Jaundiced dog

RE: Jaundiced dog

Robin Grimmer — Tue, 23 Jan 2018 10:42:02 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]You're making the mistake that liver enzymes give you a prognostic indicator which is why I gave you one star.[/quote]

Exactly why I campaign against unsubstantiated anonymous one stars!!

I didn't know that enzymes didn't prognosticate [even if I am, or was, the only vet that didn't.....]

[/quote]

Happy to point out when you are wrong

I'm willing to bet that all the mod vets knew that about liver enzymes

RE: Jaundiced dog

Anthony Todd — Tue, 23 Jan 2018 09:48:52 GMT

[quote user="Robin Grimmer"]You're making the mistake that liver enzymes give you a prognostic indicator which is why I gave you one star.[/quote]

Exactly why I campaign against unsubstantiated anonymous one stars!!

I didn't know that enzymes didn't prognosticate [even if I am, or was, the only vet that didn't.....]

RE: Jaundiced dog

Robin Grimmer — Tue, 23 Jan 2018 06:59:57 GMT

[quote user="Anthony Todd"]

[quote user="Rach"]So don’t write off every yellow dog....[/quote]

I must say I probably would have put the dog down with the liver enzymes that high, given the chance of successfully relieving the obstruction as well, so I wonder if a dog with those levels could recover or not?

What's the record??

[/quote]You're making the mistake that liver enzymes give you a prognostic indicator which is why I gave you one star. All they tell you is there is liver cell damage/leakage +-biliary stasis. They tell you nothing re prognosis, the liver has the ability to recover and regenerate depending on the disease process.

I once had a GSD with acute liver damage as a drug reaction to oxytetracycline. Liver enzymes in the 1000s. Made a complete recovery with withdrawing the drug and supportive treatment. Liver enzymes returned to normal.

And of course, you can have a dog with terminal cirrhosis that has completely normal liver enzymes.

RE: Jaundiced dog

Anthony Todd — Mon, 22 Jan 2018 23:30:31 GMT

[quote user="Rach"]So don’t write off every yellow dog....[/quote]

What's the record??

RE: Jaundiced dog

Jill Butterworth — Mon, 22 Jan 2018 20:33:51 GMT

[quote user="ell"]The second vet on second day was the one who didn't do bloods because dog had eaten something.[/quote]

Do you think we could be misinterpreting this, and 'had eaten something' was translated as 'might not be so ill after all' by the client?...hence they elected to delay again, rather than the vet avoiding?

(Unless their surgery was really busy and they didn't have a nurse to help or they couldn't get the results any faster than the next day anyway, some other conceivable reason ?)

RE: Jaundiced dog

Rach — Mon, 22 Jan 2018 18:03:16 GMT

Once scanned an interesting case, sky high ’liver parameters’ and bright yellow. Absolutely convinced I was going to find a hideous liver tumour. Not so, it was in fact some sort of toy, similar to one end of a ’Kong’ with a central hole. It had managed to become lodged in the small intestine at the exit of the bile duct, causing obstructive jaundice, yet the hole in the toy lined up with the lumen of the gut, hence the dog didn’t present like a classic foreign body. I thought this was really unusua, but a lecturer at LVS last year outlined a case that was pretty much word for word the same. So don’t write off every yellow dog....

RE: Jaundiced dog

Robin Grimmer — Mon, 22 Jan 2018 13:33:09 GMT

What exactly did the liver look like on ultrasound? With such a high tbil I would be thinking obstructive jaundice either due to intra hepatic causes or post hepatic eg pancreatitis, pancreatitic mass. Shame no post mortem.

RE: Jaundiced dog

Anthony Todd — Mon, 22 Jan 2018 11:36:38 GMT

[quote user="Bob Russell"]Vets have been treating pets in this sort of way since the year dot. [/quote]

Er, yes, dinovets did it all the time.

I would ask what conceivable blood, or any further exam, would affect the outcome?

I guess an obstructed bile duct, but I'm way out of my limited knowledge.

Be interested to get a list of possibly significant findings which could cure this dog after all these further, essential examinations.

