IBD | Long Beach Animal Hospital - Part 2

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Diseases

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This section contains extensive information on the diagnosis and treatment of specific diseases for pets and exotic animals. You will learn about anatomy, physiology, and pathophysiology. You will see videos and many high quality photos including radiographs (x-rays), ultrasound pictures, blood panels, and from surgery.

You will even get a chance to see a C-section performed by Dr. Wood and Dr. Ridgeway

It is intended to give you a basic understanding of some animal diseases, and to augment the information you receive from one of our veterinarians. First, we suggest you learn the thought process of how our vets make a diagnosis. There is much more to it than you probably realize. Then return here and click on a specific species below to learn about some of the more common diseases we treat at the Long Beach Animal Hospital.

In the last decade, there have been great advances in the medical treatment of animals. We now have at our disposal drugs to treat chronic diseases that previously caused unnecessary discomfort and pain. In addition to these drugs, there have been significant advances in the treatment of animals using a more natural approach. This involves stimulating the body’s own immune and nervous system.

These advances now allow us to utilize a balanced approach to disease treatment and prevention, utilizing medications as needed, while simultaneously stimulating the body to heal itself. We are now able successfully manage chronic diseases involving the:

 heart

 thyroid

 kidney

 urinary bladder

 liver

 skin

 intestines

 lungs

 spleen

 mouth

 bones

The natural approach utilizes diet and medications called nutraceuticals, along with compounds that occur naturally in our environment. A recent advance in the natural approach has been our ability to stimulate the nervous system to increase blood flow to diseased organs, and correct imbalances that have been present for a significant period of time. A major advantage to this approach is the fact that no anesthesia, injections, or drugs are used. You can learn more about this in our VNA page.

You might also want to familiarize yourself with our laser surgery before reading about the surgeries we perform at our hospital. It is a major advance in the reduction of pain, swelling and inflammation in animals.

Some of the following sections show actual surgical procedures performed at our hospital. You will be alerted ahead of time as to when these pictures appear on a page.

Click on the species below to get detailed information on diseases specific to that species:

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Liver Diseases

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There are a large number of diseases that affect the liver. This should not be surprising when you consider how important and metabolically active the liver is. We will discuss a few of the more common diseases we encounter.

There are many different treatments for liver disease as you will learn about in this page. Some are surgical, most are medical. In a siginficant number of cases we encounter a diseased liver that is chronic in nature, and our treatment goal is to control the symptoms by helping the liver help itself. Several natural compounds might be used:

  • S-Adenosylmethionine (SAMe, Denosyl)

This is a precursor to a major antioxidant produced by a normal liver called glutathione.

  • Milk Thistle (Silymarin) (Denamarin).

This compound has a long history of use in human medicine. We usually use Denamarin because it contains both SAMe and milk thistle in one product.

  • Vitamin E

VItamin E prevents damage to the cell membrane of the liver cells

  • Zinc

Zinc is a trace mineral that helps increase glutathione levels. It is also used in Copper Storage diseases you will learn about in this page. Zinc is combined with milk thistle and Vitamin E in a product called Marin

Hepatic Lipidosis Pathogenesis

A small amount of fat is normally present in hepatocytes. The original source of this fat is from the diet. From the intestines (remember, bile needs to be present for this to occur) fat is absorbed into bloodstream, binds to albumin and is presented to hepatocytes. This fat is in several forms, the main ones being cholesterol, triglycerides, and fatty acids.

Fat is used for energy, the production of sex and steroid hormones, in cell wall integrity, and as storage for future energy needs. In a normal liver the rate at which the fat from the bloodstream enters the liver and the rate at which the liver utilizes this fat is roughly equal. When there is an imbalance between the rate of deposition of fat in hepatocytes, and the rate of utilization of this fat, the amount of triglycerides builds up and lipidosis results. In many species this excess of fat in the hepatocytes causes no serious problem. In cats it can become a serious problem.

The exact mechanism that causes this imbalance in cats is unknown. It is speculated that excess fat stores in obese cats overwhelm the liver when these fat stores are needed for energy (a cat that is not eating or is starving). This sets off a cascading series of events that involve insulin, glucose, and the enzyme lipase, leading to excess accumulation of triglycerides in hepatocytes.

Primary

This disease, seen more often in cats than in other animals, occurs when excess fat (called triglycerides) accumulates in liver cells (hepatocytes) and bile accumulates in hepatocytes (cholestasis). It is technically called Idiopathic Hepatic Lipidosis (IHL). The idiopathic part means that the specific cause is unknown. This form of lipidosis causes liver failure, and can lead to death if left untreated.

Secondary

In this form of hepatic lipidosis the fat accumulation occurs secondary to some other problem. This is more common than primary hepatic lipidosis. Secondary hepatic lipidosis does not cause liver failure. When the primary disease is treated the liver problem tends to resolve. A large percentage of cats have hepatic lipidosis secondary to these diseases:

Signalment

IHL can occur in any age or breed of cat, although it is not commonly seen in young cats. It is the most common liver disease found in cats.

Toy breed dogs can get a lipidotic liver after fasting or not eating for a period of time. They become hypoglycemic (low blood sugar), and can even die.

History

Cats with IHL consistently have anorexia (not eating), leading to weight loss. They are usually (or were) obese, and sometimes there is a history of a recent stressful episode that caused them to stop eating. Many owners will notice jaundice (icterus) and vomiting. Other symptoms could include diarrhea, constipation, salivation, and depression.

Physical exam

Cats with IHL have lost weight (although they could still be obese when examined) and may have yellowish discoloration (icterus) on the ears, the whites of the eyes, and the oral mucous membranes (gums). an enlarged liver (hepatomegaly) might even be palpated. Some of the other common signs of liver disease as described previously might be present on occasion.

This cat has icterus (jaundice) of its oral cavity from hepatic lipidosis, although a severe enough anemia could also cause this appearance.


This is the way the blood looks just after it was obtained on this cat and spun down in our centrifuge. The serum, which is the top layer, has the same yellowish-orange appearance as this cat’s gums.


Diagnostic Tests

A blood panel will commonly show highly elevated levels of ALT and Alk Phos, and mild elevations in GGT. In addition there are commonly high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is frequently elevated, and the blood ammonia level might also be elevated on occasion.

Other findings could include anemia, low albumin (hypoalbuminemia), high cholesterol (hypercholesterolemia), low BUN, low potassium (hypokalemia), and high glucose (hyperglycemia).

Diseases that can mimic IHL in cats include FIP, cholangiohepatitis, and liver cancer. a biopsy of the liver (usually performed when the ultrasound is done) is needed to verify the diagnosis. IHL usually involves many hepatocytes, so a general sample of any liver tissue usually yields diagnostic results. This is not the case with all liver diseases though. Some are focal and involve only a small portion of the liver. Fortunately, the ultrasound can pick up these focal areas and a biopsy needle can be directed to the diseased area by the ultrasound.

Radiography

Radiography might show hepatomegaly or a normal sized liver. Weight loss might be apparent on the radiograph, yet abdominal fat stores might be normal.

Ultrasound

Ultrasound reveals hepatomegaly with telltale changes of the liver parenchyma (internal anatomy of the liver). Ultrasound might also show inflammation of the pancreas (pancreatitis).

Exploratory Surgery

If an exploratory surgery is performed the liver might appear tan or yellowish in color, enlarged, and with swollen borders. It is greasy to the touch and easily injured. Exploratory surgery allows us to take a large section of the liver for biopsy. It also allows visualization of other abdominal organs, particularly ones that might be implicated in this disease like the pancreas.

This liver and gallbladder are typical of a cat with IHL.


Histopathology

A pathologist needs to analyze the liver microscopically to make a definitive diagnosis.

Treatment

Supportive care is crucial, and may have to be instituted for a prolonged period of time. Cats with IHL should be kept in the hospital until they are taking all medications well and their blood parameters are improving.

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag to correct a deficiency that can occur with IHL. Vitamin K might be needed in cats with clotting problems. This deficiency might be due to anorexia and reduced synthesis by the atrophied intestines. Simultaneous with fluid therapy we will begin caloric support.

Caloric Support

This is the most important part of treatment for IHL, and usually involves the use of a feeding tube. It is so important that we have devoted a full page to it.

Cats need at least 60 Kcal/kg/day of caloric dense high protein diet. The lining of the small intestines (called villi) will atrophy due to a lack of use, so a short adaptive period is needed to get them functioning properly again. This is done by feeding small amounts of food for the first few days, even though full caloric requirements are not being met.

The protein level of the diet should not be restricted unless they are showing obvious signs of hepatic encephalopathy (HE).

Appetite stimulating drugs (Valium, periactin) have no place in hepatic lipidosis due to their ineffectiveness, and some of them might even predispose cats to hepatic encephalopathy (HE).

Human enteral diets do not have adequate protein, arginine, or taurine for cats.

Antibiotics

A weakened immune system, the stress of diagnostic tests, hospitalization and treatment, predisposes these cats to infections. Antibiotics will help in this situation, especially if mental depression is present from hepatic encephalopathy (excess ammonia in the bloodstream). Antibiotics minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed from the intestines into the bloodstream.

Tetracycline antibiotics should be avoided if possible because they could be an initiating cause of hepatic lipidosis.

Lactulose

This drugs helps minimize the ammonia buildup that leads to vomiting, salivation, and mental depression.

Anti-vomiting medication

Drugs like Reglan can control vomiting and minimize gastric bleeding due to ulcers. As a general rule we want to minimize the use of Valium and cortisone in cats with IHL.

Ulcer Medication

Medications like Tagamet and sucralfate will help protect the stomach lining and make pets feel much better. These pets are more inclined to eat.

Supplemental Treatment

Some cats might benefit from other treatment modalities, although this is not the case in all cats. The mechanisms of action of these supplements are postulated but not proven.

L-Carnitine- This essential amino acid is required for proper fat utilization by the liver. Even though low levels are not found in cats with IHL, supplementation might be beneficial.

Arginine- This is another amino acid. It comes from muscle protein when cats are fasted. After a prolonged fast the muscle is depleted of protein and a deficiency of arginine might occur. A deficiency might lead to high levels of ammonia and eventually hepatic encephalopathy (HE). It is an essential amino acid in the cat.

Taurine- This is also an amino acid that could be involved with IHL. It is an essential amino acid, so supplementation might be helpful.

Ursodiol- This drug has an affect on how the liver metabolizes cholesterol and decreases the toxic effects of bile.

When the appetite starts to return we will slowly decrease the volume of food given via tube feeding. When your cat is eating well on its own, and the liver tests have improved on the blood panel, we will remove the feeding tube. This can be anywhere from several days to several months.

Prognosis

This disease is reversible in most cases when treated medically. Cure rates range from 65% to 75% when treatment is started early enough.

Cats that have pancreatitis, remain persistently hypokalemic (low potassium), or whose elevated bilirubin does not decrease significantly within 10 days have a guarded to poor prognosis.

Monitoring

Changes can occur rapidly during the early phases of treatment, so blood parameters need to be routinely monitored, especially electrolytes like potassium and phosphorous. Phosphorous, potassium, and red blood cell levels should be monitored for the first 72 hours after initiating caloric support. Serum enzymes and bilirubin should be monitored weekly until appetite returns.

Prevention

Even though the specific cause of IHL is unknown, obesity is a known predisposition. Since obesity is controllable you can dramatically reduce the chance of your cat getting IHL by keeping it at a proper weight.

Overweight cats should be fed Hills Prescription diet R/D® until they decrease to their optimum weight. At that time they should be fed Hills Prescription diet W/D® to maintain their normal weight.

Early treatment dramatically increases the chance of recovery, so if your cat does not eat for 24 hours it should be brought to our clinic for an exam and blood testing.


Porto-systemic Shunt (PSS)

Pathophysiology

Ammonia comes from bacteria in the intestines and when muscles utilize protein as a energy source. In a normal animal this ammonia gets delivered through the portal vein directly into the liver. The liver cells metabolize the ammonia to urea, which is excreted by the kidneys. The liver also detoxifies bacteria and drugs that are also absorbed from the intestines before they get into the general circulation and go to the rest of the body.

Shunts occur when the blood supply through the liver is abnormal. The abnormal blood vessel shunts blood around the liver instead of through the liver. By bypassing the liver the toxins that are normally metabolized by the liver (especially ammonia) are allowed to enter the general circulation before the liver has a chance to detoxify them. It is this ammonia buildup that causes most of the symptoms observed with PSS. It is also know as hepatic encephalopathy (HE) because of its toxic effects on the brain.

Also, important “hepatotrophic” substances from the pancreas and intestines are prevented from going to the liver, causing the liver to atrophy.

Several factors can add to HE. A diet high in protein will add to blood ammonia levels, along with infection, cancer, and excess use of cortisone. Kidney disease along with constipation will also add to the problem. Some drugs, notably barbiturates, Valium, and anesthetics can also be factors.

Shunts can be multiple or single. The shunt can occur within the liver (intrahepatic) or in the blood supply before it enters the liver (extrahepatic). Larger breed dogs are more prone to intrahepatic shunts, extrahepatic shunts are more common in small breed dogs and cats. It is important to differentiate them for therapeutic purposes.

There are other diseases that can mimic PSS. They include liver toxins, liver infection, liver cancer, and hepatic lipidosis (see previous description). An organ as complex as the liver necessitates the need for a precise diagnosis before treatment can be instituted. Also, a pet with chronic liver disease leading to cirrhosis will sometimes get acquired shunts.

Causes

Congenital

The congenital version of PSS occurs more commonly in dogs than in cats. Most of these shunts are extrahepatic, meaning the shunting vessels are located outside of the liver.

Acquired.

Seen mostly in dogs, they occur when there is increased resistance to blood flow through a fibrotic liver. These shunts occur inside the liver and are not easily corrected.

Signalment

Congenital shunts tend to be found in younger dogs and cats (usually less than a year), while acquired shunts tend to occur in older animals.

Small breed dogs tend to have more extrahepatic shunts while large breed dogs tend to have intrahepatic shunts.

In some situations the symptoms of this disease are so subtle that a diagnosis of congenital shunt is not made until a pet is much older. We tend to see it more often in male cats as opposed to female cats.

Several dog breeds are predisposed:

  • Irish wolfhounds
  • Maltese
  • Yorkshire terriers (20X more prevalent than all the other breeds)
  • Miniature schnauzers
  • Lhasa Apso (also prevalent compared to other breeds)
  • Australian cattle dogs
  • Retrievers
  • Cairn terriers
  • Old English sheepdogs

Cat breeds might include:

  • Himalayan
  • Persian

History

Some of the symptoms of PSS can be subtle, and easily interpreted as a quiet puppy or kitten. Symptoms can wax and wane, thus they are easily missed. Some pets seem to have a preference for fruits and vegetables.

Behavior changes, particularly right after eating. These changes include depression, head pressing, pica (eating abnormal things) blindness, lethargy, coma, seizures, and personality changes. Anorexia, vomiting, diarrhea, and excess salivation (more so in cats) might be present. Excess urinating and drinking (PU/PD), blood in the urine (hematuria), urinary tract infection, and an increased incidence of ammonium urate bladder stones might also be present. These stones might even cause an obstruction and prevent normal urination. Other symptoms might include inhibited growth, fever, and abnormally long recovery periods from anesthesia (ex.-when a spay or neuter is performed).

