Category: Cats

Cancer

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The scientific word for cancer is neoplasia, meaning new growth. In reality, it is an abnormal growth of cells that interferes with an organ’s ability to function, resulting in a degree of failure in that organ. Some of these abnormal cells break off from the organ and spread to other organs in the body, causing them to fail. This process is called metastasis, and is the hallmark of malignant cancer.

The enlarged sublumbar lymph nodes in this dog’s abdomen are the whitish areas under the circle. A cancer called adenocarcinoma spread to them through the process of metastasis.

This is what severe bone cancer looks like on the front foreleg (radius and ulna) of a dog. It is a malignant cancer called osteosarcoma. Compare it to the normal radius and ulna below to see the signifiant bone destruction. 

A normal radius and ulna on a radiograph

 

Cancer it is not one disease, has many different causes, and can affect every organ. This makes it quite a challenge to diagnose and treat. Even though the cause is not known in many cases, we do know of major factors that predispose pets to getting cancer. An example is squamous cell carcinoma (SCC) in white cats that are exposed to the sun. We tend to see cancer more commonly in our geriatric patients.

A major predisposing factor is dogs, cats and rabbits that are not neutered and spayed when they are young.  Their chances of getting breast, testicular, and prostate cancer increase significantly when they are not altered at an early age. The following pages have detailed information on this:

Reproductive Cancers

Dog Spay

Dog Neuter

Cat Spay

Cat Neuter

Rabbit Neuter

Rabbit Spay

Dog and Cat Non-Reproductive Cancers

Intestine

Kidney

Liver

Lymph node

Mammary (breast)

Mast cell

Spleen (hemangiosarcoma)

Squamous cell carcinoma (SCC)

Ferrets

Adrenal disease

Insulinoma

Liver

Rodents

Mammary (breast)

Ovarian

Reptiles

Tegu oral tumor

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Kidney (Renal) Cancer

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Its not that often that we see a primary kidney cancer in a young pet. This page will show you how we diagnosed and treated it on a one year old Basenji.

This story emphasizes how fast things change, and a pet that is perfectly healthy on a physical exam and blood panel, can change for the worse in a short period of time.

Click on the lab data and ultrasound report photos to enlarge them and see how we made the diagnosis.

Graphic photos of a kidney with cancer on this page.

Normal Physical Exam

As part of our routine pre-operative spay exam, a blood panel is run. It came back normal.

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Note the circle over BUN and Creatinine. They are tests of the kidneys, and they are normal.

Surgery and healing progressed as expected for a young dog, and within a few days it was back to normal. Over the next several months there was no indication of any problem.

Physical Exam

History

Three months later this young dog was presented with signs of decreased appetite and not feeling herself. There were no other problems.

Physical Exam

Body Temp- 101.6 degrees F

Mucous membranes- pink

Respiratory rate- 40 breaths per minute

Heart rate- 150 beats per minute

Haircoat- normal

Musculoskeletal system (bones and muscles)- normal

Mouth- normal

Eyes- normal

Abdomen- normal

Peripheral Lymph nodes- normal

Ears- normal

Heart- normal

Urogenital- normal

Weight- 22#, no change from 3 months prior

Interpretation- Even though this exam is essentially normal, a lack of appetite in a young dog is of concern. Also, no weight gain over the last 3 months is cause for concern in a young animal that is still growing, and confirms the owners observation of lack of appetite.

Diagnostic tests are now needed to find out why the lack of appetite and weight gain. On any sick pet a minimum database is needed to start looking at all of the numerous possibilities as to the cause of these problems in a young dog.

Diagnostic Tests

Blood Panel

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It is obvious there is a serious problem with the kidney tests compared to 3 months prior. In addition, other tests are elevated, all leaning towards a serious kidney problem.

Ultrasound

This is the abdominal ultrasound report. Read it carefully to see how detailed it is and note the abnormalities. The abnormalities are marked in the pictures to follow.

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Left kidney

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Right kidney

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Liver

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Small intestine

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Cytology

A fine need aspirate (FNA) was obtained during the ultrasound. This is a non-invasive way to obtain a sample as compared to a highly invasive (and more expensive) exploratory surgery. The skill of our ultrasound doctor gives us confidence in the accuracy of the FNA, although there is no guarantee it will give us an accurate cause to the enlarged kidneys.

The sample is sent to a pathologist for microscopic analysis. It came back a malignant cancer called lymphosarcoma (LSA), also known as lymphoma.

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Necropsy photos of a different pet

Necropsy photo of an elderly cat with kidney cancer. The kidney is split down the middle and opened up to see the inside. This is how lymphoma looks in a cat, not the dog above. The cancer is at the arrow, from the 8 PM to 2 AM position on the left.

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Treatment

This dog has a serious problem that needs to be treated by a veterinary oncologist. We send all of our cancer cases to the Veterinary Cancer Group.

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They have many doctors and several offices throughout Southern California 

This is the chemotherapy treatment protocol they instituted. They also do many other types of therapy including radiation therapy.

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Four months later this dog is doing well, with the kidney tests dramatically improved:

BUN- 35

Creatinine- 1.8

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Hemangiosarcoma

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Spleen Disease (Hemangiosarcoma, Hematoma)

It is not uncommon for us to encounter problems with the spleen. Sometimes it just enlarges without any major problems, sometimes it twists on itself, sometimes it causes internal bleeding, and oftentimes it becomes cancerous. This page will emphasize cancer of the spleen, called hemangiosarcoma.

In breeds that have a high incidence of splenic tumor we recommend yearly exams starting at 5 years of age,  with radiographs and ultrasounds to catch this problem early before complications and spread, since the prognosis is poor in most cancerous spleens because they have already spread by the time of diagnosis.

Unfortunately, some pets, especially large breed dogs, will not show any symptoms until the spleen is huge. This occurred with a Labrador Retriever that was presented to us with the owner telling us “he just wasn’t doing right”.  He was eating good, was not vomiting, had no diarrhea, and was not coughing. This owner was astute and brought him in for an exam just in case.

A thorough exam and blood panel revealed no problems, so a radiograph was taken. This radiograph revealed a large abdominal mass. This could have been coming from the liver, spleen, intestines, kidneys, pancreas, or mesenteric lymph nodes. An ultrasound revealed it was from the spleen. The next day we removed an 8 pound rupturing spleen! You can see pictures of the surgery to remove this large mass in the surgery section later in this page.

Graphic surgical photos are on this page

Nomenclature

We will use some medical terms regarding the spleen:

  • Extra medullary hematopoeisis – The making of red blood cells outside of the bone marrow
  • Reticuloendothelial system – in regards to the spleen, it is the system that recycles red blood cells
  • Anemia – a low amount of red blood cells or hemoglobin
  • Thrombocytopenia – a decrease in thrombocytes, which are an important part of the clotting factors when there is bleeding.
  • Hemoabdomen – free blood in the abdomen
  • Splenomegaly – enlargement of the spleen as a result of any cause
  • Splenectomy – removal of the spleen
  • Hypersplenism- an enlarged spleen that is normal and not causing any problem

Spleen Anatomy

The spleen is an elongated and relatively flat organ that resides in the abdomen of mammals along the outer edge of the stomach. It has a tremendous blood supply that is closely attached to the blood supply supporting the stomach. It is the largest filter of blood in the body.

It has an outer capsule composed of smooth muscle and elastic fibers. The internal part of the spleen (called the parenchyma) has white pulp and red pulp. The white pulp is lymphatic tissue and the red pulp is part of the venous blood system. In between these pulps is elastic tissue that can fill up as needed.

A normal spleen in a cat

A normal spleen in a  small dog

A normal spleen in a medium sized dog

A swollen spleen in a medium sized dog

The blood supply to the spleen is closely adjoined to the stomach. You can see the dark vertical blood vessels in this photo as they enter fat between the stomach and a very enlarged and dark spleen in a semi-circle at the far right.

Physiology

The spleen has many functions. The four primary ones are:

  • Storage of cells
  • Production of red blood cells
  • Filtration of the bloodstream
  • Production of cells for the immune system

Iron that has been recycled from old red blood cells is stored in the spleen where it awaits transport to the bone marrow.

Fortunately, the body can get by without a spleen in most cases, so if there is a serious problem, and all other factors are equal, we will remove it. We tend to remove only spleens that are cancerous, rupturing, or have a torsion.

Diseases

Splenomegaly

Splenomegaly is a generalized term that simply means enlargement of the spleen. In some species, like ferrets, an enlarged spleen can be normal, and is called hypersplenism. A spleen can be enlarged diffusely or it might  have nodules in certain areas.

There are many causes for an enlarged spleen. The most common and important are listed in more detail below. Some of the more uncommon ones are due to infectious agents (erlichiosis, babesia, hemobartonella), FIP, medications, and immune mediated diseases.

This spleen has splenomegaly in addition to numerous nodules

Splenic Torsion

In this problem the spleen twists on itself, compromising the blood supply. When the spleen twists the blood keeps on pumping into it by the arterial system, but this same blood is not able to leave through the venous system, and the spleen becomes grossly engorged.

It can occur on its own, after excessive exercise, or due to trauma. It can occur in conjunction with Gastric Dilatation Volvulus (GDV), also known as bloat. We tend to see this torsion, along with GDV, in large and deep chested breeds.

If the torsion is chronic, there might be no symptoms at all, or there might be:

    • poor appetite (anorexia)
    • weight loss
    • discolored urine
    • vomiting- might be intermittent
    • weakness
    • weight loss.
    • collapse
    • death

Examination of a pet with splenic torsion might reveal:

    • pale mucous membranes (gums)
    • rapid heart rate (tachycardia)
    • painful abdomen
    • a large mass in the abdomen upon palpation
    • fever
    • dehydration
    • jaundice (icterus)

A blood panel might reveal:

    • anemia
    • low platelets (thrombocytopenia)
    • elevated white blood cells (leukocytosis),
    • elevated liver enzyme tests,
    • hemoglobin in the urine (hemoglobinuria)

This disease is diagnosed by imaging tests when the above symptoms are present. A radiograph might reveal a mass in the abdomen with the spleen abnormally located. Ultrasound can confirm the problem and give us an idea of its severity.

A splenic torsion is considered an emergency, so the treatment of choice is surgical removal after a pet has been stabilized by treating for shock. On the deep chested breeds we might even tack the stomach to the abdomen to help prevent potential GDV in the future.

Splenic Cancer

Some splenic masses that are cancerous are classified as benign, meaning they do not generally spread (metastasize), and only take up extra space within the abdomen. Even though they do not spread, sometimes this extra space they take up can interfere with other organs.

Some benign cancerous masses include lipoma (fatty tumors), hemagioma (associated with vasculature), and plasmacytosis (infiltration of plasma cells throughout the splenic nodule or tissue in general). Unfortunately, when a spleen has cancer it commonly is the malignant version and not this benign version.

The most common malignant tumor in the spleen is the hemangiosarcoma (HSA). It is also called malignant hemangioendothelioma). The cause is not known. It can spread to many different organs, making it highly malignant:

    • heart
    • lungs
    • muscle
    • skin
    • bones
    • abdomen
    • diaphragm
    • brain
    • kidney

HSA can also cause complications, such as disruption of the coagulation cascade which causes a mixture of abnormal clot formation as well as inability to control internal bleeding (known as disseminated intravascular coagulation, DIC).

Symptoms of HSA vary, and range from mild to severe. In extreme cases sudden blood loss can lead to sudden death.

These large nodules on this spleen are a malignant cancer called hemangiosarcoma

Another common type of malignant splenic cancer is lymphosarcoma, a type of cancer that can have a primary tumor in any other organ (i.e. lung, gastrointestinal tract, liver). Lymphosarcoma is one of the more common tumor types observed in the spleen of cats. Sometimes the tumor within the spleen is not even the primary tumor, but rather a single nodule or multiple nodules due to metastasis from a distant primary tumor.

Hematoma

Hematomas are one of the most common causes of an enlarged spleen in dogs, representing over 50% of splenomegaly cases. This type of splenic mass is basically an accumulation of pooled blood within the splenic tissue; many stop growing and are then resorbed after a period of time, but others grow exponentially and eventually rupture. A ruptured hematoma originating from the spleen is an emergency, and often the pet experiences an acute collapsing episode followed by a significant loss of blood into the abdomen (hemoabdomen). You can see the surgery of a dog with an 8 pound hematoma later in this page

Other causes

Congestions of the spleen can occur from iatrogenic causes, which are those associated with administration of certain drugs (i.e. anesthetic agents or tranquilizers). Congestion can also occur due to increased blood pressure within the vasculature of the liver (known as portal hypertension), which can occur secondary to congestive heat failure among others.  The spleen can over-react to particular conditions, resulting in a disease process known as hyperplastic, or reactive, splenomegaly. A spleen can become reactive when there is excessive stimulation of the immune system from conditions such as immune-mediated disease, bacterial infections, tick-borne diseases, and many more.

This spleen has a laceration

Diagnosis

Signalment

Dogs, cats, and ferrets can get splenic diseases, although it is much more of a problem in dogs. Splenomegaly itself can occur in most any age due to the numerous causes of the condition. For instance, if the cause of splenic enlargement is infectious, then the pet may be quite young. However, if the enlargement is cancerous, the pet tends to be middle aged (average 10 years in dogs). Due to the wide range of causes, there is no known gender predilection (males tend to be affected equally as often as females). Certain disease processes tend to be over-represented by specific breeds:

Splenic torsion tends to occur in large breed, deep-chested dogs:

Splenic tumors like HSA tend to occur in several breeds. It can be some common in some breeds that we  recommend physical exams, blood work, abdominal radiographs, and especially abdominal ultrasounds, yearly in these dogs as they reach 5 years of age:

    • German Shepherds
    • Golden Retrievers
    • Portugese Water Dogs
    • Boxers
    • English setters
    • English pointers
    • Great Danes
    • Skye Terriers
    • Bernese Mountain Dogs

History

In many cases, a patient with splenic disease has very little or no specific clinical signs. Observations made by owners at home might include non-specific indicators of illness:

    • lethargy
    • inappetence
    • weight loss
    • diarrhea
    • vomiting
    • collapse
    • discolored urine
    • abdominal distention

Physical Exam

Upon palpation of the abdomen, significant abnormalities of the spleen can usually be detected, especially when a large mass is present within the cranial aspect of the abdomen (toward the chest). However, a mass or enlarged organ in the cranial abdomen cannot always be differentiated from a mass or enlargement of the liver. In some cases, decreased pallor (pale gums) can be a sign of anemia or shock, which in combination with an abdominal mass can indicate a ruptured splenic mass or torsion. We confirm this with an ultrasound before surgery.

If the gums are pale, certain diseases of the spleen may lead to free blood in the abdomen, which can sometimes but not always be detected by palpation of a fluid wave. Other generalized signs might include weakness, fever, dehydration, poor pulses, increased heart rate (tachycardia), increased bleeding at site of blood draw (due to coagulopathy), and/or increased size of peripheral lymph nodes.

Diagnostic Tests

Some diagnostic tests which provide significant information include radiographs, blood work, ultrasonography, evaluation of the cells (cytology) through a fine-needle aspirate sample, and surgical exploration.

Radiography

The arrow points to what a spleen looks like on a radiograph. It is enlarged, although a lobe of the liver can easily overlap the spleen and make the spleen look enlarged. So in this case, technically its called hepatosplenomegaly.

Here is a dog with an enlarged spleen. Can you see it?

Splenectomy -SpleenRadSplenectomy -SpleenRadSplenectomy-LateralRad

The red circle delineates the enlarged spleen.

L.I. – Large Intestine

Pr- Prostate

Splenectomy -SpleenRadSplenectomy-SpleenRadCircle

Blood Panel

Blood work (clinical chemistry and complete blood counts) is a crucial component for detection of compromised organ function. Splenic involvement might reveal anemia (decreased red blood cells), thrombocytopenia (decreased platelets for clotting), leukopenia (decreased white blood cells) and reticulocytosis (increased immature red blood cells to indicate that the body is trying to compensate for the loss of mature red blood cells).

This is a blood panel that might be seen with splenic disease, although many other diseases can also cause this type of blood panel. The primary problem in this blood panel is anemia.

Fluid Analysis

If abdominal fluid is present we can remove it and analyze it. This is called abdominocentesis. There is no guarantee this will make a diagnosis since many cancers, including HSA, might not be found in this fluid.

Ultrasonography

Ultrasonography has revolutionized diagnosis in animals, and prevented many unnecessary exploratory surgeries (called celiotomies or laparotomies), while at the same time alerted us to the fact that we need to do immediate surgery. Keep in mind, our patients do not talk to us, and  an enlarging tumor in the abdomen in one of us humanoids would be uncomfortable, and cause us to seek medical care long before we see a dog or cat with a tumor growing in the abdomen.

Ultrasonography of the abdomen is an important modality for diagnosis of splenic disease because of its sensitivity to changes of organ size, shape, location, and even texture. An ultrasonographic examination in combination with radiographs provides a comprehensive understanding of which organs are involved and often helps to narrow the possibilities down to a select few differentials.

