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Practical Internal Medicine

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Practical Internal Medicine Liver Disease Wendy Blount, DVM Nacogdoches, TX – PowerPoint PPT presentation

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Title: Practical Internal Medicine


1
Practical Internal Medicine
  • Liver Disease
  • Wendy Blount, DVM
  • Nacogdoches, TX

2
Liver Disease
  • Asymptomatic Elevated Liver Enzymes
  • Chronic Liver Disease
  • Acute Liver Failure

3
Elevated Liver Enzymes in the Well Pet
  • Cats are not little dogs
  • Cats with persistently elevate enzymes should be
    worked up
  • T1/2 of liver enzymes hours, not days as in the
    dog
  • cats have 1/3 the liver SAP compared to dogs
  • Cats with significant cholangiohepatitis can have
    normal liver enzymes
  • GGT elevated significantly exceeds SAP elevation
    only in hepatic lipidosis
  • High bile acids in the cat indicates liver
    disease nearly 100 of the time
  • Any bilirubinuria in the cat is significant
  • Can be used to monitor cholestatic disease

4
Elevated Liver Enzymes in the Well Pet
  • Dogs Grrrr
  • Explore the history for untreated problems
  • Treat empirically for reactive hepatopathy first
  • Treat problems that can insult the liver
  • Occult infections urinary, metritis,
    prostatitis, etc.
  • Treat for sublinical cholangiohepatitis
  • Amoxicillin 10 mg/lb PO BID x 3 weeks
  • Put on a supplement to curtail damage by hepatic
    inflammation
  • Denosyl, Denamarin dosage chart in package
  • Milk thistle

5
Elevated Liver Enzymes in the Well Pet
  • Milk Thistle
  • Dried herb 15-20mg/lb SID (1.5-3 silymarin)
  • Concentrated extract 2-5 mg/lb BID (70-80
    silymarin)
  • Alcohol concentrated extract 2-5 mg/lb BID-TID
    (70-80 silymarin)
  • NOTE some extracts are whole herb extracts, and
    these are hard to dose high enough to be
    effective

6
Elevated Liver Enzymes in the Well Pet
  • Recheck Liver enzymes in 30 days
  • Proceed with further diagnostics for liver
    disease
  • Assess liver function with bile acids
  • Abdominal ultrasound and liver cytology
  • ACTH stimulation if signs of Cushings Disease
  • If Step 4 reveals significant undiagnosed
    problems, consider liver biopsy or referral for
    splenic portagram to rule out PSS
  • Ultrasound guided liver biopsy (50 diagnostic)
  • Surgical liver biopsy
  • Scotties can have very high liver enzymes with no
    pathology

7
Undiagnosed Problems Causing Reactive Hepatopathy
  • Occult infection
  • Urinary tract
  • Metritis, prostatitis
  • Dental Disease
  • Disease of organ drained by portal vein
  • Severe muscle disease
  • Hypoxia heart failure, respiratory disease,
    severe anemia

8
Other Problems Causing Elevated SAP with normal
ALT
  • Bone growth or osteolysis
  • Puppies and kittens
  • Bone neoplasia
  • Osteomalacia
  • Hyperparathyroidism
  • GI Disease
  • Pregancy
  • Kidney Disease
  • Drug Therapy

9
Pattern Recognition - Liver Disease
  • High liver enzymes
  • ALT hepatocellular disease
  • SAP, GGT cholestasis
  • Can be normal with prolonged chronic disease
  • Low albumin
  • Low fasting glucose
  • High prost-prandial glucose
  • Low BUN
  • Abnormal cholesterol, triglycerides
  • Ammonium biurate crystalluria
  • Prolonged recovery from anesthesia

10
Pattern Recognition - Liver Disease
  • Ascites transudate or modified transudate
  • Increased sodium retention, portal hypertension,
    hypoalbuminemia
  • PU-PD
  • Acholic feces
  • Dark urine (orange) precedes icterus
  • Icterus
  • Suspect if high bili with normal PCV
  • Seen best on sclerae, penile mucosa, soft palate,
    under the tongue
  • Icterus occurs when 10 of liver function remains
  • Look for cholestatic disease if signficant
    bilirubinemia without bilirubinuria (delta bili)

11
Pattern Recognition - Liver Disease
  • Tendency to sepsis
  • Hepatic RE system detoxifies blood from the gut
    (portal circulation)
  • GI hemorrhage death spiral
  • Decreased hepatic clearance of gastrin
  • Factors, AT3 not produced adequately
  • Increased bile acids stimulated HCl secretion
  • DIC
  • Bleeding exacerbates hepatic encephalopathy
  • Large bleed can cause depletion coagulopathy
  • Hemorrhage elsewhere only when near death
  • Petecheia, bruising, bleeding into cavities