Physical Exam

Pets with PSS will commonly be stunted in growth, but usually exhibit no abnormalities on their neurologic exams. A small liver might be palpated on smaller animals. Hair coat might be unkempt and there might be ascites on abdominal palpation. Other occasional findings include cryptorchidism.

Diagnostic Tests

Several diseases mimic PSS. They include Distemper, FIP, toxoplasmosis, FeLV related diseases, toxicities, idiopathic epilepsy, and hypoglycemia. This emphasizes the importance of proper testing to come to an accurate diagnosis.

Blood Panel

In dogs, a blood panel might show anemia along with elevated levels of ALT and Alk Phos. The BUN might be low, cholesterol might be low, the protein level might be low (hypoproteinemia), and the blood sugar might be low (hypoglycemia) in the smaller breed dogs. A bile acids tests will show an elevation, particularly after we feed a meal. If we suspect PSS as the cause to your pets problem we will run a blood ammonia level, which will come back elevated if PSS is present. An ammonia tolerance test might be needed for verification.

In cats the albumin, BUN, and cholesterol might be low or at the low end of the normal range.

Urinalysis

A urinalysis might show symptoms of urinary tract infection or abnormal crystals, particularly ammonium biurate.

Radiography

A radiograph of the liver might show a small liver (microhepatica), particularly in the dog. The liver might be hard to evaluate because a lack of abdominal fat, due to emaciation or a young animal.

Kidney changes and bladder stones might be visible, although ascites might obscure vision of internal organs. ammonium urate bladder stones might not show up on a radiograph even though they are present.

Ultrasound

Ultrasound can give further information on the liver and its blood supply, and even detect ammonium biurate bladder stones which normally don’t appear on a radiograph. Ultrasound is better at differentiated intrahepatic shunts as opposed to extrahepatic shunts.

Positive Contrast Portography

Some consider this test the gold standard for diagnosis. In this test a special dye is injected directly into one of the veins of the small intestines while a pet is under anesthesia. A radiograph is taken and the flow of the dye is followed. If a shunt is present this will show up on the radiograph.

Biopsy

A biopsy of the liver (usually performed when the ultrasound is done) will show microscopic abnormalities consistent with PSS. This usually includes small hepatocytes and a decrease in the blood vessels within the liver.

Laparotomy

Exploratory surgery to visualize the vessels directly, or to inject dye into the portal vessels, is also used to verify the diagnosis. After the dye is injected a radiograph is taken to assess absorption. Surgical repair can immediately be initiated.

Scintigraphy

A transcolonic nuclear scan can give a definitive diagnosis. In this test a small amount of radioactive (99technetium pertechnetate) material is put into the colon and its absorption is monitored. In pets with PSS this radioactive material will appear in the heart before it appears in the liver, the opposite of what should normally happen. This test does not require anesthesia like the Positive Contrast Portography test.

Treatment- Medical

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. Pets that are severely ill from PSS should not be given anything orally initially.

Cleansing Enemas

Enema’s will decrease the bacterial count of the intestines, leading to less ammonia absorption.

Lactulose

Lactulose works in the large intestine to minimize the production of ammonia by bacteria. It does this by changing the pH and converting ammonia to a form that is not readily absorbed into the bloodstream. It also stimulates normal colon bacteria to absorb ammonia, which is then passed in the feces. Finally, it stimulates the intestines so that ammonia passes through faster, which means there is less time for absorption.

Antibiotics

These drugs are also administered, especially if mental depression is present. They minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed from the intestines into the bloodstream. They work well with lactulose to decrease the ammonia level.

Antiparaciticides

Internal parasites can cause gastrointestinal bleeding and also make the symptoms of PSS worse.

Dietary Modification

A diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Meat based proteins should be avoided since they can increase the chance of HE. Most of the caloric needs of a pet with PSS should be supplied with carbohydrates like rice and pasta. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. They can act to minimize ammonia production and absorption in a manner that is similar to lactulose.

Hill Prescription Diet L/D® is very helpful in liver disease. It contains added amounts of nutrients that a diseased liver needs. It also has restricted amounts of nutrients that can make the condition worse. For example, sodium (Na) is limited to minimize fluid buildup in the abdomen (ascites).

Instituting these medical treatments is necessary even if surgery is planned because they will aid in recovery and make for a better anesthetic risk.

Treatment- Surgical

For many PSS cases surgery is the treatment of choice. The abnormal vessel that is shunting blood around the liver is identified and closed (ligated) to minimize blood flowing through it. When the abnormal blood vessel is ligated blood will now flow through the liver instead of around it. Several techniques are used, depending on the particulars of the case and the training and experience of the surgeon:

  • Cellophane Banding
  • Ameroid Ring Constrictor
  • Suture Ligation
  • Thrombogenic Intravascular Coil
  • Hydraulic Occluder

This surgery is readily accomplished for solitary extrahepatic shunts. Intrahepatic shunts can be more difficult to identify and ligate. Post surgical monitoring is important. If the pressure within the liver becomes too high due to the increased blood flow through the liver then the ligation on the shunting vessel(s) must be reduced or removed.

In some cases medical management must also be utilized to affect a cure. The final outcome of treatment depends on what age the PSS started, how long it has been present, and whether it is intrahepatic (worse prognosis) or extrahepatic in nature.

Long Term Monitoring

Pets on long term medical care need to be monitored carefully. Body weight, albumin, and total protein are watched to ensure adequate protein in the diet. Initially, these tests should be performed monthly, then every 3 months. In addition to the above tests, bile acids are monitored monthly, then every three months to assess the vitality of the liver. Blood ammonia levels are monitored monthly to assess effectiveness of treatment. When stable, ammonia levels can be monitored every 3 months.

Prognosis

Many pets with isolated extrahepatic shunts return to a normal life after surgery. There is no guarantee that surgery will correct the problem, especially those pets that develop the disease very early in life. Some of them will need medical management simultaneously. The prognosis for pets that are treated only medically varies. Cats do not do as well as dogs when surgery is attempted.

 

Chronic active Hepatitis

This disease is also known as Chronic canine Inflammatory Hepatic Disease (CCHID). It is a series of different liver diseases with similar characteristics when analyzed under the microscope (histopathology). It has similarities to cirrhosis found in humanoids.

Cause

Usually unknown. In some cases an infection caused by a bacteria called Leptospirosis or a virus called adenovirus is the cause. We protect dogs from this adenovirus when we give a DHLPP vaccine. The “H” stands for hepatitis caused by the adenovirus. This same vaccine can also protect dogs from Leptospirosis. Some dogs can get a vaccine reaction to Leptospirosis, and since the disease is not prevalent, it is not commonly given.

Pathophysiology

The immune system makes antibodies that affect liver cells. Toxic compounds add to the problem. Some of these compounds include cholesterol, iron, copper, and toxins located within the blood vessels. All of this leads to inflammation, and the eventual replacement of normal liver cells (hepatocytes) with fibrous tissue. Eventually, the blood flow through the liver is compromised, the blood pressure within the liver is elevated (hypertension), and numerous extrahepatic PSS’s develop (see PSS above). The body then shows signs of fluid buildup in the abdomen (ascites) and HE (see above). After a variable period of time liver failure often results.

Signalment

It tends to occur more often in older animals. Several dog breeds are predisposed:

  • Doberman PinschersMost common in middle-aged females with improper copper metabolism.
  • Cocker spanielsMost often in older males. Typical symptoms include fluid buildup in the abdomen (ascites) and low albumin (hypoalbuminemia) on a blood sample.
  • West Highland white terriers, Bedlington terriers, and Skye terriers.It is associated with copper accumulation in hepatocytes, sometimes seen more often in young dogs.

History

Symptoms are vague, and come and go until the disease progresses. The typical symptoms of liver disease are present, and include PU/PD, anorexia, vomiting, diarrhea, ascites, icterus, and HE. Ulcers of the stomach can occur and lead to vomiting blood (hematemesis)

Other symptoms can involve the blood system, and include bleeding disorders and vomiting blood (hematemesis). This is because the liver is involved with the production of clotting factors (remember the physiology section above?). In occasional cases the opposite occurs, and the liver causes excessive clotting of blood. This predisposes animals to a problem known as disseminated intravascular coagulation (abbreviated as DIC).

Physical exam

An exam of a pet with this disease can vary from normal to many abnormalities. Some of the abnormal findings are described in the liver exam findings above.

Diagnostic Tests

Blood Panel

A blood panel will commonly show anemia along with elevated levels of ALT and Alk Phos. There might also be an elevation in cholesterol, a decrease in BUN, glucose, and albumin. There might also be an increase in bilirubin, ammonia, and bile acids.

Urinalysis

a urinalysis might show symptoms of urinary tract infection or abnormal crystals, particularly ammonium biurate.

Radiography

A radiograph of the liver might show an enlarged liver (hepatomegaly) initially, eventually it might progress to a small liver (microhepatica).

Ultrasound

Ultrasound is the best way to make this diagnosis. The internal architecture (parenchyma) can be analyzed and a biopsy can be obtained with relative ease. In some cases it is important to know the coagulation status of the blood with a special blood panel prior to obtaining this biopsy. In many cases ultrasound is preferable to exploratory surgery since some of these animals are not good anesthetic risks and the procedure is much less invasive.

Laparotomy

The liver can be thoroughly visualized and palpated during an exploratory surgery. A biopsy can easily be obtained, and post biopsy bleeding can be monitored.

Biopsy

Samples of the liver taken with either a biopsy needle during ultrasound, or during a laparotomy, will be analyzed microscopically by a pathologist to make a definitive diagnosis and to look for a cause if possible.

Treatment

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag. Care must be taken not to give excessive amounts of fluids, especially if they contain sodium, in pets with fluid buildup in the abdomen (ascites).

Treating the Cause (when known)

Antibiotics are used to control bacterial infections and drugs that are suspected of causing this disease are stopped. We tend to use antibiotics that have minimal need for liver metabolism in order to minimize their toxic effects.

Rest

The liver has ability to heal itself if the disease is not too advanced. Rest can be a big aid, along with proper nutrition.

Ascites Reduction

Sodium restriction helps minimize fluid buildup (ascites) in the abdomen. This can be accomplished using Hills K/D Prescription Diet. Diuretics like Lasix are also used to help pull this fluid out of the abdomen.

Dietary Modification

Use a diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Hills Prescription Diet L/D® is the diet of choice. Meat based proteins should be avoided since they can increase the chance of HE. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. This is the same basic diets as for pets with PSS (see above).

A diseased liver needs calories, which sometimes need to be supplied with a feeding tube.

Ulcer Treatment

This will make pets more comfortable, more inclined to eat, and prevent bleeding in the stomach.

Liver Specific Drugs

Corticosteroids- Cortisone is used if there is evidence that the immune system is implicated as a cause of the liver problem.

Ursodiol- This drug replaces toxic bile acids with a type of bile that is less toxic.

Zinc- Supplementation might help reduce the effects of copper toxicity.

Long Term Monitoring

CCHID monitoring is similar to PSS (see above). In addition, repeating a liver biopsy 6 months after initiating therapy used.

 

Infectious Canine Hepatitis (ICH)

Background

The disease is called hepatitis because liver cells are one of the prime targets. It is caused by an adenovirus that is found world wide and affects mainly the dog family (canids). The virus is very resistant to disinfectants and can remain infectious in the environment. Many dogs get exposed to this virus, develop antibodies, and show no symptoms of the disease. Spread of this virus is usually orally and nasally, but can also be spread by utensils and external parasites. Within 7 days of exposure most dogs develop an adequate antibody response to protect the liver and other organs.

Symptoms

ICH can occur in unvaccinated dogs of any age, but usually occurs in dogs under one year. In the more severe cases vomiting and diarrhea can occur. These dogs can also have fever, coughing, swelling of the head and neck due to lymph node enlargement, abdominal tenderness and even central nervous system signs. These symptoms may last up to one week, and can be prolonged by other concurrent diseases like Distemper. A syndrome of this disease can cause rapid death leading people to conclude that the dog was poisoned. Dogs that show minimal symptoms can show ocular lesions during the convalescent phase. In uncomplicated cases these eye lesions heal completely.

Diagnosis

Blood samples give a clue to this disease but are not diagnostic. White blood cells can be low, liver enzyme tests may be elevated, and clotting factors can be disrupted. These findings, along with the previously described history and physical exam findings, are how the disease is usually diagnosed. Antibody tests are available but are not routinely used to make a diagnosis.

Treatment

Like most viral diseases therapy is directed towards symptoms. When symptoms are severe enough, intravenous fluids are administered. Since clotting factors can be disrupted particular attention needs to be paid to bleeding problems. If bleeding problems are severe enough, a whole blood transfusion must be administered. Dogs that are comatose may need intravenous glucose.

Prevention

Most pups receive adequate antibodies from the bitch, which can last up to 4 months. Vaccines are highly effective and can confer long term protection. Two vaccines need to be given at 3-4 weeks apart beginning at 8 weeks of age. The DHLPP (Distemper-Hepatitis-Leptospirosis-Parainfluenza-Parvo) vaccine contains protection against this adenovirus. The DHLPP vaccine is also known as the Da2PL. The a2 part stands for adenovirus.

A picture of our vaccine label


Copper Toxicosis (Copper Storage Disease)

The level of copper in the body is maintained by the excretion of bile. In this disease copper accumulates in hepatocytes, eventually causing inflammation and scarring, ultimately leading to liver failure (similar to CCIHD above). Excess copper released from the liver can cause hemolytic anemia.

Signalment

It is common in certain breeds:

Bedlington terriers- They have a genetic defect in how they metabolize copper and how it is excreted in the bile. This leads to excess accumulation in hepatocytes.

West Highland white terriers- They have a similar genetic defect as Bedlington terriers, but the copper accumulation is not as severe and does not always lead to liver failure.

Some Dobermans and Skye terriers with chronic liver disease also have elevated levels of copper in their hepatocytes. The copper accumulation in the liver might be a cause of the chronic hepatitis that eventually results, or an effect of a pre-existing hepatitis.

History

Bedlington’s with copper toxicity have minimal symptoms early in the disease. In the acute form, seen in younger dogs, symptoms include lethargy, anorexia, and vomiting. Death can occur in 2-3 days. Middle aged or older dogs have a more chronic course. Eventually symptoms of liver failure appear, including anemia, depression, lethargy, and anorexia.

Physical exam

Anemia might cause pale mucous membranes. There might also be icterus due to both anemia and liver failure. These dogs will also be weak and underweight.

Diagnostic Tests

A blood panel will commonly show elevated levels of ALT, GGT and Alk Phos, in addition to high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is elevated and radiography reveals a small liver. This disease is diagnosed by liver biopsy.

Treatment

Treatment has two goals: Enhance excretion of excess copper, and minimize further absorption of copper from the intestines.

Chelating agents Drugs like penicillamine bind with copper to allow easier excretion.

Zinc

Zinc will help minimize further copper absorption from the intestines.