We use ultrasound to confirm our suspicions of a splenic tumor based on the breed, history, exam findings, and blood panels and radiographs. Ultrasound confirms the diagnosis, lets us know if the spleen is already rupturing, tells us the size of the spleen, and if there are any other internal organ problems. A critical component of the ultrasonographic exam in HSA is echocardiography (evaluation of the heart). A key site of metastasis associated with hemangiosarcoma is the right atrium. HSA that has spread to the right atrium of the heart is a serious sign, and the prognosis is not good. This is important information if we are thinking of surgical removal of the spleen.

The lines demarcate the margins of this spleen

Do you see the spleen in this picture without the demarcation?

A typical ultrasound report on a dog with a cancerous spleen

This ultrasound of the heart (echocardiogram) shows spread of the tumor to the right atrium, which is a poor prognosis

RV- Right ventricle

RA- Right atrium

Cytology

Aspiration of the cells in an organ for cytological exam by a pathologist is an important part of most abdominal ultrasounds. It helps prevent an exploratory surgery, and can lead to a diagnosis in many cases. Cytologic evaluation of splenic problems is not always indicated and can sometimes be contraindicated depending on certain disease processes. Certain cancers of the spleen as well as hematomas may result in significant blood loss if stuck with a needle due their fragile nature. Even though the ultrasound guides the biopsy location, if the disease process only involves a small portion of the splenic tissue, or is sporadically located throughout, then a small needle-sized sample may not obtain the affected tissue at all.

ECG (Electrocardiogram)

This tests the electrical activity of the heart. I some HSA’s there will be an arrhythmia

Definitive Diagnosis

Histopathology is the analysis of the spleen after it is removed. This gives us our final diagnosis.

Histopathology

Treatment

Surgery is a common treatment for splenic disease. This is called a splenectomy. If there is trauma or a problem in only a small part of the spleen, we might do a partial splenectomy since we always want to preserve as much function of the spleen as possible. This partial splenectomy is not common.

We do the surgery to remove the tumor, and if malignant add chemotherapy to help prevent spread after we do the surgery. Prior to surgery we do an ultrasound of the heart as already mentioned, and also take chest radiographs to check for spread of a tumor. We also perform a clotting panel since blood loss is common in this surgery and we do not want post operative bleeding.

Unfortunately, survival time for dogs and cats with surgery alonge HSA is only 1-3 months, with most dogs dying due to spread of the HSA to other organs, causing these organs to malfunction. This emphasizes the need for an early diagnosis in the breeds prone to this cancer.

Dogs that have surgery to remove the spleen, and that are also treated with chemotherapy, might survive up to 9 months. This depends on whether the tumor has spread, and again emphasizes the need for an early diagnosis. Dogs and cats have less side effects than people on chemotherapy, and their quality of life is high if this therapy is instituted immediately after surgery.

Dogs that are diagnosed at a young age, have had the HSA rupture prior to surgery, have evidence of spread to other organs when the splenectomy is performed, or have a more aggressive grade of tumor, do not tend to live 9 months after surgery.

The primary chemotherapy drug for HSA is Adriamycin (doxorubicin). It will slow the disease process, but it will not cure your pet of this disease. The doctors at the Veterinary Cancer Group in Tustin institute this therapy.

If a pet is anemic, or we anticipate significant blood loss during surgery, we will give a blood transfusion prior to surgery or during the procedure. Post operatively if a pet is not doing well we will give a blood transfusion also.

After doing a cross match to ensure compatibility we obtain whole blood for the transfusion

Splenectomy

A splenectomy is performed to treat and sometimes cure this problem. It is sometimes done as an emergency procedure if the spleen has ruptured and there is significant internal bleeding.

Pre-anesthetic preparation is important in every surgery we perform, no matter how routine, because surgery is not an area to cut corners.  Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.

This is a sterile abdominal surgery, and our surgeons scrubs with a special antiseptic soap prior to gowning and gloving

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While our patient is being anesthetized our surgeon is already in our surgical suite setting up instruments. Our surgeon is ready to start before our patient is at a proper plane of anesthesia. Once the anesthetist gives the green light the surgery starts immediately. We want our surgeon waiting for his patient, not the other way around.  All of this is to minimize anesthetic time.

OVH-rabbit-3

OVH-rabbit-2

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem.

This machine monitors:

Temperature

Heart Rate

Heart rhythm

Oxygen saturation

Carbon dioxide level

Respiratory rate

Surgery-Monitor

In addition to our monitoring equipment our anesthetist stays “hands on” in monitoring important physiologic parameters. Our anesthetist is using a special stethoscope (esophageal), that is passed down the esophagus and lays right over the heart. This gives us a clear sound of the heart and how it is beating.

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To minimize anesthetic time we routinely have 2 doctors working as a team performing the splenectomy.  They work together as a well orchestrated team.Our patient is under anesthesia and our surgeons are completing the draping process while our anesthetist is adjusting the surgical lights.

By working together early in the surgery we minimize anesthetic time.

For a pet that might already be anemic it is important to minimize blood loss during surgery. Special care is taken on entering the abdomen to minimize loss. There is minimal bleeding at this point as our surgeon gently dissects the sub Q (subcutaneous) tissue just under the skin.

As the surgery progresses we sometimes encounter significant bleeding from blood vessels in the sub Q fat and from muscles that are cut. All of them are clamped or cauterized before proceeding further. For a pet that might already be anemic this added blood loss is important to control, and it is stopped immediately.

When all bleeders are under control (called hemostasis) we enter the abdomen. We make our incision at a specific spot in the abdominal muscles called the linea alba. It is at this spot that there are minimal blood vessels. The linea also has strong tendinous attachments to the muscle, so when we sew it back together these tendons attachments have more holding ability than the abdominal muscles alone. This will prevent a hernia.

Our first view of the spleen once we have entered the abdomen. It is the round and reddish structure at the top of the abdominal opening and just to the left of our surgeon’s finger.

A spleen that is not healthy is friable and can easily rupture when handled. Our surgeon has to gently coax it out to prevent  this from happening.

Once it is finally exteriorized the problem is obvious. At this point we do not know if it is cancerous or not. We do know it is in the process of rupturing and glad we are getting it out now.

Now that we have it ready for removal we have to ligate its blood supply. As you remember from your surgical anatomy above the blood vessels to the spleen are closely related stomach. It is important to ligate the blood supply very close to the spleen so as not to compromise the blood supply to the stomach, leading to serious consequences.

This blood supply can be surrounded by fat. We have to isolate segments before we ligate.

In the center of this picture you can see one blood vessel that is already ligated. On the right our surgeon is in the process of ligating another blood vessel.

We have completed 3 ligations at this point, with many more to go.

Our surgeons work simultaneously, each starting at a different end of the spleen, so they can complete this tedious part of the surgery sooner. Its all about secure ligation of these blood vessels and minimal anesthetic time.

As part of the natural healing process there is a tissue in the abdomen called omentum. It is like a net, and surrounds an organ that might be diseased. For example, a ruptured intestine that is leaking intestinal fluid (extremely irritating to the abdomen and will cause a peritonitis), will have this net surround the intestine to wall off the leak.

In the case of this rupturing spleen the omentum covered the spleen to help prevent further blood loss. These are clots on the omentum from that. At this point in time during the surgery we cannot determine for sure if these are clots or spread of tumor. The report from the pathologist will tell us for sure. It turns out that this time they are clots.

When the spleen is completely removed we complete our exploratory surgery by checking the other internal organs, especially the liver. Once this check is complete we suture the muscle layer (the linea alba) closed. Again, we work as a team, with each surgeon (they are both lefties) suturing the linea until they meet in the center.

Once we have finished suturing our patient, who is already on a pain patch (Duragesic or Fentanyl patch- which is removed in 3 days), is given an additional pain injection and carefully monitored post-operatively. As part of the monitoring we perform a simple blood panel to make sure there was no problem with blood loss during surgery. If the blood loss is significant we will give a blood transfusion with the blood we have already set aside specifically for this patient.

Post operatively we take radiographs of the chest and perform and ultrasound every 2 months for cases of HSA looking for distant and local metastasis.

Occasionally we come across a spleen that is so large it is hard to believe it can get this big. The following spleen was over 8 pounds, removed for a 65 pound labrador named Jake.  Dr. P and Dr. R had to do this one together. Removing it was like delivering a baby!

The size was obvious as soon as we entered the abdomen. At this point in time we were not sure if it was a boy or a girl! Dr. P is coaxing it out of the abdomen at the beginning of the surgery, being very careful not to rupture it.

We had to be very gentle  because it was quite delicate(friable) and already rupturing

Ligating the blood vessels to the spleen was more difficult than usual because of the size, scar tissue, and omental tissue that covered the rupturing spleen

It turns out that this was a hematoma and the dog did fine for several more years. Lucky this spleen did not rupture before the surgery.  Most likely, with a hematoma this large, death would have ensued rapidly.

Ancillary Treatment

After surgery we will consult with the oncologists at the Veterinary Cancer Group for further treatment

Post Surgical Treatment

Prognosis

A successful outcome from surgery depends on what disease process is present and how long it has been present.

Splenic Hematoma – good

Splenic Torsion – good

Hemangiosarcoma – guarded to poor.

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Lymph Node Diseases

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The lymph nodes are part of the lymphatic system. They have several important functions regarding the immune system, and are good indicators of disease. The mammalian body has many internal lymph nodes. These can only be visualized by exploratory surgery, a CT scan, an MRI, a radiograph, or an ultrasound.

During a physical exam the external ones can be palpated to determine if they are enlarged. The medical term for enlarged external lymph nodes is lymphadenopathy. The lymph nodes are always examined as part of our routine head to tail (if they have one!) exam on all pets presented to us.

Dr. P is getting ready to perform a lymph node exam on this cat. He will start with the paired lymph nodes under the jaw, called the submandibular lymph nodes.

Causes

Lymph nodes can enlarge due to several reasons:

  • Inflammation

    A reaction to a foreign body might cause this. If mild this will go away by itself in most cases. If not, we will use medication like cortisone to get the swelling down. Even though this type of problem is benign, if the lymph nodes get large enough they can interfered with normal physiologic functions like swallowing.

  • Infection

    Bacterial, viral, or fungal infections can cause them to enlarge. This enlargement might be a sign that they are performing their job as expected. When the infection subsides the lymph node should return to normal size. Sometimes though, and enlarged lymph is a sign that the lymph node needs help in fighting inflammation or infection, and we put that pet on antibiotics or anti-inflammatory medication.

This badly infected toe on this cat could cause the regional lymph node, in this case it would be the axillary lymph node, to be enlarged. 

  • Cancer

    The most common cancer that causes this problem is called lymphoma (also know as lymphosarcoma). This is malignant cancer.

This is the report of a dog that has lymphoma

Examination

Internal Lymph Nodes

Numerous lymph nodes exist within the thoracic and abdominal cavities. They cannot be palpated, and their enlargement does not show up on routine blood samples. They might be seen on radiographs or ultrasound if they are significantly enlarged.

This radiograph of the chest shows the heart and lungs clearly. The lower arrow points to the location of the sternal lymph node. It is barely visible in this dog because it is normal. The top arrow points to a round, white structure. It is a tumor nodule that has spread from cancer elsewhere in body.

This radiograph of the abdomen shows the liver and stomach clearly. The middle arrow points to the general location of the mesenteric lymph node. The top right arrow points to the location of the sublumbar lymph node. Neither one is visible because they are normal.

The greatly enlarged sublumbar lymph nodes are circled in this dog with cancer. See the close up below

The enlarged sublumbar lymph nodes are visible as the whitish areas under the red circle. This is from a dog with a cancer called adenocarcinoma.

Lymph nodes can also be seen with the ultrasound. This takes an experienced veterinarian, usually a veterinary radiologist.

This is a lymph node in the center of the abdomen called the mesenteric lymph node

This is a lymph node at the back of the abdomen just under the spine called the sub lumbar lymph node. It is the same lymph node as the dog above. 

This is a close up of a lymph node when seen by ultrasound

Enlarged lymph nodes can be found when performing an exploratory surgery.

The scalpel blade is pointing to the mesenteric lymph node. This node is found at the center of the small intestine loops. This one is enlarged because this cat has kidney cancer, which has spread to the mesenteric node.

Here is another enlarged mesenteric lymph node from a cat with intestinal cancer called lymphosarcoma

External Lymph Nodes

Mammals have numerous external lymph nodes (also called peripheral lymph nodes) that can be palpated during a physical examination. This is of great advantage because we can easily feel if they are enlarged without having to rely on diagnostic tests.

Reptiles and birds do not have these external lymph nodes, so they cannot be palpated during an exam.

Good luck trying to palpate the external lymph nodes on this 120# python in for its yearly exam. The only thing you will find is how powerful it is as your assistants try to hold it still for an exam.

The tonsils are lymph nodes also, but they are not palpated, just looked at during our routine exam. We do not recommend that you check them yourself because they are deep in the oral cavity, and can be confused with the organs. Also, you can injury your pet while opening the mouth wide enough to see them, or you can be injured by a bite or scratch from your pet. If you think there is something wrong with your pet’s mouth it should be brought to us for a proper and thorough exam.

Five external lymph nodes are routinely palpated during a physical exam. All of them are paired, which is another advantage because we can compare one to another and notice subtle changes in size. We will teach you how to palpate them during our exam.

  1. Submandibular

    They are located in the neck area near the angle of the jaw. They lay right next to the salivary glands, so it is important to palpate the correct structure.

  2. Prescapular

    They are located just in front of the shoulders. Follow the arm up to the point of the shoulder to find them.

  3. Axillary

    Found on each side of the chest in the armpit area. They tend to be small, and are more forward then most people realize. You need to be under the arm to feel them against the rib. 

  4. Inguinal

    Found on the abdomen towards the inside of each rear leg. There is significant fat in this area, so they might be difficult to find, even if enlarged. Also, there is mammary tissue in the area that can easily feel like an enlarged lymph node if the mammary tissue has an infection or cancer. These are not lymph nodes you would routinely palpate on your own.

  5. Popliteal

    Found on each rear leg on the opposite side of the knee. They are pea sized, and relatively superficial and easy to feel.

We will gladly teach you how to palpate these lymph nodes whenever you bring your pet in for a physical  exam. These are sensitive organs so they are always palpated in a gentle manner. You might want to palpate them on a weekly basis at home. If you think they are enlarged bring your pet in for an exam so we can determine if there is a problem.

Diagnosis

Fine Needle aspiration

This test is a relatively simple way to obtain a significant amount of information from an enlarged lymph node. In this test we use a small needle (similar to the one we use to give vaccines) and gently insert it into the enlarged lymph node. We aspirate some of the lymph node material and put it on a microscope slide.

This ferret has a very large right submandibular lymph node. Do you see the needle on the left side of the picture that we are using to obtain the aspirate sample? It is super sharp, and is no more uncomfortable than getting a vaccine. 

The aspirated material is put on a microscope slide for analysis by a pathologist. They will put special stains on the material and carefully scrutinize it under the microscope.

The fine needle aspirate test is not infallible at finding a problem. When the needle is inserted it is put in only by feel. It is possible for the lymph node to have a problem area that the needle missed. Also, we are giving the pathologist only a very small sample to read. It can be difficult to determine the health of the whole lymph node when only a small sample is taken.

Due to these limitations the pathologist sometimes cannot say for certain what caused the lymph node to enlarge. If it comes back inconclusive then we might keep the lymph node under close observation. If there are other changes in the rest of the physical exam, or laboratory data indicates there might be a significant problem, we will remove the whole lymph node and submit it for analysis.

If the fine needle aspirate report comes back that cancer is suspected we will remove the lymph node, no matter what the other laboratory tests indicate. You saw that earlier when we showed you the report of a dog with lymphoma.

Biopsy

The most accurate way to determine if a lymph node is seriously diseased is to remove the whole lymph node and submit it for analysis. It gives us significantly more information than the fine needle aspirate. It requires anesthesia and a small incision in the skin. We routinely use our laser for skin incisions for its great ability to minimize bleeding, swelling, and post-operative pain.

This cat has an enlarged popliteal lymph node

We used the laser in this case to make the skin incision

The inflamed lymph node is easily visualized. Note the lack of bleeding due to the laser cauterizing the blood vessels.

The anatomy of this lymph node is not normal. It is nodular and inflamed,  an indication that it is diseased.

Because of the unique qualities of the laser we are able to perform this surgery with a small incision that heals rapidly

 

Biopsy Reports

The report on this dog gave us a diagnosis of valley fever, which is a fungal infection. You don’t have to read through all of the medical mumbo jumbo to get to the valley fever diagnosis at the end. In the last paragraph you can see that special stains were needed to make the final diagnosis. These special stains are not easily performed on a fine needle aspirate.

This report of cancer came back on a Labrador Retriever

Treatment

Inflamed lymph nodes are treated with an anti-inflammatory like cortisone. Pets with bacterial or fungal infections are treated with antibiotics or anti-fungal medications. There is no specific treatment for a lymph node that is enlarged due to a viral infection. If cancer is the cause of the enlargement it will be treated with surgery, chemotherapy, radiation, or a combination of all of these.