12
Pattern Recognition - Liver Disease
  • PSS in Cats
  • Salivation most common clinical sign
  • Hepatic encephalopathy
  • Vomiting and diarrhea

13
Bile Acids
  • 12 hour fast red top tube
  • Feed 1-2 Tablespoons a/d
  • 2 hour post prandial red top tube
  • If not fasted, doing only the post-prandial can
    be a good screen for liver insufficiency
  • Cant run bile acids on a lipemic sample
  • Overfeeding can induce HE

14
Bile Acids
  • High bile acids in the blood can cause gastric
    hyperacidity in the stomach and diarrhea
  • Bile acids gt30-40 umol/L in the dog and gt20-30
    umol/L in the cat warrant further investigation
  • Idexx SNAP test tells you
  • lt12 umol/L
  • 12-25 umol/L
  • gt25 umol/L

15
Ammonia
  • Normal in the dog 20-80 ug/dl
  • Normal in the cat 20-120 ug/dl
  • Elevated resting ammonia is significant
  • Idexx VetTest/Catalyst does ammonia assays
  • Falsely increased by hemolysis
  • Centrifuge and decant within 30 minutes
  • Run assay within 2 hours
  • Sending to outside lab can be difficult

16
Ammonia
  • Ammonia Tolerance Test
  • 12 hour fast red top tube
  • NH3Cl capsules 45 mg/lb max dose 3g PO
  • 30 minutes later red top tube
  • Increase should be lt32
  • 100 sensitive for PSS
  • DO NOT GIVE NH3Cl if resting ammonia elevated
  • Can induce HE

17
Chronic Liver Disease
18
DDx Chronic Liver Disease
  • Immune Mediated Cholangiohepatitis
  • Westie, Doberman, Skye terrier, cats
  • Copper Storage Disease
  • Dobermans, Bedlingtons
  • Portosystemic Shunt
  • Congential or Acquired
  • Extrahepatic Yorkie, schnauzer, poodle,
    dachshund
  • Intrahepatic Doberman, Golden, Lab, Irish
    Setter, Samoyed, Irish Wolfhound
  • Microvascular Dysplasia
  • Yorkie, Cairn Terrier

19
DDx Chronic Liver Disease
  • Bacterial Cholangiohepatitis
  • cats
  • Fungal Hepatitis
  • Heterobilharzia americanum
  • Chronic Liver Disease usually Diagnosed
  • by Liver Biopsy

20
Tx Chronic Liver Disease
  • Proper Diet
  • Treat chronic infection
  • Treat chronic inflammation
  • Treat cholestasis
  • Treat fibrosis
  • Treat copper accumulation
  • Treat GI side effects
  • Manage hepatic encephalopathy
  • Manage ascites

21
DDx Acute Liver Failure
  • Hepatotoxins
  • Septicemia
  • Pancreatitis
  • Infectious Canine Hepatitis (CAV)
  • Hypoxia/Ischemia
  • Exacerbation of Chronic Liver Dz
  • SIRS

22
DDx Icterus
  • Pre-Hepatic Hemolysis
  • Hepatic
  • Post-Hepatic
  • Pancreatitis
  • Pancreatic Neoplasia, Abscess, or Granuloma
  • Liver, Bile Duct, Duodenal Neoplasia, Abscess or
    Granuloma
  • Biliary Mucoceole
  • Cholecystitis
  • Cholelithiasis
  • Duodeonal foreign body
  • PSS and steroid hepatopathy dogs are almost never
    icteric

23
DDx Acute Liver Failure
  • Hepatotoxins
  • Acetominophen
  • Aflatoxins
  • Anabolic Steroids
  • Anticonvulsants
  • Antineoplastics
  • Arsenicals
  • Carprofen
  • Diazapem
  • Diethylcarbamazine
  • Griseofulvin
  • Itraconazole
  • Kava Kava
  • Ketoconazole
  • Oxabendazole
  • Mebendazole
  • Mitotane
  • Mushrooms
  • Sago Palm (seeds)
  • Sulfonamides
  • Thiabendazole
  • TMPS

24
Hepatic Encephalopathy
  • Abnormal mental status in patients with severe
    hepatic insufficiency
  • Severity of HE does not always correlate with
    severity of liver disease
  • Things that can precipitate an HE episode
  • Increased protein intake, GI hemorrhage
  • Dehydration, diuretic therapy
  • Barbiturates and other sedatives
  • Uremia
  • Infection, endoctoxemia, constipation, increased
    aneaerobes in the colon
  • Increased methionine intake