Supportive Care

Similar to other liver diseases previously described

Diet

Hill’s Prescription Diet L/D® can be beneficial in treating this disease.

Long Term Monitoring

Serum enzymes and bilirubin should be monitored at least every 6 months

Prevention

Bedlington terriers should be screened at 1 year of age. Treatment at this early age leads to a good prognosis.


Cancer (Neoplasia)

A benign tumor of the liver is called and adenoma, a malignant one is a carcinoma.

Primary- Arising directly from the liver

  • Adenoma
  • Carcinoma
  • Hemangiosarcoma
  • Hemangioma
  • Leimyosarcoma
  • Fibrosarcoma
  • Fibroma
  • Osteosarcoma

They can arise directly from the hepatocytes where they are called hepatocellular. If they arise from the biliary system they are called cholangiocellular. Dogs get more hepatocellular, cats get more cholangiocellular. The cause of these primary neoplasia’s is unknown in most cases.

Secondary- From another organ that has spread to the liver

  • Lymphosarcoma
  • Mast cell
  • Pancreatic carcinoma
  • Myeloproliferative

The organs that commonly are the source of these secondary cancers include:

Secondary, also know as metastatic, liver cancers are much more common than primary.

Signalment

Cancer is found in most animals and most breeds. It tends to be found mostly in older animals.

History

Almost any sign of illness can potentially be attributed to neoplasia. Common ones include anorexia, lethargy, weight loss, PU/PD and vomiting.

Physical exam

Exam results of animals with liver neoplasia mimic the results found in other liver diseases.

Diagnostic Tests

A blood panel will commonly show elevated levels of liver enzymes, in addition to high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is elevated and ultrasound reveals hepatomegaly (enlarged liver) with telltale changes of the liver parenchyma (internal anatomy of the liver). Ultrasound might also show inflammation of the pancreas (pancreatitis). A liver biopsy is needed for a definitive diagnosis. There is an ultrasound picture of liver cancer in the diagnostic section above.

Treatment

Primary hepatic neoplasms are treated by removal of the affected liver lobe when possible. If multiple lobes are involved then surgery is usually not performed. Secondary hepatic neoplasms are treated with chemotherapy. The results vary, and depend on the duration, location, and degree of malignancy of the neoplasia. The prognosis is poor for long term survival.

Supportive care that is similar to other liver diseases is also used in neoplasia

Prevention

Since the cause is usually unknown prevention is difficult. Good nutrition and lots of TLC are always important in preventing any disease.

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Liver Diseases

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There are a large number of diseases that affect the liver. This should not be surprising when you consider how important and metabolically active the liver is. We will discuss a few of the more common diseases we encounter in animals at the Long Beach Animal Hospital:

Hepatic Lipidosis

Porto-systemic shunt (PSS)

Gall Bladder Disease

Chronic active hepatitis

Infectious canine hepatitis

Copper storage disease

Cancer

There are many different treatments for liver disease as you will learn about in this page. Some are surgical, most are medical. In a siginficant number of cases we encounter a diseased liver that is chronic in nature, and our treatment goal is to control the symptoms by helping the liver help itself. Several natural compounds might be used:

S-Adenosylmethionine (SAMe, Denosyl)

This is a precursor to a major antioxidant produced by a normal liver called glutathione.

Milk Thistle (Silymarin) (Denamarin)

This compound has a long history of use in human medicine. We usually use Denamarin because it contains both SAMe and milk thistle in one product.

Vitamin E

Vitamin E prevents damage to the cell membrane of the liver cells

Zinc

Zinc is a trace mineral that helps increase glutathione levels. It is also used in the Copper Storage diseases you will learn about in this page. Zinc is combined with milk thistle and Vitamin E in a product called Marin

Hepatic Lipidosis

A small amount of fat is normally present in hepatocytes. The original source of this fat is from the diet. From the intestines ( bile needs to be present for this to occur- you learned about this in the liver physiology section) fat is absorbed into bloodstream, binds to albumin, and is presented to hepatocytes. This fat is in several forms, the main ones being cholesterol, triglycerides, and fatty acids.

Fat is used for energy, the production of sex and steroid hormones, in cell wall integrity, and as storage for future energy needs. In a normal liver the rate at which the fat from the bloodstream enters the liver and the rate at which the liver utilizes this fat is roughly equal. When there is an imbalance between the rate of deposition of fat in hepatocytes, and the rate of utilization of this fat, the amount of triglycerides builds up and lipidosis results. In many species this excess of fat in the hepatocytes causes no serious problem. In cats it can become a serious problem.

The exact mechanism that causes this imbalance in cats is unknown. It is speculated that excess fat stores in obese cats overwhelm the liver when these fat stores are needed for energy (a cat that is not eating or is starving). This sets off a cascading series of biochemical events that involve insulin, glucose, and the enzyme lipase, leading to excess accumulation of triglycerides in hepatocytes.

Primary

This disease, seen more often in cats than in other animals, occurs when excess fat (called triglycerides) accumulates in liver cells (hepatocytes) and bile accumulates in hepatocytes (cholestasis). It is technically called Idiopathic Hepatic Lipidosis (IHL). The idiopathic part means that the specific cause is unknown. This form of lipidosis causes liver failure, and can lead to death if left untreated.

Secondary

In this form of hepatic lipidosis the fat accumulation occurs secondary to some other problem. This is more common than primary hepatic lipidosis. Secondary hepatic lipidosis does not cause liver failure. When the primary disease is treated the liver problem tends to resolve. A large percentage of cats have hepatic lipidosis secondary to these diseases:

Signalment

IHL can occur in any age or breed of cat, although it is not commonly seen in young cats. It is the most common liver disease found in cats.

Toy breed dogs can get a lipidotic liver after fasting or not eating for a period of time. They become hypoglycemic (low blood sugar), and can even die.

History

Cats with IHL consistently have anorexia (not eating), leading to weight loss. They are usually (or were) obese, and sometimes there is a history of a recent stressful episode that caused them to stop eating. Many owners will notice jaundice (icterus) and vomiting. Other symptoms could include diarrhea, constipation, salivation, and depression.

Physical exam

Cats with IHL have lost weight (although they could still be obese when examined) and may have yellowish discoloration (icterus) on the ears, the whites of the eyes, and the oral mucous membranes (gums). An enlarged liver (hepatomegaly) might even be palpated. Some of the other common signs of liver disease as described previously might be present on occasion.

This cat has icterus (jaundice) of its oral cavity from hepatic lipidosis, although a severe enough anemia could also cause this appearance.

This is the way the blood looks just after it was obtained on this cat and spun down in our centrifuge. The serum, which is the top layer, has the same yellowish-orange appearance as this cat’s gums.

Diagnostic Tests

A blood panel will commonly show highly elevated levels of ALT and Alk Phos, and mild elevations in GGT. In addition there are commonly high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is frequently elevated, and the blood ammonia level might also be elevated on occasion.

Other findings could include anemia, low albumin (hypoalbuminemia), high cholesterol (hypercholesterolemia), low BUN, low potassium (hypokalemia), and high glucose (hyperglycemia).

Diseases that can mimic IHL in cats include FIP, cholangiohepatitis, and liver cancer. A biopsy of the liver (usually performed when an ultrasound is done) is needed to verify the diagnosis.

IHL usually involves many hepatocytes, so a general sample of any liver tissue usually yields diagnostic results. This is not the case with all liver diseases though. Some are focal and involve only a small portion of the liver. Fortunately, the ultrasound can pick up these focal areas and a biopsy needle can be directed to the diseased area by the ultrasound.

This is the liver with the dark ball bladder in the center. An experienced veterinary ultrasonographer call tell diseased liver from healthy liver and take an accurate biopsy without surgery in most cases.

Radiography might show hepatomegaly or a normal sized liver. Weight loss might be apparent on the radiograph, yet abdominal fat stores might be normal.

The internal organs have been labeled on this radiograph, including a normal liver in this cat. 

In IHL ultrasound reveals hepatomegaly with telltale changes of the liver parenchyma (internal anatomy of the liver). Ultrasound might also show inflammation of the pancreas (pancreatitis).

Exploratory Surgery

If an exploratory surgery is performed the liver might appear tan or yellowish in color, enlarged, and with swollen borders. It is greasy to the touch and easily injured

This liver swelling and coloration is typical of a cat with IHL

Exploratory surgery allows us to take a large section of the liver for biopsy. It also allows visualization of other abdominal organs, particularly ones that might be implicated in this disease like the pancreas.

This is one way the liver is biopsied during an actual exploratory surgery, as opposed to a biopsy taken during ultrasound. The exploratory surgery method is much more invasive, but you can a much larger piece of liver as a tradeoff.  Note the proper color of this liver compared to the diseased one above. 

Histopathology

A pathologist needs to analyze the liver microscopically to make a definitive diagnosis.

Treatment

Supportive care is crucial, and may have to be instituted for a prolonged period of time. Cats with IHL should be kept in the hospital until they are taking all medications well and their blood parameters are improving.

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag to correct a deficiency that can occur with IHL. Vitamin K might be needed in cats with clotting problems. This deficiency might be due to anorexia and reduced synthesis by the atrophied intestines. Simultaneous with fluid therapy we will begin caloric support.

Caloric Support

This is the most important part of treatment for IHL, and usually involves the use of a feeding tube. It is so important that we have devoted a full page to it.

Cats need at least 60 Kcal/kg/day of caloric dense high protein diet. The lining of the small intestines (called villi) will atrophy due to a lack of use, so a short adaptive period is needed to get them functioning properly again. This is done by feeding small amounts of food for the first few days, even though full caloric requirements are not being met.

The protein level of the diet should not be restricted unless they are showing obvious signs of hepatic encephalopathy (HE).

Appetite stimulating drugs (Valium, periactin) have no place in hepatic lipidosis due to their ineffectiveness, and some of them might even predispose cats to hepatic encephalopathy (HE). A drug called mirtazapine might be used in some cases, although a feeding tube is the best way to go.

Human enteral diets do not have adequate protein, arginine, or taurine for cats.

Antibiotics

A weakened immune system, the stress of diagnostic tests, hospitalization and treatment, predisposes these cats to infections. Antibiotics will help in this situation, especially if mental depression is present from hepatic encephalopathy (excess ammonia in the bloodstream). Antibiotics minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed from the intestines into the bloodstream.

Tetracycline antibiotics should be avoided if possible because they could be an initiating cause of hepatic lipidosis.

Lactulose

This drugs helps minimize the ammonia buildup that leads to vomiting, salivation, and mental depression. It can be of significant help in this disease.

Anti-vomiting medication

Drugs like Cerenia® and Reglan® can control vomiting and minimize gastric bleeding due to ulcers. As a general rule we want to minimize the use of Valium and cortisone in cats with IHL.

Ulcer Medication

Medications like Tagamet® and sucralfate® will help protect the stomach lining and make pets feel much better. These pets are more inclined to eat.

Supplemental Treatment

Some cats might benefit from other treatment modalities, although this is not the case in all cats. The mechanisms of action of these supplements are postulated but not proven.

L-Carnitine– This essential amino acid is required for proper fat utilization by the liver. Even though low levels are not found in cats with IHL, supplementation might be beneficial.

Arginine– This is another amino acid. It comes from muscle protein when cats are fasted. After a prolonged fast the muscle is depleted of protein and a deficiency of arginine might occur. A deficiency might lead to high levels of ammonia and eventually hepatic encephalopathy (HE). It is an essential amino acid in the cat.

Taurine– This is also an amino acid that could be involved with IHL. It is an essential amino acid, so supplementation might be helpful.

Ursodiol– This drug has an affect on how the liver metabolizes cholesterol and decreases the toxic effects of bile.

When the appetite starts to return we will slowly decrease the volume of food given via tube feeding. When your cat is eating well on its own, and the liver tests have improved on the blood panel, we will remove the feeding tube. This can be anywhere from several days to several months.

Prognosis

This disease is reversible in most cases when treated medically. Cure rates range from 65% to 75% when treatment is started early enough.

Cats that have pancreatitis, remain persistently hypokalemic (low potassium), or whose elevated bilirubin does not decrease significantly within 10 days, have a guarded to poor prognosis.

Monitoring

Changes can occur rapidly during the early phases of treatment, so blood parameters need to be routinely monitored, especially electrolytes like potassium and phosphorous. Phosphorous, potassium, and red blood cell levels should be monitored for the first 72 hours after initiating caloric support. Serum enzymes and bilirubin should be monitored weekly until appetite returns.

Prevention

Even though the specific cause of IHL is unknown, obesity is a known predisposition. Since obesity is controllable you can dramatically reduce the chance of your cat getting IHL by keeping it at a proper weight.

Overweight cats should be fed Hills Prescription diet M/D® or R/D® or  until they decrease to their optimum weight. At that time they should be fed Hills Prescription diet W/D® to maintain their normal weight.

Early treatment dramatically increases the chance of recovery, so if your cat does not eat for 24 hours it should be brought to our clinic for an exam and blood testing.

 

Porto-systemic Shunt (PSS)

Pathophysiology

Ammonia comes from bacteria in the intestines and when muscles utilize protein as a energy source. In a normal animal this ammonia gets delivered through the portal vein directly into the liver. The liver cells metabolize the ammonia to urea, which is excreted by the kidneys. The liver also detoxifies bacteria and drugs that are also absorbed from the intestines before they get into the general circulation and go to the rest of the body.

Shunts occur when the blood supply through the liver is abnormal. The abnormal blood vessel shunts blood around the liver instead of through the liver. By bypassing the liver, the toxins that are normally metabolized by the liver (especially ammonia) are allowed to enter the general circulation before the liver has a chance to detoxify them. It is this ammonia buildup that causes most of the symptoms observed with PSS. It is also know as hepatic encephalopathy (HE) because of its toxic effects on the brain.

Also, important “hepatotrophic” substances from the pancreas and intestines are prevented from going to the liver, causing the liver to atrophy.

Several factors can add to HE. A diet high in protein will add to blood ammonia levels, along with infection, cancer, and excess use of cortisone. Kidney disease along with constipation will also add to the problem. Some drugs, notably barbiturates, Valium, and anesthetics can also be factors.

Shunts can be multiple or single. The shunt can occur within the liver (intrahepatic) or in the blood supply before it enters the liver (extrahepatic). Larger breed dogs are more prone to intrahepatic shunts, extrahepatic shunts are more common in small breed dogs and cats. It is important to differentiate them for therapeutic purposes.

There are other liver diseases that can mimic PSS. They include liver toxins, liver infection, liver cancer, and hepatic lipidosis (see previous description). Also, a pet with chronic liver disease leading to cirrhosis will sometimes get acquired shunts.

There are many different diseases in animals besides liver disease that can cause these symptoms, so do not assume your pet has a PSS if it is exhibiting some of these symptoms.

Some of these non-liver diseases that have symptoms similar to PSS  include Distemper, FIP, toxoplasmosis, FeLV related diseases, toxicities, idiopathic epilepsy, and hypoglycemia.

An organ as complex as the liver necessitates the need for a precise diagnosis before treatment can be instituted.  This emphasizes the importance of proper testing to come to an accurate diagnosis.