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Addison’s Disease (hypoadrenocorticism)

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This disease of the adrenal glands of dogs (it’s very rare in cats) involves inadequate hormone levels of cortisol (cortisone) and electrolytes (sodium and potassium). This unusual disease can show a vast array of different symptoms, symptoms that mimic other diseases. There is even a version of this disease called “atypical”, which adds to the complexity. Because there can be such a variety of symptoms, Addison’s disease is sometimes known as the great pretender or great imitator. In any dog that is ill, our veterinarians need to keep this disease in mind.

Addison’s is named after a physician in 1849’s who discovered this disease. President John Kennedy suffered from the human version of this disease.

Addison’s disease is the opposite of another problem with the adrenal glands called Cushing’s Disease (hyperadrenocorticism). In Addison’s there is not enough cortisol, in Cushing’s, there is too much cortisol.

We have an interesting page on adrenal disease in ferrets, which causes different symptoms in the ferret compared to dogs and cats.

Nomenclature

Several medical terms and abbreviations relate directly to Addison’s:

glucocorticoids – Cortisol tachypnea-increased respiratory rate
exogenous cortisone– supplemental cortisone by mouth or injection bradycardia-abnormaly slow heart rate
catabolic steroid– cortisol and its equivalent polyuria– excess urinating
anabolic steroid– opposite of catabolic, testosterone is the most common one polydipsia– excess drinking
hyperkalemia- high potassium (K) level in the bloodstream PU/PD– polyuria and polydipsia
tachycardia -abnormally fast heart rate mineralcorticoid-hormone that affects sodium and potassium
hypoglycemia– low blood glucose (sugar) level iatrogenic– caused by something a person does as opposed to happening naturally.
hyponatremia- low sodium (Na) in the bloodstream ACTH– adrenocorticotrophic hormone
atrophy-an  organ that is smaller than it should be adrenomegaly– enlarged adrenal gland
anemia– low red blood cells microcardia- small heart
cortisol– Cortisone made by the adrenal glands  azotemia– elevated BUN and creatinine

Adrenal Gland Anatomy

The adrenal glands are paired organs that lay right in front of the kidneys on each side. They are quite small, and measure only a few millimeters in length. This small size is not an indication of their importance though. Even though they are small, the cortisol (cortisone) they secrete, along with their other functions, have great significance to normal physiology.

The arrows point to the paired adrenal glands in front of each kidney. The extensive blood supply to the kidneys and adrenal glands is apparent. In the diagram they are easy to see. They are not so easy to see during ultrasound or exploratory surgery because normally they are small and buried in fat. They do not show up on an X-ray unless they are calcified or much larger than normal.

This is a picture of an enlarged adrenal gland (arrow) that is buried in fat near the kidney (K). It is from a ferret that has an adrenal gland tumor, so the adrenal gland is inflamed and easily visualized. This is not necessarily the case in dogs and cats that have adrenal gland tumors.

The internal architecture of the adrenal gland is made up of several distinct zones.

Cortex

The cortex (outer shell) of the adrenal gland is made up of 3 anatomical parts:

Zona Glomerulosa

This is the outer layer of the adrenal gland. This section secretes the mineralcorticoid aldosterone. Aldosterone is vital to proper sodium and potassium regulation. Aldosterone has a role in maintaining  blood pressure.

Zona Fasciculata

This is the next layer as you go inward, and produces the glucocorticoid cortisol. The cells in this area are the ones that cause Cushing’s when they secrete cortisol in excess.

Zona Reticularis

As we continue inward we come across this section that secretes the sex hormones known as androgens (male sex hormones), estrogen (female sex hormones), and sex steroids. These are usually secreted in such small amounts as to be of no major significance in healthy animals. The gonads in dog and cats secrete most of the sex hormones.

Medulla

This consists of the very center of the adrenal gland. It secretes hormones called catecholamines. The two important ones are epinephrine (adrenaline) and norepinephrine.

Physiology

The tiny adrenal glands have a profound influence on many internal organs. The hormones they secrete work in unison with other hormones and internal organs, particularly the liver, and have an enormous effect on physiology. These hormones interact with many other hormones that have the opposite effect, usually in some type of feedback mechanism that is monitored by the brain. This interaction is complex, so only a summary of adrenal hormone physiology is presented.

The adrenal glands secrete several important hormones, most of which are synthesized from cholesterol. We will explain 3 of them; cortisol, aldosterone, and epinephrine:

Cortisol

Cortisol maintains a normal blood glucose level, facilitates metabolism of fat, and supports the vascular and nervous systems. It affects the skeletal muscles, the red blood cell production system, the immune system, and the kidneys. Obviously, it is a very important hormone, and necessary for life.

It is considered a “catabolic steroid”. This means it takes amino acids from the skeletal muscles and, and with help from the liver, converts them to glycogen, the storage form of glucose. These functions are the exact opposite of “anabolic steroids”, the drugs that weight lifters take to increase muscle mass. The end result of this is an increase in the level of glucose in the bloodstream. The hormone called insulin has the opposite effect on blood glucose, adding to the complexity of this system. You can learn more about insulin by going to our diabetes mellitus page.

The level of cortisol in the bloodstream continually fluctuates as physiologic needs vary. Surgery, infection, stress, fever, and hypoglycemia (low blood sugar) will cause cortisol to increase. This continual fluctuation adds to the difficulty of diagnosing any disease involving cortisol (Addison’s and Cushing’s), because the amount of cortisol in the bloodstream is so variable.  A test taken at one moment in time might have different results if taken later.

To control the level of cortisol the hypothalamus and pituitary gland in the brain secrete chemicals into the bloodstream called releasing factors. In the case of the adrenal glands , the hypothalamus secretes a hormone called corticotropin releasing hormone (CRH). This hormone goes to the pituitary gland and stimulates it to release a hormone called adrenocorticotrophic hormone (ACTH). It is the amount of ACTH circulating in the blood stream that tells the adrenal glands (specifically, the cells at the zona fasciculata) how much cortisol to secrete. There is a negative feedback loop that allows the hypothalamus and pituitary gland to refine precisely how much cortisol circulates in the bloodstream. The more cortisol secreted by the adrenal glands, the less CRH and ACTH secreted. This allows the body to precisely refine the level of cortisol, and to change the level rapidly due to changing physiologic needs.

This negative feedback mechanism is a highly profound adaptation to evolutionary pressures, and is the basis for our survival as a species. Without this, life as we know it, would not exist for us and many species on this planet.

Numerous organ systems are affected by cortisol:

Musculoskeletal

Cardiovascular

Skin

Renal

Gastrointestinal

Immune

Mineralcorticoids

Aldosterone is the principal mineralcorticoid secreted by the adrenal glands. This hormone is secreted as a response from the kidneys when fluid volume in the bloodstream is decreasing. It involves other hormones called renin and angiotensin. The end result is an increase in sodium in the bloodstream, with a corresponding increase in blood volume and blood pressure. This increase in blood volume and pressure is because  sodium  pulls fluid from the intestinal tract, and the area around each cell called the extracellular fluid, into the bloodstream.

This hormone also interacts with and affects potassium levels. To further complicate the picture, ACTH also has an affect here, just like it does with cortisol.

Epinephrine (Adrenaline)

This compound, technically called a neurotransmitter, also has hormone-like properties. It is a very powerful chemical that affects all organ systems. It acts very rapidly, with effects remaining only for a short period of time. It is the primary reason the body has the ability to respond to an emergency. This physiologic mechanism is also known as the “flight or fight” response.

Upon stimulation of the central nervous system (ex.-fear or pain), the adrenal medulla is stimulated to secrete epinephrine into the bloodstream. We are all familiar with what happens next. The pupils dilate, the heart rate and blood pressure increase, and the palms get sweaty. Internally, the body is increasing the blood glucose level, the breathing passages are opened up, more red blood cells are secreted into the circulation, blood is shunted away from the skin and other internal organs, and blood flow is increased to the brain and skeletal muscles. All of this has the effect of bringing the brain and skeletal muscles extra glucose and oxygen, and accounts for the extra boost of awareness and energy we all feel at this time. For such a small set of organs it is apparent that the paired adrenal glands have a very important role in normal health.

Pathophysiology

When the disease affects the part of the adrenals that secrete cortisol (the zona fasiculata) a vast array of different symptoms can occur. This is because of the profound effects cortisol has on almost all body systems.

When the disease affects the part of the adrenals that secrete aldosterone (the zona glomerulosa), then electrolytes like sodium (Na) and Potassium (K) are affected.

The overwhelming majority of the adrenal cortex must be affected before it secretes inadequate amounts of cortisol and aldosterone and before any symptoms are noted.

There are 3 forms of this disease:

Primary Hypoadrenocorticism

 This classic form of the disease is due to a lack of both mineralcorticoids and glucocorticoids. The zona fasiculata and the zona glomerulosa are both involved. This means the problem is at the adrenal gland itself.

Causes:

Immune system destruction of the adrenal gland due to autoantibodies is the most common cause

Medication to treat Cushing’s disease (mitotane or trilostane)

Infection

Coagulation disease

Cancer

Loss of blood supply to the adrenal gland (an infarction)

Secondary Hypoadrenocorticism 

This more unusual form of the disease occurs when the zona fasiculata only is involved. This means the problem is at the pituitary and not at the adrenal gland, therefore only cortisol production is compromised and the electrolytes sodium and potassium are not affected.

Causes:

Abruptly stopping oral or injection cortisone that has been administered for a period of time (exogenous cortisone)

Congenital defects of the pituitary gland

Cancer or trauma to the hypothalamus

Atypical

This includes all of the dogs classified as secondary, so only cortisol is involved. In these dogs electrolytes are normal,  just like in secondary hypoadrenocorticism. What makes this atypical is that fact that many dogs might change to primary during the course of the disease. Only then will the electrolytes  be involved.  This can make treatment difficult, because a pet that is being treated successfully for secondary might need to be treated for primary at some point. This emphasizes the need for close monitoring with blood panels and exams at least every 6 months.

Diagnosis

Signalment

Usually found in female dogs that are middle aged or less. It is more commonly found in dogs that are not spayed (ovariohysterectomy).  Atypical Addison’s tends to occur more in the older dog. Certain breeds get this disease more often than others:

  • Great Danes
  • Standard Poodles
  • Bearded collies
  • Portugese water dogs
  • Rottweilers
  • Wheaten Terriers
  • West Highland White Terriers (Westies)

History

Symptoms are quite variable, and can come and go over months.  As a result, it is easy to miss this disease or get it confused with other diseases that have the same symptoms. Symptoms might be mild, or they might be life threatening, and can be found in many other diseases.

In some cases, a pet has been ill in the past, and treated with fluids with a successful outcome, and now the problem has returned. A blood panel in this situation might show a kidney problem due to dehydration, which is why the fluids helped. If this is a recurring problem, Addison’s should be tested for.

Typical symptoms might include:

  • lethargy
  • inappetence
  • weight loss
  • diarrhea or dark stools
  • vomiting
  • shaking
  • dehydration
  • shock
  • collapse
  • drinking and urinating more than usual (PU/PD)
  • abdominal pain
  • seizures if severely low blood sugar is present

Physical Exam

Just like the symptoms above, the physical exam of a dog with this disease can be quite variable. Typical exam findings we might encounter include:

  • depression
  • pale gums
  • tacky gums
  • panting
  • hair loss
  • weak pulse
  • increased heart rate (tachycardia) if shock
  • decreased heart rate (bradycardia) if potassium is high
  • increased respiratory rate (tachypnea)
  • low body temperature
  • painful abdomen upon palpation

Diagnostic Tests

Radiography

X-rays might be helpful in diagnosis, although they are not the primary way this disease is diagnosed. On a radiograph we might find a small heart and liver due to dehydration and shock. On rare occasions megaesophagus (enlarged and non-functional esophagus) might be present. None of these symptoms are diagnostic of Addison’s by themselves, since numerous other diseases can cause these symptoms.

.

The heart is the white object in the center of this radiograph. Compared to the heart in the radiograph below it is small, which might indicate dehydration due to Addison’s. 

The adrenal glands do not show up on an abdominal radiograph unless they are calcified or extremely enlarged, which would be more indicative of Cushing’s and not Addison’s.

Electrocardiogram (ECG)

If the potassium is high enough (hyperkalemia) the heart rate might be slow (bradycardia) and there might be changes in the electrocardiogram. There are other causes of hyperkalemia, so this is not diagnostic for Addison’s, it is a clue that Addison’s might be present. The most common cause we see for hyperkalemia is a cat that cannot urinate in the obstructed version of FLUTD (Feline Lower Urinary Tract Disease).

Below is a normal ECG strip for 4 beats of the heart. Below the strip is an enlargement of one beat.

If hyperkalemia is significant, changes to the ECG might include:

  • slow heart rate (the 4 beats below might only be 2-3 beats)
  • absent P waves
  • widening (prolonged) QRS complex
  • Shorter (decreased amplitude) R wave

EKG

Ultrasonography

Ultrasonography would usually show small adrenal glands, although a dog can have Addison’s and have normal adrenal glands on ultrasound. The adrenal glands in Addison’s are tiny, and can be difficult to find in some cases.

OLYMPUS DIGITAL CAMERAThis is a normal right adrenal gland enlarged for easier viewing. It is marked by the + signs.

Tuffy3

This is a small left adrenal gland like we might find in Addison’s. It is the whitish area in the center towards the top with the dark area in the center. It takes an experienced ultrasonographer to find a small adrenal gland.

Blood Panel

Blood work (chemistry and complete blood count) is a crucial component for detection of this disease. Common abnormalities might include one or more of these findings:

  • anemia (low red blood cells)
  • increased eosinophils and lymphocytes
  • low blood sugar (hypoglycemia)
  • azotemia (high BUN and creatinine)
  • hypercalemia (high calcium)
  • hyperkalemia (high potassium)
  • hyponatremia (low sodium)
  • hypochloremia (low chloride)
  • increased liver enzymes (ALT)
  • increased alkaline phosphotase (ALP)
  • hypoalbuminemia (low albumin)
  • hypercholesterolemia (high cholesterol)
  • low ratio of sodium (Na) to potassium (K). If the ratio is less than 27:1, and the history and symptoms are consistent with this disease, then a high index of suspicion is appropriate.

Cortisol decreases the blood flow (also called GFR-glomerular filtration rate) to the kidneys. This will result in an decrease in the amount of water and waste products filtered by the kidneys. On the blood panel this might show up as kidney disease, when in reality it is Addison’s. Our kidney disease page has more details.

Each of the following blood panels was taken from a dog with Addison’s. They are all different, a testimony to how variable this disease can appear on a blood panel. When coupled with the wide variety of symptoms, that can wax and wane, a diagnosis of this disease is not black and white.

 In this first blood panel, the only abnormal finding of significance is the low RBC, HGB, and HCT. This means the pet has anemia.

Notice how these tests are mostly normal, although this dog has Addison’s

BuddyHansonBlood

In this dog with Addison’s, the chloride, sodium, and glucose  are low. The Na/K ratio is OK.

Tuffy2

This dog with Addison’s has numerous abnormalities, this time including a low Na/K ratio

Special Tests

Cortisol level

In this test a baseline cortisol level is run by taking a blood sample.  If the baseline cortisol is over 2 mcg/dl (micrograms per deciliter) then the dog does not have Addison’s. There is no need to go any further since Addison’s is not involved at this point. If the baseline cortisol is less than 2 mcg/dl then we will do the ACTH stimulation test.

ACTH Stimulation test

Diagnosis is confirmed with an ACTH (adrenocorticotrophic hormone) stimulation test. This test is also used to help diagnosis the opposite problem of Addison’s disease, which is called Cushing’s disease.

ACTHgel

Once the baseline blood cortisol is obtained we give an injection of a specific amount of ACTH. One hour later we take another blood sample to check if the cortisol level has changed. We get the reports from the lab usually the next day.

If the baseline cortisol is less than 2 mcg/dl, and it does not increase on the blood sample taken one hour later after we have injected ACTH, then the disease is confirmed.

Addison's-4

Akita’s and Shiba inu’s sometimes have elevated potassium levels on blood tests. This can be very confusing when a patient has symptoms that suggest Addison’s disease. The ACTH Stimulation test will let us know if they have Addison’s.

An occasional dog will be presented with symptoms consistent with Addison’s, including abnormal sodium and potassium levels. These dogs might have Whipworms and not Addison’s. Again, the ACTH Stimulation test will let us know if they are Addisonian. We have a page on internal parasites that includes Whipworms.

Treatment

Acute Phase

In the acute phase, dogs are presented collapsed and in a state of shock and hypothermia. They need shock doses of intravenous fluids and injectable cortisone (dexamethasone) along with warmth. If the hyperkalemia is causing bradycardia, the IV fluids usually suffice.  If not, insulin needs to be administered. If hypoglycemia is present, dextrose is added to the IV fluids.

Chronic Phase- Most dogs are presented in this phase

For low cortisol we use prednisone orally at a relatively low but consistent dose. Any pet with chronic Addison’s needs to have this dose increased when there is a stress like fireworks, going to the groomer or veterinarian, or anything in general that causes extra stress.

We will test the blood every 6 months at the least to make sure there are no serious side effects to this use of cortisone. For the majority of dogs, there are no side effects, and the drug is mandatory for treatment of this disease. The symptoms of the disease, and their potentially life threatening nature, far outweigh side effects when used under our supervision.

