2 year old Jaundiced dog

Re: 2 year old Jaundiced dog

Hannah Wynne Richards — Thu, 14 Jun 2012 10:26:01 GMT

Of all the canine diseases we vaccinate against,lepto is the one with the shortest immunity and also the 1 we have no hope of eradicating due to the wildlife reservoir It also has a zoonotic potential A 2 yr old dog has a very low chance of an end stage liver, so for all those reasons I would put lepto high on the differential list and give antibiotics as well as advice on strict hygiene

David On the principle of "do no harm" many highly regarded Cert and Dip holders rate liver supplements highly On that basis I'm happy toadvise them I can understand the cost implications when you're working for a charity so have a moral responsibility to use charity donations as economically as possible It's a totally different matter with private clients They are entitled to have a choice-in fact a veterinary surgeon who didn't mention liver supplements to owners because he/she had personal issues about cost might well be on sticky ground if a complaint was made to Royal College about not complying with the Gto PC and offering a range of treatments-when a friend of the owner who had a similar case had been referred to a RCVS Specialist who had put the animal on a liver supplement

A dog of my own was discovered to have high liver enzymes when I blood tested her prior todentistry I couldn't thinkstraight because I was too emotionallly involved so referred her (toa Specialist Diploma holder ) She was found to have cirrhosis (no she hadn't been knocking back the gin) put on Zentonil and destolit,and did very well for 4 years-so I was sufficiently convinced of efficacy to use on my own animal-so I'm sufficiently convinced of efficacy to recomend to owners

Wynne

Re: 2 year old Jaundiced dog

An On MRCVS — Thu, 14 Jun 2012 08:54:44 GMT

[quote user="David Mills"]

Re antibiotics, nowhere near a first line here unless you can demonstrate bacterial infectious process (FNA, lepto serology/urinalysis).

[/quote]

Apologies for the anon log-in - on somebody else's computer.

Mr Mills, I'd have to take issue with the above. Whilst the demonstration of infection is theoretically important in any case where antibs are to be used, delaying on leptos can be a bit risky. Serology takes time, and is not without its controversy in terms of serovars studied; Urine PCR analysis isn' the most perfect test due to patchy shedding. FNAs are the proverbial needles in haystacks.

In these cases, I'd suggest antibs to be important until ruled out. And I'm afraid I'm another one who'd draw the distinction between homeopathy and herbalism. It rather undermines the rest of your case, so perhaps best left there.

Re: 2 year old Jaundiced dog

Rajat — Thu, 14 Jun 2012 08:31:31 GMT

SO once liver disease is underway, do you test liver enzymes? or in a jaundiced dog, with hepatic cause of icterus, based on your arguement, you would not test liver values ?

While the level of elevation may not directly relate to the severity of liver disease or amount of liver tissue compromised, the elevation say in ALT does give us a rough idea of how much the liver is 'suffering'. Correlating with demeanour is difficult, I think a study correlating with survival would be better.

Wish we had proof for so many of these interventions, which for many good reasons we believe to be helpful. I am happy to change my mind in the face of a negative evidence base, but absence of evidence is not evidence of absence. Some of these supplements hold great promise, and some get proven not to be helpful. The vast majority, other than making a financial impact on the owner, do not cause adverse effects. And how about frusemide in heart failure for dogs and cats?We all use it, without any evidence for its benefit. Bet no one is gonna stop soon!

Best

Raj

Re: 2 year old Jaundiced dog

David Mills — Wed, 13 Jun 2012 21:53:47 GMT

[quote user="Rajat"]

SAM-e is fantastic as an antioxidant and to provide support for the liver when liver damage exists

Recent abstract, though very focused for lomustine induced hepatopathy, supports its use (Denamarin). I also second the comments about them being herbal rather than homeopathy medication.

http://www.ncbi.nlm.nih.gov/pubmed/21689156

Plenty of evidence and trials

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=link&linkname=pubmed_pubmed_reviews&uid=2680435

Best wishes

Raj

[/quote]

There still exists no convincing evidence in dogs (or cats) that its use improves clinical outcome, recovery times, or survival times. Yes the studies show that it reduces liver enzyme levels more quickly but liver enzyme levels carry no prognostic value whatsoever and there is no correlation between their levels and the dog's demeanour in liver disease once treatment starts - it is a classic surrogate outcome as most antioxidant claptrap is. I simply cannot justify their use both financially or from an evidence base.