25
Progression ofHepatic Encephalopathy
  • Mildest form anorexia and lethargy
  • May progress to weight loss
  • Ataxia
  • Confusion, stupor, loss of training
  • Pacing and wandering
  • Twitching progressing to seizures
  • Vomiting, diarrhea
  • Temporary blindness
  • Dementia, seizures, coma
  • Multifocal deficits on neurologic exam

26
Tx Acute Liver Failure
  • Correct fluid an electrolyte imbalances
  • Treat Coagulopathy
  • Treat hypoglycemia
  • Treat hepatic encephalopathy
  • Control GI hemorrhage
  • Treat Sepsis if present

27
Sebastian
  • 9 year old neutered male pit bull
  • 2 year history of lower cervical disc disease
  • Several episodes of pain and CP deficits
  • Responded to treatment with prednisone and cage
    rest
  • 1 week ago ataxia and falling, and vocalizing
    every time he moves
  • The morning after a fight with another dog
  • Tx prednisone, methocarbamol, Tramadol, cage rest
    no response for 4 days
  • Sedated for radiographs

28
Sebastian
  • 4 days ago Sedated for radiographs
  • mid-abdomen 8cm soft tissue mass
  • no significant enlargement of liver, spleen, R
    kidney
  • Cervical lumbar intervertebral disc
    calcification
  • vomited large amount of fluid with coffee grounds
    after sedation
  • Tx carafate, IV fluids, metronidazole,
    amoxicillin
  • Albumin 2.1 g/dl (2.2 g/dl low normal)
  • SAP 2119 U/L
  • ALT 1434 U/L
  • Bili 8.2 mg/dl
  • HCT 30.8

29
Sebastian
  • Referred for ultrasound today
  • Exam
  • Can not walk
  • Muscle tremors and very jumpy when touched
  • Icteric skin
  • Abdomen tense and difficult to palpate
  • Very large urinary bladder
  • Scleral injection owner says had been present
    for 30 days

30
Sebastian
  • Neuro Exam
  • Unable to walk, unable to assess postural
    reflexes and CP
  • Cranial nerves normal
  • Spastic paresis in all 4 limbs (UMN reflexes)
  • Conscious motor activity in all 4 limbs
  • Lower cervical pain
  • Dx - Lower cervical spinal cord disease
  • Catheterized bladder and removed 1.5L of orange
    urine (bilirubin crystals)
  • Hx has been on clomipramine for some time, for
    anxiety

31
Sebastian
  • Problem List
  • Cervical myelopathy and tetraparesis
  • Surgery not an option for these owners
  • Icterus likely hepatic, post-hepatic and
    hemolysis can not be ruled out
  • Hematemesis prednisone, liver failure, spinal
    cord injury
  • Twitching hepatic encephalopathy, metronidazole
    toxicity, serotonin syndrome
  • Mid abdominal mass
  • Mild anemia

32
Sebastian
33
Sebastian
34
Sebastian
35
Sebastian
  • Radiographs
  • Large amount of air in the stomach
  • Gastric axis shifted cranially

36
Normal Dog
  • Radiographs
  • Large amount of air in the stomach
  • Gastric axis shifted cranially

37
Sebastian
  • Radiographs
  • Large amount of air in the stomach
  • Gastric axis shifted cranially

38
Sebastian
  • Radiographs
  • Large amount of air in the stomach
  • Gastric axis shifted cranially
  • Intestines appear distended with fluid
  • No mid abdominal mass seen
  • Increased soft tissue density in right cranial
    abdomen
  • Cervical and lumbar spondylosis
  • Cervical and lumbar mineralized disc material
  • Disc material in the spinal foramina
  • Dx microhepatia
  • Dx degenerative disc disease

39
Sebastian
  • Abdominal Ultrasound
  • Difficult because of the great amount of air in
    the stomach, due to aerophagia
  • Small areas of the liver seen, hyperechoic,
    mottled in echotexture
  • Gall bladder not seen
  • Many fluid filled loops of bowel
  • PT, PTT - normal

40
Sebastian
  • Plan
  • Discontinue prednisone, Tramadol, clomipramine,
    metronidazole
  • Continue Carafate, IV fluids (LRS 20 mEq/L
    KCl), ampicillin IV
  • add milk thistle, famotidine
  • Fast overnight and repeat ultrasound tomorrow
  • Repeat CBC, panel, lytes tomorrow
  • Send out Lepto titers
  • Express bladder or catheterize to empty bladder
    TID

41
Sebastian
  • Day 2
  • Ate chicken and drank water yesterday
  • Twitching stopped
  • Skin appears less icteric, scleral injection
    improved
  • HCT 17.7, Hb 5.6 g/dl
  • Albumin 1.6 g/dl
  • Bili 5.4 mg/dl
  • Neutrophilia 20K/ul
  • Lytes normal
  • No vomiting, no melena
  • Urine is golden, not orange
  • Eating chicken and drinking