Prednisone

Prednisone and prednisone are tried and true drugs that have been used to treat this disease for many decades

For an imbalance in electrolytes we use one of two drugs, although the injectable version is much more convenient and very effective:

Percorten-V (DOCP)Percorten-V works extremely well for most dogs and allows them to lead a normal quality of life. This injectable medication is given every 25 days for the majority of dogs. We will test the electrolyte levels with a blood panel early in the course of treatment to monitor Na and K levels and adjust the timetable accordingly. We will then test the blood at least every 6 months.

Percorten

Harmony is drawing up Buddy’s Percorten

Addisons-HarmonyInjection1

Buddy comes in every 25 days on the dot, and after his pinprick injection (we use a 25 gauge needle so it is jut a pinprick) he is good to go for another 25 days.

Addisons-HarmonyInjection2

Florinef – It does have some cortisone properties, and in some cases a dog does not need prednisone when on this drug. This does not apply to stressful situations, and additional medication in the form of prednisone tablets is always needed.This oral medication has fallen out of favor as a treatment because it has to be given daily, and some dogs develop a resistance wherein the dose has to be increased.

Florinel

The pills are small and easily given

Prognosis

This is a hormone disease, which means it is part of a highly tuned and refined mechanism that is in constant state of change. Vigilant monitoring is of essence for a successful outcome. We have numerous dogs at our hospital currently being treated successfully with prednisone and Percorten-V over many years. These dogs are leading a normal life, and you would have no idea they have a serious hormone disease when you see their owners bring them into our hospital or take them for a walk.

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Arthritis

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One of the most insidious diseases we encounter in animals is arthritis. It was not long ago that pets were euthanized because they seemed “old” based on their symptoms of poor appetite, decreased activity, and lethargy. In reality they were not “old”, they had arthritis, and acted like they were old because they were painful.

Today we can treat their arthritis and give them a new lease on life and lead a great quality of life for many more years. All animals get arthritis, we most commonly see it in dogs and cats. This page will emphasize it in dogs since it is most prevalent in them. Cats get arthritis also, and we wil discuss how they differ from dogs in this disease.

Many of our pets are stoic, and can have a disease process brewing on the inside yet show no external symptoms. As the disease progresses eventually the symptoms appear, and we are presented with a very ill pet that seemingly became sick overnight. The reality is that the problem was present for a long period of time. It went unnoticed until your pet went rapidly downhill, when the bodies mechanisms for compensating and coping with the disease have become overwhelmed, and your pet is in a debilitating condition. At this point the disease process is so well entrenched that the prognosis for recovery is poor.

This concept applies to arthritis in dogs and cats.With our new digital radiography that gives us much more detail, we are diagnosing it earlier. Coupled with substantially improved treatments, we can successfully treat these arthritic and painful animals, and give them a vastly improved quality of life for many more years.

This digital radiograph of the abdomen shows the tremendous detail we get with digital, and how we can see the internal organs in the abdomen. Click on the photo above if you would like to learn how to read a radiograph (you do know the 5 radiographic densities don’t you?).

What’s even better is the fact that some of these new treatments do not involve the use of drugs. We have a multi-system approach to arthritis due to its chronic and debilitating nature, and the fact we strive for treatment modalities that involve minimal use of long term drugs.

Here is a summary of how we approach this important problem. We will talk about these treatments in more detail later in this page:

If your pet is overweight, a common problem, modifying diet and feeding habits to bring it back to its fighting weight can minimize the symptoms of arthritis. This common sense, inexpensive, and drug free option, seems to escape many people.

Hills-MetabolicMobility

Hill’s makes a prescription diet called Metabolic + Mobility that addresses obesity and arthritis at the same time. It is the food of choice for overweight dogs that that are also arthritic.

Arthritis tends to be a disease of the aging. Older pets have different nutritional needs that need to be addressed. These needs cannot be addressed by going to a pet store and listening to the advice of some amateur nutritionist behind the counter trying to sell you the latest gimmick in dog food marketing. It comes after you discuss your pet’s individual lifestyle needs with your veterinarian, your pet is given a thorough physical exam, and your veterinarian has blood panel and radiographic tests on your pet. Only then will the full picture of your pets needs be understood, leading to a custom treatment protocol specific for your pet.

Chondroprotective agents called neutraceuticals can help in some cases.  These are the chondroitin sulfate- glucosamine products available everywhere, including Trader Joe’s at the checkout stand. They are not a panacea, and its important to take a critical look to see if they are working in your pet’s case. Sometimes the placebo effect seems to be transmitted in our minds to our pets, and we do not have an objective standard to determine if these medications truly help. Fortunately they do not seem to hurt, so we can achieve or first goal of “do no harm” as veterinarians.

NSAID’s  (non-steroidal anti-inflammatory drugs) are a tremendous advancement in the treatment of arthritis. Non-steroidal means they do not contain cortisone, which was one of the primary drugs used to treat arthritis in the recent past. The NSAID’s are better at treating arthritis when used judiciously to maximize their good effects, while minimizing their potential for side effects. Every pet reacts differently, so if one NSAID does not seem to work, we will try another. In cat’s we use this drug sparingly if it all due to their inabiliy to tolerate their use long term. The NSAID’s we use in cats are called Meloxicam, Metacam, or Onsior.

Veterinary Neuronal Adjustment (VNA or VOM) is a tremendous treatment modality that uses the bodies natural healing processes without the use of any drugs. It involves stimulating the autonomic nervous system (specifically the sympathetic branches) and provides substantial pain relief. We have been using VNA at the Long Beach Animal Hospital for over 15 years. This is especially important in cats, since they do not tolerate NSAID’s well for long periods of time.

Therapy Laser brings an additional and highly effective treatment modality that again does not involve the use of drugs. This laser penetrates the hair and skin and goes right to the problem area to decrease inflammatory mediators. We recently updated our equipment to include a new therapy laser called MLS that treats using two different wavelengths.

Acupuncture can also be used to augment all of the above therapies. Dr. Seto and Dr. Yamamoto are both certified in acupuncture in animals. Cats do well with acupuncture.

Stem cell therapy is starting to be used, utilizing your dogs own fat cells. It is still in the early stages, and treatment is not long lasting. If this area of treatment evolves and becomes more practical, we will utilize it.

Exercising your pet in the cooler part of the day, without excess trauma like jumping for long periods of time, will keep your pet flexible, the joins warm and lubricated, and keep its weight under control. If your pet is not afraid of water, letting it swim in a shallow area is a great way to enhance mobility.

In older cats that are prone to arthritis there are several common sense things to do:

Raise the water and food bowls slightly. This is because cats get arthritis in the elbow joint, and elevated bowels allow them to feed with the elbow in extension, which is less painful. It also gives cats with hip and stifle (knee) pain are more comfortable sitting position when feeding.

Have several litter boxes around the house, make sure they do not need to go up the stairs to access them, and if the litter pans have tall sides see if they can be cut down for easy access.

If your cat likes to perch on a window sill or lay on your bed make sure it does not need to jump to access these areas, and set up some steps for easy access.

We will use the words arthritis and osteoarthritis (OA) interchangeably, because they are the same thing in regards to the pain your pet is feeling and how it is treated.

Please be realistic about the fantastic claims that abound on the Internet for cheap treatments that will help your pets arthritis. These treatments have show to be nothing more than effective marketing. This disease is complicated and serious, and needs more than some supplement you purchase online.

What is Arthritis?

Dogs are prone to many different types of bone problems. This page will focus on the arthritis that tends to occur in dogs, especially as they age. Arthritis literally means inflammation of the joint, but the term is used more generally to describe several different processes. These include degenerative joint disease (DJD), infectious joint disease, immune mediated joint disease, and crystal-induced joint diseases. Many people use the term arthritis synonymous with osteoarthritis (OA), a complex, slowly progressive, and degenerative arthritis that is characterized by the gradual development of joint pain, stiffness, and a decreased range of motion.This is the type of arthritis common in older pets, and is increasing as pets live longer.

As we learn more about the subtleties of feline medicine we realize that many cats get significant arthritis especially in their lower back. This problem, also know as feline hypersethesia syndrome, causes tremendous discomfort and decreases the quality of life for many cats.

Anatomy

A normal joint is lined with hyaline cartilage, which is the covering over the end of the bone. It provides an almost frictionless surface for the bones to articulate, and also acts as a shock absorber. Hyaline cartilage is comprised of chondrocytes, proteoglycans, and collagen.

A normal joint is encased in a fibrous structure called the joint capsule. The joint capsule helps stabilize the joint and keeps the cartilage bathed in synovial fluid. Ligaments, which attach bone to bone, also provide joint stability.

This picture is from an actual surgery on the knee of a dog with a ruptured cranial cruciate ligament. The head is on the right, the foot is on the left, so the joint appears horizontal.

Arthritis-StifleJointArrow

The ridge of bone running horizontally at the bottom (arrow) is arthritis. The normal smooth cartilage above it is the normal groove of the knee (stifle) joint. The patella runs along this groove. 

Cause

The cause of this complex and multi factorial disease can be primary or secondary. Primary OA results from normal stresses acting on abnormal cartilage. Secondary OA is more common, and results from abnormal stresses acting on normal cartilage, such as an unstable joint caused by canine hip dysplasia, fragmented coronoid process, ununited anconeal process, patellar luxation, or a ruptured cruciate ligament. Some of the factors that can cause OA include excessive exercise, obesity, poor nutrition, trauma, immune reactions, and genetic predispositions.

The  following radiograph on the top is from a normal shoulder joint. The one on the bottom has an abnormal flap of cartilage at the arrow. This is know as osteochondritis dissecans, and is a primary OA. Without this radiograph we never would have know this limping pet had this problem.

shoulder arthritis

This normal shoulder joint shows no problems
osteochondritis

The white arrow points to a flap of cartilage that has eroded off

These two elbows from the same dog are normal

This elbow from a different dog shows advanced arthritis, probably secondary to elbow dysplasia

Damage to cartilage might occur as one event, or be the culmination of many small events over years. As swelling occurs, and the joint capsule becomes stretched, pain occurs. Your pet will use the joint less because of this pain, leading to muscle atrophy and the inability of the surrounding tendons and muscles to support the joint. As the muscular support of the joint weakens the joint capsule, ligaments, and cartilage become further stressed and stretched, leading to even further pain.

At this point the body releases chemicals called inflammatory mediators, (the therapy laser works on these mediators) which further damage the cartilage and add to even more swelling. It is obvious that this rapidly becomes a vicious cycle leading to debilitating pain. When OA progresses to the point that you notice your pet in discomfort or pain, the damage to the joint might be irreversible.

Diagnosis

Signalment

OA is commonly diagnosed in older dogs and cats. Some breeds are prone to getting it because of the conformation of their joints.

Dogs like Dachshunds have abnormally shaped long bones that might predispose them to OA. This is the wrist, forearm, and elbow of a Doxie. The medical terms are carpal, radius, ulna, and olecranon.

History

It is important to understand the initial symptoms might be subtle. Your pet will be experiencing pain or discomfort, yet it might not show any external signs.

Symptoms are related to joint pain and stiffness. Most owners notice a pet losing its ability to perform normally, such as a reluctance to jump or climb stairs, or even limping. Stiffness after rest that diminishes rapidly as your pet starts moving and warms up is a hallmark sign of OA. Other symptoms of arthritis include lethargy and poor appetite, which are the result of pain.

Initial symptoms are subtle and easily missed. Most dogs show a reluctance to run or move about. Some might not walk as long as usual, stop part way through a walk, or come back from a routine walk and go right to their bed to rest. They might be slow getting up.

Some will be reluctant to go up or down stairs, or might even be limping. As the disease progresses these dogs might be in overt pain and lose their appetite. Some of these symptoms occur in other diseases, notably hip dysplasia and intervertebral disk disease. The are treated in similar ways in some cases, in different  ways in other cases, so a proper diagnosis is imperative.

Dogs that will not go on extended walks, or dogs that pant excessively during a walk could also indicate OA. Symptoms can be worsened by obesity, too much exercise, and by cold or damp conditions.

Cats tend to show different symptoms sometimes. The most common areas for cats to have arthritis are the elbow, knee, hip, and spine. Most cats tuck their forelimbs under their bodies when they rest. If your cat consistently holds its elbow out (in extension) that could be a sign of elbow pain, a common area for arthritis to occur in cats. Cats that are reluctant to jump up to the bed or a window sill could have arthritis.

Other symptoms in cats include unkept fur due to pain when grooming. There could be overgrooming in painful areas leading to hair loss at the joints. Overgrown claws could be a sign it is not moving normally due to pain. At the end of this page is a link to the Feline Musculskeletal Pain Index to help determine if your cat is having a problem.

Physical Exam

In some pets there are no abnormalities detected during a physical exam. Pain or discomfort might be found by palpating a joint or pushing on the mid or lower back. We might feel grinding of joints (crepitus), a swollen joint, abnormal bone formation and roughened bones, or inflammation at the joint. Dogs with longer standing OA might show atrophy of muscles. Range of motion might be limited and cause discomfort or pain. There might also be subtle signs during the neurologic part of the exam.

Cats tend to have less crepitus and range of motion problems, but do have more joint swelling and pain.

Some pets are so distracted during an exam (this happens to us people commonly) that they do not exhibit signs of pain when touched in painful places. This is why we need some basic diagnostic tests.

Diagnostic Tests

Radiography is an important diagnostic test to perform on a dog or cat suspected of having OA. Even though a radiograph can be normal in a pet that has OA, it is a substantial help in verifying the diagnosis and determining the degree of involvement. Cats tend to have less radiographic evidence of arthritis, and might even have more cartilage problems than bone problems in some cases.

There are many diseases that can mimic the symptoms of OA, so a radiograph should be taken on every suspected OA  to eliminate these other causes.

This is a normal dog knee joint radiographically

This one has arthritis. The arrows point to all of the rough edges that are indicative of OA. Compare these rough edges to the smooth edges on the radiograph above. Also, the bone has a stronger whitish appearance, another indication of OA. You saw what this looks like on the picture of the knee joint above.

This dog was originally suspected of having arthritis based on a history of soreness in the hip area. It would be a mistake to treat this dog with an arthritis supplement and let the undiagnosed problem progress.

Radiographs revealed the true diagnosis was not the assumed arthritis, as can be seen at the arrow at the far left of the radiograph. The white circular area in the bone has the potential to be several different diseases, some of them serious like cancer.  A bone biopsy is need to know for sure.

A close-up view gives you a better idea of this dog’s problem

This form of OA is called spondylosis, which is arthritis of the vertebrae in the spine.
It is very common as pets age and causes substantial discomfort, nerve weakness, and even urinary and bowel incontinence.

This 12 year old Chihuahua has severe spondylosis throughout its lumbar vertebrae

The red circles show the sever spondylosis this bulldog has. The lumbo-sacral (called L-S) spondylosis on the right is very painful.  It is affecting the nerves to the bladder, causing an inability to properly urinate. The hugely distended urinary bladder is the result of this nerve problem, and can be seen as the large whitish area in the center of the radiography. A bladder this large is painful and prone to a chronic infection (UTI or cystitis).

You can learn more about the bones of the spine by going to our intervertebral disk page.

This dog was sore around its rear quarters when petted by the owner. The owners of the dog assumed it was arthritis and treated the problem on their own. When it did not improve the dog was brought to us for a proper diagnosis. Look at the lateral radiograph below of its posterior abdomen and see what you think the cause of the soreness was.

Did you figure out what is going on? Those circular white objects towards the top right of the radiograph are 3 pennies in the rectum! Even though it seems like a safe place to store your money, it was painful and causing this dog’s problem.

This is another dog that was sore in its rear quarters which that owner (and all of his well intentioned friends that love to give advice) assumed was just old dog arthritis. The circle shows the real cause of the problem in this dog’s back end. It is due to enlarged sublumbar lymph nodes from malignant cancer. 

A very important differential when diagnosing OA on a radiograph is a bone tumor. This one is on the femur (thigh bone). This dog had symptoms of muscle atrophy and limping on this leg. If a radiograph had not been taken these symptoms could have easily been mistaken for arthritis. At this stage of the disease amputation is usually the only way to temporarily stop the tumor from spreading.

This is a serious form of cancer, and usually requires amputation 

The other important differential on radiograph like this is a bone infection called osteomyelitis. The fuzzy or roughened edges at the arrows is the infection.

The incorporation of digital radiography into our practice gives us substantially more detail on a radiograph. This is easily seen in the Ferret spine radiograph.

Treatment

Treatment of OA initially includes correction of any underlying primary diseases such as surgical correction of a torn ligament or arthroscopy to remove a cartilage flap. Once any primary disease has been addressed, the goal of treatment is to slow the progression of OA and to keep your pet comfortable. It’s important to realize that there is no cure for OA. The following are the treatment options we find that are most successful, and were mentioned at the beginning of this page.

Nutrition

Most pets with OA will require some adjustment in their lifestyle. Weight management is most important, since obese pets put unnecessary strain on joints, leading to a more rapid progression of the disease. Depending on the degree of obesity your veterinarian might put your overweight pet on Hill’s Metabolic Diet. This is a weight control product with lasting effects and is our first recommendation. We might also use Hill’s W/D (weight diet) or Hill’s R/D (reducing diet).

