, gallbladder problems in Min Schnauzer
Question: Dear Dr. Richards,
My 12-yr-old neutered male Min. Schnauzer, Ruckus, had been "not himself"
earlier this year (Feb-March). Urine and blood tests all came back normal.
However, he then had a bout of pancreatitis and a second episode in late
March that included severe abdominal pain, listlessness, and yes, elevated
pancreatic enzymes. We did a sonogram on March 31st which showed gallstones
and possible inflammation of the pancreas. Surgery on April 3rd removed his
gallbladder, cut a 1 1/2" incision in his intestines to "clean out" the bile
duct, and tissue samples were taken from the liver and spleen -- both of
which appeared normal, visually. Subsequent lab biopsies of those tissues
and the gallbladder and stones showed no abnormalities other than the
gallbladder had stones and sludge, and there was a lot of infection within
it. Ruckus recovered slowly, but that seemed 'normal' for such extensive
surgery and for his age. About two or three weeks post-surgery, he had
blood work done, and the ALT was 1354 and alkaline phosphate was 1057. This
lab says the normal ranges are 5-60 for ALT and 10-150 for alk phosp. Since
he had just come off of antibiotics following the surgery and the blood work
did not show evidence of infection, we did not put him on antibiotics. He
began acupuncture treatments (my primary vet also practices/advises on
alternative medicine) on a weekly basis, a strong seeping of senna tea
once/week for six weeks, and milk thistle -- approximately 15 mg of
silymarin, three times/day. Ruckus appeared to be healthy -- good appetite,
ormal feces and urine, etc. -- but his "sparkle" didn't seem to be back.
On June 30, his ALT was 807 and alk phosp was 388 -- still not normal, but
moving in the right direction. We have continued the acupuncture and milk
thistle, and approximately two weeks ago, I switched him over to Ecliptex,
1/4 tab twice daily while still giving him 5-8 mg of the silymarin drops
every day. We also put him on 14 days of Flagyl and Baytril, "just in case"
there was an infection going on that wasn't giving indications in his blood
work. About that same time, his sparkle seemed to be returning, and he is
currently peppy, alert, and playful. (Earlier in July, we also did the
blood test to rule out Cushing's, which he does not have.) On July 20, we
did another blood workup -- expecting everything to be close to normal by
now, especially given his improving behavior and "sparkle". Alarmingly,
everything has worsened. The ALT is now 910 and alk phosp is 508.
Admittedly, this lab says that the levels can be "three times or so the
normal range" and still be considered OK, but these recent findings are now
outside even that parameter and definitely moving in the wrong direction.
My vet said the "only thing" he can suggest at this time is to do a needle
biopsy during a sonogram. I don't want to do yet another invasive
procedure, requiring sedation, if it can't tell me anything specific that
can be treated. In other words, my sense is that cancer is about the only
thing such a biopsy would show us, and given that liver cancer is fatal,
there would be nothing to do about that so why put Ruckus through the
procedure? Ruckus also has mild symptoms of sick sinus syndrome, and I am
very reluctant to have him sedated needlessly.
Is there anything else we should/could do? Are we missing something that
should be looked at here? I've read some of the chain of e-mails on your
site, and it looks as if there might be other things to consider. Any
insight or recommendation you can give at this time would be very much
appreciated.
