Spencer Has Higher Liver Values - Biopsy Result At Post 82

[greyhead]

Although Spencer's dental went fine yesterday and he has been doing very well, his blood work results came back from the lab today with liver enzymes that have doubled and tripled since September. I've tried to attach a text file with the numbers to this post. If it doesn't work, I'll come back and copy/paste through an edit.

 

liver values.txt

 

In September 2012 the ALT was 202 and now is 495. The alkaline phosphatase was 473 and now is 1457. He took and passed a bile acids test last summer, I believe. (His liver values had been creeping up for some time.) His vet asks if his eating and drinking have increased a lot, and they have not. He is eating more, but only because I offer it in trying to put some weight back on him. Surely she's wondering about Cushings. She wants a first-catch urine sample next week.

 

So if it's not Cushings, could it be all the meds he has taken since September? He was back on budesonide and metronidazole for a few weeks in the fall, was treated with Drontal and Drontal Plus on a couple of occasions, takes Tylan and soloxine daily always, started gabapentin and tramadol last summer, Adequan a couple months ago, and took Trifexis for three months after Interceptor became unavailable. I didn't like his response to Trifexis (diarrhea in an IBD dog makes one nervous), so I've found a source for Interceptor and put him back on that last month instead. We also just started Denamarin in December but at a very low dose, like 1/2 to 1 tablet per day. (The internist recommended it at that time, after reviewing the blood work he'd had done in September.)

 

The rest of his blood work looks so good to me!!! He has gained a couple much-needed pounds over the last month, but his eyes have developed that sunken look, with dark circles underneath. (That has happened before, but it went away.) Not seeing any yellowing, like jaundice.

 

My vet is gone for the day and may not be back until Tuesday. (She emailed me the blood work and her question about eating/drinking.) So any thoughts about what this might mean? Meanwhile, I'll be mining the archives, my books, and the Internet. But I was hoping to reap some wisdom here before everybody starts their weekend.

 

Thanks.

Edited April 2, 2013 by greyhead

[tydyelady]

Oh My ME, I am sorry. I know nothing about this, and I only know what about half of the medications are. But you are in my thoughts, and I hope you can find out what is causing this and what it means, and that Spencer will be fine.

I was going to ask if you were going to the GPA wine tasting in Renton tomorrow, we are going around 3, and bringing Toley.

[greyhead]

Oh My ME, I am sorry. I know nothing about this, and I only know what about half of the medications are. But you are in my thoughts, and I hope you can find out what is causing this and what it means, and that Spencer will be fine.

I was going to ask if you were going to the GPA wine tasting in Renton tomorrow, we are going around 3, and bringing Toley.

 

Thanks, Susan. We're doing the closing for our re-fi tomorrow at 2:00, and after that we'll probably just collapse with wine at home. It has been quite a week for everybody in this house -- yours too, I think! We do so much want to meet Toley, though! I'll text you when we're done and see if you're still there.

[JJNg]

There are a number of different things that can cause elevated liver enzymes, not all of them even directly related to the liver. Cushing's is definitely on the list, although it doesn't sound like Spencer is showing any of the classic signs. Even IBD and pancreatitis can cause mild liver elevations. I found one reference to Tylan potentially causing falsely elevated liver enzymes on some bloodwork machines, although if he's been on it consistently, I'm not sure if that would account for the upward trend.

Any meds that he has been off of for the past month shouldn't cause persistently elevated levels. Most of the time if a medication is causing an increase liver enzymes, those levels return to normal several weeks after stopping the medication (and the only possible culprit would be the budesonide). None of the meds he's been on would be expected to cause any permanent liver damage, and none of the current meds should cause high liver enzymes.

An upward trend in liver enzymes is definitely indication for further workup. The best way to assess his liver would be to have an ultrasound done. If he hasn't had that done since the liver enzymes started creeping up, I'd personally want to start there to make sure there isn't an obvious liver problem. But it's certainly reasonable to test for Cushing's as well. I'd suggest consulting with the internist who is familiar with his case to see how they'd recommend proceeding and which tests to do first.

[greyhead]

Thanks so much, Jennifer, for the information and suggestions. I confess I've felt quite lost this evening, just knowing that it could be a lot of things and not having a clue where to dig in to sort it out. I'll sleep better now with an outline of a plan!

[a_daerr]

Agree with everything Jennifer said. At this point, I would be concerned if they were double or triple the right amount. Probably time for another bile test.

[krissn333]

Just wanted to say that I hope you get some answers. Liver number issues can be so mysterious and frustrating!