As I've said before nowadays the object seems to be not to fix the problem, more to do more tests and examinations with no reference to the difference in outcome the additional [fee generating] procedures will provide.

I think dinovets, certainly I, thought what might we be able to do to fix this animal given what we know at this stage in this case.

RE: Jaundiced dog

Bob Russell — Mon, 22 Jan 2018 11:13:45 GMT

Another one that cannot see too much wrong with the way things were done but also no problems with bloods in a non-fasted dog.

I would be concerned about lepto but have not seen a liver case in years.

Vets have been treating pets in this sort of way since the year dot. It is nice to be able to scan and biopsy everything but for many this is more than is affordable or wanted by the client.

RE: Jaundiced dog

Rach — Sun, 21 Jan 2018 21:20:55 GMT

With the extra information I would suggest that if bloods were offered and declined at the outset, the advice given and the subsequent choice of synulox and cerenia was not inappropriate. I am another that wouldn’t have waited for a starved sample (the dog was yellow, it’s bile acids would be elevated regardless of whether it had eaten or not, and I can’t see it having a significant influence on any other parameter in this case).

Its great to encourage discussion of cases within a team, just take care to ensure it isn’t only the ones with a negative outcome that are discussed, otherwise you will do the opposite of what you are intending.

RE: Jaundiced dog

Michael Woodhouse — Sun, 21 Jan 2018 20:59:07 GMT

I've never NOT done bloods in a sick animal just because its eaten. That does seem a bit of a strange justification for not doing them. Maybe just a quiet chat with the person?

With new vets the way I find simplest to get them talking about cases is to discuss some of mine with them. I'll often ask if they've seen anything interesting that day. It becomes 2nd nature after a while.

RE: Jaundiced dog

ell — Sun, 21 Jan 2018 20:50:01 GMT

Hi,

The first vet on first day offered bloods but client wanted to wait till next day to see if any improvement after Synulox injection. The second vet on second day was the one who didn't do bloods because dog had eaten something.

RE: Jaundiced dog

ell — Sun, 21 Jan 2018 20:45:37 GMT

There hasn't been a complaint and I would disagree that the whole tone of the post is critical.

As I've said on other replies I'm trying to work out a better way of our vets dealing with such situations and to work out if as a practice we really covered animal welfare adequately.

RE: Jaundiced dog

ell — Sun, 21 Jan 2018 20:41:48 GMT

Thanks for that reply Michael. I'm trying to work out a way of getting a future similar case

discussed more. No one knows all of the answers all of the time and it would be better working it out together as it went along.

RE: Jaundiced dog

ell — Sun, 21 Jan 2018 20:38:23 GMT

I agree I don't think it would have changed outcome, but someone would probably have said "go ahead and take bloods even if eaten"

The dog had to wait another 24 hours with nothing happening.

RE: Jaundiced dog

ell — Sun, 21 Jan 2018 20:34:37 GMT

No I don't think anything particularly negligent but do think also that bloods would have been better done even tho dog had eaten

RE: Jaundiced dog

ell — Sun, 21 Jan 2018 20:32:28 GMT

No, we aren't thinking of disciplining anyone. Just trying to work out a way of dealing in the future with such a case. The owners were essentially happy to pay but I do think there was a limit.

RE: Jaundiced dog

Avril Mc Ginn — Sun, 21 Jan 2018 20:19:26 GMT

[It was given cerenia and Synulox injection.]

My take on this would be given the presentation synulox and cerenia in an older jaundiced dog with polydipsia were unlikely to treat the problem initially and would be justified if this was explained to the owner and any investigation declined.

If finances restricted investigation initially then a manual PCV may rule out pre-hepatic causes, and a USG and quantify water intake may guide hepatic causes?

RE: Jaundiced dog

Anthony Todd — Sun, 21 Jan 2018 11:26:13 GMT

This thing happened with us all the time because the last or previous vet, or the first, in an on-going situation, didn't make sure he/she would definitely see the dog again and, if that was impossible [for all sorts of roster reasons], make sure the client knew that and the next vet was fully informed.