Thank you, LizAnswer: Liz-
I think that I'd consider the use of ursodiol (Actigal Rx) in this
circumstance. This medication protects against toxic forms of bile acids
and aids in bile flow. I do not know of a specific contraindication to the
use of this medication in cases of surgical relocation of the bile ducts or
removal of the gall bladder but it would be a good idea to monitor its use
very carefully at first in this circumstance.I would not automatically assume that cancer is present. I'd be more
concerned about residual obstruction to bile flow, either from the original
causes of the gallstones or from post-surgical complications.If you want to do a non-invasive procedure to assess how the liver is
functioning, a bile acid response test is simple and only involves drawing
a couple of blood samples. If the function is good, I think it would ease
your fears some. If it isn't so good, that would be stronger incentive to
try the ursodiol or to consider a liver biopsy to try to get more specific
information in case there are other options it might reveal.Schnauzers are prone to hyperlipidemia, which can make pancreatitis more
likely and possibly could be a contributing factor in the formation of
cholesterol stones in the bile. If the blood work already done included
cholesterol and triglyceride levels it might be worth rechecking to see if
this is a problem, too. If so, controlling this might also help with the
long term prognosis.You and your vet have done well to get Ruckus to the point that you are at
now. I am hopeful that your success in dealing with this situation will
continue. The fact that he feels good is a very good sign and should be
given strong weight in your evaluation of the need for further testing and
lab procedures. There is often a lag time between when a dog or cat feels
better and when the lab values reflect that improvement.Mike Richards, DVM
7/26/2000
Question: Dr. Richards, I raise labs. My yellow lab was scheduled to be
spayed last fall after having had four litters of puppies. After a
routine blood test it was found that her Alt and liver enzymes were
way up. We had biop done and ulta sound. Diagnoised with liver
disease and we had her spayed. She is on medication and l/d diet
and is doing wonderfully. We have a two year old pup out of her
and another almost 1 year old. I'd like to bred both as the pedigree
is extremely good. I have had prelim's done on the two year old's
hips (excellent) and eye are due to be done. As precaution I had
blood work run re liver problems. ALT came back at 110 additional
blood work not back as of today. My vet (very) young, just out of
vet school immediately said she's got liver disease. I called the
specialist who did the bio and ultrasound on the dogs mother he
says 110 ALT is not cause for alarm unless the rest of the tests
come back bad. He suggested re-testing in a month and
suggested using a different lab. I'm not into passing bad genes
and would not hesitate to spay this dog or the pup if she tests
badly however I'm concerned that this may be hereditery.I will forward the results once I have them regarding the additional
liver tests.
Gayle-Answer: I don't think that you should worry much about 1 blood test with an ALT
value of 110. Different labs have different normal values for ALT, but our
lab uses 118 as the high normal value, which would actually make this a
normal value, for our particular laboratory. However, I do think that with
the history of the mother and a lab value in the high end of normal that it
does make sense to recheck the liver value in a month or so and perhaps
even to monitor it over time. If an elevation in ALT does occur, it would
be a good idea to pursue additional testing, such as bile acid response
testing and liver biopsy before making a decision on breeding or not
breeding, if this puppy has attributes that would improve the breed in general.I am not aware of a liver disease that is known to be familial in Labradors
but the reaction to Rimadyl (Rx) in which liver disease is induced by the
medication, while rare, affects Labs more than other breeds based on the
initial data. There are some instances of copper accumulation in the liver
in Labs and they may be more prone to chronic active hepatitis than the
average breed --- but none of these disorders has been proven to be genetic
in origin, as far as I know.If you do end up doing further testing and if the lab results do appear to
be similar to her mother's it would be good to keep the specialist you have
been conferring with informed, as that is the only way that genetic links
can be recognized and identified.Mike Richards, DVM
6/12/2000
Liver Values - RimadylQ: Dear Dr. Michael Richards;
I have had a very confusing recent event regarding my 13 yr. old
female dog come up and I will include the blood analysis for your evaluation also.
First; my dog, Kahlua, is 13 yr. old, a little stiff due to old injury and
arthritis.
She eats very well, never vomits, no diarrea, norm stools. She plays in the
evenings with us,and takes short walks during the day in her field. I
placed her on Rimadyl a few months ago to help with her discomfort due to the
arthritis.
I took her to my vet to see if we should continue with the Rimadyl,
and to have her checked. He also did blood work as he said she has not had any in a
while. I also had them repeated on another visit. I will give you both
results.