If your pet is not overweight  we will utilize a food called Hill’s J/D (joint diet). It has added chondroitin sulfate and glucosamine in addition to essential fatty acids and carnitine. These foods are complete and balanced nutrition and can be fed for the rest of your pets life. There is a version for dogs and one for cats. Like all Hill’s foods it highly recommend in almost every case of arthritis unless your pet has some other disease that precludes their use. All Hill’s Prescriptions Diets our doctors recommend are unconditionally guaranteed. We have a detailed page on Nutrition Advice to help clear the air on all the hype that exists on the Internet to get you to put your money into this multi billion dollar a year business.

Omega-3 fatty acids have been shown to improve activity in cats with arthritis. They are included in many health diets already, so added amounts are not needed in most cases.

Exercise

Excessive exercise that leads to pain or discomfort should be avoided, but moderate exercise is recommended. Swimming is an excellent exercise for pets that have OA and aren’t fearful of water. Most pets do best with several short, exercise periods per day rather than fewer extended periods. Each patient will have their own unique program of weight management and exercise, and we can help you individualize one for you and your pet.

There are even veterinarians that specialize in rehabilitative therapy, with specialized swimming pools and therapy methods.

Chondroprotective Agents

These products typically contain precursors of cartilage and joint fluid synthesis. We like to use these medications first since there are negligible side effects and they might be an aid in preventing further deterioration of the cartilage. Hill’s J/D contains adequate amounts of these ingredients. Please remember that if a little is good, a lot is not necessarily better, because you disrupt the nutrient balance that is so important in nutrition.

These products have a positive effect on cartilage matrix synthesis and  an inhibitory effect on the enzymes that break cartilage down. They might require up to 6 weeks of use before OA symptoms are diminished. Unfortunately they do not work in every case, so be realistic and make a careful assessment as to their efficacy.

Adequan

Adequan (polysulfated glycosaminoglycan) is an injectable chondroprotective agent. Adequan incorporates into joint cartilage and inhibits several enzymes that break down cartilage. No studies have been done in animals other than horses and dogs, but it appears to be safe and effective in other species including cats, rabbits, ferrets, and birds.

The intramuscular injections are initially given twice weekly (every 3-4 days) for a month, then given monthly as needed. Adequan seems to be most effective when given in the early stages of OA. 

Dasuquin

Unlike the injectable adequan, Dasuquin and other oral joint supplements are considered nutraceuticals, or nutritional supplements, and do not require FDA approval. Cosequin contains glucosamine and chondroitin sulfate, agents proven to be effective at supporting and protecting joint cartilage.

In addition, Dasuquin contains ASU (avocado/soybean unsaponifiables) that makes the glucosamine and chondroitin sulfate more effective.

There is a Dasuquin made for cats also

NSAID’S

The non-steroidal anti-inflammatories (NSAID’S) are the most commonly used drugs in treating OA in dogs. We also use them in cats, but for a shorter duration. NSAID’s are highly effective and tend to be the drug of choice when we put your pet on actual arthritis medication. They are so effective we even use them for routine post operative pain control in dogs and cats. They have saved many a dog from long term pain, and even euthanasia.

NSAID’S work by inhibiting an enzyme in the inflammatory pathway, thereby providing analgesia (pain relief), antipyrexia (decreased fever) and reduced tissue swelling. The enzyme that is inhibited is  cyclooxygenase (abbreviated COX). This enzyme causes an inflammatory reaction in the joint fluid that surrounds the joint.

A common NSAID is Rimadyl. We use other NSAID’s in addition to this one.

Before we start your pet on NSAID’S we perform an examination and run a baseline blood sample. Every 6 months we will examine your pet and recheck the blood to look for any potential side effects. This will make sure kidney and liver function is adequate.

This pet has kidney disease, and the kidney problem needs to be addressed before we institute NSAID therapy. We would use a lower dose of the NSAID many times in a pet with kidney disease like this to make sure the NSAID is not making the kidney disease worse. 

Using NSAID’S alone is not recommended since the signs of arthritis are masked, leading to a more active dog and a quicker progression of arthritis. NSAID’S, in combination with weight loss and chondroprotective agents, provide cartilage building blocks in addition to pain relief, and may slow the progression of OA.

All NSAID’S carry a small risk of side effects, so careful observation of your pet while on one of these medications is important. If they occur, the most common side effects are vomiting and diarrhea. There might also be kidney and liver problems, and even bleeding. These side effects can be minimized by using the lowest dosage and frequency possible, giving the medication on a full stomach, and giving Pepcid AC  prior.

The best way to minimize the potential for side effects, yet still get the most out of NSAID’s, is to use the lowest effective dose of the NSAID of choice, and combine it with proper diet,  VNA and Companion Laser as additional treatments. You will learn more about these treatments below.

We do not routinely use NSAID’s in cats due to their potential to cause kidney damage. These cats do best with weight loss if they are overweight, J/D diet if they are not overweight, Dasuquin, VNA, and Companion Laser. A new NSAID for cats is called Onsior. It is approved for treatment of pain and inflammation for 3 days, so we use it routinely in our post operative cat patients.

The other primary NSAID we use in cats is called meloxicam (Metacam). It is used only for a few days due to the potential for problems with the kidneys.

VNA (also called VOM in the past)

An additional treatment modality that has yielded great success  for well over the last 20 years is called VNA. It has been a game changer for us in the treatment of arthritis in a wide variety of animals.

It is a non-invasive and non-painful way to stimulate the autonomic nervous system to help correct the problem. Through the use of VNA we can decrease the use of the above medications in almost all cases. By decreasing the use of these medications, we help your pet live a longer and healthier life, while decreasing you medication costs over the life of your pet. Click here to learn more about VNA.

This dog is getting VNA therapy for its arthritic spine

Cats respond very well to VNA treatment. They get what is called the “Feline Hyperesthesia Syndrome. In this syndrome, their lower backs are extremely sensitive, so much so that they start licking compulsively when scratched there, can bite an owner due to pain, and even go into a seizure.

Look how sensitive this cat is when scratched at its rear quarters

As we perform VNA the cat relaxes completely because the sensitivity is diminished

We use VNA in a wide variety of species. This rabbit has GI stasis, and felt much better after this treatment.

Companion Laser Therapy

In the last few years we have added a new and natural way to treat arthritis using the Therapy Laser. This modality has been used to treat people for over 30 years and has recently been approved by the FDA for use in animals. This treatment modality has been a huge boon to our geriatric pets with painful arthritis, especially when used with low dose NSAID’s and VNA.

To learn more about it please click here or on the picture below.

Acupuncture

This can also be used at any time to augment the treatment already being utilized. To learn more about how we use acupuncture follow this link.

Do you see the two acupuncture needles on this pet’s neck?

Miscellaneous Pain Medications

Galliprant

This is a prostaglandin antagonist that helps with pain and inflammation. It is used only in dogs.

Gabapentin

This seizure medication is another useful adjunct as the arthritis progresses.

Brupenorphine

Short term use can be effective for pain control.

Regenerative Medicine

What this is not doing is to generate new and healthly cartilage, as is a common misconception. What this treatment does is take a high concentration of growth factors and anti-inflammatories and bring them to an area of relatively poor tissue healing with the chance there will be a reduction on the inflammatory process.

Stem Cell Therapy- (Adipose Derived Stem Cells ( Ad-SCT ))

This promising yet unproven treatment utilizes stem cells from your own dog’s fat cells to alleviate arthritis symptoms. This means there is no chance of rejection, a major advantage of this technique.

Your dog has to be anesthetized for a short time in order to harvest the fat cells. Collection sites can be in many areas depending on your dogs conformation and fat reserves. Once the fat cells are harvested they are shipped overnight to the company that isolates the stem cells with a specialized technique. They are returned usually within 48 hours. We sedate your pet again and inject the stem cells into the affected area.

We will keep you posted as this promising therapy is given better scrutiny to make sure it has no deleterious effects in the long run and actually helps.

Platelet Rich Plasma (PRP)

This is a blood sample from your pet with a high concentration of  platelets without red blood cells (RBC’s) and some white blood cells (WBC’S). These platelets have growth factors and anti-inflammatory properties.

Rehabilitation

This can range from using wobble boards and exercise balls up to underwater treadmills. These can be beneficial, and we would send you to a veteriinary specialist to help determine if this will help in your pet’s case.

Here is the link to the Feline Musculskeletal Pain index. Please print it out and bring it in when we examine your cat.

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Liver Disease

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This page has a detailed description of this disease in dogs and cats (canine and feline). This page shows detailed information, with many links, of how we diagnose and treat liver diseases,  You will learn proper medical care with well established medical treatments, that also includes natural remedies with food and homeopathic treatments. Our pets cannot talk to us, so it is important that you understand this disease as much as possible.

The largest organ in the body is the liver, an indication of its importance in health. It is involved with almost all of the biochemical pathways that allow growth, fight disease, supply nutrients, provide energy, and aid reproduction. Liver cells, which are called hepatocytes, go through thousands of complex biochemical reactions every second in order to perform these myriad functions.

Since the liver is involved with almost all biochemical processes it is no wonder that there are many different diseases that will affect it. This page will cover some of the more important ones we see in animals. The beginning of this page will discuss liver anatomy and physiology, eventually leading to detailed explanations of the more common liver diseases we encounter. This complex organ does not lend itself to easy classification or understanding. Many of the functions of the liver overlap with other organs, and some of the liver’s functions involve complicated biochemical pathways. If this page is too complex for your needs you can go right to our summary page on liver disease.

Even though it makes for good reading, you can skip the anatomy and physiology section and go right to the section on specific diseases if that is all that interests you:

 


Terminology

It is helpful to be exposed to several medical terms that will be used later in this page:

hepatic- having to do with the liver icterus (jaundice) – yellow discoloration of skin or mucous membranes
hepatocyte- individual liver cell hypertrophy- increased size of an organ
hypoalbuminemia – low albumin polyuria- excess urinating
hypoproteinemia- low protein polydypsia- excess drinking
polyphagia- excess appetite PU/PD- polyuria and polydypsia
ascites- fluid buildup in the abdominal cavity gluconeogenesis- the manufacture of glucose
hypertension- increased blood pressure iatrogenic- caused by something a person does as opposed to happening naturally.
euglycemia- normal blood glucose (sugar) level homeostasis- normal physiology
hepatomegaly- enlarged liver septicemia- excess accumulation of bacteria and toxins in the bloodstream
hepatitis- a general term for inflammation of the liver parenchyma- the internal anatomy of an organ
encephalopathy- chemicals, like ammonia, that depress the brain laparotomy- exploratory surgery of the abdomen
anorexia- poor appetite H.E.- hepatic encephalopathy
metastatic- a tumor that has spread from elsewhere in the body microhepatica- abnormally small liver
cholestasis – excess bile accumulation in the liver

Next you will learn about Liver Anatomy

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Bladder Stones

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Stones in the urinary tract are common in dogs and cats. Even though dogs and cats do get kidney stones, it is bladder stones that cause more problems. The medical terms for bladder stones are urolithiasis or cystic calculi. We will use stone, calculi, and urolith synonymously in this page. The two most common calculi are calcium oxalate and struvite.

Stones can also occur in the kidneys, where they are called nephroliths. This page will limit its discussion to stones in the bladder.

Towards the end of the page we have a video on a surgery where we remove bladder stones with the laser.

Graphic pictures and videos on this page.

Cause

There are several factor, usually working in combination, that lead to urolith formation:

  • Mineral Crystals

    Urine that is saturated with excess amount of certain minerals is prone to form bladder stones. These minerals commonly include magnesium, phosphorous, calcium, and ammonia. Most stones consist of an organic matrix of protein surrounded by crystalline minerals.

    Diet can have a major impact here, and is one of the primary methods we use to treat and prevent uroliths.

  • Urine pH

    pH is an indicator of acidity by measuring the hydrogen ion concentration. A pH of 7 is neutral. Below 7 is acidic, above 7 is alkaline. As a general rule, dog and cats tend to have an acidic urine. Some uroliths have a propensity to form in acidic urine, while others tend to form in alkaline urine. Urine pH needs to be measure immediately upon voiding from the bladder for it to be accurate.

  • Bacteria

    Some uroliths form due to the presence of bacteria in the urine, so control of these bacteria is important. Bacteria are diagnosed by culturing the urine during a sterile urinalysis, or by culturing the inside of a stone after surgical removal. Normal urine is sterile, so any bacteria cultured from the urine is abnormal. When bacteria are cultured a pet has a urinary tract infection (UTI) and needs antibiotics. Common bacteria in UTI’s include E. coli, Staph. spp., and Proteus.

    If any bacteria are cultured in the urine our laboratory will test numerous antibiotics to determine which are the best ones to eliminate the bacteria. This is called sensitivity testing. We also do a test called MIC (Minimum Inhibitory Concentration) to let us know the best antibiotic to use and the best dose of that antibiotic.

  • Diseases

    Liver shunts are an abnormality of blood flow to the liver. Blood that would normally flow through the liver now bypasses the liver. One of the many consequences of this disease, called Portosystemic shunts (PSS), is the formation of ammonium urate bladder stones.

  • Medications

    Medications can predispose pets to forming bladder stones. Sometimes they do this by increasing the calcium level in the urine. Medications that increase or decrease the pH of the urine can also set the stage for stone formation. Some medications can actually cause formation of stones when used for long periods of time. The following list includes some of these medications:

    • Lasix
    • Cortisone
    • Ascorbic Acid (Vitamin C)
    • Sulfa medications
    • Tetracycline’s

Predisposing causes of bladder stones include pets that are not drinking enough or are not allowed to urinate frequently. Bacteria and stone forming chemicals stagnate in the urinary bladder and increase the chance of a stone forming. Mechanical flushing of the bladder, in the form of normal and frequent urination, will prevent this.

Always make sure your pet has access to fresh water, changed several times per day, and the ability to urinate frequently. As a matter of fact, if you feed dry food you should be giving more than one cup of water per cup of dry food. An easy way to get around this important requirement for water is not to feed dry food at all. Your pet’s urine should be clear, with no odor or color, and your pet should urinate every few hours. Sometimes these common sense suggestions are so obvious that we tend to forget about their importance.

Typical symptoms of bladder stones:

  • Straining to urinate (stranguria)
  • Blood in the urine (hematuria)
  • Urinating small amounts frequently (pollakiuria)
  • Often times there are no symptoms at all, and the problem is discovered on routine abdominal palpation or radiography.

There might also be excess urination (polyuria), pain in the rear quarters, reluctance to jump or play, or even lethargy and a poor appetite. Some pets can have bladder stones without any apparent symptoms at all!

The bladder stones can pass out of the bladder and lodge in the urethra, especially in male dogs due to the smaller diameter of their urethra. In some cases they can block the flow of urine, which is a medical emergency. This can cause problems with the kidneys, leading to the buildup of toxic waste products. Common areas for these urethral obstructions are the ischial arch near the pelvis and further down the urethra at the os penis. Both of these areas have small diameter urethras that do not expand to allow passage of a stone. You will learn more about this later.


Diagnostic Tests

  • Urinalysis

    A urinalysis is crucial in making a correct diagnosis. The pH of the urine, and the presence of bacteria or crystals all provide valuable information.

    Abnormalities that can be found in the urine in a pet with a urolith include:

    • Blood
    • Increased white blood cells
    • Increased protein
    • Crystals
    • Bacteria
    • Low or high pH

    The presence of crystals (crystalluria) is a sign that a urolith is possible, and usually warrants further investigation. At this point we might take radiographs, do an ultrasound, do a urine culture, or recheck it in the next few weeks or months.

    This is an example of a normal cat urinalysis. The pH is neutral, there are a few white blood cells (WBC’s) and red blood cells (RBC’s),  with calcium carbonate crystals, and no bacteria.

  • Urine Culture

    Bacteria are implicated in many cases of urolithiasis. Culturing the urine will let us know what bacteria, if any, are involved, and which antibiotic(s) will be effective. In addition to serving as a nidus for urolithiasis, these bacteria can ascend from the bladder into the kidneys, causing a pyelonephritis.

    This is a culture & sensitivity report we received from our lab. We sent them a sample of urine directly from the bladder, and asked them to let us know if there are bacteria in the normally sterile urine. The organism they cultured is E. coli, a common bacteria in both animals and humanoids. This bacteria is pathogenic in the bladder, and is causing a urinary tract infection. The lab tests numerous antibiotics and determines which antibiotic(s) E. coli is sensitive to.

As you can see from this culture, E. coli is resistant (R) to numerous antibiotics


After we have determined that bacteria are part of the problem our lab provides us with information on how effective antibiotics will be at the level of the bladder.

Radiography

One of the best methods to make a diagnosis of uroliths is radiography. Many stones are radiopaque, which means they show up vividly on an x-ray. Radiopaque stones include struvite and calcium oxalate. Some stones are radioulucent, and depending on size and number, do not show up on a regular x-ray. These stones are diagnosed by injecting air, dye, or a combination of both, into the bladder to outline any suspected stone. Ultrasound is a great way to detect these stones. Radiolucent stones include ammonium urate.

