Elevated Liver Values - What's Going On?

[NeylasMom]

My mom's cairn terrier Molly hasn't been doing well and I wanted to get some insight from you guys to possibly pass on to her.

 

Apparently she's been "off" for a bit - lethargic (going upstairs and sleeping instead of staying downstairs iwth my mom like she normally would, not wanting to walk or getting part way in and then just laying down) & not as interested in eating for a while, but my mom initially thought it was the heat. Then she noticed that she was gaining weight despite her decreased appetite so she took her in to the vet and they discovered that her liver values are really high. They're all very high, but the ALP was off the charts (literally, the upper limit the machine can measure is 2400 and her value read 2400+).

 

She also started drinking a LOT of water this weekend although that hadn't been a symptom up until that point. The blood work was done about 2 weeks ago (maybe slightly less) and she's been on Amoxy and Flagyl since then. At that time, they did an ultrasound and found a "humongous" liver (literally what is written in the vet's notes in her chart) and an enlarged gall bladder. They did a bile test on Friday, results will come in tomorrow. Other blood work was within normal ranges (T4 was very good).

 

Vet wants to wait another week (so total 3 wks on ABs) before redoing the liver values as he felt that amt of time was needed to see improvement if this is an infection. The other thing he had mentioned was Cushing's, which my mom didn't think fit, but after seeing the water consumption this wkd (new symptom) I am suspicious.

 

She is really fat - she's always run a little big for a cairn, around 16 or 17 lbs, but she weighed in at 24 lbs at the vet, which is a huge increase for a dog that small! I thought she looked a little pot-bellied, but it was really tough to tell just because she was so big (not to mention that she's got a very furry bell) so that may have been my imagination.

 

Anyway, I was wondering if this sounded like anything in particular to you guys, or if there are next steps you would recommend. I did suggest my mom see a specialist, but she is very confident in her vet and while she isn't saying she wont' see one (he's even mentioned that as a possibility moving forward) she wants to move through his recommended steps/tests first because she trusts him, which I understand. She did say she was going to ask him to pursue the Cushing's test after I did a little research and we talked about it (I read ALP in particular runs high in Cushing's, plus there was the new water drinking symptoms, and we looked at her blood work together and while the bar on the cholesterol reading read in the top third of normal, the value read something like 331 when the upper limit on the bar was 200something - if that makes sense - and I had read that chol can be elevated wtih Cushing's as well).

 

Anyway, any input would be appreciated. Tx!

[krissn333]

You're right where I'd be with the suspicion of Cushing's.

 

Hope it's something treatable and that Molly (I little Toto pups!) is feeling better soon

Edited August 20, 2012 by krissn333

[JJNg]

How old is Molly? Did the vet mention if the ultrasound revealed any other abnormalities within the liver, such as masses, changes in texture or density? Any stones or sludge in the gall bladder that might indicate a biliary obstruction? Did they also ultrasound the adrenal glands? While there are some general practitioners who are very good at ultrasound, I find that specialists tend to be more experienced and more likely to recognized subtle abnormalities.

 

On the bloodwork, was her total bilirubin elevated? If bilirubin is significantly elevated, there's really no reason to do bile acid testing.

 

While some of her signs seem to point toward Cushing's, others don't really fit. Cushing's usually doesn't cause all of the liver enzymes to be elevated, usually just the ALP and not to such an extreme degree. The decreased appetite also isn't consistent with Cushing's. It's still a possibility, and worth testing for, but I'd be a little more concerned about hepatobiliary disease.

 

Personally, I'd want to have a specialist (internist or radiologist) repeat the ultrasound, especially getting a closer look at the liver, gall bladder, and adrenal glands, and perhaps do a liver aspirate or biopsy.

[NeylasMom]

Jennifer, Molly is 8 or 9, 8 I think. Bilirubin was not elevated at all. Vet looked for, but did not find any masses (or other abnormalities as far as I know) and nothing else was reported on the gall bladder. There was no mention of the adrenal glands. I remember reading that they're not always easily seen (or maybe looked at in this case) - I honestly don't know if he tried to look at them or not.