Re: 2 year old Jaundiced dog

Rajat — Wed, 13 Jun 2012 21:20:22 GMT

SAM-e is fantastic as an antioxidant and to provide support for the liver when liver damage exists

Recent abstract, though very focused for lomustine induced hepatopathy, supports its use (Denamarin). I also second the comments about them being herbal rather than homeopathy medication.

http://www.ncbi.nlm.nih.gov/pubmed/21689156

Plenty of evidence and trials

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=link&linkname=pubmed_pubmed_reviews&uid=2680435

Best wishes

Raj

Re: 2 year old Jaundiced dog

Stephen Courtney — Tue, 05 Jun 2012 00:01:28 GMT

I agree about the comments on the bile acid stim - pointless in the face jaundice, will tell you nothing new. Mea culpa.

As for SAMEs, last time i looked they weren't homeopathic. Plenty of herbs are useful - aspirin, digitalis are the only ones i can recal but ultimately all medicines once came from plants.

Our Cert SAMs are happy to use them, and animals have returned from referrals to diplomates on them too. they seem to help, and certainly can do no harm.

Re: 2 year old Jaundiced dog

Christopher Saul — Mon, 04 Jun 2012 23:22:42 GMT

[quote user="Hannah Bose"]

[quote user="Stephen Courtney"]a bile acid stim test would be a good idea [/quote]

My understanding was that if you have hyperbilirubinaemia, as in this case, you know the liver isn't functioning properly (having ruled out pre-hepatic jaundice), so the BAST cannot tell you any more. I also thought that the BAST was in some way less reliable in the presence of hyperbilirubinaemia?

[/quote]

The bile acid stim test is essentially a test of enterohepatic recirculation. If you have a jaundice that you know not to be prehepatic then the very presence of jaundice tells you that this recirculative pathway is interrupted.

In terms of the reliability of the BAST, it is generally more sensitive but less specific than the presence of jaundice.

In short, BAST would not be useful for this case. I never bother doing a BAST when I have jaundice.

Clotting factors (PT and APTT) would be a good idea, especially if liver biopsy is a possibility....

Hope this helps

Chris

Re: 2 year old Jaundiced dog

Virginia Campbell — Mon, 04 Jun 2012 18:59:08 GMT

[quote user="David Mills"]

Re antibiotics, nowhere near a first line here unless you can demonstrate bacterial infectious process (FNA, lepto serology/urinalysis).

[/quote]

Hmm, if I thought a dog even might have lepto I wouldn't hang around waiting for the serology, dunno how quick/reliable the urinalysis is, and I wouldn't be confident sticking a needle into a liver and expecting to find leptospires. Maybe others have had different experiences. I would start antibs now and only stop when I had taken a paired serum sample in a couple of weeks and it came back no rising titres. (If Os have the cash I would even send one serum sample now, then paired sample in a fortnight - as far as I remember best run in the same batch for optimal results. Prob would also send a pretreatment urine if you have it but wouldn't stop abs based on a negative).

How sick is the dog? The few leptos I have seen have been really, really miserable and puking +++

Re: 2 year old Jaundiced dog

HMC — Mon, 04 Jun 2012 16:11:16 GMT

[quote user="David Mills"]This somewhat smells of homeopathy.[/quote]

I am firmly opposed to homeopathy but I am very open minded for herbalism, which is what the liver supplements are. There is a distinction to be made.

Re: 2 year old Jaundiced dog

HMC — Mon, 04 Jun 2012 16:06:59 GMT

[quote user="Stephen Courtney"]a bile acid stim test would be a good idea [/quote]

Re: 2 year old Jaundiced dog

David Mills — Sun, 03 Jun 2012 23:10:07 GMT

[quote user="Stephen Courtney"]

Given how little we can actually do for unhappy livers, SAMEs and destolit ( ursodeoxycholic acid) have their place

[/quote]

Sometimes the best course of action is to do nothing.

Essentially what you are saying is that you have seen reductions in liver enzymes on these alone, no other treatment. This somewhat smells of homeopathy. Even the pharmas own trials prove negligible, if any benefits. You are harnessing the homeopathic deception with this kind of story telling.

