practical internal medicine liver disease wendy blount, dvm nacogdoches, tx
TRANSCRIPT
Practical Internal Medicine
Liver Disease
Wendy Blount, DVM
Nacogdoches, TX
Liver Disease
Asymptomatic Elevated Liver Enzymes
Chronic Liver Disease
Acute Liver Failure
Elevated Liver Enzymes in the Well Pet
Cats are not little dogs• Cats with persistently elevate enzymes should be
worked up – T1/2 of liver enzymes hours, not days as in the dog
– cats have 1/3 the liver SAP compared to dogs
• Cats with significant cholangiohepatitis can have normal liver enzymes
• GGT elevated significantly exceeds SAP elevation only in hepatic lipidosis
• High bile acids in the cat indicates liver disease nearly 100% of the time
• Any bilirubinuria in the cat is significant– Can be used to monitor cholestatic disease
Elevated Liver Enzymes in the Well PetDogs… Grrrr…1. Explore the history for untreated problems
2. Treat empirically for reactive hepatopathy first• Treat problems that can insult the liver
– Occult infections – urinary, metritis, prostatitis, etc.
• Treat for sublinical cholangiohepatitis– Amoxicillin 10 mg/lb PO BID x 3 weeks
• Put on a supplement to curtail damage by hepatic inflammation
– Denosyl, Denamarin – dosage chart in package– Milk thistle
Elevated Liver Enzymes in the Well Pet
Milk Thistle• Dried herb: 15-20mg/lb SID (1.5-3% silymarin)• Concentrated extract: 2-5 mg/lb BID (70-
80% silymarin)• Alcohol concentrated extract: 2-5 mg/lb BID-
TID (70-80% silymarin)
• NOTE:NOTE: some extracts are whole herb extracts, and these are hard to dose high enough to be effective
Elevated Liver Enzymes in the Well Pet3. Recheck Liver enzymes in 30 days
4. Proceed with further diagnostics for liver disease
– Assess liver function with bile acids– Abdominal ultrasound and liver cytology– ACTH stimulation if signs of Cushing’s Disease
5. If Step 4 reveals significant undiagnosed problems, consider liver biopsy or referral for splenic portagram to rule out PSS
– Ultrasound guided liver biopsy (50% diagnostic)– Surgical liver biopsy
Scotties can have very high liver enzymes with no pathology
Undiagnosed Problems Causing Reactive Hepatopathy
• Occult infection– Urinary tract– Metritis, prostatitis
• Dental Disease• Disease of organ drained by portal vein• Severe muscle disease• Hypoxia – heart failure, respiratory disease,
severe anemia
Other Problems Causing Elevated SAP with normal ALT
• Bone growth or osteolysis– Puppies and kittens– Bone neoplasia– Osteomalacia– Hyperparathyroidism
• GI Disease• Pregancy• Kidney Disease• Drug Therapy
Pattern Recognition - Liver Disease• High liver enzymes
– ALT – hepatocellular disease– SAP, GGT – cholestasis– Can be normal with prolonged chronic disease
• Low albumin• Low fasting glucose• High prost-prandial glucose• Low BUN• Abnormal cholesterol, triglycerides• Ammonium biurate crystalluria• Prolonged recovery from anesthesia
Pattern Recognition - Liver Disease• Ascites – transudate or modified transudate
– Increased sodium retention, portal hypertension, hypoalbuminemia
• PU-PD• Acholic feces• Dark urine (orange) precedes icterus• Icterus
– Suspect if high bili with normal PCV
– Seen best on sclerae, penile mucosa, soft palate, under the tongue
– Icterus occurs when 10% of liver function remains
– Look for cholestatic disease if signficant bilirubinemia without bilirubinuria (delta bili)
Pattern Recognition - Liver Disease• Tendency to sepsis
– Hepatic RE system detoxifies blood from the gut (portal circulation)