 

This is the side view of a dog with a very large radiopaque stone in its urinary bladder

 

This is a picture of the stone that was in the x-ray above

 

Other stones aren’t always this smooth. Even though this stone is small, the roughened edges were probably painful in this dogs bladder.

This dog has stones in the bladder and in the urethra as marked by the two arrows on the right. The arrow on the left is showing an enlarged liver lobe.

Click on any of these photos to make them larger

Did you notice the stones in the kidney also?

Radiographic appearance right after surgery to remove the stones in the urinary bladder

This radiograph is from a rabbit that has calcium carbonate sludge in its bladder. You can learn more about this and how we treat it from this link.

Ultrasound

Ultrasound is a very precise method to diagnose stones in the urinary bladder. It is particularly helpful for radiolucent stones and anatomical defects of the bladder wall.

OLYMPUS DIGITAL CAMERA

In this picture the bladder stone is demarcated by the two crosses.

This cat had blood in the urine and a urinary tract infection. There were no calculi in the bladder. Unfortunately there was a malignant cancer in the bladder called a transitional cell carcinoma. Surgery was performed to removed the cancerous portion of the bladder. What we originally thought was a urinary tract infection, with possible cystic calculi, turned out to be a more serious problem. This ultrasound finding, and subsequent treatment, emphasizes the importance of thorough diagnostics.

Bagel Freer Nichole bladder surgery TCC? Linda Larsen

Without the ultrasound we would have not found this tumor soon enough to treat.

 


Composition

We send our stones to the Minnesota Urolith Center at the Univ of Minnesota. They have more experience than any other place in the world regarding animal bladder stones.

minnurolith4

Bladder stones are compliclated, and made of many layers and compounds

minnurolith2

They give us a detailed report on the stone

minnurolith3

This is the protocol for a calcium oxalate stone to prevent recurrence

There are many different types of bladder stones. Some of the most common ones include:

    • Struvite

      This urolith is diagnosed in almost half the cases of bladder stones. It is also called MAP (Magnesium-ammonium-Phosphate), or triple phosphate. Struvite uroliths come in many different shapes and sizes, are radiodense, and form in an alkaline urine.

      It is the predominant stone type in female dogs of all breeds except Dalmatians. This is because of the high association of struvite crystals with urinary tract infections, which are more common in female dogs. If a female dog gets a bladder stone, 80% of the time it is struvite because of this association. Dogs under a year of age, no matter what  sex, get struvite as the most common bladder stone for this same reason. Miniature Schnauzers are the most commonly affected breed, along with bichon frise, cocker spaniels, and miniature poodles.

      Canine  urine is commonly supersaturated with struvite crystals due to the high protein and mineral content of current diets. This excess of these crystals in the urine, stored in the urinary bladder, combines with bacteria to set the stage from the formation of bladder stones (uroliths). Bacteria that are commonly implicated include Staphlycoccus, Enterococcus, and Mycoplasma.  These bacteria increase the amount of organic debris available for crystallization.

      These bacteria also produce urease as a by product of their metabolism. They  split the urea in urine into ammonia and carbon dioxide. As this ammonia is broken down it changes the pH of the urine from its usual acid (pH less than 7) to alkaline (PH > than 7). High urine ammonia concentrations in the urinary bladder can damage the glycosaminoglycans that help prevent the bacteria from adhering to the bladder mucosa (interior lining of the bladder). When we treat for this disease we address these issues.

      What does all of this mean?

Excess struvite crystals in the urine  set the stage for the formation of the urolith.

Urinary Tract Infection (UTI)- some bacteria produce a byproduct called urease. Urease will increase the pH of the urine and promote ammonium in the urine.

The formation of an alkaline (pH greater that 7.0) urine from the diet, or from urease producing bacteria, will cause the struvite crystals to precipitate out of solution and begin the formation of a urolith.

Urine that stays in the bladder longer than usual gives the struvite crystals further opportunity to precipitate out of solution and form a urolith.

    • Cats commonly form struvite bladder stones in the absence of a urinary tract infection. This is probably because cat urine is more concentrated (higher specific gravity) than dogs, so the urine is more saturated (we call this supersaturation) with magnesium, ammonium, and phosphate. This is especially true when the urine pH is highly alkaline, which can occur with the use of some drugs, in certain diets, and when the tubules of the kidney are diseases. If there is a bacteria involved it is usually Staphlycoccus.

Calcium Oxalate

This is the second most prevalent type of urolith after struvite, making up around 30-50% of the uroliths we diagnose, especially in male dogs of all species, except Dalmatians. They come in two versions; the monohydrate and the dihydrate. Sometimes the two are found together, sometimes they are found with other uroliths like calcium phosphate, struvite, or ammonia irate. They show up well on a radiograph. They form in an acidic or neutral urine (pH is 7 or just slightly less). Recurrence is common, so diligence on your part is needed to prevent recurrence.
Feeding an older pet with Kidney problems a food like Hills Prescription Diet K/D may slow or prevent further growth.
If this stone is small and not causing any apparent problem it can be monitored. Some pets will have high calcium (hypercalcemia) in the bloodstream.

Several predisposing factors work together to increase the chance of this urolith forming:

Increased calcium in the bloodstream (hypercalcemia)

Increased calcium in the urine (hypercalciuria) with no hypercalcemia

Concurrent Cushing’s disease

Use of cortisone for skin allergies or Addison’s (hypoadrenocorticism) disease.

Feline
These tend to occur in neutered middle aged cats and older cats, especially Burmese, Himalayan, and Persian breeds. One of the predisposing conditions might be an increased calcium level in the bloodstream. These uroliths tend to form in an acidic urine.
Canine

This is a problem most commonly in older male dogs. It is suspected that there is a correlation with hormone changes that occur as a pet ages. Several breeds are prone:

Miniature Schnauzer

Lhasa apso

Yorkshire terrier

Bichon Frise

Shih Tzu

Miniature poodle

Urate and Ammonium Urate

This is a common urolith found in Dalmatians around middle age, with males affected much more often than females. This is because they metabolize protein differently in the liver, with the end result being uric acid buildup in the urine. In addition to their high prevalence in Dalmatians, they are found in Bulldogs and Yorkshire terriers.
There does not seem to be a connection with a urinary tract infection, and they tend to form in an acidic urine.
Urate stones are radiolucent. If they get large or covered with other minerals they might become radiopaque. Urate calculi tend to be small and occur as several stones. These stones usually form in the bladder, and when passed through the urethra, can become lodged.

Ammonium urate uroliths are sometimes formed in pets with PSS (liver disease) due to improper metabolism of ammonia to urea. This will cause excess uric acid levels in the bloodstream. The kidneys filter out this excess uric acid in the production of urine, thus increasing the level of uric acid in the bladder. The excess ammonia that is in the bloodstream from the liver problem also builds up in the urine in the bladder. These two compounds combine to form the ammonium urate bladder stone.
Dogs with ammonium urate bladder stones might have ammonium urate crystals in their urine and a low specific gravity (dilute urine). These stones might not be seen on a radiograph because they are radiolucent. This same radiograph might also show a small liver, an indication of PSS. This small liver is due to the diverted blood flow to the liver. Dogs with PSS will commonly have abnormalities in the blood sample to give us further clues.

Compound Uroliths

Most bladder stones are caused predominantly by one type of mineral. The more common ones have been described above. In a small percent of cases, the bladder stone is caused by a combination of minerals in similar quantities. These stones are called mixed uroliths. Some bladder stones consist of a core mineral surrounded by a lesser amount of a different mineral in a different layer. These are called compound uroliths. Why some minerals form mixed uroliths and others form compound uroliths is not understood.
Compound uroliths form when the factors that predispose to one type of stone formation have now changed to factors that favor a different type of stone formation. If a struvite stone is treated with antibiotics and urinary acidifiers the problem tends to resolve. The change in urine pH might promote excess calcium in the urine, resulting in a shell of calcium oxalate formation around the core struvite stone. The opposite can occur also- a struvite stone can form over a calcium oxalate stone.
In general, these stones are removed surgically and an effort is made to medically prevent the mineral that is at the core of the stone.

Miscellaneous Uroliths

There are other uroliths that occur, although they are relatively uncommon. They include cystine, silica, calcium phosphate, and miscellaneous minerals.


Treatment

Struvite

Most cases of struvite are treated surgically. The procedure is explained below.

Struvite bladder stones can also be be treated medically with a food called Hills S/D. The mechanism involves creating a urine that is undersaturated with the crystals that caused the struvite urolith to form in the first place. This undersaturation literally cause the urolith to dissolve in the urine, and then get urinated out. It is a slow and gradual process, although most pets get relief from straining and blood in the urine soon after starting this diet.

S/D has several modifications in its ingredients to set up this undersaturated urine. Its reduced in protein, so there is less ammonia buildup in the bladder from bacteria. Magnesium and phosphorous are restricted also. With less contents of the minerals that form the struvite urolith (magnesium, ammonia, and phosphorous- MAP) the urolith starts dissolving.

S/D also has an increased amount of salt (sodium chloride). This promotes drinking and urination and literally helps flush the struvite crystals out of the bladder. It also changes the pH to a more acidic state, which further makes the struvite stone dissolve.

The rate of dissolution is proportional to the surface area of the stone expose to this now undersaturated urine and the control of the urinary tract infection in dogs.  Feline struvite stones tend to dissolve faster than canine because bacteria are not implicated.

We can measure the size of a stone with our digital x-ray to make sure it is getting smaller early in the process of dissolving it

S/D must be the only food fed for it to work. We can monitor whether or not an owner is doing this by looking at the pH of the urine along with the specific gravity of the urine. also, the BUN (blood urea nitrogen) of a pet on S/D should be lower than normal.

We have clues from other diagnostic tests to help decide if a urolith found in the urinary bladder on a radiograph is truly struvite. The urinalysis gives us an idea of the composition of the urolith by looking at the crystals in the sediment. The pH of the urine will be alkaline. Also, the presence of bacteria on a culture in a breed that is prone to struvite uroliths is also a strong indication.

If bacteria are found on a urine culture in dogs then antibiotics must be used simultaneously while a pet is on S/D. It must be the correct antibiotic, so the importance of the urine culture is obvious. Both S/D and antibiotics are used for one month after the stone is no longer visible on a radiograph. If there is a persistent urinary tract infection we might use a urease inhibitor called acetohydroxamic acid. Urinary acidifiers are usually not used.

If the urolith is still present after 2 months of S/D and antibiotics, then surgery should be performed. Most pets need to be fed S/D for 4-6 months for complete resolution. It should be fed for an addition 30 days after there is no longer any stone based on a radiograph.

S/D is restricted in protein, so it is not a complete diet for long term use in dogs. It also should not be used pregnant dogs, lactating dogs, ground dogs, and after surgery due to this protein restriction. While on S/D your dog’s blood should be monitored to ensure there are no side effects of the restricted protein.

Due to the high salt (sodium chloride) it should not be used in dogs with congestive heart failure and hypertension.

S/D diet tends to work faster in cats because bacteria are not usually involved. S/D should also be fed for 30 days after there is no more evidence of a stone in the bladder when radiographed. Feline S/D is not protein restricted, so it can be used for the rest of your cat’s life.

Calcium Oxalate

The only treatment for these uroliths is surgical removal. This is the easy part, its preventing their recurrence that is difficult. The protocol in how to do this was shown earlier.

Urate

If there is no PSS these uroliths can sometimes be handled medically also. A food called Hills U/D should be used. It is low in purines and has restricted protein. A medication called allopurinol is given which helps minimize the amount of uric acid produced in the urine. Potassium citrate is also used to make the urine less acidic, although this might occur with the use of U/D alone. Adding salt to the diet or mixing water with the food will also promote urination of the urate crystals. Recurrence is common, so this diet needs to be used for the life of your pet, especially in Dalmatians. We will talk more about this later in the prevention section.

Surgical Treatment

Many bladder stones are treated surgically.

We usually use the laser to make an incision in the bladder. Here is a link to how we do surgery at our hospital.

Many of these bladders are thickened from chronic irritation, which means they have an extensive blood supply. You will see that in the following photos. When you watch the laser surgery on one of these thickened bladders notice the blood supply and how little bleeding there is.

Surgery-Monitor

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem

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Once our surgeon has scrubbed up and is  in sterile gown, gloves, and mask, the surgery begins

The surgical removal of a stone in the urinary bladder is called a cystotomy. It involves making an incision into the abdomen, exteriorizing the urinary bladder, removing the stone(s), and resuturing the bladder. When we make the incision into the bladder the laser is used in almost all cases because of dramatically less bleeding during the surgery and dramatically less inflammation after we remove the stone and suture the bladder.  For those of us that have had surgery we know the importance of minimizing post operative pain. Your pet will be happy we used the laser!

The laser is a precise machine customized for each surgery. Watch how we set it up and how it checks its circuits and calibrates itself in this video

Laser-cystotomy

The initial incision of this thickened bladder with the laser. Notice the lack of bleeding, even though this is the second time these stones have been removed. Click on this link to see a short movie of this incision

 

Laser-cystotomystone

The actual calcium oxalate stone (there were 5 of them overall) removed from this bladder

A movie of this stone removal

 

The bladder is not the only location for stones to occur. This dog has 2 in its urethra at the tips of the black arrows.

 

A close-up view give better visualization. This is an example of stones that are lodged at the ischial arch, described previously in the symptoms section.

We passed a urinary catheter under anesthesia and started flushing the stones towards the bladder. Once they are in the bladder they can be removed via cystotomy.

In this view you can see how the stones have moved slightly from the flushing. It took 8 more flushings to move them all the way into the bladder.

This is a picture of the bladder during the actual flushing. The bladder has an incision in it because this dog also had a calculi in its bladder, which has already been removed. It takes significant force to move the stones from the urethra back into the bladder.

You can see the saline solution flowing out of the bladder towards the left (arrow)

How we suture the bladder after the stones are removed

These are the three stones that were removed- one was in the bladder and two were in the urethra

 

This is the stone analysis of the above uroliths verifying that they are calcium oxalate stones

The center of the stone was cultured. The culture yielded an organism called nonhemolytic coagulase negative Staph. This is the same bacteria that can be found on your skin.

This bacteria is sensitive (S) to 5 of the antibiotics on the list.

There is another common area for stones to lodge in the urethra of male dogs. Towards the end of the urethra male dogs have a boney structure that surrounds the urethra. This structure is called the os penis. In this area the urethra cannot expand to let a stone pass, hence stones commonly lodge here. This can prevent urination, with potentially serious consequences for the kidneys.

The white line outlines the urethra as it passes from the bladder, goes over the ischial arch and through the os penis. The arrow points to the beginning of the os penis, the area where a stone would lodge.

buddy1

The arrow points to a stone at the os penis

buddy2

It was flushed back into the bladder with a catheter. Here it is part way back.

buddy3

After a few more flushings it was pushed back into the urinary bladder, along with the other stones that are already in the bladder. It was removed doing a routine cystotomy.

buddy5

After the large stones we removed the smaller ones, which are hard to visualize in the bladder, are flushed out. This radiograph after surgery shows there are no more stones in the bladder.

buddy7

This is the stone that was originally stuck behind the os penis, and flushed back into the bladder. It is only a few millimeters in size, but with its rough appearance, is probably not very comfortable to say the least.

There are several sequelae to these stones in the urethra. If the urinary bladder has been distended long enough it loses its ability to contract and urinate properly. Nerve damage in the spinal cord can also cause this. The end result is an animal where the urine builds up in the bladder until the point it passively overflows and they dribble.  These animals are predisposed to chronic infections, not to mention the pain and discomfort of a distended urinary bladder.

This radiograph shows a dog with a seriously distended urinary bladder (UB). Its the large white area in the middle of the radiograph. The dark area to the left and slightly overlapping the front of the urinary bladder is the stomach (S) filled with food.

Prevention

Medical dissolution or surgical removal of the bladder stone is the first step in the process. The next, and just as important step, is the prevention of the stone’s recurrence. Some of these stones will require a diet change only, while others might require long term medication. Some breeds are predisposed to forming stones in spite of what we do to prevent them. Our doctors will set up a specific protocol for your pet based on the breed and type of stone removed.

Long term follow up is important. Your pet will have to return periodically to recheck a urinalysis, culture the urine for bacteria, and x-ray the bladder. Many stones recur because owners forget the importance of long term prevention.

At all times make sure your pet has access to fresh water and the ability to go to the bathroom. This treatment alone will go a long way to prevent recurrence. Giving your pet food that has more moisture will increase the flow of water through the urinary system and minimize crystal formation in the bladder. As a general rule, we do not recommend adding salt (sodium chloride) to the food to get your pet to drink more water because it might promote calcium formation in the urine, thus setting the stage for a stone to form. Your doctor will let you know if this applies in your case.

Struvite

Pets that have struvite urolithiasis, whether treated surgically or medically, have a chance of recurrence if not monitored carefully. If the urine is alkaline on a urinalysis it should be cultured to check for bacteria. Antibiotics are indicated if the culture is positive. If the pH stays alkaline in spite of antibiotic therapy, then Hills C/D should be used. It will help maintain an acidic urine, and has some mild restrictions in protein and minerals. As a general rule, we recommend C/D for all pets that have had struvite crystals. It can be used on a long term basis, and is helpful in preventing FLUTD in cats. S/D can also be used long term in cats.