May 18th test results; ALB = 4.29g/dl , ALKP = 867 U/L , ALT = 1095 U/L, (A
DILUTION OF 1:1), CHOL = 520 mg/dl, GLU =126.7 mg/dl, Ca =12.24 mg/dl, K =
5.73, TBIL = .83 mg/dl.
Bile acids;
18.l umol/L and bile acids post =31.2. Lipemia 2+.May 29th test results; AlKP =1780 U/L, ALT =391 U/L, AST = 33 U/L, CHOL
=575MG/DL, CALCIUM =11.7MG/DL, AMYLASE =1337 U/L, GGTP =
32, Platelet Count = 482, Tot. Protein = 7.4G/DL, Tbil = .1, K = 5.5 MEQ/L.
I also had an ultrasound done and it was inconclusive as to what this
might be. They did not several lesions, and suggested a biopsy.
My question to the vet was to my concern about the Rimadyl and it's
involvement-she stated that it only affects acutely in the first two weeks of
treatment. I also have stopped the Rimadyl after the May 18th test. After
the May 29th test- I have put her on Milk thistle 70G, Low Protein,Low Salt dry
food, give Etogesic 300 mg 1 x day, give promethazine 1 x day, and also give
her rec dosage of Hip Health-Glucosomine 1000mg+vit c 100mg.
What do I do next? I am thinking of repeating the test with a
question of bile duct blockage-she licks alot but had her anal glands removed years ago,
and would also like to know if it sounds like I'm on the right track as
far as meds and food go also.
Again, she is not showing any symptoms of being ill at all. How can all
this be happening and she is fine??
Thanks so much, Karen
A: Karen-
The reactions to carprofen (Rimadyl Rx) that have been confirmed do seem to
show up most frequently in the first few days to weeks of treatment.
Despite that, I'd still be suspicious if a pet of mine had high liver
enzyme levels and then I discontinued Rimadyl and the liver values
improved. Since this is what happened to Kahlua, your suspicions seem
reasonable to me --- just not certain.We have seen several patients with sudden onset of illness in which the
liver enzymes were elevated but later returned to normal (within a few
weeks), or got close to normal, without us ever being able to figure out
what happened. Most of these dogs have gone on to do fine despite the lack
of a diagnosis. Since things are improving and since Kahlua feels OK, I
don't see a problem with rechecking the liver values in a few days to a
week or so and then basing the next diagnostic and treatment decisions on
whether the enzyme levels continue to improve.The calcium level on the first test was high enough to be worrisome.
Hypercalcemia can indicate that neoplastic (malignant) cancer is present.
Since it came down in the subsequent test this is less worrisome. It might
still be worth carefully examining her lymph nodes for enlargement and
rechecking the calcium level along with the liver enzymes.With alkaline phosphatase levels in the 600 to 1000 range in an older dog,
I always worry about the possibility of Cushing's disease
(hyperadrenocorticism). This disorder sometimes causes elevations in
cholesterol levels, too. Usually there is increased drinking and urinating
associated with this problem but not always.Your impression of how Kahlua feels is pretty important. In general, it is
OK to be a little more cautious and take some time re-evaluating lab work
when a patient is eating well and feels well. Our experience has been that
a lot of the time these dogs are "telling" you the truth --- they are OK.Mike Richards, DVM
6/1/99
Q: Dear Mike, having a sick dog has led me to search the net for answers
and coming across your site has been great since it occupied my mind and
gave me things to read that were related to my situation.
After refusing to eat or drink from one day to the next and vomiting
what I tried to coax her into, she was tested for possible obstructions as was
extensive blood work done and a stool sample taken. There was no
obstruction, the blood was normal, only slightly elevated pancreas numbers but they
found a lot of coccidia in her stool. She was given Alban for the coccidia
along with antibiotics. She continued to eat very little and threw up most of
what she ate. Back to the vet for more blood work, now her liver numbers are
all very high and the vet recommends, after doing an ultrasound where he
sees no masses but a enlarged gallbladder, to do exploratory surgery. He opens
her up but finds no obvious tumors, all her organs look good to the eye,
just a very enlarged spleen. He takes biopsies of both liver and spleen.