This is what a liver with a PSS looks like during an exploratory surgery. It is yellow-colored and swollen. 

Causes

Congenital

The congenital version of PSS occurs more commonly in dogs than in cats. Most of these shunts are extrahepatic, meaning the shunting vessels are located outside of the liver. They tend to occur in the smaller breed dogs like pugs, schnauzers, Maltese, Shih thus, and especially in Yorkshire terriers.

When they are intra-hepatic they tend to occur in large and medium sized breeds like Irish wolfhounds, Labrador retrievers, old English sheepdogs, and Australian shepherds.

Acquired.

Seen mostly in dogs, they occur when there is increased resistance to blood flow through a fibrotic liver. These shunts occur inside the liver and are not easily corrected.

Diagnosis

Signalment

Congenital shunts tend to be found in younger dogs and cats (usually less than a year), while acquired shunts tend to occur in older animals.

Small breed dogs tend to have more extrahepatic shunts while large breed dogs tend to have intrahepatic shunts.

In some situations the symptoms of this disease are so subtle that a diagnosis of congenital shunt is not made until a pet is much older. We tend to see it more often in male cats as opposed to female cats.

Several dog breeds are predisposed:

Irish wolfhounds

Maltese

Yorkshire terriers (20X more prevalent than all the other breeds)

Miniature schnauzers

Lhasa Apso (also prevalent compared to other breeds)

Australian cattle dogs

Retrievers

Cairn terriers

Old English sheepdogs

Cat breeds might include:

Himalayan

Persian

History

Some of the symptoms of PSS can be subtle, and easily interpreted as a quiet puppy or kitten. Symptoms can wax and wane, thus they are easily missed.

Some pets seem to have a preference for fruits and vegetables. Behavior changes, particularly right after eating, commonly occur. These changes include depression, disorientation, circling, head pressing, pica (eating abnormal things) blindness, lethargy, coma, seizures (65% of cats have seizures), and personality changes.

Anorexia, vomiting, diarrhea, and excess salivation (hypersalivation-more so in cats) might be present. Excess urinating and drinking (PU/PD), blood in the urine (hematuria), urinary tract infection, cystitis, and an increased incidence of ammonium bitrate crystals and  bladder stones might also be present. These stones might even cause an obstruction and prevent normal urination. Other symptoms might include inhibited growth, fever, and abnormally long recovery periods from anesthesia (ex.-when a spay or neuter is performed).

Physical Exam

Pets with PSS will commonly be stunted in growth, but usually exhibit no abnormalities on their neurologic exams. A small liver might be palpated on smaller animals. Hair coat might be unkempt and there might be ascites on abdominal palpation. Other occasional findings include cryptorchidism.

Diagnostic Tests

Blood Panel

In dogs, a blood panel might show anemia along with elevated levels of ALT and Alk Phos. The BUN might be low, cholesterol might be low, the protein level might be low (hypoproteinemia), and the blood sugar might be low (hypoglycemia) in the smaller breed dogs. A bile acids tests will show an elevation, particularly after we feed a meal. If we suspect PSS as the cause to your pets problem we will run a blood ammonia level, which will come back elevated if PSS is present. An ammonia tolerance test might be needed for verification.

In cats the albumin, BUN, and cholesterol might be low or at the low end of the normal range.

_D2A8688

This young cat with a PSS shows elevated liver enzymes and also a low BUN

Bile Acids Test

This is a liver functions test as opposed to a liver enzyme test like ALT. An increased  bile acids test is a very accurate indicator of PSS. There can be false negatives, and even false positives (in some Maltese).

A fasting biles acids test is measure first, the a meal is given, and another bile acids test is performed 2 hours later.

A bile acids test of 135 before this pet has been fed is a strong indicator of PSS (normal is < 13)

Urinalysis

A urinalysis might show symptoms of urinary tract infection or abnormal crystals, particularly ammonium biurate.

_D2A8689

This a urine sample from the cat above. It shows the elevated (> 50) ammonium urate crystals at the bottom.

A bile acids test of 135 before this pet has been fed is a strong indicator of PSS (normal is < 13)

Blood Ammonia

Since ammonia builds up in the bloodstream on a pet with a shunt (this causes hepatic encephalopathy leading to CNS signs) it can be measured. This test is not performed routinely any more due to the difficulty of running it. It has been replaced with the bile acids test.

Radiography

A radiograph of the liver might show a small liver (microhepatica), particularly in the dog. The liver might be hard to evaluate because a lack of abdominal fat, due to emaciation or a young animal.

Kidney changes and bladder stones might be visible, although ascites might obscure vision of internal organs. Ammonium urate bladder stones might not show up on a radiograph even though they are present. This is because they are radiolucent and not radiopaque. They can be seen on ultrasound though.

This liver is normal in size. It still could have PSS. Its a small liver that is more indicative of PSS though. 

Ultrasound

Ultrasound can give further information on the liver and its blood supply, and even detect ammonium biurate bladder stones which normally don’t appear on a radiograph. It takes an expert at ultrasound to find this problem in the liver. Ultrasound is better at differentiated intrahepatic shunts as opposed to extra-hepatic shunts.

This is what the liver looks like during an abdominal ultrasound

Ultrasound has the ability to follow the blood flowing through the liver using the doppler.

_D2A8699

The abnormal shunt vessels are the white area to the right of the word shunt. They are found wiht the doppler that traces the flow of blood in the liver.

This is an ultrasound report of a cat with PSS

Positive Contrast Portography

Some consider this test the gold standard for diagnosis. In this test a special dye is injected directly into one of the veins of the small intestines while a pet is under anesthesia. A radiograph is taken and the flow of the dye is followed. If a shunt is present this will show up on the radiograph.

Biopsy

A biopsy of the liver (usually performed when the ultrasound is done) will show microscopic abnormalities consistent with PSS. This usually includes small hepatocytes and a decrease in the blood vessels within the liver.

Laparotomy

Exploratory surgery to visualize the vessels directly, or to inject dye into the portal vessels, is also used to verify the diagnosis. After the dye is injected a radiograph is taken to assess absorption. Surgical repair can immediately be initiated.

Scintigraphy

A transcolonic nuclear scan can give a definitive diagnosis. In this test a small amount of radioactive (99technetium pertechnetate) material is put into the colon and its absorption is monitored. In pets with PSS this radioactive material will appear in the heart before it appears in the liver, the opposite of what should normally happen. This test does not require anesthesia like the Positive Contrast Portography test.

_D2A0909

This cat has a PSS

Medical Treatment

Anti Seizure Drugs

Valium or a similar benzodiazepine drug is used when a pet is presented in seizures due to hepatic encephalopathy.

Fluids and Electrolytes

This crucial treatment corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. Pets that are severely ill from PSS should not be given anything orally initially.

Cleansing Enemas

Enema’s will decrease the bacterial count of the intestines, leading to less ammonia absorption.

Lactulose

Lactulose works in the large intestine to minimize the production of ammonia by bacteria. It does this by changing the pH and converting ammonia to a form that is not readily absorbed into the bloodstream. It also stimulates normal colon bacteria to absorb ammonia, which is then passed in the feces. Finally, it stimulates the intestines so that ammonia passes through faster, which means there is less time for absorption.

Antibiotics

These drugs are also administered, especially if mental depression is present. They minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed from the intestines into the bloodstream. They work well with lactulose to decrease the ammonia level. Typical ones include metronidazole (Flagyl) and amoxicillin.

Antiparaciticides

Internal parasites can cause gastrointestinal bleeding and also make the symptoms of PSS worse.

Omeprazole

Used when GI (gastrointestinal) bleeding is present

Dietary Modification

A diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Meat based proteins should be avoided since they can increase the chance of HE. Most of the caloric needs of a pet with PSS should be supplied with carbohydrates like rice and pasta. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. They can act to minimize ammonia production and absorption in a manner that is similar to lactulose.

Hill Prescription Diet L/D® is very helpful in liver disease. It contains added amounts of nutrients that a diseased liver needs. It also has restricted amounts of nutrients that can make the condition worse. For example, sodium (Na) is limited to minimize fluid buildup in the abdomen (ascites).

Unfortunately, it is hard to find this food for cats, but their K/D diet has worked well in its place.

Nutraceuticals

Denamarin (s-adenoslymethionine or SAMe) and milk thistle might also be used to help increase the antioxidant glutathione. Glutathione helps reduce the damage caused by free radicals in the liver.

Instituting these medical treatments is necessary even if surgery is planned because they will aid in recovery and make for a better anesthetic risk.

Surgical Treatment

For many PSS cases surgery is the treatment of choice. The abnormal vessel that is shunting blood around the liver is identified and closed (ligated) to minimize blood flowing through it. When the abnormal blood vessel is ligated blood will now flow through the liver instead of around it. Several techniques are used, depending on the particulars of the case and the training and experience of the surgeon:

Click here to see detailed surgical pictures of using the Ameroid Ring in a cat with an extra-hepatic shunt.

This is not a routine surgery, and it takes a veterinarian with advanced training and expertise to perform it successfully. Click on the picture above to see an actual surgery. 

This surgery is readily accomplished for solitary extrahepatic shunts. Post surgical monitoring is important. If the pressure within the liver becomes too high due to the increased blood flow through the liver then the ligation on the shunting vessel(s) must be reduced or removed. Complications in a small number of cases can include seizures and death. A medication called Levetiracetam can be helpful to minimize seizures when started prior to surgery.

Intrahepatic shunts can be more difficult to identify and ligate. They are sometimes corrected with interventional radiology using coils to fix the shunt vessels.

In some cases medical management must also be utilized to affect a cure. The final outcome of treatment depends on what age the PSS started, how long it has been present, and whether it is intrahepatic (worse prognosis) or extrahepatic in nature.

Long Term Monitoring

Pets on long term medical care need to be monitored carefully. Body weight, albumin, and total protein are watched to ensure adequate protein in the diet. Initially, these tests should be performed monthly, then every 3 months. In addition to the above tests, bile acids are monitored monthly, then every three months to assess the vitality of the liver. Blood ammonia levels are monitored monthly to assess effectiveness of treatment. When stable, ammonia levels can be monitored every 3 months.

Prognosis

Many pets with isolated extrahepatic shunts return to a normal life after surgery. There is no guarantee that surgery will correct the problem, especially those pets that develop the disease very early in life. Some of them will need medical management simultaneously. The prognosis for pets that are treated only medically varies. Cats do not do as well as dogs when surgery is attempted.

 Gall Bladder Disease

Dogs tend to get problems with the gall bladder more than cats, although it is not a common problem in the dog,. The symptoms are variable, and usually involve poor appetite, lethargy, and vomiting.

Click on the link below to learn how we diagnose and treat this problem surgically.

Gall bladder removal surgery

Chronic active Hepatitis

This disease is also known as Chronic canine Inflammatory Hepatic Disease (CCHID). It is a series of different liver diseases with similar characteristics when analyzed under the microscope (histopathology). It has similarities to cirrhosis found in humanoids.

Cause

Usually unknown. In some cases an infection caused by a bacteria called Leptospirosis or a virus called adenovirus is the cause. We protect dogs from this adenovirus when we give a DHLPP vaccine. The “H” stands for hepatitis caused by the adenovirus. This same vaccine can also protect dogs from Leptospirosis. Some dogs can get a vaccine reaction to Leptospirosis, and since the disease is not prevalent, it is not commonly given.

Pathophysiology

The immune system makes antibodies that affect liver cells. Toxic compounds add to the problem. Some of these compounds include cholesterol, iron, copper, and toxins located within the blood vessels. All of this leads to inflammation, and the eventual replacement of normal liver cells (hepatocytes) with fibrous tissue. Eventually, the blood flow through the liver is compromised, the blood pressure within the liver is elevated (hypertension), and numerous extrahepatic PSS’s develop (see PSS above). The body then shows signs of fluid buildup in the abdomen (ascites) and HE (see above). After a variable period of time liver failure often results.

Signalment

It tends to occur more often in older animals. Several dog breeds are predisposed:

  • Doberman Pinschers

    Most common in middle-aged females with improper copper metabolism.

  • Cocker spaniels

    Most often in older males. Typical symptoms include fluid buildup in the abdomen (ascites) and low albumin (hypoalbuminemia) on a blood sample.

  • West Highland white terriers, Bedlington terriers, and Skye terriers.

    It is associated with copper accumulation in hepatocytes, sometimes seen more often in young dogs.

History

Symptoms are vague, and come and go until the disease progresses. The typical symptoms of liver disease are present, and include PU/PD, anorexia, vomiting, diarrhea, ascites, icterus, and HE. Ulcers of the stomach can occur and lead to vomiting blood (hematemesis)

Other symptoms can involve the blood system, and include bleeding disorders and vomiting blood (hematemesis). This is because the liver is involved with the production of clotting factors (remember the physiology section above?). In occasional cases the opposite occurs, and the liver causes excessive clotting of blood. This predisposes animals to a problem known as disseminated intravascular coagulation (abbreviated as DIC).

Physical exam

An exam of a pet with this disease can vary from normal to many abnormalities. Some of the abnormal findings are described in the liver exam findings above.

Diagnostic Tests

Blood Panel

A blood panel will commonly show anemia along with elevated levels of ALT and Alk Phos. There might also be an elevation in cholesterol, a decrease in BUN, glucose, and albumin. There might also be an increase in bilirubin, ammonia, and bile acids.

Urinalysis

A urinalysis might show symptoms of urinary tract infection or abnormal crystals, particularly ammonium biurate.

Radiography

A radiograph of the liver might show an enlarged liver (hepatomegaly) initially, eventually it might progress to a small liver (microhepatica).

Ultrasound

Ultrasound is the best way to make this diagnosis. The internal architecture (parenchyma) can be analyzed and a biopsy can be obtained with relative ease. In some cases it is important to know the coagulation status of the blood with a special blood panel prior to obtaining this biopsy. In many cases ultrasound is preferable to exploratory surgery since some of these animals are not good anesthetic risks and the procedure is much less invasive.

Laparotomy

The liver can be thoroughly visualized and palpated during an exploratory surgery. A biopsy can easily be obtained, and post biopsy bleeding can be monitored.

Biopsy

Samples of the liver taken with either a biopsy needle during ultrasound, or during a laparotomy, will be analyzed microscopically by a pathologist to make a definitive diagnosis and to look for a cause if possible.

Treatment

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag. Care must be taken not to give excessive amounts of fluids, especially if they contain sodium, in pets with fluid buildup in the abdomen (ascites).

Treating the Cause (when known)

Antibiotics are used to control bacterial infections and drugs that are suspected of causing this disease are stopped. We tend to use antibiotics that have minimal need for liver metabolism in order to minimize their toxic effects.

Rest

The liver has ability to heal itself if the disease is not too advanced. Rest can be a big aid, along with proper nutrition.

Ascites Reduction

Sodium restriction helps minimize fluid buildup (ascites) in the abdomen. This can be accomplished using Hills K/D Prescription Diet. Diuretics like Lasix are also used to help pull this fluid out of the abdomen.

Dietary Modification

Use a diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Hills Prescription Diet L/D® is the diet of choice.