[GreyTzu]

There are a number of different things that can cause elevated liver enzymes, not all of them even directly related to the liver. Cushing's is definitely on the list, although it doesn't sound like Spencer is showing any of the classic signs. Even IBD and pancreatitis can cause mild liver elevations. I found one reference to Tylan potentially causing falsely elevated liver enzymes on some bloodwork machines, although if he's been on it consistently, I'm not sure if that would account for the upward trend.

 

Any meds that he has been off of for the past month shouldn't cause persistently elevated levels. Most of the time if a medication is causing an increase liver enzymes, those levels return to normal several weeks after stopping the medication (and the only possible culprit would be the budesonide). None of the meds he's been on would be expected to cause any permanent liver damage, and none of the current meds should cause high liver enzymes.

 

An upward trend in liver enzymes is definitely indication for further workup. The best way to assess his liver would be to have an ultrasound done. If he hasn't had that done since the liver enzymes started creeping up, I'd personally want to start there to make sure there isn't an obvious liver problem. But it's certainly reasonable to test for Cushing's as well. I'd suggest consulting with the internist who is familiar with his case to see how they'd recommend proceeding and which tests to do first.

 

:nod

[Guest sirsmom]

When one of our mutts had cushings the first symptoms were excessive water drinking and peeing in the house so if youre not having that it's probably something else. I wonder if one of the meds he's on could be causing it. Hope he feels better soon.

[galgrey]

No advice, but please accept my good thoughts. Keep us posted.

[EllenEveBaz]

Adding our good thoughts for your handsome hero houndie.

[greyhead]

The vet emailed me today. I'll take the urine sample in tomorrow, and I know she'll check the specific gravity and perhaps the protein levels. I don't know if she plans to follow that with the urine cortisol/creatinine test, but I'll probably request it as it seems like the best preliminary screening test. (Found a really good web site for a crash course on Cushings: http://www.kateconnick.com/library/cushingsdisease.html ) Then I'm thinking we'll move to ultrasound.

 

Upon reflection, and since the vet told me of a few more observable symptoms than I'd been aware of, I see where his eating, drinking, coat condition, and temperature preferences have not been typical for him. You're always thrilled when an IBD dog eats more! But not only does he eat extra because I'm giving it to him, he also gets uncharacteristically pushy about eating and asks for meals sooner than they normally would occur. And he drinks for a longer time when he's at the water bowl, though I can't tell yet if he goes to it more often. The back end weakness that we chalk up to LSS and disk issues (which he really does have) could be symptomatic of Cushings also, as is his prefrence for shorter walks now. I also learned that these symptoms all creep up gradually and are easy to read as just old age.

 

Not sure what to hope for, frankly, Cushings or liver issues! That web site mentioned a new drug getting good results in Europe for Cushings, called Vetopryl, I think. It's a lot less harsh-sounding than the other treatments. They say you can get it if you get a waiver from the FDA. I can only imagine how hard that might be to get! But I shouldn't get ahead of myself too much now, right?

 

Thanks so much for the info, advice, and good wishes. They are all much appreciated.

[Guest 2dogs4cats]

Daisy has high liver values, has a hearty appetite and drinks a lot when her blood sugar goes up. She's diabetic. I think diabetes and cushings are related somehow and the symptoms are very similar. Hopefully it's nothing.

[JJNg]

The additional signs you mentioned probably put Cushing's higher on the list of possibilities. Ultrasound is helpful with that diagnosis as well since they can check the size of the adrenal glands.

That web site mentioned a new drug getting good results in Europe for Cushings, called Vetopryl, I think. It's a lot less harsh-sounding than the other treatments. They say you can get it if you get a waiver from the FDA. I can only imagine how hard that might be to get!

Vetoryl was FDA approved for use in the US and has been available now for at least 2-3 years. So no difficulty getting it anymore.

[greyhead]

Thanks, Jennifer and Mary!

[greyhead]

Well, it's dinner time and I still haven't heard from the vet. Dropped off the sample early this a.m. before she got in, and it was far from being dilute! ( It was actually pretty dark, though it didn't look bloody.) So I doubt they even needed to run a specific gravity. But I'm not sure I believe that this alone can rule out Cushings. In any case, I don't know anything official now. Will update when I do.

 

Am I the only one who gets paralyzed waiting for results? I find things to occupy myself, but I don't get in the shower, don't go to the store until I absolutely have to, for fear of missing the call. And I just munch, munch, munch!