If your dog gets recurring urinary tract infections, thus predisposing it to a struvite bladder stone, it is important to examine it for abnormal anatomy of the vulva, for obesity, and problems with the urethral sphincter.

Calcium Oxalate

Recurrence rates with this urolith are high, so a long term plan and commitment to sticking with it are important.

Baseline data consisting or radiographs, urinalysis, urine culture, and blood panel needs to be obtained. Particular attention is paid to the blood calcium level.

A diet with reduced quantities of protein, calcium, and sodium, that also does not make an acidic urine, is the ideal diet to feed. Too much of a reduction in these nutrients can be detrimental, so no supplements should be added. The primary diet in the cat that accomplishes this ideal is Hills Prescription Diet K/D. In dogs, K/D, W/D, and U/D are used. The use of U/D might preclude the use of potassium citrate as long as there are not calcium oxalate crystals in the urine and the pH is alkaline. There is a C/D that treats calcium oxalate uroliths in cats.

Certain foods that are high in oxalates or calcium, or foods that increase calcium levels, must be avoided. They include high protein foods, spinach, rhubarb, parsley, milk products, and table salt.

When we diagnose a calcium oxalate stone we will check the calcium level in the bloodstream to make sure it is not abnormally high. This normal calcium level was from the dog above that had the surgery to remove the calcium oxalate stones from its bladder and urethra.

Vitamin C and D, along with drugs that make the urine more acidic, should not be added to the diet. Cortisone also should be used cautiously because it increases the calcium level in the urine.

Potassium citrate will inhibit calcium oxalate crystal formation and keep the pH of the urine in the ideal range. We will use this if U/D does not keep the urine alkaline.

After surgery your pet should return in 2 weeks for a urinalysis. If there are calcium oxalate crystals in the urine we will add potassium citrate as per above. If there are no crystals we will not need to do a recheck for 3 months. At this 3 month recheck of the urine we will also re-radiograph the bladder and check a blood panel noting the calcium level.

Two weeks after surgery this is the urine sample of the dog with the above stones. This is what we want to see- no crystals, no bacteria, and an alkaline pH.

If calcium oxalate crystals persist in the urine 2 weeks after adding potassium citrate, we will add Vitamin B6 to the diet. If the B6 does not eliminate the crystals, we will use a drug called hydrochlorothiazide. Use of this drug requires close monitoring of the potassium level and the calcium level in the bloodstream.

A urinalysis should be performed every 3-6 months to look for crystals in the urine and monitor the pH. A urine culture should also be performed at this time to decide if antibiotics are needed.

Ammonium Urate and Urate – Medical care for Dalmatians after surgery includes:

  1. Increasing water consumption so the specific gravity of the urine is near 1.018. adding water to dry food, feeding more canned food, and adding encapsulated light salt (KCl) all will help.
  2. Feeding a diet low in purines. Diets low in purines include the Hills Prescription Diets K/D or U/D dry and U/D canned.
  3. Increasing the pH of the urine to 7.0-7.5. The above diets might accomplish this pH. If not, adding oral potassium citrate to the diet will help.
  4. Controlling urinary tract infections, if any, by performing urine culture and sensitivity tests every 3-6 months, and using antibiotics on a long term basis if needed.
  5. Adding allopurinol to the diet to prevent the conversion of purine to uric acid.This therapy needs to be followed diligently for the life of your Dalmatian.

Medical care for cats and non-Dalmatian dogs after surgery is similar. Most of these uroliths are caused by a PSS, thus surgery to correct the liver problem will help prevent the recurrence of these stones in the bladder. In some PSS’s the liver problem cannot be completely resolved, adding to the risk of formation of these bladder stones in the future. Long term therapy is similar to Dalmatians:

  1. Increasing water consumption so the specific gravity of the urine is near 1.018 for dogs and 1.025 for cats. adding water to dry food, feeding more canned food, and adding encapsulated light salt (KCl) all will help.
  2. Feeding a diet low in purines for dogs. Diets low in purines include the Hills Prescription Diets K/D or U/D dry and U/D canned. For cats feed diets that do not acidify the urine, which unfortunately, many do to prevent FLUTD.
  3. Increasing the pH of the urine to 7.0-7.5. The above diets might accomplish this pH. If not, adding oral potassium citrate to the diet will help.
  4. Controlling urinary tract infections by performing urine culture and sensitivity tests every 3-6 months, and using antibiotics on a long term basis if needed.

Compound Uroliths

Since these stones have a combination of minerals they present a dilemma in their prevention. In general, it is recommended that an effort is made to prevent the mineral that forms the core of the stone.

The majority of compound stones are struvite core with a calcium phosphate outer core.

An additonal treatment modality, used especially after we remove the urolithiasis is VNA. It is a non-invasive and non-painful way to stimulate the nervous system to increase blood flow to the kidneys. This will increase urine output, making it more difficult for the stone to start all over again. It is a highly effective way to help prevent the problem from recurring.


Dietary Information

Pet food manufacturers have dramatically increased their sophistication in treating bladder problems in dogs and cats. It is because of these advances that we are able to treat and prevent many of these uroliths medically. Unfortunately, a change in food to treat struvite uroliths predisposes a pet to calcium oxalate uroliths, and vice versa. One of the ways we have gotten around this is to produce a food in cats, called C/D multicare, that prevents both. There is even a C/D stress diet for cats in multiple cat households, or those prone to stress.

In order to remedy this situation it is important to make a correct diagnosis so that the proper type of food can be used. To ensure that you are not setting up an environment for a different urolith to form in the future, the urine should be monitored every 3 months.

Another remedy is to use combined diets that have been formulated to take care of both of these calculi simultaneously. This might help if compound uroliths are present.

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Sarcoptic Mange (Scabies)

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Sarcoptic mange (cats get a version called notoedric mange ), commonly know as scabies, is caused by an external parasite called Sarcoptes scabei  that burrows deep into the skin. It commonly occurs in dogs, not so commonly in cats, unless is it notoedric mange), also occurs in foxes, ferrets, rabbits, sheep, goats, cattle, pigs and guinea pigs.

It is contagious to other pets and occurs in many different animals. It causes intense itchiness, especially affecting the ear margins, elbows, and face. People can pick up this disease from their pet and show symptoms of itching, but it goes away by itself in many cases and usually  does not require treatment in most cases (always check with your doctor).

It is important to note that the diagnosis of this skin condition, like most skin conditions, cannot be made just by looking at a pet. Diagnostic tests are mandatory to arrive at a correct diagnosis and achieve a satisfactory outcome to therapy. Stating that an animal looks “mangey” is not the same thing as making a positive diagnosis of mange. Pets that have Ringworm , Demodex. and allergies can look like they have Sarcoptic mange.

 Life Cycle

This ectoparasite spends it life cycle of 14-21 days entirely on the host it has infected.  Overcrowded conditions increase risk for transmission. Stress from many sources can also be a factor.

History

The following history for an itching pet with sarcoptes usually involves:

  • Severe itching that is non-seasonal
  • Recently adopted or boarded pet
  • Multiple pets in the house
  • Humans in the same house that are itching with red lesions on their skin.

 Symptoms

In dogs most of the symptoms involve intense itching at the ear margins, elbows, hocks and abdomen. Less common areas of itching can include the face and feet. This itching will inflame the skin and cause scabs, with a secondary bacterial infection (pyoderma) occurring due to the trauma. Some pets will shake their ears excessively and cause an aural hematoma (swollen ear). These symptoms can mimic those of other skin conditions, so the rules of the diagnostic process should be carefully adhered to.

Other symptoms that might be present sometimes include:

  • Lethargy and depression
  • Lack of appetite
  • Weight loss

Cat mange (notoedres cati)

In cats, sarcoptic mange is caused by a mite called notoedres cati, a microscopic ectoparasite that burrows in to the skin. It is not as itchy, and occurs more often on the face, ears, paws, and tail.

This is a highly magnified view of notoedres cati as it appears under the microscope

This cat has scabies, but you can’t say that for sure just by looking at it

The top of his head shows how irritating the problem is, especially at the ears

Diagnosis

The primary way to diagnose sarcoptic mange is to do a skin scraping where the patches of alopecia occur. Finding these mites, their eggs, or their feces,  under the microscope can be very difficult in this disease. a pet that has the symptoms of Sarcoptic mange and is negative on skin scrapings for the parasite can still have the disease. In these cases we commonly treat for the disease anyway, because the treatment is highly effective.

In rare cases we will do a skin biopsy, which is a great way to rule out other diseases that have similar symptoms.

Other diseases in dogs that mimic scabies include:

  • Folliculitis
  • Malassezia (fungus)
  • Allergies
  • Contact dermatitis
  • Cancer
  • Pemphigus (immune system disease)

Diseases in cats that mimic scabies include:

  • Demodectic mange
  • Otodectic mange
  • Cheyletellia
  • Herpes dermatitis
  • Allergies

Treatment

The usual treatment for Sarcoptic mange is a drug called Ivermectin. It is an injection given weekly for up to 6 weeks. Most pets decrease their scratching rapidly after the first injection. Some dogs, particularly Collies, Shetland Sheepdogs, and Old English Sheepdogs, do not tolerate the medication well. In these pets we use a dip called Lyme Sulfur that is also very effective.

The disadvantage to the dip is the odor it causes and the staining of white coated animals. All pets in a household should be treated regardless of whether they are showing symptoms or not. Pets that have secondary skin infections from the trauma might also be put on antibiotics. Other common treatments include Revolution (selamectin) topical.

Other pets in the same household are commonly treated if they are in close contact. Treating the environment is usually not needed if all pets in the house are treated.

Some pets itch more in the first few days of treatment due to dying mites. These pets can be put on low dose cortisone for a few days in a reducing dose to get over this phase.

This dog has scabies

This is a picture from the dog above 7 days after its first Ivermectin injection

Prevention

Good nutrition and plenty of play and exercise are always important to maintain the proper balance to fight off disease. All pets in a household that has a pet diagnosed with this disease should also be treated.

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Seizures (Epilepsy)

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One of the most disturbing things to witness in an animal is a seizure, the most common neurologic problem we see in our hospital. It can traumatize the person witnessing it, and always seems to go on forever. Unfortunately, it is not uncommon for animals to have seizures, particularly dogs. Fortunately, the overwhelming majority of seizures are not life threatening, and most dogs can live a relatively normal life. Cats and other species also get seizures, but not as frequently as dogs.

This page will give you a complete explanation as to the cause of these traumatic episodes, and how we diagnose and treat them. The overwhelming majority of dogs that are seizuring have epilepsy, so we will emphasize this disorder when discussing treatment.

Here are some medical terms we will be using:

neuron- nerve cell ictus- an actual seizure
idiopathic- unknown cause postictus- period immediately after a seizure
hypoglycemia- low blood glucose (sugar) status epilepticus- continuous or clusters of seizures
hypocalcemia- low blood calcium level epilepsy- brain disorder characterized by seizures
aura- initial manifestation of a seizure EEG- electroencephalogram
syncope- a heart problem that mimics a seizure Depression- not as alert as usual
Dementia- dull or emotionless Stupor- semi conscious, asleep often, hard to arouse
Coma- Unconscious, unable to arouse at all CSF (cerebrospinal fluid)- normal fluid in the brain and spinal cord

Normal Anatomy & Physiology

The profound complexity of the brain precludes us from going into significant detail regarding anatomy and physiology. You would need to be a neuroanatomist to even begin to understand its basics. The basic unit of the brain is called a neuron, which is a specialized nerve cell. Some of these nerve cells process information, others cause a reaction. For example, your eyes, which are an extension of your brain, process images. Other neurons cause the muscles in your eyes to move in response to movement.

In all cases, there are millions upon millions of neurons in the brain, all with complex connections to each other. It is these connections that leads to the complexity and the sophistication of the mammalian brain. Unfortunately, when a neuron has a problem, these connections can let this problem spread elsewhere. If an individual neuron has is a seizure, the seizure activity in this one neuron can easily and instantaneously spread to other neurons, leading eventually to a generalized seizure.

As a rough comparison, the mammoth power failure that occurred in the Northeast U.S. in august of 2003 shows how a small problem in one area can rapidly spread to other areas. Multiply all those electrical lines and power stations with their connections by a million times, and you start approaching what occurs every second in the mammalian brain. It is beyond human comprehension to understand the complexity of all of these connections.

Pathophysiology

Seizures (fits, convulsions) are caused by abnormal activity in the brain cells, particularly in the frontal and temporal lobes of the cerebral cortex. When a neurons fires off in a seizure, it sets off a chain reaction in other neurons, and the seizure spreads. If this chain reaction stays within a specific location, a partial seizure might occur. If it spreads to occur on both sides of the cerebral cortex, a generalized seizure, the most common type of seizure, might occur.

Characteristics

  • Aura

    Behavior just prior to a seizure. Typical behaviors include panting, pacing, barking, and restlessness. Ranges from several minutes to several hours prior to the actual seizure.

  • Ictus

    The actual seizure, characterized by involuntary muscle tone and movement. Lasts from seconds to minutes, although it seems like hours when you are observing it.

  • Postictus

    Period immediately after seizure, characterized by disorientation, unusual behavior, appetite change, or weakness. It can last up to several days.

Classification

  • Generalized

    This is the most common seizure encountered in dogs and cats. Nerve cells on each side of the cerebral cortex start discharging, causing all parts of the body to be affected. Even though the original source of the seizure is usually only a small number of neurons on one side of the cerebral cortex, the discharge of these neurons causes other neurons to discharge also, eventually causing the seizure to be generalized.

  • Partial (focal)

    This seizure also starts as a small number of neurons, yet in this case it does not spread far beyond these initial neurons. Symptoms that are seen depend on which neurons are discharging. It can affect motor areas, causing involuntary movement, or it can affect areas of the brain involved with behavior, causing intermittent behavioral changes. Eventually this type of seizure can progress to a generalized seizure.

This movie is typical of a pet having a partial seizure.
Double Click Here to view the movie

Cause

Idiopathic (epilepsy, primary, genetic, true, inherited)

The word “idiopathic” means that the cause is unknown. It is also known as epilepsy in humanoids. It is a diagnosis of exclusion- if all the other causes of seizure are eliminated, then this is the cause. This is the most common type of seizure, and occurs in up to 2% of all dogs, relatively rare in cats. Any dog breed can be affected, with the larger breeds having more severe seizures. In general, we see it more often in purebred animals. The more common breeds are:

  • Alaskan Malamutes
  • Cocker and Springer spaniels
  • Beagles
  • Collies
  • Boxers
  • Dachshunds
  • Dalmations
  • German Shepherds
  • Golden and Labrador retrievers
  • Irish Setters
  • Mastiffs
  • Schnauzers
  • Poodles
  • Saint Bernards
  • Siberian Huskies
  • Vizslas
  • Australian Shepherd
  • Border Collie

In the large breeds seizures tend to be more severe. In the Border Collie and Australian Shepherd there is a severe genetic epilepsy present, and these dogs need to be started on seizure medication when seizures first start.

Secondary

Secondary seizures causing epilepsy occur when there is a structural abnormality in the brain.

Hydrocephalus

This disorder, sometimes know by its more common name of “water on the brain”, occurs in small breed dogs and sometimes cats. It is the excessive accumulation of cerebrospinal fluid (CSF) in the brain. The pressure from the fluid causes the seizures. It is not a problem that is easily corrected, and usually requires lifetime medication. Surgery can be used in select cases, but is not always effective. Pets with severe symptoms early in life have a guarded prognosis.

Common dog breeds that get hydrocephalus:

  • Chihuahua
  • Yorkshire Terriers
  • Maltese
  • Pomeranian
  • Lhasa apso
  • Toy Poodle
  • Pug
  • Pekingese
  • Boston Terrier

The most common symptom with this disorder is behavioral. If seizures occur, they start early in life.

Brain Tumor

We tend to encounter brain tumors in middle aged and older pets. Some arise directly from brain tissue, others spread to the brain via the bloodstream (since the brain has an extensive blood supply). Strangely enough, its not the neurons (brain cells) that become cancerous, it is the cells supporting the neurons, called glial cells, that cause the problem.

Tumors that arise directly from the brain include:

  • Astrocytoma
  • Oligodendroglioma

Symptoms of brain tumor depend on exactly where in the brain they arise, and how fast they grow.

Brain tumors are best diagnosed with an MRI.

Most brain tumors are treated medically- surgery is used only on rare occasion. The progress is poor if your pet has a brain tumor.

Can you see the large tumor in this brain?

Trauma

Pets that have fallen and hit their heads can develop scar tissue in the brain when they heal, leading to seizures later in life.

Stroke

More correctly called “vascular disorders”, they involve damaged blood flow to the brain. The neurons that are normally nourished by these blood vessels can now have a problem.

Viral Disease

Rabies and Distemper are both viral diseases that can cause seizures in dogs.

Reactive Seizures

In this type of seizure the brain is reacting to a problem elsewhere in the body.