Nothing hacks clients off more than seeing someone different unexpectedly, even for a second vaccination!!

Particularly when the next vet [and clients always pick up on minor differences] says something even slightly different from the last vet.....

PS I'm guessing the first vet just didn't want to do the bloods.....

RE: Jaundiced dog

Robin Grimmer — Sun, 21 Jan 2018 08:15:40 GMT

[quote user="Michael Woodhouse"]

[quote user="Robin Grimmer"]Why say this? It implies you don't trust their clinical judgment or they did something wrong. Would it have changed the investigation or outcome? I don't think so.[/quote]

We talk about interesting and unusual cases all the time. I'm sure if this had been seen by any of us it would be discussed. More brains on a problem is better and it also means if it pops up OOH we are all peripherally aware of what's going on if at home with no notes and deciding if it needs seeing.

If it's sick and yellow, it's lepto until ruled out. Biggest cause of jaundice we see, but then its a rural practice with lots of farm and shooting dogs, many lapsed vaccines.

If we're happy it's liver Dz then she let it die without steroids. There's only 1 rule in this game..............

[/quote]

Fair point, I don't disagree with you. But the whole tone of the post seems to be critical of the handling of the case. The only thing I question is delaying the bloods because not starved as others have said. I'm guessing perhaps there has been a complaint?

RE: Jaundiced dog

Michael Woodhouse — Sun, 21 Jan 2018 02:31:46 GMT

[quote user="Robin Grimmer"]Why say this? It implies you don't trust their clinical judgment or they did something wrong. Would it have changed the investigation or outcome? I don't think so.[/quote]

If it's sick and yellow, it's lepto until ruled out. Biggest cause of jaundice we see, but then its a rural practice with lots of farm and shooting dogs, many lapsed vaccines.

If we're happy it's liver Dz then she let it die without steroids. There's only 1 rule in this game..............

RE: Jaundiced dog

Robin Grimmer — Sat, 20 Jan 2018 20:09:09 GMT

[quote user="ell"]

Unfortunately the vet didn't discuss the case with other colleagues.(was in branch).

[/quote]

Why say this? It implies you don't trust their clinical judgment or they did something wrong. Would it have changed the investigation or outcome? I don't think so.

RE: Jaundiced dog

Lindsey Edwards — Sat, 20 Jan 2018 19:58:17 GMT

[quote user="Julie Innes"]I'm not really seeing anything negligent[/quote]

I agree - as long as owner was offered investigations as described then this is a reasonable approach but I also would have blood tested for basic panel regardless of fasting (just not a BAST, which wasn't described anyway). More info on physical exam findings (incl colour of faeces - was bile obstructed?) and haematology would be required in order to assess if any additional medical options may have been available. I think it is important to remember that 'gold standard', referral hospital intensive investigation and treatment is not always practicable for owner, branch clinic or patient and sometimes, many of us have to play with the hand we are dealt in terms of resources and client finances, prioritising patient welfare only

RE: Jaundiced dog

Julie Innes — Sat, 20 Jan 2018 16:19:22 GMT

I don't see too much wrong with this case. Treatment was tried, at owners request,but when no better/ worse owner now more willing to go for further investigation. Bloods and ultrasound are what I would also have done. Sounds like euthanasia was ultimately the right decision. All done within a few days, so not really prolonged. Especially as owners offered bloods on day 1. Only things I might have done differently were to do the bloods despite dog having eaten, and carried out ultrasound the day the dog was in on ivft

I'm not really seeing anything negligent

RE: Jaundiced dog

Kate Richardson — Sat, 20 Jan 2018 15:04:19 GMT

encourage notes explaining differentials and decisions eg jaundice- pre/intra/post hepatic-discussed options, offered bloods, owners elected treatment trial.

Doesnt need to be an essay

dont understand need to delay bloods due to having eaten- routine monitoring/planned sampling yes, in this situation wouldn't have worried

also can't see why ex lap was an option- only if confirmed biliary obstruction and then only indicated if could be surgically fixed there and then. Or for biopsies but could be done with ultrasound guidance and would have wanted to check coags first either way