42
Sebastian
  • Ultrasound
  • Liver small, mottled, hyperechoic
  • Liver cytology suppurative hepatitis with
    cholestasis
  • Gall bladder wall thickened - cholecystitis
  • No fluid in the abdominal cavity
  • Plan add Baytril Vitamin K, monitor PCV

43
Sebastian
  • Day 3
  • Vomited overnight chicken, melena on
    thermometer
  • HCT 14.9, Hb 4.6
  • neutrophils 21.7K/ul
  • Albumin 1.5 g/dl
  • Lytes normal
  • Plan
  • Whole blood transfusion
  • Ate chicken rice well that night, drinking
    water
  • Continue milk thistle, ampicillin, enrofloxacin,
    carafate, famotidine, Vit K, IV fluids,
    catheterize TID

44
Sebastian
  • Day 4
  • Not feeling well, passed melena, fever 103.4F
  • Will not eat, licked lips when food offered
  • Abd US still no evidence of perforation, but
    deep ulcer seen in the duodenum
  • PCV 25, albumin 1.8 g/dl, lytes normal
  • Plan
  • Continue milk thistle, ampicillin, enrofloxacin,
    carafate, famotidine, Vit K, IV fluids,
    catheterize TID

45
Sebastian
  • Day 5
  • Fever has resolved, feels better
  • Eating chicken, but not rice
  • Urinating on own, but does not empty the bladder
  • Can support weight on rear legs but not front
    legs
  • If ulcer perforates, owners will not do surgery
  • PCV 20, albumin 1.8 g/dl
  • Plan
  • Continue milk thistle, ampicillin, enrofloxacin,
    carafate, famotidine, Vit K, IV fluids,
    catheterize BID

46
Sebastian
  • Day 6
  • Will not eat, no fever
  • When put on feet, attempts to move forward, but
    can not move front legs well yet, can take a few
    steps
  • Urinating on own
  • neutrophils 75K, monocytes 1,100/ul
  • No stools passed, but melena on thermometer
  • Ultrasound

47
Sebastian
  • Day 6
  • Will not eat, no fever
  • When put on feet, attempts to move forward, but
    can not move front legs well yet, can take a few
    steps
  • Urinating on own
  • neutrophils 75K, monocytes 1,100/ul
  • No stools passed, but melena on thermometer
  • Ultrasound

48
Sebastian
  • Day 6
  • Will not eat, no fever
  • When put on feet, attempts to move forward, but
    can not move front legs well yet, can take a few
    steps
  • Urinating on own
  • neutrophils 75K, monocytes 1,100/ul, 6 bands
  • No stools passed, but melena on thermometer
  • Ultrasound
  • Local peritonitis R Cranial abdomen

49
Sebastian
  • Plan
  • Drained fluid percutaneously
  • Discontinue catheterization
  • Continue milk thistle, ampicillin, enrofloxacin,
    carafate, famotidine, Vit K, IV fluids
  • Wrap front feet to prevent abrasions from
    knuckling

50
Sebastian
  • Day 7
  • neutrophils 38K, monocytes normal, 3 bands
  • HCT 20
  • Albumin 1.6 g/dl, glob 5.3 g/dl
  • SAP gt4600 U/L, ALT 1868, bili 6.7 mg/dl
  • Black tarry liquid stools
  • Plan
  • Barium 5ml/lb PO
  • Continue milk thistle, ampicillin, enrofloxacin,
    carafate, famotidine, Vit K, IV fluids, wrap
    front feet

51
Sebastian
52
Sebastian
53
Sebastian
54
Sebastian
  • Day 8
  • Owners came to visit Sebastian ate a rib eye
  • Black tarry soft stools
  • Can walk 5-10 feet without assistance
  • Plan
  • Continue milk thistle, ampicillin, enrofloxacin,
    carafate, famotidine, Vit K, IV fluids, wrap
    front feet

55
Sebastian
  • Over the next 2 weeks
  • Switched form injectable to oral meds
  • Recovered well
  • Recurrence of liver failure 1 year later
  • Owners elected euthanasia

56
Inky
57
Inky
58
Handouts
  • This PowerPoint behind the blue tab
  • Client Drug Handouts
  • Colchicine
  • Cyproheptadine
  • Lactulose
  • Milk Thistle
  • SAMe
  • Ursodiol

59
Handouts
  • Client Handouts
  • Cholangiohepatitis
  • Chronic Liver Disease
  • Fatty Liver
  • Leptospirosis
  • Portasystemic Shunt
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