 

I will continue to encourage my mom to go to the specialist. I encouraged her to do that after the initial visit, but she seems to be confident in her vet and doesn't want to go there until he recommends it. I did tell her that she only needed to pay for the consult, that she didn't necessarily need to do everything they recommend (or pay them to do it) and that specialists are good with working with your regular vet to determine a dx/treatment plan/etc but there's only so much I can say since it's her choice.

 

I'll post the results of the bile tests tomorrow and ask her to ask the vet for additional u/s results. No idea what hepatobiliary disease is, off to look that up. Thank you!

[JJNg]

Jennifer, Molly is 8 or 9, 8 I think. Bilirubin was not elevated at all.

 

Not that old, but old enough to start to have age-related diseases or cancer a little higher on the list of possibilities. That's good that the bilirubin is not elevated. With a severely elevated ALP and an enlarged gall bladder, that raises concern about biliary obstruction. How high was her ALT?

 

There was no mention of the adrenal glands. I remember reading that they're not always easily seen (or maybe looked at in this case) - I honestly don't know if he tried to look at them or not.

 

Yes, they can be difficult to find - one of the reasons an experienced ultrasonographer is preferred. The size and appearance of the adrenal glands can provide a lot of information about whether Cushing's is likely, and it can also distinguish between pituitary-dependent and adrenal-dependent Cushing's.

 

No idea what hepatobiliary disease is, off to look that up.

 

Sorry, just a general term for primary liver and/or gall bladder disease. Best wishes for your mom's dog.

[NeylasMom]

Her ALT was 504, high end of normal is 118. ALP was 2400+.

 

Bile acids test came back normal today. My mom is taking her back on Thursday for new blood work and is supposed to take a urine sample as well. She neglected to tell him about the new increased water consumption symptom and ask about the Cushing's test.

 

Vet said if blood work hasn't improved with the ABs then he will refer her to the specialist. Oh, she did discuss your other comments JJng and he admitted he hadn't looked for adrenals as he's not qualified.

 

If anyone has any other thoughts, please let me know. Sounds like they are in good hands, I just hate that they're not able to figure out what's going on.

Edited August 21, 2012 by NeylasMom

[JJNg]

Sounds like they have a good plan in place. An ALT of 500 is high enough to be concerned, but not super high. Anything more than twice the high end of normal is usually considered clinically significant. With the ALP being much more severely elevated, the high ALT may be secondary to whatever process is causing the high ALP. Hoping they get some answers soon.

[Guest OPointyDog]

Our German Shepherd/greyhound mix, Star, had some similar symptoms and lab results. A lot of lab tests later, she was diagnosed with the adrenal form of Cushing's disease. It was caused by tumor on her adrenal glands, which had presumably spread in her abdomen, including her liver, which had nodules (likely cancer). Ultrasound of her abdomen picked up the abnormalities, though we didn't ever know for sure if they were malignant. The adrenal glands are in a very vascularized area, so biopsy was not recommended.

 

Cushing's disease comes in two forms: adrenal and pituitary. The putuitary form is much more common (about 80% of cases), and is treatable in dogs with the use of drugs. The adrenal form (which Star had) is much harder to treat. It can be cured with surgery, but it's such a complicated and risky surgery that the survival rate isn't very good. We were also concerned that she was an older dog (12) and the Cushing's had also likely compromised her immune system and would make her recovery difficult. In the end we treated the symptoms but it was a difficult choice.

 

It's important to figure out if Molly has Cushing's and then if so, which form she might have, since it will impact the course of treatment.

