After a particularly busy day, I (Perry Jameson) had answered all my calls and emails, completed all my records, made sure my patients were settled for the night, made rounds with the emergency doctor on duty and was headed for the door when an ER nurse stopped me to let me know a dog was coming in with an acute abdomen.
This refers usually to a dog with a painful or distended abdomen. A bleeding tumor, twisted stomach, intestinal obstruction and peritonitis are the biggest concerns. The records were faxed over and as I began looking through them, I suspected something even worse.
Skye was a 6-year-old Doberman who had been diagnosed with liver disease two years previously. Looking at the blood tests that had been performed earlier in the day by her family veterinarian, there were multiple indications that her liver disease had progressed. I was concerned she was in liver failure.
The usual suspects of an acute abdomen are serious but often reversible with surgery. End stage liver failure is not.
Dogs can develop many forms of liver disease. Toxins such as Sago palms, Xylitol and large doses of acetaminophen can seriously damage their liver. Bacteria can ascend up the bile duct causing infections of the gall bladder and liver. A small number of dogs will have unexplained reactions to medications we are administering for another problem, resulting in liver injury.
Skye’s problem was not associated with an infection or toxin she had ingested. Her condition is called chronic hepatitis. This is a syndrome where there is inflammation of the liver without infection.
Anywhere in the body where there is chronic inflammation, scarring occurs. This scar tissue replaces the normal functioning tissue. Ultimately when there are no longer enough functioning cells, the organ fails.
Early on dogs are asymptomatic with the only indicator being elevations in liver values on blood tests. The first clinical symptom is often a decreased appetite and weight loss followed by vomiting and diarrhea. Ultimately, as liver function continues to decline, jaundice (a yellow coloring of the eyes and skin), decreased ability to clot and ascites (fluid in the abdomen) occur.
Bedlington terriers, West Highland white terriers, Skye terriers, Dalmatians, Labrador retrievers and Doberman pinschers all have an increased incidence of chronic hepatitis. In biopsies from these dogs’ livers, most not only show inflammation and scarring but many have increased levels of copper.
These dogs are not eating or being exposed to more copper than other dogs but have a metabolic defect where even the normal amounts found in food accumulate in their liver cells. This increased level of copper causes the excessive inflammation and resulting fibrosis.
Blood work will tell us we are dealing with liver disease and to some degree how serious it is. Abdominal ultrasound lets us visually assess the liver and may help diagnose certain cancers. Unfortunately, a biopsy is often the only way to know for sure which form of disease we are dealing with. Also, the copper levels can be measured to determine if they are at toxic levels. Surgery or laparoscopy are often necessary to obtain samples of adequate size.
The management for chronic hepatitis begins first by removing the primary cause if it is identified, such as toxins or mediations. The four major goals for therapy should then be:
1) dietary manipulation
2) specific therapy directed at reducing inflammation, fibrosis and/or copper
3) basic hepatic support
4) treating secondary complications that result from liver disease
There are multiple diets available for dogs with liver disease. They are copper restricted and have a moderate protein content. You have to be strict about only feeding the diet to avoid continued copper accumulation. When proteins are digested, toxins are produced. If the liver is function properly, it will filter out these proteins. However, a diseased liver may allow these toxins to get by, which has a negative effect on the brain. Disorientation, blindness, seizures and even coma can occur.
Decreasing inflammation is an important therapy used to reduce the amount of hepatocellular death and fibrosis. Steroids such as prednisone are usually the first medication used since they act quickly. Often other drugs are added with the hope they will allow the prednisone to be tapered or even stopped.
If there is significant copper accumulation, then we must administer medications to remove it. These drugs usually require three to four months to remove the copper. Getting another liver biopsy is the only way to know if levels have dropped. Once a dog has had copper removed, zinc is started to prevent copper reaccumulation.
There is evidence of oxidative damage in chronic hepatitis and justification for using antioxidants or various nutraceuticals to provide an environment for optimal liver function. I often prescribe one or several of the following antioxidants: vitamin E, SAMe, and milk thistle.
Unfortunately, dogs with chronic hepatitis have a guarded prognosis. Studies reveal dogs with significant scarring often live less than a month. When diagnosed with inflammation alone and treated aggressively, they survived 20-30 months. This would indicate the earlier we intervene the better and another reason the annual blood test your family veterinarian recommends is worth it.
We have been able to stabilize Skye and get her home. We cannot get her to gain weight, however, and she still has abdominal fluid. When this stage is reached in people the patient would be considered for a liver transplant. This is not an option in dogs. Hopefully, we can keep her comfortable with her family for a few more weeks.
Dr. Henri Bianucci and Dr. Perry Jameson are with Veterinary Specialty Care LLC. To send questions, go to Veterinaryspecialtycare.com and click the “ask the pet docs” icon.