Meat based proteins should be avoided since they can increase the chance of HE. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. This is the same basic diets as for pets with PSS (see above).

A diseased liver needs calories, which sometimes need to be supplied with a feeding tube.

Ulcer Treatment

This will make pets more comfortable, more inclined to eat, and prevent bleeding in the stomach.

Liver Specific Drugs

Corticosteroids- Cortisone is used if there is evidence that the immune system is implicated as a cause of the liver problem.

Ursodiol- This drug replaces toxic bile acids with a type of bile that is less toxic.

Zinc- Supplementation might help reduce the effects of copper toxicity.

Long Term Monitoring

CCHID monitoring is similar to PSS (see above). In addition, repeating a liver biopsy 6 months after initiating therapy used.

 

Infectious Canine Hepatitis (ICH)

Background

The disease is called hepatitis because liver cells are one of the prime targets. It is caused by an adenovirus that is found world wide and affects mainly the dog family (canids). The virus is very resistant to disinfectants and can remain infectious in the environment. Many dogs get exposed to this virus, develop antibodies, and show no symptoms of the disease. Spread of this virus is usually orally and nasally, but can also be spread by utensils and external parasites. Within 7 days of exposure most dogs develop an adequate antibody response to protect the liver and other organs.

Symptoms

ICH can occur in unvaccinated dogs of any age, but usually occurs in dogs under one year. In the more severe cases vomiting and diarrhea can occur. These dogs can also have fever, coughing, swelling of the head and neck due to lymph node enlargement, abdominal tenderness and even central nervous system signs. These symptoms may last up to one week, and can be prolonged by other concurrent diseases like Distemper. A syndrome of this disease can cause rapid death leading people to conclude that the dog was poisoned. Dogs that show minimal symptoms can show ocular lesions during the convalescent phase. In uncomplicated cases these eye lesions heal completely.

Diagnosis

Blood samples give a clue to this disease but are not diagnostic. White blood cells can be low, liver enzyme tests may be elevated, and clotting factors can be disrupted. These findings, along with the previously described history and physical exam findings, are how the disease is usually diagnosed. Antibody tests are available but are not routinely used to make a diagnosis.

Treatment

Like most viral diseases therapy is directed towards symptoms. When symptoms are severe enough, intravenous fluids are administered. Since clotting factors can be disrupted particular attention needs to be paid to bleeding problems. If bleeding problems are severe enough, a whole blood transfusion must be administered. Dogs that are comatose may need intravenous glucose.

Prevention

Most pups receive adequate antibodies from the bitch, which can last up to 4 months. Vaccines are highly effective and can confer long term protection. Two vaccines need to be given at 3-4 weeks apart beginning at 8 weeks of age. The DHLPP (Distemper-Hepatitis-Leptospirosis-Parainfluenza-Parvo) vaccine contains protection against this adenovirus. The DHLPP vaccine is also known as the Da2PL. The a2 part stands for adenovirus.

A picture of our vaccine label

 

Copper Toxicosis (Copper Storage Disease)

The level of copper in the body is maintained by the excretion of bile. In this disease copper accumulates in hepatocytes, eventually causing inflammation and scarring, ultimately leading to liver failure (similar to CCIHD above). Excess copper released from the liver can cause hemolytic anemia.

Signalment

It is common in certain breeds:

Bedlington terriers- They have a genetic defect in how they metabolize copper and how it is excreted in the bile. This leads to excess accumulation in hepatocytes.

West Highland white terriers- They have a similar genetic defect as Bedlington terriers, but the copper accumulation is not as severe and does not always lead to liver failure.

Some Dobermans and Skye terriers with chronic liver disease also have elevated levels of copper in their hepatocytes. The copper accumulation in the liver might be a cause of the chronic hepatitis that eventually results, or an effect of a pre-existing hepatitis.

History

Bedlington’s with copper toxicity have minimal symptoms early in the disease. In the acute form, seen in younger dogs, symptoms include lethargy, anorexia, and vomiting. Death can occur in 2-3 days. Middle aged or older dogs have a more chronic course. Eventually symptoms of liver failure appear, including anemia, depression, lethargy, and anorexia.

Physical exam

Anemia might cause pale mucous membranes. There might also be icterus due to both anemia and liver failure. These dogs will also be weak and underweight.

Diagnostic Tests

A blood panel will commonly show elevated levels of ALT, GGT and Alk Phos, in addition to high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is elevated and radiography reveals a small liver. This disease is diagnosed by liver biopsy.

Treatment

Treatment has two goals: Enhance excretion of excess copper, and minimize further absorption of copper from the intestines.

Chelating agents Drugs like penicillamine bind with copper to allow easier excretion.

Zinc- will help minimize further copper absorption from the intestines.

Supportive Care

Similar to other liver diseases previously described

Diet

Hill’s Prescription Diet L/D® can be beneficial in treating this disease.

Long Term Monitoring

Serum enzymes and bilirubin should be monitored at least every 6 months

Prevention

Bedlington terriers should be screened at 1 year of age. Treatment at this early age leads to a good prognosis.

Cancer (Neoplasia)

A benign tumor of the liver is called and adenoma, a malignant one is a carcinoma.

Primary- Arising directly from the liver

  • Adenoma
  • Carcinoma
  • Hemangiosarcoma
  • Hemangioma
  • Leimyosarcoma
  • Fibrosarcoma
  • Fibroma
  • Osteosarcoma

They can arise directly from the hepatocytes where they are called hepatocellular. If they arise from the biliary system they are called cholangiocellular. Dogs get more hepatocellular, cats get more cholangiocellular. The cause of these primary neoplasia’s is unknown in most cases.

Secondary- From another organ that has spread to the liver

  • Lymphosarcoma
  • Mast cell
  • Pancreatic carcinoma
  • Myeloproliferative

The organs that commonly are the source of these secondary cancers include:

  • Pancreas
  • Lymph nodes
  • Spleen
  • Mammae
  • Adrenal glands
  • Bone and bone marrow
  • Lungs
  • Thyroid
  • Intestines

Secondary, also know as metastatic, liver cancers are much more common than primary.

Signalment

Cancer is found in most animals and most breeds. It tends to be found mostly in older animals.

History

Almost any sign of illness can potentially be attributed to neoplasia. Common ones include anorexia, lethargy, weight loss, PU/PD and vomiting.

Physical exam

Exam results of animals with liver neoplasia mimic the results found in other liver diseases.

Diagnostic Tests

A blood panel will commonly show elevated levels of liver enzymes, in addition to high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is elevated and ultrasound reveals hepatomegaly (enlarged liver) with telltale changes of the liver parenchyma (internal anatomy of the liver). Ultrasound might also show inflammation of the pancreas (pancreatitis). A liver biopsy is needed for a definitive diagnosis. There is an ultrasound picture of liver cancer in the diagnostic section above.

Treatment

Primary hepatic neoplasms are treated by removal of the affected liver lobe when possible. If multiple lobes are involved then surgery is usually not performed. Secondary hepatic neoplasms are treated with chemotherapy. The results vary, and depend on the duration, location, and degree of malignancy of the neoplasia. The prognosis is poor for long term survival.

Supportive care that is similar to other liver diseases is also used in neoplasia

Prevention

Since the cause is usually unknown prevention is difficult. Good nutrition and lots of TLC are always important in preventing any disease.

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Liver Disease Summary Page

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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 chemical 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.

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:

The word “hepatitis” will be used throughout his page. Hepatitis is a general term meaning inflammation of the liver. There are many diseases that cause this, some of them are much different that what we encounter in homo sapiens.

Anatomy

The liver is a multi-lobed organ that is located at the most forward part of the abdomen. It is so far forward that it lays up against the diaphragm, the muscle that aids in breathing in mammals (birds and reptiles do not have a diaphragm).

This autopsy picture of a cat shows the gallbladder in green, with several lobes of the liver laying right up against the diaphragm (towards the top of the picture). On the other side of the diaphragm is the chest cavity containing the lungs and heart.

This close-up of the gallbladder and one of the lobes of the liver gives you a feel for what a normal liver lobe looks like in a cat.

The gallbladder can be seen with ultrasound

The liver is the largest organ that is located in the body, a testament to its importance. It has 6 distinct lobes organized into 3 regions. Like the kidneys, 25% of the blood ejected with each beat of the heart goes to the liver. Of tremendous significance is the fact that a healthy liver has great reserve power, using only a small amount of its full potential at any one time. Unfortunately, this great reserve power means that diseases that affect the liver can be well entrenched before a diagnosis is made. This obviously makes the prognosis worse. The liver does have an advantage though. Liver cells (hepatocytes) can regenerate themselves. This regenerative ability allows a diseased liver to return to normal function in some cases. Very few organs in the body have this ability.

The liver is supplied with nutrients from the hepatic artery and the portal vein, which is different from other internal organs.

The extensive blood supply to the liver is apparent in this picture.

Biliary System

The biliary system consists of the gallbladder, bile ductules, hepatic ducts, and the common bile duct.

The gallbladder is located between two of the liver lobes. It stores bile that is made by the liver, and secretes this bile through the common bile duct into the beginning of the small intestine (duodenum). The bile that is secreted into the duodenum aids in the digestion of many compounds, especially fat.

This is a picture of a greatly enlarged gall bladder and common bile duct in a cat.

BD- Bile duct

GB- Gall Bladder

L- Liver

The bile that is stored in the gallbladder is secreted into the beginning of the small intestines (called the duodenum) through the common bile duct. This picture gives you a great view of bile as it is being secreted.

Physiology

It is an understatement to say that the liver is an important organ. Its complexity precludes us from discussing all of its functions, so we will limit the physiology section to some of its more important functions.

The liver has reserve functional power and can operate effectively when most of the hepatocytes are not working well. In addition, diseased hepatocytes can actually regenerate and return to normal function.

Metabolism

The liver is the organ that orchestrates the metabolism of fats, carbohydrates, and protein. It does this in conjunction with the circulatory system, the lymphatic system, and the endocrine (hormone) system. A healthy liver is critical to proper protein, carbohydrate, and fat metabolism.

Detoxification

Drug detoxification is an important liver function. It is a complex process that occurs in the endoplasmic reticulum of the hepatocyte. Several phases are involved with this detoxification:

Bile Metabolism

Bile is made up of electrolytes, cholesterol, bile acids, bilirubin, and globulins. It is produced by hepatocytes, secreted by hepatocytes into channels in the liver called bile cannaliculi, and stored in the gall bladder Drugs are eliminated in the bile, red blood cell are recirculated through the bile system, and fats are absorbed from the intestines into the bloodstream only in the presence of bile.

The fat soluble vitamins, A, D, E, and K, require bile for proper absorption form the intestines. These vitamins are stored in the liver, and are converted to active compounds as the liver maintains normal physiology (homeostasis).

Coagulation Factors

The proteins that initiate and maintain clotting of blood are synthesized by the liver. These proteins go through very complex biochemical processes to achieved this vital function. A diseased liver is unable to synthesize these proteins, leading to a potential bleeding problem. Vitamin K is also an essential component of these clotting mechanisms. When rat poison (warfarin poisoning) is ingested it interferes with the ability of vitamin K to perform this vital function.

Red Blood Cell System

The liver removes old or damaged red blood cells from the circulation, and is involved with the storage of iron and the breakdown of hemoglobin. Because of this, chronic liver disease could cause anemia. The liver (along with the spleen), is a storage organ for blood. If these is a severe blood loss the liver expels this blood into the bloodstream to help make up for the loss.

Reticuloendothelial System

Specific cells called Kupffer cells line the inside of the liver. These cells are part of the immune system. They eliminate and degrade the substances that are brought into the liver by the portal vein. Some of these substances are bacteria, toxins, nutrients, and chemicals. A diseased liver will not filter these compounds normally, resulting in toxic accumulations of toxins, chemicals, or bacteria. Excess accumulation of bacteria in the bloodstream is called septicemia, and is one of the reasons that antibiotics are commonly used in liver disease.

Vitamins

Many vitamins are stored in the liver, and perform their functions only when activated by the liver, and are degraded by the liver. These include some of the B vitamins and Vitamin C, along with A, D, E, and K previously described.

Cause

Trauma

Animals that receive a severe and blunt blow to the front of the abdomen can suffer from liver disease. The most common cause of this type of blow is being hit by a car. A liver lobe can be fractured and bleed into the abdomen, even leading to death. A more common occurrence is a bruise (contusion) that heals itself. Heatstroke, diaphragmatic hernia and liver lobe torsion can also cause liver problems.

Inflammation

An inflamed liver is called hepatitis. Trauma can cause this, along with drugs, bacteria, bile, and toxins.

Pancreatitis

The severe inflammatory process that occurs with digestive enzymes can spill over into the liver and cause severe disease.

Anemia

Hemolytic anemia can decrease the oxygen available to liver cells and lead to their death.

Infection

Bacteria, viruses, and fungi can all cause liver disease. Since bacterial infection is common in many liver problems it is routine to use antibiotics when treating liver problems. Specific diseases include Infectious canine Hepatitis, canine Herpesvirus, Feline Infectious Peritonitis (FIP), Leptospirosis, abscesses, histoplasmosis, coccidiomycosis, and Toxoplasmosis.

Heartworms

These worms can block blood flow into the liver and cause liver failure.

Toxins

There are literally thousands of chemicals that could be toxic to the liver. a few examples of these chemicals that are commonly used to treat ill animals include:

  • Rimadyl (arthritis treatment) in Labradors
  • Thiacetarsamide (heartworm treatment)
  • Ketaconazole (fungal treatment)
  • Tylenol (acetaminophen)
  • Glucocorticoids (cortisone)
  • Anthelmintics (worming medication)
  • Parasiticides
  • Phenobarbital (epilepsy medication)

Cancer

Cancer can arise directly within the liver (primary) or spread from elsewhere (metastatic or secondary) through the circulatory or lymphatic systems. In the anatomy section we mentioned the dual blood supply to the liver; the portal vein and the hepatic artery. This extra blood supply increases the chance the a tumor in a different organ that has spread into the blood stream will end up in the liver. As mentioned in the physiology section, liver cancer is usually detected only after the disease is well established since functional reserve capacity allowed the liver to function normally for a prolonged period of time.

Metabolic diseases that cause secondary liver problems:

Symptoms

Symptoms of liver disease are variable and subtle in the early stages of the problem. The classic symptoms are:

Poor appetite (anorexia)- This is a common symptom

Weight loss- The poor appetite that occurs in liver disease eventually leads to loss of weight. Improper metabolism of fat, carbohydrates, and proteins complicates the situation also.

Polyuria/polydipsia (PU/PD)- This is excess urinating and excess drinking of water. This can occur in liver disease, although several other important diseases cause these symptoms also, notably, kidneydiseaseCushing’s disease, pyometra, and diabetes mellitus (sugar diabetes).

Lethargy- Poor appetite and disruption in normal physiologic processes leads to this symptom. Anemia adds to this lethargy, along with ascites due to the discomfort it causes.

Anemia- Improper nutrition from a poor appetite, along with disease in the hepatocytes will cause this.