• GI hemorrhage death spiral– Decreased hepatic clearance of gastrin– Factor’s, AT3 not produced adequately– Increased bile acids stimulated HCl secretion– DIC– Bleeding exacerbates hepatic encephalopathy– Large bleed can cause depletion coagulopathy
• Hemorrhage elsewhere only when near death– Petecheia, bruising, bleeding into cavities
Pattern Recognition - Liver Disease
• PSS in Cats– Salivation – most common clinical sign– Hepatic encephalopathy– Vomiting and diarrhea
Bile Acids
1. 12 hour fast – red top tube
2. Feed 1-2 Tablespoons a/d
3. 2 hour post prandial red top tube
If not fasted, doing only the post-prandial can be a good screen for liver insufficiency
Can’t run bile acids on a lipemic sample
Overfeeding can induce HE
Bile Acids
High bile acids in the blood can cause gastric hyperacidity in the stomach and diarrhea
Bile acids >30-40 umol/L in the dog and >20-30 umol/L in the cat warrant further investigation
Idexx SNAP test tells you • <12 umol/L• 12-25 umol/L• >25 umol/L
Ammonia
Normal in the dog 20-80 ug/dl
Normal in the cat 20-120 ug/dl
Elevated resting ammonia is significant
Idexx VetTest/Catalyst does ammonia assays
Falsely increased by hemolysis
Centrifuge and decant within 30 minutes
Run assay within 2 hours
Sending to outside lab can be difficult
Ammonia
Ammonia Tolerance Test:
1. 12 hour fast – red top tube
2. NH3Cl capsules 45 mg/lb max dose 3g PO
3. 30 minutes later – red top tube
Increase should be <32%
100% sensitive for PSS
DO NOT GIVE NH3Cl if resting ammonia elevated
• Can induce HE
Chronic Liver Disease
DDx Chronic Liver DiseaseImmune Mediated Cholangiohepatitis
• Westie, Doberman, Skye terrier, cats
Copper Storage Disease• Dobermans, Bedlingtons
Portosystemic Shunt• Congential or Acquired
• Extrahepatic – Yorkie, schnauzer, poodle, dachshund• Intrahepatic – Doberman, Golden, Lab, Irish Setter,
Samoyed, Irish Wolfhound
Microvascular Dysplasia• Yorkie, Cairn Terrier
DDx Chronic Liver DiseaseBacterial Cholangiohepatitis
• cats
Fungal Hepatitis
Heterobilharzia americanum
Chronic Liver Disease usually Diagnosed
by Liver Biopsy
Tx Chronic Liver DiseaseProper Diet
Treat chronic infection
Treat chronic inflammation
Treat cholestasis
Treat fibrosis
Treat copper accumulation
Treat GI side effects
Manage hepatic encephalopathy
Manage ascites
DDx Acute Liver Failure
Hepatotoxins
Septicemia
Pancreatitis
Infectious Canine Hepatitis (CAV)
Hypoxia/Ischemia
Exacerbation of Chronic Liver Dz
SIRS
DDx Icterus
Pre-Hepatic – Hemolysis
Hepatic
Post-HepaticPancreatitis
Pancreatic Neoplasia, Abscess, or Granuloma
Liver, Bile Duct, Duodenal Neoplasia, Abscess or Granuloma
Biliary Mucoceole
Cholecystitis
Cholelithiasis
Duodeonal foreign body
PSS and steroid hepatopathy dogs are almost never icteric
DDx Acute Liver Failure
Hepatotoxins• Acetominophen• Aflatoxins• Anabolic Steroids• Anticonvulsants• Antineoplastics• Arsenicals• Carprofen• Diazapem• Diethylcarbamazine• Griseofulvin
• Itraconazole• Kava Kava• Ketoconazole• Oxabendazole• Mebendazole• Mitotane• Mushrooms• Sago Palm (seeds)• Sulfonamides• Thiabendazole• TMPS
Hepatic Encephalopathy
Abnormal mental status in patients with severe hepatic insufficiency
• Severity of HE does not always correlate with severity of liver disease
• Things that can precipitate an HE episode:– Increased protein intake, GI hemorrhage– Dehydration, diuretic therapy– Barbiturates and other sedatives– Uremia– Infection, endoctoxemia, constipation, increased aneaerobes in
the colon– Increased methionine intake
Progression ofHepatic Encephalopathy