This dog has been in good shape, we walk daily and jog at times as
well. She didn't show any signs of problems until she just stopped
eating very suddenly. At the moment I have her at a university hospital because
after taking her home on the second day following surgery she didn't do
well, still refused to eat and just drank a lot of water and generally
laid around. At the hospital they put her back on IV, gave her anti nausea
pills so she now eats and at this point looks great again, except the
urinates frequently and drinks lots of water which I am told is a sign of liver
disease. We are desperately waiting for the results from the pathology
report that my vet sent by REGULAR MAIL OUT OF STATE!! I was appalled
by the way my vet treated the matter without any sense of urgency or
compassion for the pet owner and wonder if this is general procedure.
Her being ill started January 8, she was operated on Jan 20 and as of
today Jan 25 the biopsy samples have not even arrived at the pathologist.
I would be interests in your thoughts on the case and what other
information I can give you besides of course the pathology report which I will
e-mail after discussing it with the vet.
Lydia
A: Lydia-
I am glad that you have taken your dog to a university veterinary
hospital. That is usually a good way to get opinions from experts in several fields
of study pretty quickly and complicated cases sometimes require that sort
of collaboration. It is reasonable to suspect liver disease when a dog
stops eating suddenly and even though it was an aggressive approach,
exploratory surgery is a good option in these cases because it allows
resolution of the worry over intestinal obstruction and gives the
opportunity to take biopsies.In patients in which I am worried about the progression of a disease or
the time factors involved in getting lab samples I will usually send them by
Federal Express or sometimes express mail through the post office in
order to insure that they get to the lab quickly. Sending packages by Federal
Express does cost a lot more and I do try to make a judgment call on the
need to get the biopsy report quickly. I usually use a lab that is within
the next day delivery area for U.S. mail and it takes at least a day or
so for tissue to fix in formalin for examination so most of the time we
aren't faced with worrying about a long delay. In retrospect, since your dog did
experience progression of the clinical signs it probably would have been
better to use a faster delivery service but that is still a judgment
call.We have experienced delays in mail and have had two lab samples simply
disappear. After the first one we learned to keep a small section of most
tissue samples we submit for biopsy (sometimes this isn't possible) just
in case something goes wrong. It is worth asking your vet to do this in the
future, just in case he or she hasn't had the bad experience we have had.
We learned it the hard way.I am assuming that there is lab work that supports the diagnosis of liver
disease and am hopeful that means that the liver biopsy will turn out to
be useful. It is possible to take a biopsy sample from an unaffected part of
the liver even when disease is widespread but the veterinary school may
be able to do an ultrasound guided needle biopsy if that problem occurs.I will be glad to try to help you understand any diagnosis that is
delivered via the biopsy sample. Hopefully you will get an answer soon on
that.Mike Richards, DVM
Liver Disease - Hepatitis, Leptospirosis, copper toxicity
Q: Dear Mike, thanks for the super fast reply. I have in the meantime
forgiven my vet for delaying the prognosis since he seemed to be sorry at least,
plus I feel I need to continue to work with him since he does know the case. I
had him send me the report from the pathologist and here is his diagnosis:
Liver: Severe, diffuse lymphoplamacytic and histiocytic portal hepatitis
and hemosiderosis with associated, moderate, hepatocellular fatty change.
Spleen: Red pulp hemosiderosis.I was up at the university hospital today and my dog looked like her old
self, I took her for a walk and she was peppy and ready to take on a
German shepherd that we met. The jaundice in her eyes is gone and the university
doctor seems very pleased. She will now however also read this report and
I will hear from her tomorrow. I would appreciate your input and thoughts and particularly your
prognosis.
