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Liver Disease in Dogs - Hepatic Nodular Hyperplasia
Hepatic nodular hyperplasia Choleangiohepatitis
Nodular hyperplasia
also see Liver problems
Also see Liver tests
Hepatic nodular hyperplasia and CholeangiohepatitisQuestion: I am a new subscriber who discovered your helpful site
while researching information on liver problems in
dogs.My 5 year old German Shepard/Chow mix recently had
been losing weight and not eating, so I took him in to
the vet,where they discovered his abdomen was full of
fluid. They did an ultrasound guided liver biopsy,
and the likely diagosis according to our vet was liver
cancer. Thankfully, the biopsy results came back
negative for cancer cells but the doctor wanted to try
to get a better sample. He said that Riley's liver
was so bumpy and abnormal looking and cancer was the
only thing he knew to cause that. They did a second
liver biopsy, and the results came back the same- no
cancer cells. They have concluded that it is
choleangiohepatitis, either caused from a bloodbourne
infection or food allergy. It seems to me that it
would be fairly easy to distinguish the cause-
wouldn't an infection be able to be figured out from
the biopsy? And wouldn't a food allergy have presented
with other symptoms as well? They want to start him
on a hypoallergenic diet after he finishes his course
of meds. Wouldn't it be better to determine if a food
allergy is even the problem first? Just wanted your
opinion.
Thanks! Sally-Answer: There is a condition in dogs, hepatic nodular hyperplasia, which causes
lumps on the liver that look just like cancer but are benign lesions. It is
usually possible for the pathologist to identify this condition from a
biopsy sample, but the sample does have to come from an affected area,
which is one of the problems with needle biopsies -- they produce small
samples. I have worried over the possibility of cancer after examining a
liver with these hyperplastic nodules so I assume this probably happens to
other vets, too. Unfortunately, it is also possible to miss a tumor in the
liver with a needle biopsy, even an ultrasound guided one. Sometimes it is
necessary to do an exploratory surgery to get a larger biopsy sample. If
there is still some confusion about other possible disorders, it would be
possible to biopsy other organs at the same time.I do think it is a good idea to try to rule out disorders other than liver
disease prior to doing an exploratory surgery, or to do testing that is
more specific for liver function, such as bile acid response testing, to
try to be sure that the liver is not functioning well.The only way to tell if a food allergy is present is to feed a diet that
isn't likely to cause an allergic reaction. Most of these diets are not
truly hypoallergenic, they just contain ingredients that the dog isn't
likely to be currently allergic to (foods that haven't been eaten at any
prior time). There are newer hydrolyzed protein diets that really are
hypoallergenic -- actually unlikely to ever cause an allergic
reaction. Feeding one of these diets long enough to see if clinical signs
disappear is the test for food allergies. It usually takes six to eight
weeks to be sure that a food allergy is not present but it may take less
time if one is present -- the dog will get better before six weeks in many
cases.The causes of fluid accumulation in the abdomen include heart failure,
liver disease, disorders causing low protein in the bloodstream
(inflammatory bowel disease, parasites, kidney disease) and
cancer. Sorting through these possible problems can be difficult. It is
important to try to rule out causes that aren't related to the liver, too,
though. Analyzing the fluid from the abdomen can be helpful in determining
what it is. Once in a while, heart problems lead to ascites without any
obvious sign such as a heart murmur.This is one of those situations in which it can take a concerted effort to
figure out what is going on. It may take a concerted effort on your part
and on your vet's part to get to a diagnosis but it is usually possible to
eventually get one.Mike Richards, DVM
8/29/2000
Liver problems in older Golden -Nodular hyperplasia or Cushing's possible
Question: Dear Dr. Richards,
I have a 13 year old golden retriever, named Kirby, who had intermittent diarrhea for about 2
weeks. We kept thinking about taking him to the vet, but then it would clear up for a day or two
before it came back. Finally, it got much worse and he became nauseous, and we brought him in.
Since Kirby had gone swimming in the Chattahoochie River here in Atlanta about two weeks ago
the vet suspected giardia. Two fecal flotations were negative for giardia, but did show a bit of
blood in his stool. He was put on flagyl, and when that didn't help after 48 hours, also on
ampicillin. We also did a full blood workup. It came back with some bad liver values, as the vet
put it. In fact, she called us in for emergency x-rays, which she said did not show anything
immediately life threatening, but said his liver was smaller than it should be.