• Mildest form – anorexia and lethargy• May progress to weight loss• Ataxia• Confusion, stupor, loss of training• Pacing and wandering• Twitching progressing to seizures• Vomiting, diarrhea• Temporary blindness• Dementia, seizures, coma• Multifocal deficits on neurologic exam
Tx Acute Liver Failure
Correct fluid an electrolyte imbalances
Treat Coagulopathy
Treat hypoglycemia
Treat hepatic encephalopathy
Control GI hemorrhage
Treat Sepsis if present
Sebastian• 9 year old neutered male pit bull• 2 year history of lower cervical disc disease
• Several episodes of pain and CP deficits• Responded to treatment with prednisone and cage
rest
• 1 week ago ataxia and falling, and vocalizing every time he moves
• The morning after a fight with another dog• Tx prednisone, methocarbamol, Tramadol, cage
rest – no response for 4 days• Sedated for radiographs
Sebastian• 4 days ago Sedated for radiographs
• mid-abdomen 8cm soft tissue mass• no significant enlargement of liver, spleen, R kidney• Cervical & lumbar intervertebral disc calcification• vomited large amount of fluid with coffee grounds
after sedation• Tx carafate, IV fluids, metronidazole, amoxicillin• Albumin 2.1 g/dl (2.2 g/dl low normal)• SAP 2119 U/L• ALT 1434 U/L• Bili 8.2 mg/dl• HCT 30.8%
Sebastian• Referred for ultrasound today• Exam
• Can not walk• Muscle tremors and very jumpy when touched• Icteric skin• Abdomen tense and difficult to palpate• Very large urinary bladder• Scleral injection – owner says had been present for
30 days
Sebastian• Neuro Exam
• Unable to walk, unable to assess postural reflexes and CP
• Cranial nerves normal• Spastic paresis in all 4 limbs (UMN reflexes)• Conscious motor activity in all 4 limbs• Lower cervical pain• Dx - Lower cervical spinal cord disease
• Catheterized bladder and removed 1.5L of orange urine (bilirubin crystals)
• Hx – has been on clomipramine for some time, for anxiety
SebastianProblem List• Cervical myelopathy and tetraparesis
• Surgery not an option for these owners
• Icterus – likely hepatic, post-hepatic and hemolysis can not be ruled out
• Hematemesis – prednisone, liver failure, spinal cord injury
• Twitching – hepatic encephalopathy, metronidazole toxicity, serotonin syndrome
• Mid abdominal mass• Mild anemia
Sebastian
Sebastian
Sebastian
SebastianRadiographs• Large amount of air in the stomach• Gastric axis shifted cranially
Normal DogRadiographs• Large amount of air in the stomach• Gastric axis shifted cranially
SebastianRadiographs• Large amount of air in the stomach• Gastric axis shifted cranially
SebastianRadiographs• Large amount of air in the stomach• Gastric axis shifted cranially• Intestines appear distended with fluid• No mid abdominal mass seen• Increased soft tissue density in right cranial abdomen• Cervical and lumbar spondylosis• Cervical and lumbar mineralized disc material• Disc material in the spinal foramina• Dx – microhepatia• Dx – degenerative disc disease
SebastianAbdominal Ultrasound• Difficult because of the great amount of air in
the stomach, due to aerophagia• Small areas of the liver seen, hyperechoic,
mottled in echotexture• Gall bladder not seen• Many fluid filled loops of bowel
PT, PTT - normal
SebastianPlan• Discontinue prednisone, Tramadol, clomipramine,
metronidazole• Continue Carafate, IV fluids (LRS + 20 mEq/L KCl),
ampicillin IV• add milk thistle, famotidine• Fast overnight and repeat ultrasound tomorrow• Repeat CBC, panel, lytes tomorrow• Send out Lepto titers• Express bladder or catheterize to empty bladder TID