[Batmom]

Well, it's dinner time and I still haven't heard from the vet. Dropped off the sample early this a.m. before she got in, and it was far from being dilute! ( It was actually pretty dark, though it didn't look bloody.) So I doubt they even needed to run a specific gravity. But I'm not sure I believe that this alone can rule out Cushings. In any case, I don't know anything official now. Will update when I do.

 

Am I the only one who gets paralyzed waiting for results? I find things to occupy myself, but I don't get in the shower, don't go to the store until I absolutely have to, for fear of missing the call. And I just munch, munch, munch!

 

A negative UCCR does rule out Cushing's. A positive doesn't rule it in, though.

 

Color doesn't really correlate with specific gravity. You can guess from the color, and at least 30% of the time you'll be wrong.

 

I don't munch but I give the vet my cell number (a rare ... privilege ).

[greyhead]

So the vet emailed me that the specific gravity was 1.048 and that that, combined with good kidney values, rules out Cushings. (Seems like kind of an indirect measure, unlike the cortisol/creatinine ratio, doesn't it?) She added that the other clinical signs were doubtless secondary to something else, perhaps endocrine related, and that we don't need to do anything else for now. While I don't want to panic, I can't say I'm entirely comfortable with this response. I suppose I could email the new liver values and symptoms to the internist for her opinion, but that makes me feel a bit sneaky. Of course, when it comes to my dogs, I can probably sneak if that's what it takes to keep them well. But what do you guys think?

Meanwhile, he's on Denamarin now, more religiously than I'd been doing it before. I also had discontinued his Tylan a couple days ago, but his poop quality deteriorated and he got a rumbly tummy last night, so his IBD treatment may require that we stick with the Tylan. Eeesh.

 

(I should probably mention that Spencer was on budesonide for 2-1/2 years straight before we were able to discontinue it and just use it when he has flares. He was also on metronidazole for 3-1/2 years and Tylan even longer. I guess these things can add up over time and make the liver unhappy, but it's odd that his numbers have risen so much since he has been mostly off them for months.)

Edited January 29, 2013 by greyhead

[Batmom]

So the vet emailed me that the specific gravity was 1.048 and that that, combined with good kidney values, rules out Cushings.

 

That's not true. You would *usually* see low specific gravity in Cushing's, but not necessarily. And you usually don't see a high BUN in Cushing's disease -- having "good kidney values" doesn't rule it out.

 

From what you have described, *I* would not suspect Cushing's, but I'm not you and I'm not observing the dog directly. If you're worried about it, insist on the UCCR (the "rules out but not in" test).

 

Has he had an abdominal x-ray lately? I wouldn't necessarily suggest you get one but it might be a useful avenue if you feel Something Is Not Right And I Need To Know What, KWIM?

 

Good luck!

[greyhead]

Thanks, Jey. I'm not attached to a Cushings diagnosis by any means. I'd just like to understand why USG is a rule-out, and what you're saying makes sense to me that it's not. The next puzzle is why there's no suggestion of a follow-up examination of something -- x-ray, ultrasound, whatever. With his history and liver values that far out of range in such a short period of time (since September), I feel like I ought to be doing something besides Denamarin. But I don't know anything except that liver disease isn't pretty, since I lost two cats to it many years ago.

[Batmom]

Your vet may feel that the liver values aren't high enough. At this point, they're of concern -- will they keep going up or stabilize or drop again? -- but not panic. So your vet may be taking an approach of, let's wait and see if any symptoms develop that point us in a useful direction. The liver can be insulted -- and can recover -- from all kinds of things (even just stress) which are not outright liver disease.

 

Again, I don't know what the appropriate route is in your pupper's case -- maybe JJNg and some others will have ideas. I know you're worried about him and want to give only the best care.

[4My2Greys]

I don't have any advice I just want to add my well wishes for Spencer.

[tbhounds]

Has your vet mentioned running a bile acid test??

Edited to add---again?

Edited January 30, 2013 by tbhounds

[greyhead]

Has your vet mentioned running a bile acid test??

Edited to add---again?

 

No, she hasn't. And that's the thing, she hasn't mentioned doing anything else at all. Btw, I checked, and the last bile acids test was done in the summer of 2011, not 2012.

 

ETA: and it was the internist who ordered it that time.

Edited January 30, 2013 by greyhead

[a_daerr]

No, she hasn't. And that's the thing, she hasn't mentioned doing anything else at all. Btw, I checked, and the last bile acids test was done in the summer of 2011, not 2012.

 

ETA: and it was the internist who ordered it that time.

 

I think a bile test would be the next logical step. Have you consulted with OSU yet?