The abnormal values are as follows:
total protein - 4.8 (L)
alkaline phosphatase - 522 (H)
calcium - 8.3 (L)
CPK - 54 (L)
Magnesium - 1.4 (L)
T4 - 0.4 (L)
some other values, like cholesterol and triglycerides look borderline bad as well.
After being on these antibiotics for a week Kirby's appetite is back to normal, and he is acting alert
and happy. However, he still has abnormal stools that are loose and bloody. My vet wants to try
using panacure, in case there are worms. I see no evidence of these in the stool, and he is on a
heartworm preventative that has dewormer in it. He is also scheduled for an ultrasound, but it can't
be done for a week. I could insist on a reference and maybe get the ultrasound done sooner, but
my vet seems to think that if they find that this is being caused by the liver, there will be no real
treatment options anyway, since it would be digestive cancer.
Are there any tests that we should have done to figure out the cause of this, or is treating with
medicine and seeing if it responds the best way to do things? Are there diet and medicine options
for Kirby's reduced liver function that I should be implementing now?
I have had four goldens who have all lived to past 15 years. I think with a little care, attention, and
luck that this is not an unreasonable age expectation. However, every time I walk into a vet's office
everybody acts amazed that I have an old, healthy dog!
Thanks for your time, and sorry this was so long.
sincerely,
Debra
Answer: Debra-
When there is a rise in alkaline phosphatase, without a rise in other liver enzymes in an older dog, the
two most common causes are probably hyperadrenocorticism (HAC, Cushing's disease) and nodular
hyperplasia of the liver. There can be other causes, though.Nodular hyperplasia can be seen on ultrasound exam sometimes, but not always. Liver biopsy, which
can be done in association with the ultrasound exam (ultrasound guided biopsy) is often necessary to
confirm this diagnosis. I have to admit that I am not too excited about doing liver biopsies in patients
that just have elevated alkaline phosphatase (SAP) levels, when they feel well and show no other
signs of liver disease. It is the only way to be sure of the diagnosis that I know of, though. This is a
benign condition that causes dogs to have high SAP levels but usually liver function tests like bile acid
response testing and other liver enzyme levels are normal.Cushing's disease is always a consideration in older patients but it usually causes other signs, like hair
loss, increased drinking and urinating, pendulous abdominal muscles, muscular weakness and/or
panting.The low protein levels could be a result of liver disease, can occur with kidney problems and with
intestinal inflammation. In this case, I think I'd worry about intestinal inflammation the most, but that
opinion might change if I was evaluating the patient and not the history alone.Panacur (tm) is pretty safe and it kills giardia as well as hookworms, whipworms and roundworms,
so I we use it in situations like this, sometimes, too.I don't think that you know at this point whether or not Kirby actually has reduced liver function. You
know that there is something that is causing a rise in alkaline phosphatase and something, possibly
liver disease, leading to decreased protein levels. The calcium level is low only because the protein
level is low. Calcium rides around in the bloodstream attached to protein --- when the protein is low,
the total calcium level will be low. Ionized calcium (the active form) is usually still normal in these
cases. T4 levels drop in many instances in which there is any systemic illness, so right now, this value
is not meaningful. Once the problems are under control it might be a good idea to retest to see if
there is a true hypothyroid state.To find out if Kirby has decreased liver function, the best test is a bile acid response test. This is easy
to do and any general practice using an outside lab should be able to do it. If this test is normal,
which is very likely, then there isn't much reason to make dietary changes. Sometimes ursodiol
(Actigal Rx) is helpful when there are alkaline phosphatase rises, milk thistle seems reasonable to use
and SAMe (Denosyl SD4 tm) is also recommended frequently for liver diseases. It might be worth
considering using one or more of these medications.It is nice to see older healthy dogs and we make a fuss over them, too. We see a number of older
dogs with chronic health problems of one sort or another and it is just good to see one that is doing
well. It isn't that we think it is really unusual or that we are expecting bad things right away --- it is
just really nice to see someone doing well!Hope this helps.
Mike Richards, DVM
8/10/2000
Last edited 11/21/04