  • Hypoglycemia (low blood sugar)

This puppy has coccidia parasite, causing its blood sugar to plummet

  • Hypocalcemia (low blood calcium) This video shows an Iguana with twitching muscles caused by hypocalcemia. It is not a seizure. We show it to give an idea of how the bodies neurologic system is affected by hypocalcemia. You can learn more about this Iguana’s problem, which is called Metabolic Bone Disease

    Click Here to watch a Iggy

  • HypothyroidismA low thyroid level, called hypothyroidism, can precipitate seizures.
  • Kidney diseaseThe buildup of waste products in the bloodstream, called uremia, can cause seizures. Our Kidney Page has extensive detail on this problem.
  • Liver disease – Hepatic encephalopathy, a disorder of blood flow into the liver, can cause seizures. Our Liver Page explains it in much more detail.
  • Poisons The vast number of toxins that can cause seizures precludes us from going into detail on each one. One of the most common ones we encounter in our practice is Metaldehyde, also know as snail bait poison. Snail Bait Poison The active ingredient in this product is metaldehyde, a potent drug that will cause seizures in animals. There is no specific antidote- pets need to be sedated to stop the seizures, induced to vomit to rid the stomach of this poison, and even have their stomach flushed if necessary. After this initial treatment to prevent further absorption of the metaldehyde, we will give your pet intravenous fluids, sedate and even anesthetize it, check a blood panel for damage to internal organs, and monitor its life signs. If a dog that eats snail bait poison is brought to us immediately we can usually help them. This is a short movie of Eddie the morning after he was treated for snail bait poisoning. Notice how unsteady he is (called ataxia) when he lands after jumping up. His seizures are gone but he is still suffering the effects of the poison the next day

    Click Here to see Eddie

  • Other toxins that can cause seizures include:
    • Lead Poisoning-found in old paint, putty, tile, linoleum, used motor oil, drapery weights, bullets, and fish sinkers
      • Organophosphates and Carbamates – found in many different insecticides
      • Pyrethrins- found in insecticides
      • Strychnine- found in rat poison
      • Chocolate
      • Ivermectin- found in antiparasiticides
      • Mitaban- found in Demodex mange mite treatment
      • Caffeine- found in chocolate and NoDoz
      • Ethylene Glycol- found in antifreeze
      • Fungus
      • Some fungi can affect the brain and cause seizures. One of them is called cryptococcus.

This cat was negative for Cryptococcus

Non epileptic Seizures

Syncope

Dogs that have heart disease with an abnormal heart beat (called an arrhythmia), can pass out in a manner that looks just like a seizure. Sometimes syncope can be difficult to differentiate from a seizure. In syncope, a dog does not usually exhibit the motor activity (paddling) or urination/defecation symptoms seen in a seizure. This is one of the may reasons we follow a rigorous approach to the diagnosis of any disease.

Seizures in Cats

Cats have seizures much less commonly than dogs, and they don’t seem to have generalized seizures as often. Seizure symptoms that might occur in cats include:

  • Facial twitching
  • Salivation
  • Attacking invisible objects (although this can be normal behavior in some cats)
  • Running frantacially as if something unknown is chasing them
  • Colliding with objects (also ban be a normal behavior)

Secondary epilepsy tends to be more common in cats. In addition to the causes in dogs, common causes in cats might also include:

Depending on the cause, they are treated in a similar fashion.

In both dogs and cats we also classify seizures as to their cause when making a diagnosis. Those that occur directly in the brain are called intracranial. Examples include brain tumors, CNS infections and inflammations. Those that occur primarily outside the brain are called extracranial. Examples include hypocalcemia and hypoglycemia

Symptoms

Seizures commonly start while your pet is sleeping. Typical symptoms in a severe, or grand mal seizure, include: Falling

  • Loss of Consciousness
  • Extension of the limbs
  • Paddling of the limbs
  • Chomping at the jaws
  • Dilated pupils
  • Excess salivation
  • Defecation
  • Urination

Behavior changes during a milder seizure include:

  • Fear
  • Hysteria
  • Aggression
  • Barking or meowing
  • Hiding or cowering

In milder seizures your pet might remain conscious, and appear anxious or walk like it is drunk. Even though people like to compare this to “petit mal” seizures in people, it is not the same thing. Milder seizures might last for a few minutes, or could go on for hours, maybe even leading to a generalized seizure.

Pets appear to have an aura (preictal) prior to a seizure. They might be restless, seek attention, try to hide, whine, or tremble. After their seizure (postictal) they might show similar symptoms, even blindness, aggression, or sleepiness. The postictal stage lasts a variable period of time, up to hours after the seizure.

Diagnosis of seizures in dogs and cats

In most cases, by the time we examine a pet that has seizures, the seizures are no longer present. It is important to follow the tenets of the diagnostic process closely when making a diagnosis of seizures, especially since the syncope that occurs with heart disease mimics a seizure. A large part of the diagnosis in this disease is based on history, which you learned about when your linked to thediagnostic process page.

Signalment

Idiopathic seizures occur in any age dog or cat, particularly the breeds previously mentioned. Usually a dog with idiopathic epilepsy is between 1-3 years of age. Dogs not in this age range have a greater potential for secondary seizures as their cause.

History

Exposure to toxins, a prior history of head trauma, or concurrent diseases like liver and kidney disease, give us a clue to seizures and their cause. It is important to differentiate syncope from seizure, since some cases of syncope can look like your pet is having a seizure. If we suspect syncope we will perform tests to analyze the heart and lungs. You will find these tests in our heart page.

Physical Exam

In most cases the physical exam is normal. This is because most seizures are caused by idiopathic epilepsy. If your dog has a seizures caused by a brain tumor or infection/inflammation in the central nervous system (CNS), we might see neurologic signs like uneven pupils.

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This is a picture of an adult dog with diseased teeth, which might be an indication of Distemper when it was younger

In some cases of Distemper the pads might be thickened

As part of the physical exam on of our doctors might feel a need for a more detailed neurologic exam. Things that might be checked are:

  • Mental status – alert, depressed, unresponsive to stimuli, comatose, circling, head pressing, behavior change and disorientation
  • Cranial Nerves – menace response, pupillary light reflex (PLR), eyeball deviations (strabismus, nystagmus), oculocephalic reflex
  • Postural reflexes – conscious proprioceptive (CP), tremors, gait, extensor thrust, and wheelbarrowing
  • Spinal reflexes – pelvic limb (patellar reflex and perineal reflex), thoracic limb triceps reflex and biceps reflex)
  • Muscle – mass and tone
  • Pain and tactile reflexes – deep pain and light touch reflexes
  • Cutaneous trunci reflex
  • Tail tone

Diagnostic Tests

A Blood Panel and Urinalysis might give us a clue as to the secondary or extracranial cause of seizures. Careful interpretation is needed. If a dog has a low blood sugar (hypoglycemia) on the blood panel, it might be because the seizure activity has depleted its stores of glucose, not because it has hypoglycemia. This is why sometimes its a good idea to perform the exam well after a seizure has occurred, and the body has a chance to get back to normal.

Our routine blood panel also includes a thyroid check to make sure the level is not too low, which can precipitate a seizure.

Radiographs

Radiographs of the head of dogs and cats are complex compared to humanoids. There is a much smaller brain to view, the bones are more massive and overlapping, and there is great degree of variation among breeds. They can be used to diagnose hydrocephalus, trauma, or cancer, although they can’t be relied upon in most cases.

If we radiograph the hey can help us identify a secondary cause of seizures like an enlarged liver or kidney. We can sometimes see cancer on a radiograph as it has spread from its primary location to other parts of the body, particularly the lungs and lymph nodes. We might note fluid in the abdomen (ascites), an indication that a cat has FIP.

CSF Pressure

When a pet has a brain tumor there will be increased pressure within the central nervous system (CNS). This increased pressure, when it occurs, is measure by performing a spinal tap, and measuring the pressure with a manometer. Fluid that is obtained this way (called cerebrospinal fluid) can also be analyzed for inflammation and infection by our pathologist. This is how we diagnosis meningitis and encephalitis.

MRI

One of the most accurate and efficient ways to diagnoses the cause of a seizure, especially if there is a brain tumor, is Magnetic Resonance Imaging (MRI). It is also used to diagnose hydrocephalus, and blood vessel problems in the brain. If you double click on the picture below you will view a series of “slices” of the brain. The first picture shows a side view of a dog’s brain, and gives you an idea of the “slices” as the pictures continue on through the brain. This dog’s nose is on the far left. In slices 6-10 it will be obvious there is a problem when you see the large white mass in the middle of the brain – that is a tumor.

Click here to view a movie on MRI sequence

Treatment

In most cases by the time you can bring your dog to us for treatment the seizure has subsided. If your pet experiences a seizure, move any furniture out of the way, move things like lamps that might fall, remove other pets from the area, make sure it cannot fall down any stairs, and let the seizure run its course. Most will run their course within 1-2 minutes. Do not put your hands in your pets mouth to prevent it from swallowing its tongue- all that will do is get you bitten severely. If your pet turns blue during a seizure it is because its muscles of respiration (ribs, diaphragm) are locked, and it is not breathing temporarily. This problem will resolve itself, unless the rare occurrence of status epilepticus is present. Have a crate or airline carrier present to bring your dog to your veterinarian.

One rare but serious type of seizure is called status epilepticus, where the seizure lasts more than 5 minutes, it doesn’t stop at all , or it stops but returns soon after. This is a medical emergency, and requires the use of injectable medication, and even general anesthesia, to prevent it from progressing to a life threatening problem. If your dog is experiencing this problem call us immediately. If we are not available for some reason, you should have information at hand for a 24 hour emergency hospital close to you that will take care of you.

Idiopathic

Idiopathic epilepsy cannot be cured, only controlled, and once treatment is started, it is lifelong. Most dogs respond well to anticonvulsant medication give orally.

Deciding when to treat idiopathic epilepsy is just as important as how to treat. Some dogs only have 1 or 2 seizures per year, and don’t require treatment. Some dogs have seizures weekly or daily, and require treatment. Other dogs can be in the gray zone. They might have a seizure every 1-4 months, so making a determination to treat them is not so clear cut. If these dogs with infrequent seizures start having them more frequently, then we recommend anticonvulsant medication. As a general guideline, if your dog as 2 or more seizures in a 6 month period we should start an anti-convulsant therapy. The sooner we start on these dogs the better the long term outcome.

In some breeds the seizures will increase in severity, so it is wise to treat when seizures first appear and try to prevent this problem. This applies to Border Collie’s and Australian Shepherds. In these breeds more than one seizure medication needs to be started earlier in the course of disease if the first medication does not work well.

Every dog is different, and what works in one dog might not work in another. Doses sometimes need to be adjusted, and even combination therapy with several different medications might be needed to control the seizures.We don’t start a second seizure medication until we are sure the first medication is at optimum therapeutic levels with a blood panel.

These medications will take several days to take affect, so a seizure during that time might occur. Never abruptly discontinue them. Our goal is to balance seizure control with quality of life, using minimal medication. In most cases of idiopathic epilepsy we are able to achieve this goal, at least initially. Some dogs with epilepsy do not respond to medication.

Monitoring serum levels of anti seizure medications is important for the following reasons:

Determine effective drug concentrations after we have started treatment

Determine if a drug failure is due to a low level of the drug in the blood stream (inadequate dose), or if it is due to a drug that is not working, no matter what the dose.

Determine if treatment failure is caused by poor compliance

Prevent toxic effects if level is too high

Allows individual treatment

Phenobarbitol

One of the most common and effective medications for epilepsy is phenobarbitol, given twice to three times daily. The overwhelming majority of dogs are maintained at twice daily dosing in our hospital. It takes several weeks for the blood level of phenobarbitol to reach adequate levels, so there might be an occasional seizure during that time. Phenobarbitol works in the majority of dogs, is inexpensive, and safe, so it is widely used. The dose of this drug has a wide range, so if your dog is not responding to phenobarbitol, and the blood level of the drug is low to normal, we might increase the dose. Doses are changed gradually since it takes time for the effects of this drug to become apparent. An injectable version of this drug given intravenously (IV) to stop status epilepticus.

Never give your dog oral phenobarbitol if it is experiencing status epilepticus as described above- it needs to be seen by a veterinarian immediately. Never put your hands in the mouth of a dog having a seizure because you believe it is swallowing it’s tongue because it is turning blue. It is not swallowing it’s tongue, and all you will end up doing is getting injured.

Some dogs will be sedated initially, but may eventually return to normal activity. Other dogs might drink and urinate more than usual, and have an increased appetite. In rare cases the liver will become toxic due to this drug. This is why we check a full blood panel every 6 months while your pet is on this medication.

Phenobarbitol levels can be measured in the bloodstream, and are an important guide to proper dose of this drug. This will make sure we are at adequate levels in the bloodstream. One of the reasons a dog might continue to have seizures while on phenobarbital is an inadequate blood level. In this case we adjust the dose.

We recommend performing the phenobarbitol check every few weeks to months for the first few months of therapy in order to get an idea of how your pet reacts to the medication. The phenobarbitol level is interpreted in conjunction with the amount of seizures that is occurring. All adequately controlled dogs on long term phenobarbitol should have an exam, blood panel with urinalysis, and phenobarbitol level checked every 6 months at least. Dogs can become refractory to phenobarbitol, so it is imperative you give the medication as prescribed and monitor carefully so we can decide the best course of action in this case. It is not uncommon to have to increase the dose in some dogs.

When giving this medication on a twice daily basis it is important for busy households to give the medication as directed. Using a dedicated calendar to help you know when the next dose is due, along with monitoring seizure activity, is the best way to prevent inadequate dosing, especially when several people are involved with treatment. It is not unusual for dogs to spit out the pill on occasion, so always verify it went down the hatch. If you have trouble at any time giving this medication our nurses will assist you. They can review proper administration techniques, and will even give the medication for you in our hospital if necessary.

If your dog has gone over 1 year without a seizure me might slowly lower the medication over several months, and even stop it completely on a trial basis. This does not apply to every breed of dog.

Phenobarbitol has been around for a long time, so the price makes it the most cost effective anti seizure medication.

Imepitoin

This is another good first time treatment like phenobarbital. It is not easily monitored with a blood test to see if it is at a propper theraeutic level in dogs.

Keppra (levetiracetam)

This anti-seizure medication is used commonly as an additional drug given simultaneously when the first drug was not effective. It does not do as well when given by itself in the dog.

Potassium Bromide

This drug is used as a first drug for dogs with with a low initial frequency of seizures. If a dog is on phenobarbitol, and it is not adequately controlling seizures, even as we increase the dose, we will sometimes add this drug to the treatment regimen instead of Keppra. It can sometimes take several months for this drug to achieve enough potency in the bloodstream to prevent seizures. Whenever we have a dog on both medications we start dosing conservatively, and make changes gradually so the body has time to adjust.

It is also monitored with a blood sample periodically in a similar fashion to phenobarbitol.

Side effects can be similar to phenobarbitol, and also include an unsteady gait and inflamed pancreas (called pancreatitis). Liver toxicity to this drug is not usually a problem, so we can use it in cases where phenobarbitol is working but might be affecting the liver. Give it with a meal to prevent an upset stomach, and don’t change your dogs diet abruptly because salt in the diet influences how potassium bromide is absorbed.

Valium

Valium is given intravenously (IV) to dogs with status epilepticus. It is usually the drug of choice in status epilepticus because it is so effective. We might also give you a valium solution, to be given via rectum if your dog starts the continual seizure seen in status epilepticus. This gives you an effective treatment at home if this occurs, although if it does not work you need to seek medical care immediately.

In cats we sometimes use oral Valium (diazepam) as the first drug to control seizures. It is inexpensive and works well, although it might cause sedation.

Alternative Treatments

Vagal nerve stimulation, in 2 small studies, showed a significant (34%) decrease in seizure frequency in a population of 10 dogs.

Ketogenic diets are not effective, and might even cause pancreatitis.

MCT diets, which are medium chain triglyceride diets used for Cognitive Dysfunction Syndrome, have been shown to be effective in some dogs. The food here is Hill’s B/D (Brain Diet).

Omega 3 fatty acid supplementation is not effective.

Acupuncture- Not enough data is available in dogs. When data for humans is analyzed acupuncture is found to be of no value.

With the recent relaxing of marijuana (cannabis) laws in several states we might be able to find out if this works in a bona fide study.

Alternative Medications

Since seizures have been around for many years, well intentioned people have postulated many treatment regimens that range from high doses of vitamins to herbal treatments, all in the name of being better than drugs because thely are “natural”. These claims are yet to be proven, and until proper clinical trials are performed, these claims have no basis in fact, and are just a repeat of anecdotal evidence that has been around so long and repeated in print so often that it has become fact. Many of these “natural” remedies are drugs themselves, drugs in which no studies have been performed to see if they work and to make sure there are no toxic effects. Herbal treatments contain drugs, and just because they are natural does not mean they are not toxic.

Several drugs used in humanoid medicine are being investigated for use in the dog. We might use them if the standard medications are not working, although they are too new to know for sure how they react in the dog or cat.They have the ptential to be more toxic than the use of phenobarbitol and valium.

Long Term Plan

Everything regarding your pets seizures she be noted on a calendar. It will help us look for trends, and let us know if the medication is working. You should also note the dates your pet needs to return for an exam or blood sample.

Never discontinue medications just because your pet has not had a seizure in a while.

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