Liver disease/Cushings? - next step

Re: Liver disease/Cushings? - next step

Rob Loxley — Wed, 01 Jan 2014 20:57:35 GMT

[quote user="David Mills"]transcutaneous biopsy...
...much less invasive than an exlap[/quote]

But you can do more at exlap than just biopsy the liver

Re: Liver disease/Cushings? - next step

Mark Holmes — Wed, 01 Jan 2014 20:31:55 GMT

To be honest I would be less concerned about a specific diagnosis. You have ruled out cushings and tumour (more or less) Treatment of the rest is pretty much similar. I would be trying some destolit, SAMe, ampicillin and would question further to be sure the presenting problem is liver associated. It's not necessarily a liver problem.

Re: Liver disease/Cushings? - next step

David Mills — Wed, 01 Jan 2014 19:55:17 GMT

I agree with what Mr Flynn says; I'd be very surprised if this dog was Cushingoid.

Surely the next step would be to sedate the dog and perform a more thorough abdominal scan. Doing a transcutaneous biopsy is very easy and minimal risk if you're doing it ultrasound guided, and if the changes on US are widespread you should get a good diagnostic sample - small nick in skin, some intramuscular local and use a spring-loaded biopsy punch; much less invasive than an exlap. FNAs in liver disease are OK if you're thinking infectious or neoplastic but are rarely 100% diagnostic (though can be cheap and cheerful).

Wouldn't be concerned about APTT at those levels - the test, IMO, is a pretty insensitive one and I'd only worry if it was over 200-250 and would want some support of other clotting tests before worrying about any clotting issues.

Good luck.

Re: Liver disease/Cushings? - next step

John Flynn — Wed, 01 Jan 2014 19:00:30 GMT

[quote user="Kerry Peak"]USG 1.030[/quote]

[quote user="Kerry Peak"]maybe request urine for creatinine:cortisol ratios to be performed[/quote]

I'd pass on the UCCR with urine that concentrated and no convincing signs of cushings - it's almost certainly going to be a waste of time and money.

[quote user="Kerry Peak"]lipase was normal, didn't think to run a cPL[/quote]

Others will have a different view, but I can't see what a cPL will be likely to achieve in case management... (though "normal" is a little vague for a lipase result to fully interpret it )

Re: Liver disease/Cushings? - next step

Kerry Peak — Wed, 01 Jan 2014 18:50:44 GMT

thank you all for your input!

I forgot to mention that I performed urinalysis: USG 1.030 so possibly suggestive of PUPD and rest of it unremarkable.

the bile acids were performed in house so our machine only gives of a value of >30 (I guess sometimes not that helpful!)

no steroids have been given to this dog

unfortunately referral really isn't an option as we live on the isle of wight and the owners are not keen at all to go elsewhere!

the ultrasound was really limited sadly, so I cannot say that the pancreas is ok, but I couldn't see any evidence of biliary obstruction. however I am aware that this doesn't rule it out! lipase was normal, didn't think to run a cPL actually because no abdominal pain but I can certainly do this

the dog is currently quite bright and well and is eating a fair amount of 'tasty' food at home. I'm really not convinced it does have Cushings either (one of my colleagues is!), so I think I will start him on some SAMe and vitK, and maybe request urine for creatinine:cortisol ratios to be performed, with a view to repeating the bloods next week and then proceeding with an ex lap if appropriate.

Re: Liver disease/Cushings? - next step

Andrew Kent — Wed, 01 Jan 2014 17:37:35 GMT

I think Cushings is unlikely so wouldn't worry about that too much, especially in the absence of compatible clinical signs. Plus as others have said diagnosing it in a sick dog is fought with difficulty.

however i am not convinced the bloods scream liver disease, at first glance they seem more consistent with cholestasis - high ALKP, high TBIL. bile acids not that useful without a figure but likely just high from cholestasis.

so personally I would want to consider the biliary tract before an ex-lap and consider things like pancreatitis (have you got a lipase or done a cPLI - not that helpful if normal as not that much of a surprise if chronic but helpful if abnormal. Or can you image pancreas?) or things like cholecystitis ( did you image bile ducts or gall bladder? Was cholesterol normal?)

i wouldn't worry about your coats if you do go for ex-lap, they need to be more than 25% out before it is a major concern. You could give VitK. If you do go for ex-lap then be sure to examine the biliary tract, squeeze the gall bladder to check emptying and get bile and liver for culture.

if the owner doesn't want to go for ex-lap I would probably give a low fat diet and a month of antibiotics and see what happens to the bloods.