Re: 2 year old Jaundiced dog

Stephen Courtney — Sun, 03 Jun 2012 17:38:52 GMT

I have seen liver enzymes fall in response to SAMEs and rise again after they are withdrawn. Given how little we can actually do for unhappy livers, SAMEs and destolit ( ursodeoxycholic acid) have their place

Re: 2 year old Jaundiced dog

David Mills — Sun, 03 Jun 2012 14:07:29 GMT

[quote user="Stephen Courtney"]

It would also be an idea to start her on denemarin or zentonil in the short term pending further investigations.

[/quote]

You could, but the evidence for efficacy is weak to non-existent, mainly the latter. Same as rubbish like milk thistle.

If you follow Mr Saul's advice above you can't go too far wrong. Liver imaging in itself can tell you whether there is bile duct obstructon/dilation and some subjective architecture change which in part depends on your machine settings as to how impressive it is - the diagnostic yield is very low without some sort of sampling - FNA or, better, try-cut biopsy; equally bile aspiration for C/S.. I really can't see how ultrasound alone can refine your ddx to any significant degree, regardless of imager's experience.

It can be very helpful for pancreatitis though - pyloric/prox duodenal area if it's bright white and painful to the probe touch it's pancreatitis.

Re antibiotics, nowhere near a first line here unless you can demonstrate bacterial infectious process (FNA, lepto serology/urinalysis).

Re: 2 year old Jaundiced dog

Stephen Courtney — Sun, 03 Jun 2012 09:59:20 GMT

It would also be an idea to start her on denemarin or zentonil in the short term pending further investigations. An ultrasound by an experienced person, and a bile acid stim test would be a good idea as next steps, and you have the antibiotic side covered for now.

Repeating bloods is useful but don't do it too soon, the half life of the enzymes is fairly long in the dog so a daily sample tells you little more. If the dog is clinically deteriorating then the results will be of little further help. a few days down the line, prognostic value increases.

Re: 2 year old Jaundiced dog

An On MRCVS — Sun, 03 Jun 2012 00:35:50 GMT

Thanks for your help so far - first time posting on here so v grateful

Haematology was all normal, temp was 39.2oC (sorry forgot to put this on the initial post)

I will speak to the owners tomorrow and try to do an ultrasound scan to see if can see obvious post-hepatic signs, was also thinking poss repeat biochem to check if ALT, TBIL changing for better or worse. She is from a farm and have started on antibiotic tonight. She is still very bright and eating well at the moment.

Re: 2 year old Jaundiced dog

Christopher Saul — Sat, 02 Jun 2012 21:45:39 GMT

First priority with jaudiced patients is to classify the jaudice as prehepatic, hepatic, or posthepatic.

Prehepatic patients will be very anaemic; what is the PCV?

Posthepatic will have dilated bile ducts on ultrasound; whilst these can be hard to spot if you're inexperienced in ultrasound, if the gallbladder is small then you can rule it out.

If it is prehepatic she may require a blood transfusion; if posthepatic then may need a stent placing in the bile ducts.

Lepto cases will frequently have high urea/creat as well as elevations in liver parameters, but NOT always. Is she a farm dog? Do you have reason to suspect she may have been exposed? If unsure then yes, antibiotics as well as barrier nursing.....

could she have pancreatitis? If she has then whe will need ANALGESIA...

Any history of foreign travel ( babesiosis?)

Re: 2 year old Jaundiced dog

AlanH — Sat, 02 Jun 2012 18:30:05 GMT

HI there, Id rule out pre hepatic jaundice first so above comment re RBC important, then likely hepatic or post hepatic - check pancreatic lipase? ( less likely a problem as no V+ or abdo pain ) then I'd start on antibiotics, zentonil and perhaps destolit but scan be useful !

Best of luck!

Alan

Re: 2 year old Jaundiced dog

Claire Fisher — Sat, 02 Jun 2012 17:27:36 GMT

I wouldn't unless pyrexic or there was an increased WBC count. What are her red blood cells doing? Could she have IMHA?

Re: 2 year old Jaundiced dog

Michael Woodhouse — Sat, 02 Jun 2012 17:19:09 GMT

We see lepto out here in the sticks. I would always use antibiotics in these cases. Just some amoxycillin if lepto unlikely but if I suspect it I give high doses of either crystapen or oxytet IV.