Light colored stool- If the biliary tree is prevented from secreting normal bile pigments into the intestine the stool will lack pigmentation and appear lighter in color.

Bleeding disorders- The normal clotting system is impaired since it depends on a healthy liver.

Distended abdomen due to ascites or hepatomegaly. If the distention is severe enough breathing might be labored from pain or the pressure on the diaphragm.

Vomiting (emesis) nausea, or diarrhea. Sometimes blood is present in the vomitus (hematemesis), especially if a gastric ulcer is present. The ulcer comes from a complex interaction of histamine, nitrogen, bile acids, Gastrin, portal hypertension, and altered mucous membrane lining the inside of the stomach. d

Pain due to distention of a diseased liver.

Orange colored urine or mucous membranes due to jaundice.

Behavioral changes- circling, head tilt, heap pressing, and seizures, particularly right after a meal.

 


Diagnosis

A thorough approach is needed for a correct diagnosis of any liver problem. an organ like the liver that is so intimately involved with other important organs will exhibit symptoms that mimic disease in these other organs. Also, what initially might appear as a diseased liver is in reality a disease elsewhere in the body that is involved with the liver secondarily. This is why it is crucial to follow a thorough and methodical approach called the diagnostic process.

1. Signalment

Liver disease can occur in pets of any age. If it occurs in young animals we tend to think more of toxicity, a liver shunt or a viral disease like adenovirus in dogs, or FIP in cats. In older pets we tend to think more of inflammation and cancer as the cause of the liver problem.

Several canine breeds are prone to getting liver disease:

Bedlington terrier’s, Skye terriers, Doberman pinschers, and West Highland White terriers get a problem with excessive copper accumulation that results from failure of normal biliary excretion of copper.

Cocker spaniels have an increased incidence of chronic hepatitis.

2. History

Early signs of liver disease are subtle, and might exhibit as some of the symptoms described above. It is important to remember that some pets do not show any symptoms early in the course of the disease. This is another reason for yearly exams, along with blood and urine samples in dogs and cats 8 years of age or more.

The recent use of pesticides, insecticides, and drugs might give us a clue. Some Labradors are sensitive to the use of the arthritis medicine Rimadyl. These dogs should have a blood panel analyzed prior to initiating Rimadyl therapy. Every 6 months this panel should be repeated.

A history of poorly controlled diabetes mellitus might also clue us in to liver problems. Pets with liver shunts might have stunted growth and become depressed right after eating. In cats with hepatic lipidosis the history usually involves a lack of appetite (anorexia), especially if the cat was previously obese.

3. Physical Exam

Routine physical exam findings might include:

Distended abdomen due to enlargement of the liver (hepatomegaly). This can be palpated in some situations, especially in the smaller animals. An enlarged liver from a disease other than liver disease can cause hepatomegaly. This includes heart disease and Cushing’s Disease.

Enlarged lymph nodes due to secondary bacterial infections or spread of a primary or metastatic liver tumor.

Bruising (hematoma) might be observed under the skin, or when a blood sample is obtained. This is due to the liver’s affects on the clotting mechanism.

Fever- A rectal temperature of greater than 103 degrees F could accompany liver disease when inflammation or infection is present.

Skin infections and wounds that do not heal, or recur after antibiotics are stopped.

Yellowish discoloration (icterus or jaundice) of the ears, gums, or hairless areas of the skin

Anemia might be observed by checking the mucous membranes for a proper pink color.

4. Diagnostic Tests

Several tests are used as an aid in making this diagnosis.

Blood Panel

A CBC (complete blood count) and BCP (biochemistry panel) should be run on every pet 8 years of age or more, especially if they have any of the symptoms of liver disease.

The CBC might show a decrease in the number of red blood cells (RBC’s). This decrease in RBC’s is called anemia. The white blood cell count (WBC) might be elevated (leukocytosis), normal, or decreased (leukopenia), mostly depending on the cause of the liver problem and how long it has been present.

A good way to diagnose liver disease is with the biochemistry panel, abbreviated as BCP. There are several tests on the BCP of dogs and cats that aid us in our diagnosis of liver disease. Many of these are called liver enzyme tests, a few of which we will discuss. When they are elevated it could be a sign of liver disease, but not necessarily so. There are a multitude of conditions that will cause an increase in these enzymes even though the liver is not primarily diseased. (a good example is Feline Hyperthyroidism). They need to be at least 1.5x normal to be of significance. If a pet has significant elevations in the liver enzymes tests then they should be repeated and trends noted. Only then can we get an indication if the liver truly has a problem. To further add to the complication, these tests can be normal in dogs and cats that have severe liver disease.

This older dog has all the classic blood parameters of a dog with liver disease. The alk Phos, ALT, GGT, and Total Bilirubin are significantly elevated. Even the cholesterol is high, which sometimes accompanies liver disease.

Bile Acids

This is liver function test, not an enzyme test, and is not a routine part of the BCP. We will request this test when we suspect a liver problem, whether the enzyme tests are normal or not. This test is performed by taking a blood sample, giving a meal, then taking another blood sample 2 hours after the meal. Comparing the pre-meal and post-meal blood results gives us valuable information. The bile acids test is an accurate measure of liver function.

Urinalysis

A urine sample can give us important clues as to the existence of liver disease. The specific gravity might be below normal, an indication that PU/PD is present. Bilirubin might be present, a finding that is always abnormal in cats. There also might be ammonium biurate crystals, a sign of improper ammonia metabolism found in Hepatic Encephalopathy.

Abdominocentesis

Analysis of the fluid obtained from a pet with ascites can give valuable clues as to its cause. There are numerous causes to ascites, some of the more common ones are heart disease, liver disease, and cancer.

Fluid is removed from the abdomen with a special needle and syringe.

Liver Biopsy

This is a very valuable test in the diagnosis of liver disease. a sample of the liver can be obtained during an exploratory surgery or during an ultrasound procedure. The pathologist can look at the hepatocytes microscopically and determine if disease is present and what the cause is.

It is helpful to run a coagulation panel prior to any liver biopsy. A diseased liver might not be able to clot properly, and a biopsy could cause hemorrhage into the abdomen.

Stool

A dog that excretes stool without normal pigmentation could indicate liver disease. It occurs when there is obstruction of the biliary system and normal bile pigments are not secreted to cause the normal dark color of stool.

Radiography

An enlarged liver on a radiograph is called hepatomegaly, an abnormally small one is called microhepatica. Either one can be a sign of a liver problem.

The liver in this radiograph is enlarged because the edge of the liver is protruding far beyond the last rib. The edges of this liver are very sharp and clearly outline its borders.

Some radiographs of a liver with hepatomegaly don’t show the routine shape of the liver lobes. This case of a liver cancer has a very rounded appearance. an tumor of the stomach, spleen, or intestines can also have this appearance.

Sometimes we diagnose hepatomegaly or microhepatica indirectly by looking at the angle of the stomach This picture shows the angle of the stomach in a normal radiograph of the abdomen.

This liver is pushing the stomach (S) towards the rear, an indication of hepatomegaly, even though it is difficult to clearly see the liver.

Ultrasound

Ultrasound is highly beneficial in the diagnosis of liver disease. We recommend ultrasounding a liver when the liver enzymes tests are elevated over time, or the bile acids test is abnormal.

The internal structure (called parenchyma) can be analyzed, and post hepatic liver disease can be differentiated from hepatic liver disease. This can be very important because disease in the liver can often be diagnosed with a biopsy during the ultrasound. Post hepatic liver disease is diagnosed and treated with an exploratory surgery (called a laparotomy).

This liver ultrasound reveals a mass in the liver. Can you see its circular appearance at the arrow? It also shows abdominal effusion (this is the ascites described previously).

Exploratory Surgery

Being able to literally look at the liver and palpate individual liver lobes is sometimes needed to confirm a diagnosis of a problem. Taking a biopsy of a diseased part of the liver is enhanced this way.

This picture is from an exploratory surgery (called a laparotomy) on a cat with kidney cancer. We are looking at the liver for any sign of problems- this one is healthy. It is obvious that a laparotomy gives us a great view of the liver.

5. Response to Therapy

The liver has tremendous ability to recover from a disease and literally regenerate hepatocytes. If we treat a liver problem that we diagnosed as treatable, and the liver does indeed recover, then we probably made the correct diagnosis.

In many general problems our doctors recommend Hills Prescription diet K/D or I/D.

Liver Diseases

There are a large number of diseases that affect the liver. We will discuss a few of the most common ones.

Hepatic Lipidosis Pathogenesis

A small amount of fat is normally present in hepatocytes. The original source of this fat is from the diet. From the intestines (remember, bile needs to be present for this to occur) it is absorbed into bloodstream, binds to albumin and is presented to hepatocytes. This fat is in several forms, the main ones being cholesterol, triglycerides, and fatty acids.

Fat is used for energy, the production of sex and steroid hormones, and in cell wall integrity, and as storage for future energy needs. In a normal liver the rate at which the fat from the bloodstream enters the liver and the rate at which the liver utilizes this fat is roughly equal. When there is an imbalance between the rate of deposition of fat in hepatocytes and the rate of utilization of this fat, the amount of triglycerides builds up and lipidosis results. In many species this excess of fat in the hepatocytes causes no serious problem, not so in cats.

The exact mechanism that causes this imbalance in cats is unknown. It is speculated that excess fat stores in obese cats overwhelm the liver when these fat stores are needed for energy (a cat that is not eating or is starving). This sets off a cascading series of events that involve insulin, glucose, and the enzyme lipase, leading to excess accumulation of triglycerides in hepatocytes.

Primary

This disease, seen more often in cats than in other animals, occurs when excess fat (called triglycerides) accumulates in liver cells (hepatocytes) and bile accumulates in hepatocytes (cholestasis). It is technically called Idiopathic Hepatic Lipidosis (IHL). The idiopathic part means that the specific cause is unknown. This form of lipidosis causes liver failure, and can lead to death if left untreated.

Secondary

In this form of hepatic lipidosis the fat accumulation occurs secondary to some other problem. This is more common than primary hepatic lipidosis. Some of the more common causes are:

Secondary hepatic lipidosis does not cause liver failure. When the primary disease is treated the liver problem tends to resolve. A large percentage of cats have hepatic lipidosis secondary to these diseases (and others).

Signalment

IHL can occur in any age or breed of cat, although it is not commonly seen in young cats. It is the most common liver disease found in cats.

Toy breed dogs can get a lipidotic liver after fasting or not eating for a period of time. They become hypoglycemic (low blood sugar), and can even die.

History

Cats with IHL consistently have anorexia (not eating), leading to weight loss. They are usually (or were) obese, and sometimes there is a history of a recent stressful episode that caused them to stop eating. Many owners will notice jaundice (icterus) and vomiting. Other symptoms could include diarrhea, constipation, salivation, and depression.

Physical Exam

Cats with IHL have lost weight (although they could still be obese when examined) and may have yellowish discoloration (icterus) on the ears, the whites of the eyes, and the oral mucous membranes (gums). An enlarged liver (hepatomegaly) might even be palpated. Some of the other common signs of liver disease as described previously might be present on occasion.

This cat has icterus (jaundice) of its oral cavity from hepatic lipidosis, although a severe enough anemia could also cause this appearance.

 


This is the way the blood looks just after it was obtained on this cat and spun down in our centrifuge. The serum, which is the top layer, has the same yellowish-orange appearance as this cats gums.

Diagnostic Tests

A blood panel will commonly show highly elevated levels of ALT and Alk Phos, and mild elevations in GGT. In addition there are commonly high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is frequently elevated, and the blood ammonia level might also be elevated on occasion.

Other findings could include anemia, low albumin (hypoalbuminemia), high cholesterol (hypercholesterolemia), low BUN, low potassium (hypokalemia), and high glucose (hyperglycemia).

Diseases that can mimic IHL in cats include FIP, cholangiohepatitis, and liver cancer. A biopsy of the liver (usually performed when the ultrasound is done) is needle to verify the diagnosis. IHL usually involves many hepatocytes, so a general sample of the liver tissue usually yields diagnostic results. This is not the case with all liver diseases though. Some are focal and involve only a small portion of the liver. Fortunately, the ultrasound can pick up these focal areas and a biopsy needle can be directed to the diseased area by the ultrasound.

Radiography

Radiography might show hepatomegaly or a normal sized liver. Weight loss might be apparent on the radiograph, yet abdominal fat stores might be normal.

Ultrasound

Ultrasound reveals hepatomegaly with telltale changes of the liver parenchyma (internal anatomy of the liver). Ultrasound might also show inflammation of the pancreas (pancreatitis).

Exploratory Surgery

If an exploratory surgery is performed the liver might appear tan or yellowish in color, enlarged, and with swollen borders. It is greasy to the touch and easily injured. Exploratory surgery allows us to take a large section of the liver for biopsy. It also allows visualization of other abdominal organs, particularly ones that might be implicated in this disease like the pancreas.

Histopathology

This is the only way to confirm the diagnosis.

Treatment

Supportive care is crucial, and may have to be instituted for a prolonged period of time. Cats with IHL should be kept in the hospital until they are taking all medications well and their blood parameters are improving.

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag to correct of a deficiency that can occur with IHL. Vitamin K might be needed in cats with clotting problems. This deficiency might be due to anorexia and reduced synthesis by the atrophied intestines. Simultaneous with fluid therapy we will begin caloric support.

Caloric Support

This is the most important part of treatment for IHL, and usually involves the use of a feeding tube. It is so important that we have devoted a full page to it.

Cats need at least 60 Kcal/kg/day of caloric dense high protein diet. The lining of the small intestines (called villi) will atrophy due to a lack of use, so a short adaptive period is needed to get them functioning properly again. This is done by feeding small amounts of food for the first few days, even though full caloric requirements are not being met.

The protein level of the diet should not be restricted unless they are showing obvious signs of hepatic encephalopathy (HE).

Appetite stimulating drugs (valium, periactin) have no place in hepatic lipidosis due to their ineffectiveness, and some of them might even predispose cats to hepatic encephalopathy (HE).

Human enteral diets do not have adequate protein, arginine, or taurine for cats.

Antibiotics

A weakened immune system predisposes these cats to infections, along with the stress of diagnostic tests, hospitalization, and treatment. Antibiotics will help in this situation, especially if mental depression is present from hepatic encephalopathy (excess ammonia in the bloodstream). Antibiotics minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed from the intestines into the bloodstream.

Tetracycline antibiotics should be avoided if possible because they could be an initiating cause of hepatic lipidosis.

Lactulose

This drugs helps minimize the ammonia buildup that leads to vomiting, salivation, and mental depression.

Anti-vomiting medication

Drugs like Reglan can control vomiting and minimize gastric bleeding due to ulcers. As a general rule we want to minimize the use of valium and cortisone in cats with IHL.

Ulcer Medication

Medications like Tagamet and sucralfate will help protect the stomach lining and make pets feel much better. These pets are more inclined to eat.

Supplemental Treatment

Some cats might benefit from other treatment modalities, although this is not the case in all cats. The mechanisms of action of these supplements are postulated but not proven.

L-Carnitine- This essential amino acid is required for proper fat utilization by the liver. Even though low levels are not found in cats with IHL, supplementation might be beneficial.