Re: Liver disease/Cushings? - next step

Michael Woodhouse — Wed, 01 Jan 2014 16:34:16 GMT

Computer says mid Jan for Synachten

Re: Liver disease/Cushings? - next step

Dalya Livy — Wed, 01 Jan 2014 16:02:35 GMT

Given that the dog was not making it easy, how confident are you about your scan findings? A steroid hepatopathy/Cushingoid liver tends to look generally hyperechoic but retains a normal architecture/appearance. Your description of a mottled/abnormal liver structure would make Cushings less likely for me.

Likewise, at least in my experience, it would be unusual for Cushings to disturb liver function (BAST, coags) in absence of clinical signs for the dog (PU/PD/PP etc).

Ruling out Cushings definitively may be difficult. I agree with the others, a urine cortisol:creatinine would be great, but if positive then LDDT would be the next step and in a stressed/ill dog a false positive LDDT is more likely. Liver FNAs may be useful for diagnosing lipidosis or lymphoma, but untrustworthy for other DDx.

If you do go for an ex-lap, and if the dog is well enough to wait a few days, I would consider pre-treating with Vit K + SAMe for up to a week and repeating BAST/coags. Destolit may also help assuming biliary obstruction can be ruled out.

Re: Liver disease/Cushings? - next step

Yantha Smyth — Wed, 01 Jan 2014 15:04:50 GMT

Ditto re the urine cortisol/creat ratio- if normal rules out Cushings. If abnormal not conclusive, but at least if it was negative you could stop pursuit of Cushings and concentrate on liver I also understand that liver related coagulopathy is thought to be vit k responsive and agree that pre op vit k and surgical biopsies would get you the best chance of a definitive dx. Not sure where you are located, but an in btwn option for imaging that doesn't involve referral of the entire case and subsequent work-up etc, would be referral for 'out-patient' abdominal ultrasound. I know the RVC does this at a pretty reasonable cost, other places may also do it. The owner takes the dog and they have the ultrasound done 'while you wait'; there is not consultation or reporting of findings to the owner- they take the dog away again, and you get the report from RVC which you can then discuss with the owner and move forward from there. They would also be likely to be able to assess the adrenals and other organs in detail at the same time Cheers Yantha

Re: Liver disease/Cushings? - next step

tess — Wed, 01 Jan 2014 14:45:52 GMT

Kerry -You could send urine for cortisol:creatinine ratio. If it's normal then it rules out Cushings.

Re: Liver disease/Cushings? - next step

karen jones — Wed, 01 Jan 2014 13:31:34 GMT

As anyone imported cortosyl to use instead of syntacthen. We have a Cushing dog on vetoryl with a very intense owner who spend his life on Cushing websites and is unhappy about doing basal cortisol levels for monitoring and wants us to look into importing some. Does anyone know when syntacthen is likely to be available to us?

Re: Liver disease/Cushings? - next step

John Flynn — Wed, 01 Jan 2014 11:43:12 GMT

Doesn't sound like Cushings.

Ruling Cushings out in an ill patient will probably be a thankless task - before doing a LDDST just think what will you do differently if it fails to suppress?

Steroid-induced ALKP is a relatively cheap test (probably still won'd add much diagnstic detail though) that I think can *sometimes* be of use to show where the ALKP is coming from as if SIAP level is pretty low then that adds additional evidence that is not from cushings, though results may add nothing to what you know if SIAP proportion is not suitably low.

Most liver-induced coagulopathies are vitamin K responsive (apparently) so can give 3-5days vitamin K and then just crack on and biopsy by open approach in my mind.

APTT of that elevation may be artifactual due to sampling/postage etc at this time of year in particular?

FNA of liver would be alterantive and *might* make you more comforatble that is not cushings and thus on to surgical biopsy.

I'm no expert, but as a fellow GP I'd put on vit K for few days (assuming in good enough health to permit this, otherwise I'd just crack on now as I doubt you'll have any bleeding problems) and then do open surgical biopsy of liver which usually at least gives a fair chance at definitive diagnosis. I'd treat empirically for hepatopathy in meantime.

EDIT - oh and the other advantage of openin up is can check there's not biliary obstruction and look at pancreas etc (I'm guessing you've already decided no biliary obstruction from ultrasound, but anyway...) that level of ALKP if not from steroid-induction probably indicates marked biliary stasis...

Re: Liver disease/Cushings? - next step

Robin Grimmer — Wed, 01 Jan 2014 11:40:19 GMT

I would do urinalysis for dip and sg. Some owners don't notice pupd. Then low dose dex and imaging. What were the actual BAST results? I would do this before diving in with an ex lap. Also, has the dog had any steroids from previous vet?