SebastianDay 2• Ate chicken and drank water yesterday• Twitching stopped• Skin appears less icteric, scleral injection improved• HCT 17.7%, Hb 5.6 g/dl• Albumin 1.6 g/dl• Bili 5.4 mg/dl• Neutrophilia 20K/ul• Lytes normal• No vomiting, no melena• Urine is golden, not orange• Eating chicken and drinking
SebastianUltrasound• Liver small, mottled, hyperechoic• Liver cytology – suppurative hepatitis with cholestasis• Gall bladder wall thickened - cholecystitis• No fluid in the abdominal cavity
Plan – add Baytril & Vitamin K, monitor PCV
SebastianDay 3• Vomited overnight – chicken, melena on thermometer• HCT 14.9%, Hb 4.6%• neutrophils 21.7K/ul• Albumin 1.5 g/dl• Lytes normal
Plan• Whole blood transfusion• Ate chicken & rice well that night, drinking water• Continue milk thistle, ampicillin, enrofloxacin, carafate,
famotidine, Vit K, IV fluids, catheterize TID
SebastianDay 4• Not feeling well, passed melena, fever 103.4F• Will not eat, licked lips when food offered• Abd US – still no evidence of perforation, but deep
ulcer seen in the duodenum• PCV 25%, albumin 1.8 g/dl, lytes normal
Plan• Continue milk thistle, ampicillin, enrofloxacin, carafate,
famotidine, Vit K, IV fluids, catheterize TID
SebastianDay 5• Fever has resolved, feels better• Eating chicken, but not rice• Urinating on own, but does not empty the bladder• Can support weight on rear legs but not front legs• If ulcer perforates, owners will not do surgery• PCV 20%, albumin 1.8 g/dl
Plan• Continue milk thistle, ampicillin, enrofloxacin, carafate,
famotidine, Vit K, IV fluids, catheterize BID
SebastianDay 6• Will not eat, no fever• When put on feet, attempts to move forward, but can
not move front legs well yet, can take a few steps• Urinating on own• neutrophils 75K, monocytes 1,100/ul• No stools passed, but melena on thermometer
Ultrasound
SebastianDay 6• Will not eat, no fever• When put on feet, attempts to move forward, but can
not move front legs well yet, can take a few steps• Urinating on own• neutrophils 75K, monocytes 1,100/ul• No stools passed, but melena on thermometer
Ultrasound
SebastianDay 6• Will not eat, no fever• When put on feet, attempts to move forward, but can
not move front legs well yet, can take a few steps• Urinating on own• neutrophils 75K, monocytes 1,100/ul, 6% bands• No stools passed, but melena on thermometer
Ultrasound• Local peritonitis R Cranial abdomen
SebastianPlan• Drained fluid percutaneously• Discontinue catheterization• Continue milk thistle, ampicillin, enrofloxacin, carafate,
famotidine, Vit K, IV fluids• Wrap front feet to prevent abrasions from knuckling
SebastianDay 7• neutrophils 38K, monocytes normal, 3% bands• HCT 20%• Albumin 1.6 g/dl, glob 5.3 g/dl• SAP >4600 U/L, ALT 1868, bili 6.7 mg/dl• Black tarry liquid stools
Plan• Barium 5ml/lb PO• Continue milk thistle, ampicillin, enrofloxacin, carafate,
famotidine, Vit K, IV fluids, wrap front feet
Sebastian
Sebastian
Sebastian
SebastianDay 8• Owners came to visit – Sebastian ate a rib eye• Black tarry soft stools• Can walk 5-10 feet without assistance
Plan• Continue milk thistle, ampicillin, enrofloxacin, carafate,
famotidine, Vit K, IV fluids, wrap front feet
SebastianOver the next 2 weeks• Switched form injectable to oral meds• Recovered well
Recurrence of liver failure 1 year later• Owners elected euthanasia
Inky
Inky
Handouts• This PowerPoint – behind the blue tab• Client Drug Handouts
• Colchicine• Cyproheptadine• Lactulose• Milk Thistle• SAMe• Ursodiol
Handouts• Client Handouts
• Cholangiohepatitis• Chronic Liver Disease• Fatty Liver• Leptospirosis• Portasystemic Shunt