Lydia
A: Lydia-
It is sometimes hard to interpret the pathology reports from pathologists
without their guidance. However, my interpretation of the report below is
that a drug reaction would have to be considered if your terrier is on any
drug with the potential to cause hepatitis -- these would include
Filaribits Plus (Rx), phenobarbital, Rimadyl (Rx), enalapril and related
heart medications, phenylbutazone and other medications.In addition it may be a good idea to consider the possibility of copper
toxicity as this has been seen in a number of terrier breeds, including
Norwich terriers, wire-haired fox terriers, Bedlington terriers, Airedale
terriers, bull terriers, West Highland white terriers and Kerry Blue
terriers. While Tibetan terriers aren't on that list it seems reasonable to
assume that they could also be affected and that it just hasn't been
documented. Checking hepatic copper levels may give a clue if the
pathologist thinks it is reasonable to suspect this.There are probably viral and bacterial illnesses that could produce the
changes noted in the biopsy, too.I usually call the pathologist when I get a report like this, since the
description of the changes seen in the liver aren't specific to a
particular disease. Asking the pathologist what the possibilities are and
what the next best diagnostic step can be helpful.I also think it is really important to evaluate the dog when dealing with
liver disease. They usually feel better before the lab work looks a lot
better and they often recover from problems that seem really bad based on
lab work and pathology reports. When things are looking good I am more
hesitant to change treatments or to suggest further invasive testing.Good luck with this.
Mike Richards, DVM
Liver disease - continued
Q: Dear Mike, I don't know whether you ever got my e-mail with all those
numbers on the liver, but I have brought her home 2 days ago and she is doing
really well. Amazingly well, considering the diagnosis. She is playful I go
for walks with her she is eating and still drinking more than usual and with
every day she is more the dog I know, tonight was the first time she was
begging for dinner table scraps, which really made us thing she is back to
normal. I was at a friends vet today, however, who was very surprised to see
how perky she is and did a quick blood test. Her ALT was 545 that is down
from 745 just two days ago. Do you suppose I should have hope again, it's
almost that I am scared to do that. I have gone through an incredible
emotional roller coaster and now it looks like she is recovering fast. Is
that even possible with that diagnosis. They are also still talking about an
outside change of some bacteria that deer etc. carry (I am sorry I don't
know the medical term) but one of the things that result from that bacteria
is acute hepatitis. We do live on a marsh and there is a lot of wildlife, we
also have an incredible amount of canadian geese on our lawn all Summer and
Fall. Your thoughts on this at least for me very complicated case would be
highly appreciated. LydiaA: Lydia-
I suspect that the bacteria being worried over is leptospirosis but I am
not sure. There may be others that affect wildlife and domestic pets.In any case, I think that you have good reason to believe that things will
work out well at this time. While many times it is not possible to give a
specific diagnosis, a lot of dogs with acute liver disease do recover fully
and do not experience recurrences of the illnesses that affected them. I
hope that this will be the case for your terrier, too.I did get the email but I have just recently added a new computer and have
managed to lose a few messages in the transition to it. If I remember
correctly there was a slight downward trend in the numbers which appears to
have been confirmed.In liver disease, the attitude of the patient is often more indicative of
how things are going than the lab work is. I really do think that it sounds
like things will be OK, even if a diagnosis can not be confirmed.Mike Richards, DVM
Necrolytic migratory erythema (NME)
Q: My dog has been diagnosed with diabetis mellitus and shows symptoms of necrolytic mig. erythema
on her feet. What is the recommended treatment for this condition. Any help would be appreciated.
Currently using an antibiotic ointment and have considered trying Willard Water as a homeopathic remedy.Thanks very much for your anticipated response.
