Medical management of portosystemic shunt

Re: Medical management of portosystemic shunt

Silvia Maldonado — Mon, 29 Jun 2015 10:19:28 GMT

I see... I'm feeling better now

Re: Medical management of portosystemic shunt

Andrew Kent — Mon, 29 Jun 2015 10:13:17 GMT

[quote user="Silvia Maldonado"]Also, after reading all your previous posts, I come across some comments about how important it is that PSS dogs eat frequently. This dog had obviously not eaten well for a couple of days (vomiting, anorexic) and deffo didn't eat anything that night. I wonder now if that could have worsen her condition :([/quote]

Hi Silvia,

Actually if anything not eating improves some shunt dogs temporarily as they are reducing their own protein intake. The frequency of feeding discussed previously is more about eating smaller amounts frequently rather than eating more frequently.

Andy

Re: Medical management of portosystemic shunt

Silvia Maldonado — Sun, 28 Jun 2015 00:43:57 GMT

It might be, Charlotte. Apparently surgeons were not able to get into it, so it ought to be intrahepatic

Re: Medical management of portosystemic shunt

Silvia Maldonado — Sun, 28 Jun 2015 00:37:45 GMT

You are right, Andy, it doesn't sound like encephalopathic. All the case is quite confusing, and having passed away, I'm not so willing to ask for more info. Being referred for a GIT disorder, stable, no permission to perform any work unless her condition deteriorated (and contacting owners first), and learning about her panting recent episodes once she was dead. It looked more like some sort of pulmonary embolism.

Also, after reading all your previous posts, I come across some comments about how important it is that PSS dogs eat frequently. This dog had obviously not eaten well for a couple of days (vomiting, anorexic) and deffo didn't eat anything that night. I wonder now if that could have worsen her condition :(

Re: Medical management of portosystemic shunt

Andrew Kent — Sat, 27 Jun 2015 22:26:15 GMT

Hi Silvia,

we see larger breed dogs with portosystemic shunts relatively frequently, they are often more likely to be intrahepatic (and so harder to manage surgically) than the little guys.

however what you describe does not sound classic for an encephalopathic crisis and so I would wonder if it could be unrelated, but I guess we will never know and without more details about the original shunt surgery difficult to make many guesses!

Andy

Re: Medical management of portosystemic shunt

Charlotte Marshall — Sat, 27 Jun 2015 18:14:24 GMT

If the dog had shunt surgery at 1 year old it was probably a congenital shunt. I had a client with a weimaraner with a shunt that could not be surgically closed. That was medically managed for quite a few years.

Re: Medical management of portosystemic shunt

Silvia Maldonado — Sat, 27 Jun 2015 17:23:37 GMT

Hi, all,

Very interesting answers. I would like to discuss a sad case I had on a recent night shift. A 4yo FN 25kg, crossed labrador, was transferred to us for monitoring and IVFT overnight, and the next day the MP will do more investigation. The hx was vomiting, she'd been given synulox, was currently on lactulose, and little else. All I was told is that she'd had a sx when 1 yo for PSS, and it was not completely successful.

Admitted by 21:00h roughly, lethargic but ambulatory, not offered food (poss GA next day), and hartmanns 2xmaintenance. TPR all fantastic, CRT 1s, MM pink and moist, good pulses, no fever. Night uneventful until 2:00h, when I heard her panting. Went to check her, HR wnl, couldn't assess RR, but back to normal in 15 mins (no need of O2 or other meds). By 4:00h was going to go for a walk, and the vet nurse noticed her panting again. HR wnl, and cardiopulm auscult unremark, but this time I decided to give her vetergesic low dose and stop fluids. Assessed RR was 60bpm, down to 46 by 4:30h, and then 36bpm by 5:00h. I went to have some rest, while the VN was awake. By 5:40h she screamed, the VN called me, and had her on O2. Quickly her condition deteriorated, became cyanotic, I had to sedate her to be able to intubate her (slow IV propofol, 5ml for a 25kg dog), enough to place the tube. Her colour improved, and by 5:45h her heart stopped. With adrenaline IV and CPR her heart and breathing started again, but by 5:55h, again, heart arrest, stopped breathing and died. You can only imagine how confused I was, how stressed the VN felt... We called her owners, obviously were shocked, but somehow it seemed they were expected something like this to happen. Her O mentioned she had been panting on and off the last couple of weeks, was checked by her vet and was suspected her PSS condition was deteriorating. Although they were very nice, despite the outcome, and sent us an email the next day saying she had a chronic illness and were pleased we tried to save her, I am still very confused about this case, hence I am posting it. Sorry I don't have a more accurate information in regards to the "chronic illness".

My main concerns are: How many of you have any experience of PSS in medium/large dogs? What could cause liver shunt in these breeds? What could I have done differently?

Re: Medical management of portosystemic shunt

Andrew Kent — Tue, 02 Dec 2014 10:49:43 GMT

Hi Nicola,

I would start with antibiotics, lactulose and diet and continue that combination for the next few months whilst you continue to monitor the dog and make sure that its proteins etc don't fall (which diet are you using?).

