Liver changes on screening bloods

RE: Liver changes on screening bloods

Andrew Kent — Thu, 11 Feb 2016 16:20:37 GMT

Liver disease is a mystery! And I think there is still a lot more for us to discover about it.

Michael - from the point of view of your dog I wouldn't be rushing into anything too invasive based on a single test, but abdominal imaging to exclude significant extra-hepatic disease is always sensible. Any possibility of access to any drugs or toxins (any NSAIDs previously?). If imaging is normal I would see if it persists over the next 3-4 weeks and then might think about a biopsy if it does.

The general discussion about biopsies is definitely a useful one, I think there are two aspects to that that are worth discussion.

The first is whether or not it changes what we do, and its true that a good number of the cases that we biopsy will come back as 'chronic hepatitis' and we have to just manage those supportively, but we are looking for those more unusual cases where there might be a treatable primary cause - that is primarily evidence of copper accumulation (primary or secondary), vascular diseases or infections and (as Evelyn says) to exclude neoplastic disease. But even if we have a generic chronic hepatitis the severity of it is still useful for us to know because if the fibrosis (scarring) is already extensive then I know I can't use steroids or I am likely to make the disease worse - if there is minimal fibrosis then steroids may be indicated (dependent on the underlying histological pattern).

So I usually say to owners that about 2/3 of cases it doesn't change at all what we do - but the only way we know if you are in the 1/3 where it does is to do it!

The second thing about biopsies is that if you take them you have to get the maximum amount of information from the procedure - that for me means multiple samples (from different lobes), it means a bile sample (cytology and culture) and it means a decent pathologist. I would always then stain for copper and, if indicated, look at other specialist stains like fluorescence in-situ hybridisation (FISH) or PCR for infectious agents.

I think as testing ability has got more advanced we are getting more and more information from biopsies and there are more and more cases that change direction as a result. But yes, owners have to be happy that there dog may be one of the ones that it doesn't help directly.

Just my thoughts!

Andy

RE: Liver changes on screening bloods

Evelyn Barbour-Hill — Thu, 11 Feb 2016 16:15:20 GMT

[quote user="John Flynn"]

I rarely founnd any change in treatment based on liver biopsy and have generally stopped doing so many - what might I be mising that might treat differently based on biopsy results? i.e. what percentage of cases like this with a liver biopsy actually get different treatment as a result?

I've always found liver disease a bit of a mystery!

[/quote]

It's not my field, but what the owners always want to know is "is it cancer?".

RE: Liver changes on screening bloods

Anthony Todd — Thu, 11 Feb 2016 15:49:17 GMT

[quote user="John Flynn"]i.e. what percentage of cases like this with a liver biopsy actually get different treatment as a result?[/quote]

Interested as well.

RE: Liver changes on screening bloods

John Flynn — Thu, 11 Feb 2016 15:29:50 GMT

I've always found liver disease a bit of a mystery!

RE: Liver changes on screening bloods

Anthony Todd — Thu, 11 Feb 2016 10:45:15 GMT

[quote user="Julie Innes"]

I've got a similar case that is driving me insane! Repeated elevation of ALT, ALKP, GGT, BAST high. Levels getting higher, not lower, but dog absolutely fine in itself. O not keen on biopsy, ultrasound looks normal to me! Dog won't eat diet, won't take tablets or powders, O keep coming up with bright ideas they've read on internet (coconut oil, raw feeding.....) Only clinical symptoms are occasional D+ with straining. Can't afford referral. Have to admit, I am running out of patience!!

[/quote]

Why did the dog come to you initially then?

I'd test the lab rather than testing the dog again and I'd definitely let the owner try his or her ideas, after all, the idea is to fix the dog not lab values.

Sounds like the intermittent D+ will be dietary anyway and if you don't let the owner try his/her ideas they'll do it anyway.....

RE: Liver changes on screening bloods

Martin Atkinson — Thu, 11 Feb 2016 10:14:11 GMT

Seems odd the albumin would go up with liver disease one would expect it to be lower. I would however also want bile acids plus GGT to see if there is any obstructive liver disease which may indicate tumours. Ultrasound would be nice if its easy but way too soon to be talking about biopsies. I'd also want a CBC and may be worth a urine cortisol:creatinine ratio to rule out HAC, but may just be trying with SAMe if there is no significant clinical disease.

RE: Liver changes on screening bloods

Julie Innes — Thu, 11 Feb 2016 08:37:03 GMT

RE: Liver changes on screening bloods

Arlo Guthrie — Thu, 11 Feb 2016 07:57:39 GMT

[quote user="Michael Woodhouse"]

Arlo Guthrie - the forum allows me to paste a screenshot, but it seem to be lost when I post the thread.

Will attach as an image

[/quote]

It's showing in both posts on my computer (first embedded, then attached)

RE: Liver changes on screening bloods

Michael Woodhouse — Thu, 11 Feb 2016 00:44:30 GMT

[quote user="robloxley"]I'd probably do the imaging and maybe a BAST especially as you have some haemolysis, and look at possible non-hepatic primary causes. If nothing came up on a well dog I'd be inclined to wait and retest after a few weeks.[/quote]

I was thinking along that line. I was going to ring Idexx in the morning and add bile acids and a single cortisol. I've never bothered with a BAST if they are already raised.

Will put the scanner on her and see what I can see. Typical vet dog - a terrible patient!

RE: Liver changes on screening bloods

Rob Loxley — Thu, 11 Feb 2016 00:40:00 GMT

[quote user="Michael Woodhouse"]

[quote user="robloxley"]How far the client wants to go in a well dog is a question. [/quote]

My dog.

[/quote]

I'd probably do the imaging and maybe a BAST especially as you have some haemolysis, and look at possible non-hepatic primary causes. If nothing came up on a well dog I'd be inclined to wait and retest after a few weeks.

RE: Liver changes on screening bloods

Michael Woodhouse — Thu, 11 Feb 2016 00:31:36 GMT

[quote user="robloxley"]How far the client wants to go in a well dog is a question. [/quote]

My dog.

RE: Liver changes on screening bloods

Rob Loxley — Thu, 11 Feb 2016 00:30:36 GMT

Significant hepatocellular injury.
If you have elevated bilirubin it is usually suggestive of cholestasis so BAST often doesn't give you much more info. You do have some haemolysis so you might consider whether that might be affecting bilirubin levels. Imaging would be my next port of call likely ultrasound. Ultimately with many (most?) hepatopathies once you've ruled out extrahepatic diseases you really need a biopsy for a full diagnosis. How far the client wants to go in a well dog is a question.

RE: Liver changes on screening bloods

Robin Grimmer — Thu, 11 Feb 2016 00:08:56 GMT

You have fairly significant liver disease. I would start with an ultrasound and bile acid stim test. Other differentials would include endocrinopathy eg Cushings, but I think this is unlikely without compatible clinical signs and you would usually have an much more elevated ALP than ALT. Ultimately you may need a liver biopsy for a definitive diagnosis.

RE: Liver changes on screening bloods

Michael Woodhouse — Wed, 10 Feb 2016 23:04:39 GMT

Arlo Guthrie - the forum allows me to paste a screenshot, but it seem to be lost when I post the thread.

Will attach as an image