A: Dear S-
Necrolytic migratory erythema (NME) is a disorder in which a primary
disease in the liver, a glucagon producing tumor or diabetes causes
secondary skin disease. The skin disease consists of sores on the face,
ears, feet and sometimes other areas. There are usually significant changes
in serum chemistry values correlating with the primary disease. In many
dogs with this condition the NME shows up before the diabetes does.I do not know if there is a definitive understanding of what causes this
condition but the prevailing theory seems to be that it is partially caused
by nutritional deficiencies induced by the underlying diseases. There are a
number of suggested food additives, including essential fatty acids, amino
acid supplements, zinc, and egg whites (presumably for their protein
value). It doesn't appear that any of these things work really well based
on the literature available to me at this time but they probably don't
hurt. Treating for bacterial infection of the damaged skin with appropriate
antibiotics or topical antiseptics may be helpful, too. Moderate to high
fiber diets are often used to help control diabetes but in dogs with NME
they may not be a good idea because the need for higher quality protein may
over-ride the benefits of the fiber.Most dogs with necrotizing migratory erythema do not do well over the long
term. As far as I know there is no consistently successful therapy. I am
sorry to hear that this condition may be affecting your dog. It may be a
good idea to consider asking for referral to an internal medicine
specialist or veterinary school if your vet is not having success in
dealing with the problem. That wouldn't be unusual and the specialist may
not be able to help much either, but if there is a new treatment or a
differential diagnosis that may be confused with necrotizing migratory
erythema a specialist would probably know of it before most general
practitioners.Good luck with this.
Mike Richards, DVM
Q: Dear Dr Mike
I am looking for some help as i am still deeply upset by the apparently sudden death
of my 4 and a half year old pet Maltese bitch, Georgie, 3 weeks ago.She had been diagnosed as having bacterial colitis and was being treated
with salazopyrene for about a week. She then suddenly refused all food and began
vomiting quickly becoming dehydrated. During the treatment her urine had
been yellowish and so had her stools - which was at that time thought to be due
to the yellow colouration of the medicine.She was admitted as an emergency and put on a drip to rehydrate her.
Abnormal liver test results followed and an open biopsy of her liver,
stomach and intestines. Results showed severe liver disease with necrotic areas (I
do have more detail if needed). Before we even got the written report the lab
phoned and asked if Georgie could have ingested any toxins. I was sure not
as we are so careful and always kept her on a lead when we took her for
walks. Could the salazopyrene have caused an adverse drug reaction and the
liver insult?Georgie was on a drip and being fed via naso-gastric tube and very weak.
She seemed to be making a little progress and the drip was removed. But she died
suddenly the same evening following a probable embolism.Have you any suggestions that could make any sense of this? I have been in
close contact with the breeder who raised Georgie and she knows of no
family history anywhere in her breed line.Yours Sandy C
Hertfordshire, England
A: Sandy-
I am nearly certain that the medication you are referring to is known here
in the U.S. as sulfasalazine (I have seen it referred to as salazosulfapyridine
but not salazopyrene). If this is not the case then the following reply is not
going to be very useful.Sulfasalazine is used in inflammatory bowel disorders and chronic colitis.
I think that it is used primarily for its anti-inflammatory effect which
occurs because it breaks down into a sulfa antibiotic and salicylate, which
is anti-inflammatory. We have used sulfasalazine but I have never noticed
whether or not it caused a yellow color in the urine.According to Dr. Plumb's Veterinary Drug Handbook side effects other than
keratoconjunctivitis sicca (decreased tear production) are thought to be
rare. Liver damage is one of the side effects noted to occur rarely,
though. Hemolytic anemia can occur and allergic reactions to sulfa drugs
have been seen, too.Liver toxicity occurs as an unusual side effect to many medications,
including phenobarbital, primidone, diethylcarbamazine/oxibendazole
heartworm preventatives (Filaribits Plus Rx), carprofen (Rimadyl Rx),
trimethoprim/sulfa combination antibiotics (Ditrim Rx, Tribrissen Rx),
corticosteroids, metofane and halothane (anesthetics). It might be a good
idea to review Georgie's medical history for the recent use of one of these
medications, too. Copper toxicity occurs in some breeds (Bedlington
terriers being the one I can remember) but I don't think that that is
likely in a Maltese. It is the result of a defect in copper metabolism, not
ingestion of copper.A bacterial infection of the intestinal tract could result in an infection
spreading into the bile ducts and then the liver. If this occurred and the