Arginine- This is another amino acid. It comes from muscle protein when cats are fasted. after a prolonged fast the muscle is depleted of protein and a deficiency of arginine might occur. A deficiency might lead to high levels of ammonia and eventually hepatic encephalopathy (HE). It is an essential amino acid in the cat.

Taurine- This is also an amino acid that could be involved with IHL. It is an essential amino acid, so supplementation might be helpful.

Ursodiol- This drug has an affect on how the liver metabolizes cholesterol and decreases the toxic effects of bile.

When the appetite starts to return we will slowly decrease the volume of food given via tube feeding. When your cat is eating well on its own, and the liver tests have improved on the blood panel, we will remove the feeding tube. This can be anywhere from several days to several months.

Prognosis

This disease is reversible in most cases when treated medically. Cure rates range from 65% to 75% when treatment is started early enough.

Cats that have pancreatitis, remain persistently hypokalemic (low potassium), or whose elevated bilirubin does not decrease significantly within 10 days have a guarded to poor prognosis.

Monitoring

Changes can occur rapidly during the early phases of treatment, so blood parameters need to be routinely monitored, especially electrolytes like potassium and phosphorous. Phosphorous, potassium, and red blood cell levels should be monitored for the first 72 hours after initiating caloric support. Serum enzymes and bilirubin should be monitored weekly until appetite returns.

Prevention

Even though the specific cause of IHL is unknown, obesity is a known predisposition. Since obesity is controllable you can dramatically reduce the chance of your cat getting IHL by keeping it at a proper weight.

Early treatment dramatically increases the chance of recovery, so if your cat does not eat for 24 hours it should be brought to our clinic for an exam and blood testing.

Portosystemic Shunt (PSS)

Pathophysiology

Ammonia comes from bacteria in the intestines and when muscles utilize protein as a energy source. In a normal animal this ammonia gets delivered through the portal vein directly into the liver. The liver cells metabolize the ammonia to urea, which is excreted by the kidneys. The liver also detoxifies bacteria and drugs that are also absorbed from the intestines before they get into the general circulation and go to the rest of the body.

Shunts occur when the blood supply through the liver is abnormal. The abnormal blood vessel shunts blood around the liver instead of through the liver. By bypassing the liver the toxins that are normally metabolized by the liver (especially ammonia) are allowed to enter the general circulation before the liver has a chance to detoxify them. It is this ammonia buildup that causes most of the symptoms observed with PSS. It is also know as hepatic encephalopathy (HE) because of its toxic effects on the brain.

Several factors can add to HE. A diet high in protein will add to blood ammonia levels, along with infection, cancer, and excess use of cortisone. Kidney disease along with constipation will also add to the problem. Some drugs, notably barbiturates, valium, and anesthetics can also be factors.

Shunts can be multiple or single. The shunt can occur within the liver (intrahepatic) or in the blood supply before it enters the liver (extrahepatic). Larger breed dogs are more prone to intrahepatic shunts, extrahepatic shunts are more common in small breed dogs and cats. It is important to differentiate them for therapeutic purposes.

There are other diseases that can mimic PSS. They include liver toxins, liver infection, liver cancer, and hepatic lipidosis (see previous description). An organ as complex as the liver necessitates the need for a precise diagnosis before treatment can be instituted. Also, a pet with chronic liver disease leading to cirrhosis will sometimes get acquired shunts.

Causes

Congenital The congenital version of PSS occurs more commonly in dogs than in cats. Most of these shunts are extrahepatic, meaning the shunting vessels are located outside of the liver.

Acquired.

Seen mostly in dogs, they occur when there is increased resistance to blood flow through a fibrotic liver. These shunts occur inside the liver and are not easily corrected.

Signalment

Congenital shunts tend to be found in younger dogs and cats, while acquired shunts tend to occur in older animals. In some situations the symptoms of this disease are so subtle that a diagnosis of congenital shunt is not made until a pet is much older. We tend to see it more often in male cats as opposed to female cats.

Several dog breeds are predisposed:

  • Irish wolfhounds
  • Maltese
  • Yorkshire terriers
  • Miniature schnauzers
  • Australian cattle dogs
  • Retrievers
  • Cairn terriers
  • Old English sheepdogs

Cat breeds might include:

  • Himalayan
  • Persian

History

Some of the symptoms of PSS can be subtle, and easily interpreted as a quiet puppy or kitten. Symptoms can wax and wane, thus they are easily missed and can be subtle. Some pets seem to have a preference for fruits and vegetables.

Behavior changes, particularly right after eating. These changes include depression, head pressing, blindness, lethargy, coma, seizures, and personality changes. anorexia, vomiting, diarrhea, and excess salivation (more so in cats) might be present. Excess urinating and drinking (PU/PD), blood in the urine (hematuria) and an increased incidence of ammonium urate bladder stones might also be present. Other symptoms might include inhibited growth, fever, and abnormally long recovery periods from anesthesia (ex.-when a spay or neuter is performed).

Physical Exam

Pets with PSS will commonly be stunted in growth, but usually no abnormalities on their neurologic exams. A small liver might be palpated on smaller animals. Hair coat might be unkept and there might be ascites on abdominal palpation. Other occasional findings include cryptorchidism.

Diagnostic Tests

Several diseases mimic PSS. They include Distemper, FIP, toxoplasmosis, FeLV related diseases, toxicities, idiopathic epilepsy, and hypoglycemia. This emphasizes the importance of proper testing to come to an accurate diagnosis.

Blood Panel

In dogs, a blood panel might show anemia along with elevated levels of ALT and Alk Phos. The BUN might be low, the protein level might be low (hypoproteinemia), the blood sugar might be low (hypoglycemia) in the smaller breed dogs, and the cholesterol might also be low. A bile acids tests will show an elevation, particularly after we feed a meal. If we suspect PSS as the cause to your pets problem we will run a blood ammonia level, which will come back elevated if PSS is present. An ammonia tolerance test might be needed for verification.

In cats the albumin, BUN, and cholesterol might be low or at the low end of the normal range.

Urinalysis

A urinalysis might show symptoms of urinary tract infection or abnormal crystals, particularly ammonium biurate.

Radiography

A radiograph of the liver might show a small liver (microhepatica), particularly in the dog. The liver might be hard to evaluate because a lack of abdominal fat, due to emaciation or a young animal.

Kidney changes and bladder stones might be visible, although ascites might obscure vision of internal organs. ammonium urate bladder stones might not show up on a radiograph even though they are present.

Ultrasound

Ultrasound can give further information on the liver and its blood supply, and even detect ammonium biurate bladder stones which normally don’t appear on a radiograph. Ultrasound is better at differentiated intrahepatic shunts as opposed to extrahepatic shunts.

Positive Contrast Portography

Some consider this test the gold standard for diagnosis. In this test a special dye is injected directly into one of the veins of the small intestines while a pet is under anesthesia. A radiograph is taken and the flow of the dye is followed. If a shunt is present this will show up on the radiograph.

Biopsy

A biopsy of the liver (usually performed when the ultrasound is done) will show microscopic abnormalities consistent with PSS. This usually includes small hepatocytes and a decrease in the blood vessels within the liver.

Laparotomy

Exploratory surgery to visualize the vessels directly, or to inject dye into the portal vessels, is also used to verify the diagnosis. After the dye is injected a radiograph is taken to assess absorption. Surgical repair can immediately be initiated.

Scintigraphy

A transcolonic nuclear scan can give a definitive diagnosis. In this test a small amount of radioactive (99technetium pertechnetate) material is put into the colon and its absorption is monitored. In pets with PSS this radioactive material will appear in the heart before it appears in the liver, the opposite of what should normally happen. This test does not require anesthesia like the Positive Contrast Portography test.

Treatment

Medical

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. Pets that are severely ill from PSS should not be given anything orally initially.

Cleansing Enemas

Enema’s will decrease the bacterial count of the intestines, leading to less ammonia absorption.

Lactulose

Lactulose works in the large intestine to minimize the production of ammonia by bacteria. It does this by changing the pH and converting ammonia to a form that is not readily absorbed into the bloodstream. It also stimulates normal colon bacteria to absorb ammonia, which is then passed in the feces. Finally, it stimulates the intestines so that ammonia passes through faster, which means there is less time for absorption.

Antibiotics

These drugs are also administered, especially if mental depression is present. They minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed from the intestines into the bloodstream. They work well with lactulose to decrease the ammonia level.

Dietary Modification

A diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Meat based proteins should be avoided since they can increase the chance of HE. Most of the caloric needs of a pet with PSS should be supplied with carbohydrates like rice and pasta. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. They can act to minimize ammonia production and absorption in a manner that is similar to lactulose.

Surgical

For most PSS cases surgery is the treatment of choice. The abnormal vessel that is shunting blood around the liver is identified and closed (ligated) to minimize blood flowing through it. When the abnormal blood vessel is ligated blood will now flow through the liver instead of around it. This is readily accomplished for solitary extrahepatic shunts. Intrahepatic shunts can be more difficult to identify and ligate. Post surgical monitoring is important. If the pressure within the liver becomes too high due to the increased blood flow through the liver then the ligation on the shunting vessel(s) must be reduced or removed.

In some cases medical management must also be utilized to affect a cure. The final outcome of treatment depends on what age the PSS started, how long it has been present, and whether it is intrahepatic (worse prognosis) or extrahepatic in nature.

Long Term Monitoring

Pets on long term medical care need to be monitored carefully. Body weight, albumin, and total protein are watched to ensure adequate protein in the diet. Initially these tests should be performed monthly, then every 3 months. In addition to the above tests, bile acids are monitored monthly, then every three months to assess the vitality of the liver. Blood ammonia levels are monitored monthly to assess effectiveness of treatment. When stable, ammonia levels can be monitored every 3 months.

Prognosis

Many pets with isolated extrahepatic shunts return to a normal life after surgery. There is no guarantee that surgery will correct the problem, especially those pets that develop the disease very early in life. Some of them will need medical management simultaneously. The prognosis for pets that are treated only medically varies. Cats do not do as well as dogs when surgery is attempted.

Chronic Active Hepatitis

This disease is also known as Chronic Canine Inflammatory Hepatic Disease (CCHID). It is a series of different liver diseases with similar characteristics when analyzed under the microscope (histopathology). It has similarities to cirrhosis found in humanoids.

Cause

Usually unknown. In some cases an infection caused by a bacteria called Leptospirosis or a virus called adenovirus is the cause. We protect dogs from this adenovirus when we give a DHLPP vaccine. The “H” stands for hepatitis caused by the adenovirus. This same vaccine can also protect dogs from Leptospirosis.

Pathophysiology

The immune system makes antibodies that affect liver cells. Toxic compounds add to the problem. Some of these compounds include cholesterol, iron, copper, and toxins located within the blood vessels. All of this leads to inflammation, and the eventual replacement of normal liver cells (hepatocytes) with fibrous tissue. Eventually, the blood flow through the liver is compromised, the blood pressure at the liver is elevated (hypertension), and numerous extrahepatic PSS’s develop (see PSS above). The body then shows signs of fluid buildup in the abdomen (ascites) and HE (see above). After a variable period of time liver failure often results.

Signalment

It tends to occur more often in older animals.

Several dog breeds are predisposed:

  • Doberman Pinschers

    Most common in middle-aged females with improper copper metabolism.

  • Cocker spaniels

    Most often in older males. Typical symptoms include fluid buildup in the abdomen (ascites) and low albumin (hypoalbuminemia) on a blood sample.

  • West Highland white terriers, Bedlington terriers, and Skye terriers.

    It is associated with copper accumulation in hepatocytes, sometimes seen more often in young dogs.

History

Symptoms are vague, and come and go until the disease progresses. The typical symptoms of liver disease are present, and include PU/PD, anorexia, vomiting, diarrhea, ascites, icterus, and HE. Ulcers of the stomach can occur and lead to vomiting blood (hematemesis)

Other symptoms can involve the blood system, and include bleeding disorders and vomiting blood (hematemesis). This is because the liver is involved with the production of clotting factors (remember the physiology section above?). In occasional cases the opposite occurs, and the liver causes excessive clotting of blood. This predisposes animals to a problem known as disseminated intravascular coagulation (abbreviated as DIC).

Physical Exam

An exam of a pet with this disease can vary from normal to many abnormalities. Some of the abnormal findings are described in the liver exam findings above.

Diagnostic Tests

Blood Panel

A blood panel will commonly show anemia along with elevated levels of ALT and Alk Phos. There might also be an elevation in cholesterol, a decrease in BUN, glucose, and albumin. There might also be an increase in bilirubin, ammonia, and bile acids.

Urinalysis

A urinalysis might show symptoms of urinary tract infection or abnormal crystals, particularly ammonium biurate.

Radiography

A radiograph of the liver might show an enlarged liver (hepatomegaly) initially, eventually in might progress to a small liver (microhepatica).

Ultrasound

Ultrasound is the best way to make this diagnosis. The internal architecture (parenchyma) can be analyzed and a biopsy can be obtained with relative ease. In some cases it is important to know the coagulation status of the blood with a special blood panel prior to obtaining this biopsy. In many cases ultrasound is preferable to exploratory surgery since some of these animals are not good anesthetic risks and the procedure is much less invasive.

Laparotomy

The liver can be thoroughly visualized and palpated during an exploratory surgery. A biopsy can easily be obtained, and post biopsy bleeding can be monitored.

Biopsy

Samples of the liver taken with either a biopsy needle during ultrasound or during a laparotomy will be analyzed microscopically by a pathologist to make a definitive diagnosis and to look for a cause if possible.

Treatment

Fluids and Electrolytes

This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag. Care must be taken not to give excessive amounts of fluids, especially if they contain sodium, in pets with fluid buildup in the abdomen (ascites).

Treating the Cause (when known)

Antibiotics are used to control bacterial infections and drugs that are suspected of causing this disease are stopped. We tend to use antibiotics that have minimal need for liver metabolism in order to minimize their toxic effects.

Rest

The liver has ability to heal itself if the disease is not too well entrenched. Rest can be a big aid, along with proper nutrition. A diseased liver needs calories, which sometimes need to be supplied with afeeding tube.

Ascites Reduction

Sodium restriction helps minimize fluid buildup (ascites) in the abdomen. This can be accomplished using Hills K/D Prescription Diet. Diuretics like Lasix are also used to help pull this fluid out of the abdomen.

Dietary Modification

Use a diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Hills Prescription Diet K/D is the diet of choice. Meat based proteins should be avoided since they can increase the chance of HE. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. This is the same basic diets as for pets with PSS (see above).

Ulcer Treatment

This will make pets more comfortable, more inclined to eat, and prevent bleeding in the stomach.

Liver Specific Drugs

Corticosteroids- Cortisone is used if there is evidence that the immune system is implicated as a cause of the liver problem.

Ursodiol- This drug replaces toxic bile acids with a type of bile that is less toxic.

Zinc- Supplementation might help reduce the effects of copper toxicity.

Long Term Monitoring

CCHID monitoring is similar to PSS (see above). In addition, repeating a liver biopsy 6 months after initiating therapy used.

