Medical management of Portosystemic Shunt

RE: Medical management of Portosystemic Shunt

Andrew Kent — Fri, 29 Jan 2021 20:16:36 GMT

Yeah seems unlikely to be PSS so castration likely reasonable. Whether you pursue it further probably then comes down to level of owner concern. I likely wouldn't make any change if the dog is clinically normal otherwise.

Andy

RE: Medical management of Portosystemic Shunt

Anthony Dennison — Fri, 29 Jan 2021 16:55:43 GMT

I wouldn't say that the post meal BAs aren't that high - I would be happy to castrate him.

RE: Medical management of Portosystemic Shunt

Emily Ross — Thu, 28 Jan 2021 13:07:46 GMT

This little dog, lets call him Henry, has come in for his BA stim- 22 pre, 61 post, and bilirubin of 3.6. Which from what Andy said (thank you so much) looks really promising regarding unlikely to be PSS. However does it increase confidence regarding castrating him? Even if I avoid ACP and am cautious with opiates and NSAIDs. And would it be appropriate to make no changes to either diet or anything else at this stage?

RE: Medical management of Portosystemic Shunt

Jill Butterworth — Wed, 20 Jan 2021 16:29:09 GMT

I recall one had classic signs of feminisation from a seminoma, the other there was thickening in the groin and swelling in the descended testicle, so some metastasis, so we castrated the dog, and removed as much as possible. The owner didn't have much money for more diagnostics/chemo etc and was lost to follow up, but definitely survived in the short term, but it was >10 years old.

RE: Medical management of Portosystemic Shunt

Emily Ross — Wed, 20 Jan 2021 13:53:35 GMT

Thanks Gill, out of interest how did you find it/ what were the clinical signs in your dogs?

RE: Medical management of Portosystemic Shunt

Jill Butterworth — Tue, 19 Jan 2021 09:52:00 GMT

I remember going on CPD where the specialist said that even a late diagnosis cancerous retained testicle carried a reasonably good prognosis. I've seen the odd late presentation and castrated them and they've done well. Maybe just scan to monitor the retained testicle and take a view with GA risk if it arises?

RE: Medical management of Portosystemic Shunt

Andrew Kent — Mon, 18 Jan 2021 22:19:09 GMT

[quote userid="17458" url="~/001/veterinary-clinical/small-animal/medicine/f/discussions/29605/medical-management-of-portosystemic-shunt/227939#227939"]Andy is Purina HA worth considering in any dog with raised bile acids?[/quote]

Well it is a balanced diet and suitable for growth so no real down sides other than cost and perhaps over kill for many. But certainly it would be worth it for any dog with BA's over 100 if further testing not possible.

Andy

RE: Medical management of Portosystemic Shunt

Emily Ross — Mon, 18 Jan 2021 12:04:31 GMT

Thank you everyone for your amazing replies. Andy is Purina HA worth considering in any dog with raised bile acids?

RE: Medical management of Portosystemic Shunt

Andrew Kent — Mon, 18 Jan 2021 10:12:28 GMT

Yeah I think we used to use renal diets on the basis of them being slightly less protein restricted but this was before we had good access to non-meat based diets and before recognition that protein type may be more important than protein amount.

RE: Medical management of Portosystemic Shunt

Anthony Dennison — Sun, 17 Jan 2021 22:49:10 GMT

I remember being told at university not to use liver diets in these cases as they are protein restricted, but renal diets may be beneficial

RE: Medical management of Portosystemic Shunt

Andrew Kent — Sun, 17 Jan 2021 09:34:13 GMT

No definite answers with these cases but will give my thoughts.

Were these fasted or post-prandial bile acids? I suppose its likely that this dog has a shunt but most PSS dogs have PP BA over 100 umol/L so this is in a little bit of a grey area. It could, for example, represent an alternative disease such as portal vein hypoplasia (microvascular dysplasia) which is insignificant in most dogs.

So I suppose ideally I might do a bit more to explore this further. A proper bile acid stim would be a start then other options would include measurement of protein C (although this has to be shipped to the US so becomes expensive) or imaging (US or CTA).

If it is a shunt then dogs diagnosed older are a challenge (although this dog is quite young still and perhaps does have some manifestations in small stature). Overall evidence suggests dogs do better with surgical management but of course there are exceptions.

If we do opt for long-term medical management then again different views on that - it is recognised that, even though we perceive dogs as being normal, they can get a degree of subclinical encephalopathy which may only become apparent when we start to treat.

I tend to start by giving diet and lactulose in these patients as they are relatively benign interventions and I try to avoid antibiotic use where possible. As others have suggested we no longer advise protein restriction in shunt dogs as it can worsen HE if they get into a negative energy balance. Instead we use modified protein sources which are less ammoniogenic. So I would put this dog onto Purina HA which is a soya based diet.

Also agree with the comment about urates - even dogs that seem to be doing well can still sometimes present with urate stone formation.

Hope that helps, some good discussion points!

Andy

RE: Medical management of Portosystemic Shunt

Beats — Fri, 15 Jan 2021 20:20:16 GMT

I'm not an expert. My thoughts would be that if has reached the age of 1y9m with few problems, and is genuinely doing fine, then I'm not sure I'd do much other than caution about changing current diet suddenly and particularly not to a high protein diet suddenly, and add a note to the file for should I be GA-ing in future etc. I might make dietary suggestions dependent on what currently gets fed.

I would not castrate unless there was a very clear reason to do so and for me, an abdominal testicle in this instance would not count as a clear enough reason, but I expect that point will be debated.

I might check the urine for urate crystals. I've had a couple small breed adult PSS cases where I first found out about them when they were unable to urinate.

RE: Medical management of Portosystemic Shunt

Sara Ramsey — Fri, 15 Jan 2021 18:40:05 GMT

I now don't use a protein restricted diet as some can have too low a level of protein. Instead a highly digestible, with high quality protein tends to be recommended.. usually one of the digestive support diets.

I have one case where the shunt was discovered by accident, whilst scanning adrenals! she had a raised BAST but was asymptomatic once we sorted her hypocortisolaemia. She was started on lactulose and amoxycillin plus diet initially, We stopped the amoxycillin as a trial and then weaned the lactulose down...still asymptomatic.