 

The lab results we got over time were pretty weird and our vet was constantly scratching his head, since the liver function would fluctuate a lot, and she also had all kinds of strange symptoms as the cancer likely spread. I had a lot of conversations with him that started with, "This dog is pretty unusual..." For the most part, she did very well, though she had one very bad episode when she stopped eating completely, and we asked the vet for an appetite stimulant, which was a miracle worker. She bounced back and did well for several months after that. I'm surprised that fewer people on GT don't use them, since I haven't seen them mentioned. Sounds like Molly is still eating well, though.

 

The drug that seemed to work really well for Star's liver function was Denamarin - it wasn't cheap, but it helped her liver function improve and she felt better and so then ate better. You might ask the vet about getting a prescription - it's basically a supplement, and and at least in our case, it helped a lot with no side effects.

Edited August 22, 2012 by OPointyDog

[GreyTzu]

Our German Shepherd/greyhound mix, Star, had some similar symptoms and lab results. A lot of lab tests later, she was diagnosed with the adrenal form of Cushing's disease. It was caused by tumor on her adrenal glands, which had presumably spread in her abdomen, including her liver, which had nodules (likely cancer). Ultrasound of her abdomen picked up the abnormalities, though we didn't ever know for sure if they were malignant. The adrenal glands are in a very vascularized area, so biopsy was not recommended.

 

Cushing's disease comes in two forms: adrenal and pituitary. The putuitary form is much more common (about 80% of cases), and is treatable in dogs with the use of drugs. The adrenal form (which Star had) is much harder to treat. It can be cured with surgery, but it's such a complicated and risky surgery that the survival rate isn't very good. We were also concerned that she was an older dog (12) and the Cushing's had also likely compromised her immune system and would make her recovery difficult. In the end we treated the symptoms but it was a difficult choice.

 

It's important to figure out if Molly has Cushing's and then if so, which form she might have, since it will impact the course of treatment.

 

The lab results we got over time were pretty weird and our vet was constantly scratching his head, since the liver function would fluctuate a lot, and she also had all kinds of strange symptoms as the cancer likely spread. I had a lot of conversations with him that started with, "This dog is pretty unusual..." For the most part, she did very well, though she had one very bad episode when she stopped eating completely, and we asked the vet for an appetite stimulant, which was a miracle worker. She bounced back and did well for several months after that. I'm surprised that fewer people on GT don't use them, since I haven't seen them mentioned. Sounds like Molly is still eating well, though.

 

The drug that seemed to work really well for Star's liver function was Denamarin - it wasn't cheap, but it helped her liver function improve and she felt better and so then ate better. You might ask the vet about getting a prescription - it's basically a supplement, and and at least in our case, it helped a lot with no side effects.

 

Denamarin is a canine liver life-saver. It isn't a prescription and available on the web. Marin is another good liver support supplement, but it is on back order from most places on the web. I am not sure what is going on with Nutramax. I have seen one other liver support mentioned to replace Marin and that is from Standard Process, Hepatrophin PMG. I will be asking my Vet if it is OK for Disco next week when we do his recheck.

[tbhounds]

Hepto Support by rx vitamin is a good liver supplement second to Denamarin. Not sure what's going on with NutraMax-we have plenty on our shelfs at the clinic.

[NeylasMom]

Wendy, I really like the Standard Process products. My only issue sometimes is that their formulas can have a lot of stuff in it and I like to know what each thing is for/doing so in some cases I've opted not to go with them, but I know they are good quality products.

 

Isn't Denamarin just sam-e and milk thistle? You can easily supplement those on your own at a much lower cost than the Denamarin I believe. I like the milk thistle product from Thorne Research, I think it's called Siliphos (it's bound for increased absorption) and have always used the NatureMade sam-e available at Costco.

[GreyTzu]

Hepto Support by rx vitamin is a good liver supplement second to Denamarin. Not sure what's going on with NutraMax-we have plenty on our shelfs at the clinic.

 

Cool. I just ordered small dog Marin thinking I can give him two or three. I cannot find the bigger size. If I need the bigger size, I'll let you know.

 

And I'll ask about the Hepto Support too.