 


Infectious Canine Hepatitis (ICH)

Background

The disease is called hepatitis because liver cells are one of the prime targets. It is caused by an adenovirus that is found world wide and affects mainly in the dog family (canids). The virus is very resistant to disinfectants and can remain infectious in the environment. Many dogs get exposed to this virus, develop antibodies, and show no symptoms of the disease. Spread of this virus is usually orally and nasally, but can also be spread by utensils and external parasites. Within 7 days of exposure most dogs develop an adequate antibody response to protect the liver and other organs.

Symptoms

ICH can occur in unvaccinated dogs of any age, but usually occurs in dogs under one year. In the more severe cases vomiting and diarrhea can occur. These dogs can also have fever, coughing, swelling of the head and neck due to lymph node enlargement, abdominal tenderness and even central nervous system signs. These symptoms may last up to one week, and can be prolonged by other concurrent diseases like Distemper. A syndrome of this disease can cause rapid death leading people to conclude that the dog was poisoned. Dogs that show minimal symptoms can show ocular lesions during the convalescent phase. In uncomplicated cases these eye lesions heal completely.

Diagnosis

Blood samples give a clue to this disease but are not diagnostic. White blood cells can be low, liver enzyme tests may be elevated, and clotting factors can be disrupted. These findings with previously described history and physical exam findings are how the disease is usually diagnosed. Antibody tests are available but are not routinely used to make a diagnosis.

Treatment

Like most viral diseases therapy is directed towards symptoms. When symptoms are severe enough, intravenous fluids are administered. Since clotting factors can be disrupted, particular attention needs to be paid to bleeding problems. If bleeding problems are severe enough, a whole blood transfusion must be administered. Dogs that are comatose may need intravenous glucose.

Prevention

Most pups receive adequate antibodies from the bitch, which can last up to 4 months. Vaccines are highly effective and can confer long term protection. Two vaccines need to be given at 3-4 weeks apart beginning at 8 weeks of age. The DHLPP (Distemper-Hepatitis-Leptospirosis-Parainfluenza-Parov) vaccine contains protection against this adenovirus. The DHLPP vaccine is also known as the Da2PL. The a2 part stands for adenovirus.

A picture of our vaccine label

 


Copper Toxicosis (Copper Storage Disease)

The level of copper in the body is maintained by the excretion of bile. In this disease copper accumulates in hepatocytes, eventually causing inflammation and scarring, ultimately leading to liver failure (similar to CCIHD above). Excess copper released from the liver can cause hemolytic anemia.

Signalment

It is common in certain breeds:

Bedlington terriers- They have a genetic defect in how they metabolize copper and how it is excreted in the bile. This leads to excess accumulation in hepatocytes.

 

West Highland white terriers- They have a similar genetic defect as Bedlington terriers, but the copper accumulation is not as severe and does not always lead to liver failure.

Some Dobermans and Skye terriers with chronic liver disease also have elevated levels of copper in their hepatocytes. The copper accumulation in the liver might be a cause of the chronic hepatitis that eventually results, or an effect of a pre-existing hepatitis.

History

Bedlington’s with copper toxicity have minimal symptoms early in the disease. In the acute form, seen in younger dogs, symptoms include lethargy, anorexia, and vomiting. Death can occur in 2-3 days. Middle aged or older dogs have a more chronic course. Eventually symptoms of liver failure appear, including anemia, depression, lethargy, and anorexia.

Physical exam

Anemia might cause pale mucous membranes. There might also be icterus due to both anemia and liver failure. These dogs will also be weak and underweight.

Diagnostic Tests

A blood panel will commonly show elevated levels of ALT, GGT and Alk Phos, in addition to high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is elevated and radiography reveals a small liver. This disease is diagnosed by liver biopsy.

Treatment

Treatment has two goals: Enhance excretion of excess copper, and minimize further absorption of copper from the intestines.

Chelating agents Drugs like penicillamine bind with copper to allow easier excretion.

Zinc

Zinc will help minimize further copper absorption from the intestines.

Supportive Care

Similar to other liver diseases previously described

Long Term Monitoring

Serum enzymes and bilirubin should be monitored at least every 6 months

Prevention

Bedlington terriers should be screened at 1 year of age. Treatment at this early age leads to a good prognosis.

 


Cancer (Neoplasia)

A benign tumor is called and adenoma, a malignant one is a carcinoma.

Primary- Arising directly from the liver

  • Adenoma
  • Carcinoma
  • Hemangiosarcoma
  • Hemangioma
  • Leimyosarcoma
  • Fibrosarcoma
  • Fibroma
  • Osteosarcoma

They can arise directly from the hepatocytes where they are called hepatocellular. If they arise from the biliary system they are called cholangiocellular. Dogs get more hepatocellular, cats get more cholangiocellular. The cause of these primary neoplasia’s is unknown in most cases.

Secondary- From another organ that has spread to the liver

  • Lymphosarcoma
  • Mast cell
  • Pancreatic carcinoma
  • Myeloproliferative

The organs that commonly are the source of these cancers include:

  • Pancreas
  • Lymph nodes
  • Spleen
  • Mammae
  • Adrenal glands
  • Bone and bone marrow
  • Lungs
  • Thyroid
  • Intestines

Secondary, also know as metastatic, liver cancers are much more common than primary.

Signalment

Cancer is found in most animals and most breeds. It tends to be found mostly in older animals.

History

Almost any sign of illness can potentially be attributed to neoplasia. Common ones include anorexia, lethargy, weight loss, PU/PD and vomiting.

Physical Exam

Exam results of animals with liver neoplasia mimic the results found in other liver diseases.

Diagnostic Tests

A blood panel will commonly show elevated levels of liver enzymes, in addition to high levels of bilirubin in the bloodstream and the presence of bilirubin in the urine. A bile acids test is elevated and ultrasound reveals hepatomegaly (enlarged liver) with telltale changes of the liver parenchyma (internal anatomy of the liver). Ultrasound might also show inflammation of the pancreas (pancreatitis). A liver biopsy is needed for a definitive diagnosis. There is an ultrasound picture of liver cancer in the diagnostic section above.

Treatment

Primary hepatic neoplasms are treated by removal of the affected liver lobe when possible. If multiple lobes are involved then surgery is usually not performed. Secondary hepatic neoplasms are treated with chemotherapy. The results vary, and depend on the duration, location, and degree of malignancy of the neoplasia. The prognosis is poor for long term survival.

Supportive care that is similar to other liver diseases is also used in neoplasia

Prevention

Since the cause is usually unknown prevention is difficult. Good nutrition and lots of TLC are always important in preventing any disease.

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Homeopathy

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Homeopathy is a healing art that was discovered by Samuel Hahnemann(1755-1843) in the 1700s while he was working as a translator. Hahnemann was a medical doctor and chemist. Disenchanted by medicine, he stopped practicing medicine and was translating medical texts. While translating a book by a physiologist named William Cullen, Hahnemann disputed the author’s explanation of how Peruvian bark cured malaria.

Hahnemann actually took several doses of Peruvian bark that caused him to develop fever, chills and symptoms similar to malaria. Similia Similibus Curentur- “Like Cures Like”. Any substance, which can produce a totality or symptoms in a healthy human, can cure those symptoms in a sick human being. Hahnemann went on to develop “Homeopathy”, from the Greek words homoios meaning similar and pathos meaning suffering. Homeopathy recognizes it is the symptoms that will lead the doctor to the cure, not just the disease.

Homeopathy works on an energetic level. Hahnemann used the term “vital force” to describe the spirit-like energy force that maintains the life of the individual. Without the vital force, the body dies. When the vital force is in a state of balance, health exists.

There is never one particular remedy for a disease condition. For example, a cat with inflammatory bowel disease would receive remedies based on the symptoms the cat was expressing, not the inflammatory bowel disease. Also, emotional issues have to be addressed, in which case, Bach flowers are used.

Another term coined by Dr. Hahnemann was “Miasm”, which explained an underlying tendency to get sick. In lay terms, a miasm is a weakness or susceptibility that leads to disease or illness, often passing through generations, although miasms are not always inherited. Some are “created” miasms, due to drug toxicity, environmental causes, stress, vaccines and natural diseases. These created miasms can also pass through generations.

Disease or illness does not necessarily come from viruses of bacteria, it comes from within the pet. Bacteria and viruses are opportunistic and infect unhealthy or susceptible creatures. The disease and the pet are linked on an energy level. A miasm is a weakness in the pets vital force that allows an opening to form, letting in disease.

How Homeopathic remedies work

Homeopathy works assuming that the body knows best how to respond to illness and that it only needs assistance in its efforts to heal, not resistance. Symptoms are actually the healing process. The remedy creates similar symptoms, which reinforces the body in the direction of healing.

Conventional medicine works by treatment of opposites, for example, if a pet has a fever, antibiotics are taken to bring down the fever. This supports the theory that the symptoms are the illness and that these symptoms are of no benefit to the body. But actually, the word symptom is derived from the Greek word meaning, “sign” or “signal”.

A symptom is not a disease, but a sign or signal of a disease process. Although symptoms may suggest that an organism’s health is disturbed, homeopaths and a growing number of medical scientists recognize that symptoms are adaptive responses of the organism to physiological stress.

The symptoms are innate obligatory efforts on the part of the organism to defend and heal itself. Therefore suppressing the symptoms without addressing the source of the problem tends to suppress the body’s healing responses.

For instance, a nasal discharge is a response of the body to viruses that cause upper respiratory infection. This nasal discharge is composed of virus and dead white blood cells. If a pet with an URI (upper respiratory infection) takes a medication that dries mucous membranes, elimination of this dead matter is suppressed, which may lead to head and chest congestion.

From a homeopathic perspective the body is not as efficient in expectorating mucus through the mouth as it is in discharging it from the nose, and the resulting chest congestion is more likely to lead to more serious health problems.

The homeopathic remedy works on an energy level. The energy of the homeopathic remedies are similar in action to the energy of the disease. As the remedies rid the body of the disease, the vital force becomes in balance. The difference between treating a pet with homeopathy compared to conventional treatment is that with homeopathy, the disease state is removed, not the symptoms. When the disease state is removed, the symptoms go along with it.

For the past 200 years, homeopaths have performed experiments called “provings” (derived from the German word pruefung, which means “test”), in which healthy subjects are given repeated doses of a substance from the plant, animal , or mineral kingdom, which is where homeopathic remedies are derived from.

These experiments are conducted only on humans, as they are able to communicate their symptoms. For example, the remedy China, which comes from the Kina-kina tree, will repeatly cause intermittent fever in healthy subjects. This was one of the first remedies proved and used to treat malaria, which causes intermittent fever.

Because of the similarity China’s effects to the symptoms of intermittent fever, it is this similarity that enables China to treat intermittent fever, by curing diseases which have symptoms similar to the remedies effects, thus “law of similars”.

Sometimes a remedy will work quickly, usually in an acute case. With a chronic condition, homeopathy is probably not going to work as quickly as conventional medicine. This is where combining conventional medicine and homeopathy is recommended.

Diseases Treated With Homeopathy The following diseases can be treated with Homeopathy, although this is not all-inclusive:

Keep in mind all of these treatments will probably involve the use of conventional medications. In the case of cancer treatment, homeopathy will be used to support the immune system through chemotherapy/ radiation, NOT replace it.

All species can be treated with homeopathy, such as, birds for feather picking,

As with any disease process, a full diagnostic work-up with lab work, etc. will be recommended as holistic treatment involves treating with both eastern and western medicine

Homeopathy is not a “magic pill”, but can achieve some amazing results. The following are two case studies.

Case Studies

This is a 12-year-old female, spayed, Yorkshire terrier, which was presented for “very bad skin”. The condition had been presented for years. The owner had been to two other veterinarians, but the condition continued to worsen. The pet had been on antibiotics, antihistamines and steroids with no improvement.

The patient was given a remedy and the owner called three months later to say her pet’s fur had completely grown back.

This is the same dog 6 months later on a recheck

The next case is a 9 year old, male, neutered Jack Russell Terrier who was presented for a chronic skin condition which had started 2 years prior. The pet had been to various veterinarians, including a veterinary dermatologist . The pet ended up on chronic antibiotics, steroids, antifungal and antihistamines, along with expensive hypoallergenic diets. The pet’s skin never seemed to improve and the pet was very uncomfortable.

This pet has been on homeopathic remedies along with minimal use of steroids for several months, and as you can see from the photo, this pet’s quality of life has improved.

Initial Changes

Initially when a homeopathic remedy is taken nothing may appear to happen. The remedy will start to work, but you may not notice a change. In acute conditions, the effect may be more rapid. One important thing to look for is an aggravation- this refers to a slight worsening of symptoms for a short while, followed by improvement. This is the healing reaction to the body, and is a good sign that the correct remedies were chosen. Usually, in chronic disease, the aggravation may be seen after about three to five days. Than gradual improvement should be noted. Even though there may be some worsening of the symptoms, the pet overall should have more energy and vitality. Sometimes suppressed symptoms from the past may appear. This is because a specific symptom that was treated with suppressive drugs may come to the surface to be released. Healing may go backwards through the history of illnesses that the patient had suffered, but in a much milder fashion. The body may also heal from the inside of the body to the outside. For example, a liver condition may resolve, only for a skin rash to appear. This may be a skin rash from the past, or the body externalizing the disease. Often, there are various layers of disease that need to be peeled away.

Equipment and Technique

The equipment used to make your pets remedies includes remedy vials, which are used to select the proper remedies needed to treat your pet’s illness.

The remedies are selected based on a Q-tip swab with a sample of your pet’s saliva and muscle testing with the use of one of our technicians as a surrogate for your pet, so your pet does not have to be involved.

Also, there are 37 types of Bach Flowers which are used to treat emotional issues, such as, separation anxiety, excessive skin chewing, aggressiveness, gastrointestinal symptoms associated with stress, to name a few.

A 30 to 60 minute diagnostic kinesiological process is performed on your pet’s saliva sample. Through this testing, a list of weaknesses in your pet’s body are determined, relating to pet’s problem. Next, the remedies required to heal those weaknesses are determined. A combination of those remedies is made into small pellets.

Administration

The remedy pellets (or beads), can be put in your pet’s drinking water, given orally, or with or without food. If other pets drink the same water, that is fine.  It is not a problem for all your pets to take the remedies as the remedies are very safe and may even be helpful to you other pets, as a single remedy can cure several different problems

Follow Up

Every 30 days you will return the original vial the remedies came in (keep any remaining pellets to use until you get the new remedy), also get a small amount of saliva on a Q-tip and place it in a small baggie, along with an update of how your pet is doing. Include everything that is different, in your update, whether it is attitude, appetite, etc. Every small change is important for the doctor to know to adjust the remedy. You will drop off the vial, saliva sample and update prior to 1PM on a Wed. and will be able to pickup the adjusted remedy after 3PM the same day. We are open 7 days a week, so you could even drop-off the remedy on a Sun, if you like. Based on the update you give the doctor, there may be an addition of remedies, a change in potency of the remedy, or if emotional issues appear, Bach Flowers may be added to help with those issues. Each vial will have this information and how to use the remedy.

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