infection or resulting inflammation was severe it could lead to liver
necrosis. I think, but am not absolutely certain, that necrosis from other
causes looks very similar to toxic changes in the liver. I am basing this
on my experiences sending in liver samples for biopsy when the cause of
death was something other than liver disease but toxic liver changes were
reported, not experience as a pathologist.I know that this doesn't clear things up much. The antibiotic could
potentially cause liver damage. That is reported to be a rare occurrence,
though. A bacterial infection spreading into the liver would be more common
but the pathologist did sound pretty convinced that liver toxicity was
likely. A good course of action might be to call the pathologist and see if
he or she thinks the damage found was consistent with the expected toxic
changes with sulfasalazine reactions. If you aren't comfortable making this
call ask your veterinarian to do it for you. Most would be willing to.Mike Richards, DVM
Vomiting with increased liver valuesA: Dear Dr. Mike - My 12 year old Lab started vomiting about 4 days ago. First, it was only liquid but yesterday she vomited up both breakfast and dinner. I took her to the vet and she ran blood tests and put her on rice/ground beef - small portions 4-5 times a day. She has only vomited up one out of 5 feedings since then. She does not seem any more lethargic than usual and seemed interested in trying to go for a walk although we felt she should get all the rest she can. The vet called me tonight and told me her liver enzymes are way above normal. She explained the possible causes and has me watching her very carefully for the next day. I am worried what this all means. Can her liver be failing from old age? What are the options if it is diminished liver function? Is it fatal or can it be treated. I would appreciate your thoughts. Thanks
A: It isn't possible to give you much information without knowing which liver enzymes are elevated. There are some "bad" causes of increased liver enzymes, like liver cancer, but more frequently these elevations are due to problems not directly in the liver (like Cushing's disease, administration of corticosteroids or other primary causes) or they are the result of chronic liver diseases which can often be controlled long term with diet and/or medications.
Your vet sounds concerned and I am sure she will keep you well informed about what she is thinking. Don't be afraid to ask any questions you have. Just keep asking them until you are sure you have the information you need. Your vet may need to schedule some time to consult with you but that would be worth paying for if you are confused.
Mike Richards, DVM
Q: Dr. Mike,My four year old border collie recently died from suspected liver disease. She appeared to be healthy until about 8 days prior to her death. She was four years old. She developed ascites (abominal swelling from fluid). Lab results that day were an albumin level of 2.4 g/dl, ast (sgot) of 155, alk phos 238, GGT 32, all else normal. The fluid was a pure transudate. Her liver was judged to be normal by abdominal ultrasound five days later. Kidney problems were ruled out through urine:protein:creatinine ratios and urinalysis. After consulting with a specialist, liver disease secondary to some primary cause was suspected. Serum bile acid measurements were attempted to evaluate liver function but they testing was unsuccessful due to repeated vomiting. She was sent to an internal medicine specialist at this time. Liver biopsy was performed after laparoscopic exam of the abdomen. She did not do well post surgery and died the evening following liver biopsy after seizuring and hemorrhaging.
We have contact with a veterinarian who own's Tory's littermate, Kate. She ran bile acid levels on her and they were elevated. (pre 27, post 32). That made a genetic link seem likely. However, we tested our other border collie, Boone, who is unrelated, and his bile acid levels were also elevated (pre 22 post 80). Both dog's blood panels were otherwise normal. Both dogs seem normal and completely asymptomatic. The vets felt that Tory was probably sick for 6 months to a year prior to her death, even though she showed no symptoms of liver disease.
We wondered about toxins but understand that to cause this kind of disease there may have been exposure to toxin over a long period of time. The only toxin used at our home is every other month treatment for spiders and ants using Dursban 50W by a professional extermination service with a technician we feel is competent. The treatment has only been done 4 times. We were careful to keep the dogs in for at least 4 hours after spraying. We feel an infectious agent could not have affected all three dogs since Kate is not at our household and has not been exposed to our dogs except on a very limited basis and not recently. We are considering the possibility of lab error. Kate's blood is being rechecked at another lab. We are expecting the results of Tory's liver biopsies today and hoping they will shed some light on this mystery. Any help you can offer in understanding this situation would be appreciated.