[NeylasMom]

Well new bloodwork is back. After 2 wks on ABs, the ALT went down, but there was no change in the ALP so they are going to do the Cushing's test (the "sophisticated" one according to my mom's email ) as I guess a last step before the specialist.

 

I don't really know what's left after that if it's negative, just age related liver disease?

 

Or an unidentified cancer.

Edited August 23, 2012 by NeylasMom

[tbhounds]

Is the pup acting sick? Did they run a Lepto PCR?

[NeylasMom]

Is the pup acting sick? Did they run a Lepto PCR?

She's lethargic, panting a lot, won't finish walks, and now is drinking a lot of water. She also gained a LOT of weight despite not eating much. So yes.

 

No to the lepto test. I thought lepto typically affected the kidneys? Would it cause an enlarged liver and gall bladder?

[JJNg]

Lepto most commonly affects the kidneys, but it often affects both kidneys and liver. In a smaller percentage of cases, it can show up mostly in the liver. Any inflammation/infection in the liver can cause enlargement, but not sure whether it would specifically affect the gall bladder.

[NeylasMom]

Wouldn't they have seen improvement on the ABs though? If I recall correctly, lepto is typically treated with doxy and Molly is on Flagyl and something like Clindamycin or Cephalexin (or Clavamox?, one of those generic 'C' antibiotics ), but you would think it might make a dent?

 

I did pass it along to my mom though. If the Cushing's test is negative, she could always try a course of doxy before seeing the specialist and dropping loads of cash. Although if she does just have liver disease, is there a danger in that - are ABs processing through the liver?

Edited August 24, 2012 by NeylasMom

[JJNg]

While lepto is a possibility, and it'd be a good idea to do titers, I don't think it's a strong enough possibility to just do a trial treatment. Especially since she is ill, it would be best to go ahead and pursue further liver testing (bile acids, ultrasound, liver aspirate/biopsy) to try to get some answers sooner rather than later.

 

Lepto isn't always a straightforward disease to treat, and a case that is primarily liver-related, with no kidney involvement, would definitely not be typical. It's usually treated with penicillins (which include amoxi or Clavamox, which I think she's already been on?) and/or doxy. But more chronic cases don't always respond immediately to treatment. Doxy is processed by the liver, but actual liver toxicity isn't something that's really seen clinically. Plumb's Veterinary Drug Handbook states: "Increased liver enzymes (ALT, ALP) have been reported in up to 40% of dogs treated. The clinical significance of increased liver enzymes has not been determined."

 

The ACVIM Consensus Statement on Leptospirosis is a good source of info about this disease. Here are a few relevant quotes:

 

"Chronic active hepatitis was reported in 1 kennel in association with development of antibodies to serovar Grippotyphosa and in another to serovar Australis. Attempts to detect leptospiral DNA in liver samples from dogs with chronic hepatitis were unrewarding. Leptospirosis should be considered as a differential diagnosis in dogs with hepatitis or hepatic fibrosis."

 

"The role of antimicrobial therapy in the treatment of human leptospirosis has been controversial. Treatment initiated after 4–7 days of illness is less effective in promoting clinical recovery."

 

"The optimal treatment for leptospirosis is unknown. Penicillins or doxycycline traditionally have been the antimicrobials of choice for treatment of humans and dogs with leptospirosis."

[seeh2o]

Reviving this thread as a greyhound mix I know has an elevated ALT, it's 361, was 315, went down to 300 on Denamarin, came off Denamarin and it went up to 361.  Dog has no symptoms, though lost 2lbs when being boarded.  Question: can a TBD cause something like this?

[GreyTzu]

There is a Denamarin Advanced now.

[seeh2o]

45 minutes ago, GreyTzu said:

There is a Denamarin Advanced now.

Thanks for that, I just shared it with her. Have you tried it on any of your pets?

[GreyTzu]

21 minutes ago, seeh2o said:

Thanks for that, I just shared it with her. Have you tried it on any of your pets?

Not the new stuff.