If the dog stays stable then I would gradually try to wean down the meds and monitor clinical signs. Yes we have some dogs who are managed with diet alone (or sometimes even with just modification of feeding frequency). I would monitor those dogs fairly frequently for UTI's, bladder stones etc but they can do fairly well (albeit less well long term than surgery if we take a recent publication at face value).

The owners should be warned that they can have acute flares of disease, usually due to scavenging, GI bleeds or concurrent inflammation (UTI most often) and at that time you would need to ramp the meds back up.

Hope that helps,

Andy

Re: Medical management of portosystemic shunt

karen jones — Mon, 01 Dec 2014 22:22:15 GMT

A westie we sent to Liverpool spent its life on amoxicillin , lactulose and diet and eventually was pts after getting bladder stones

Re: Medical management of portosystemic shunt

Nicola Cole — Mon, 01 Dec 2014 19:21:07 GMT

Puppy doing very well. How long would you normally keep on antibiotics for? And presumably lactulose and diet ongoing if not moving to surgical management? Or do you phase lactulose out and just treat with diet?

Re: Medical management of portosystemic shunt

Nicola Cole — Tue, 25 Nov 2014 20:50:42 GMT

The puppy is a miniature schnauzer. Many thanks for the replies.

Re: Medical management of portosystemic shunt

Christopher Saul — Mon, 24 Nov 2014 12:34:59 GMT

What breed is the pup in question? It's a very very long shot but if it's a collie then definitely check B12/folate. Congenital cobalamin deficiency can present with encephalopathic signs. As you say, a bile acids are important. I would do a bile acid stimulation test but make sure this is done at an external laboratory; the dynamic range of the in-house ones are insufficient for sorts of derrangements you would see in a shunt.

Re: Medical management of portosystemic shunt

Christopher Saul — Mon, 24 Nov 2014 12:20:16 GMT

As Andy says, feeding small amounts of food frequently is as important as what you feed it. I too use an intestinal type diet, only using hepatic diets if this doesn't work.

We should avoid highly protein restricted diets in the first instance because a young growing puppy will have quite high protein requirements, and if we do not meet these by diet then the pup will get its protein from accelerated muscle breakdown which can only be detrimental.

The logic behind ultra low protein diets was that the rise in postprandial ammonia was thought due to bacterial fermentation of protein in the colon. It's now thought that the postprandial rise in portal ammonia is possibly more due to glutamine metabolism in the small intestinal enterocytes (the only way of avoiding this would be to not feed the dog at all, which is of course out of the question).

That's not to say that the ammonia due to colonic fermentation plays no part at all in HE; it probably does - we just don't think it's the whole story. Therefore HIGH protein diets ( such as puppy life stage diets) should be avoided. Current thinking is that we should feed a moderate protein but most importantly HIGHLY DIGESTIBLE protein diet fed in SMALL FREQUENT MEALS. in this way (in theory) most of the dietary protein will be absorbed in the SI and relatively minimal amounts will make it though to the colon for fermentation.

Soy based diets have a better branched chain to aromatic amino acid ratio than do meat based diets, and this MIGHT be helpful. I would add though that as far as I am aware there is no evidence to suggest that this actually makes a clinical difference in practice. But it might help so I like the idea. Also soy I think has less urates than meat so a soy based diet is less likely to support urate urolith development.

So - we need a moderate, highly digestible protein diet (perhaps based on soy). For my PSS patients I use Purina HA as it ticks these boxes, but to be honest any intestinal or hydrolysed diet might be fine.

Hope that helps

Chris

Re: Medical management of portosystemic shunt

Andrew Kent — Sun, 23 Nov 2014 22:25:36 GMT

People used to use renal diets as they were the most protein restricted diets. However as understanding of encephalopathy changed they have gone out of fashion as excessive protein restriction can have negative effects on these dogs. Some renal diets are also quite high in purines which is unwanted in PSS dogs. Andy

Re: Medical management of portosystemic shunt

Nicola Lawlor — Sun, 23 Nov 2014 21:36:23 GMT

[quote user="Anthony Dennison"]

We got told at Bristol that Renal diets rather than Hepatic diets were good for shunts

[/quote]

I had a young (8mths ish) Yorkshire terrier a few years ago that had a liver fibrosis issue with acquired shunts so surgery not an option. I managed that dog well on lactulose and k/d diet for around 2 years before they moved away from the area. The dog did brilliantly. I think at the beginning we had the dog on ampicillin for a short while as well. Despite being young the k/d diet seemed not to cause any major concerns to the dog developing. We knew from the outset the dog would not have a long life span, but she did better than we might have hoped for in the time I dealt with her. I would use it again if I had a similar case.

Re: Medical management of portosystemic shunt

Anthony Dennison — Sun, 23 Nov 2014 11:24:07 GMT

We got told at Bristol that Renal diets rather than Hepatic diets were good for shunts

Re: Medical management of portosystemic shunt

Andrew Kent — Sat, 22 Nov 2014 22:33:51 GMT

We would go for a highly digestible diet (so a GI diet) fed little and often initially which will control signs in most cases. If that doesn't work then you may need to look at the hepatic diets. Frequency of feeding is as important as diet type. Andy