A: I took the information below from three sources, "Kirk's Current Therapy XII" ed. Bonagura, The Clinics of North America, "Liver Disease", March 1995, ed. Dimski and "Clinical Diagnosis by Laboratory Methods" by Willard et al.
It does seem highly likely from the history you reported that Tory had a primary liver problem and that the biopsy results will be very helpful. You didn't include her bile acid test results, unless I missed them. Pure transudates are uncommon except from liver insufficiency, kidney failure and protein loss through the intestinal tract. Usually, the albumin level is less than 1.5g/dl when a pure transudate is present. I think you were only reporting total protein measurements when the transudate was found so it is likely that could have been the case.
I think it is less likely that you can be certain that either Kate or Boone actually has liver disease, although you have to be highly suspicious with the lab values reported. It is important to know what the normal lab values are for the reporting lab, though. Test results for bile acids are sensitive to the technique used and can vary between laboratories. Even though the general consensus is that a fasting bile acid level should be less than 20umol/L for any of the testing methods, some labs will report higher normal values -- the normal range has been reported to be nearly 30umol/L in some instances for radioimmunoassay (RIA) testing. Serum bile acid measurements may be falsely elevated when serum is lipemic. This is less likely to be a problem with RIA testing. It would be a good idea to find out what the normal values are for the lab your vet used and to determine what type of test was run. Also, make sure that the serum samples were not lipemic. Hemolysis can falsely lower serum bile acid measurements, if it was present in the sample.
While fasting bile acid measurement is pretty reliable as an indicator that the hepatic function is decreased, it does not rule out liver problems which are caused as a secondary problem when other organs are damaged. Serum bile acid levels may be very high with pancreatitis and are elevated with inflammatory bowel disorders, hyperadrenocorticism, administration of glucorticoids (i.e. prednisone, dexamethasone, etc.), heart disease and other diseases which exert an effect on the liver.
I can not claim to be an expert on bile acid testing. In fact, I find some of the recommendations for interpreting bile acid measurements in the literature to be contradictory and almost all of them to be at least slightly confusing. One source (Drs. Anwer and Meyer in "Liver Disease") suggests that any value over 20umol/L indicates liver pathology with relative certainty while another source (Willard, et al) suggests that in a dog with no clinical signs of liver disease (such as Kate and Boone) that levels up to 10 times normal may not indicate a need for further testing --- in this case they are using the established norm of about 8umol/L, I think. That means that Boone's level of 80umol/L just barely falls into the "should be explored" category.
I do not think that chronic liver disease is likely from the limited exposure to Dursban. If your dogs have been on prednisone for any other condition recently, that should be considered in the interpretation of the lab results. It is probably a good idea to continue to reflect on events that may have lead to liver disease in your dog's pasts, but it may be impossible to determine without doubt that your dogs have not been exposed to a toxin, despite careful review.
It is important in medicine to evaluate the patient as a whole and not to attempt to diagnose problems with lab work alone. Since Boone and Kate appear to be normal and have normal serum chemistry levels I think that you should lean heavily towards considering them to be normal, despite the serum bile acid measurements reported. If you were my client, I know that I would advise you to wait a month or so and retest these values if they are outside the testing laboratory's normal values, providing that no further signs of liver disease occurred during that time. If they remained high, then it might be worthwhile to consider liver biopsy but I'd still lean towards watching carefully for signs of problems and checking serum chemistry values on a routine basis. But you have to rely on your vet's instincts because your vet can evaluate your pets by physical exam and I can not. I'm sure that she will be looking after Kate in the way she feels is best and is probably researching this whole issue, too. Working with her, I'm sure that Boone will be well cared for.
Michael Richards, DVM
Last edited 01/08/05