Hepatomegaly in a dog

[pgg]

I'm a people-doctor and I'd like an animal-doctor perspective on what my dog's vet told me today. It didn't seem quite right, and I'm trying to decide if I should take him to another vet.

11 year old neutered male 1/2 lab 1/4 rottweiler 1/4 healer dog. 80 pounds. Current on vaccinations. We took him in because I thought he had developed some ascites and he had some right sided abdominal tenderness when I started poking him. He's been mostly asymptomatic, maybe a slightly decreased appetite, no weight gain or loss. No behavioral changes to speak of.

The vet did an exam (agreed that he had an enlarged liver), drew some blood, did a UA, and got abd plain films.

Blood showed a normal CBC and electrolytes. Alk phos elevated to 400, ALT 200. UA showed a UTI. Films showed the liver extending about 8 cm beyond his lowest rib, some bowel gas, no stones, no masses, nothing else the vet was concerned about.

The vet gave us some antibiotics to treat the UTI but kind of shrugged off the liver findings.


I'm a bit concerned that the exam/xray/labs showed an abnormal liver, but that we don't have a diagnosis or further diagnostic plans. Again, I've got a MD not a DVM, but in people a UTI doesn't explain away hepatomegaly, +/- ascites, and elevated liver enzymes. I'd appreciate some feedback from veterinarians or vet students on this.

Am I misinterpreting the data here? Is this a reasonable treatment plan? (For all I know, liver findings like this are common and unconcerning in dogs.)

Thanks, and sorry for posting a "diagnose my pet" kind of question on your forum.

---

Members don't see this ad.

 

[WhtsThFrequency]

Just debating on if I can answer this without giving "medical advice...."

About the elevated liver enzymes... these guys are quite possibly the bane of a veterinarian's existence, because elevation can mean SO many things, or in some cases, nothing at all. I've seen panels with elevated enzymes from completely healthy dogs. Do you have his chemistry from years past to compare "how much" of an elevation it is?

If the rest of the chem panel and the CBC came back normal I wouldn't get too worked up over it. Maybe take a re-test in 2-3 weeks after the infection has cleared up and the body has recovered from antibiotics. There is nothing wrong with getting a second opinion, though. Just like human doctors, there are some "over-diagnosing" vets and "under-diagnosing" vets. Nothing wrong with shopping around, so to speak.

 

[chris03333]

The vet gave us some antibiotics to treat the UTI but kind of shrugged off the liver findings.


I'm a bit concerned that the exam/xray/labs showed an abnormal liver, but that we don't have a diagnosis or further diagnostic plans. Again, I've got a MD not a DVM, but in people a UTI doesn't explain away hepatomegaly, +/- ascites, and elevated liver enzymes. I'd appreciate some feedback from veterinarians or vet students on this.

Am I misinterpreting the data here? Is this a reasonable treatment plan? (For all I know, liver findings like this are common and unconcerning in dogs.)

If you are concerned, did you discuss your concerns with the vet? Ask he/she what thier reasoning was?

if yes and you are satisfied, then fine.
if yes and you are not satisfied OR if no and you are not satisfied...Get a second opinion (I gather this may be the right direction or you wouldn't be posting here)

One thing I was taught is to treat the patient, not the clin path, so I would not really be comfortable saying anything about this case without examining the dog and playing as 20 quesions with you first

Good luck

 

[dvm'08]

Hepatomegaly and elevation in liver enzymes would, in my eyes, at least warrant a liver ultrasound +/- a biopsy... plus a more thorough cardiovascular exam (BP measurements, ECG, maybe a chest rad(s))...

but thats just me...

 

[Bill59]

Yeah, talk to the veterinarian some more and let them know you are concerned about some of the abnormal findings and would like to know if there are any other diagnostic tests they would recommend. Base your next step on what he or she says.

You might also ask in passing about hyperadrenocorticism, which could explain the liver enzymes, hepatomegaly, "ascites" (increased abdominal fat), and UTI.

Make sure you mention you heard about it on an internet message board. We love it when clients say that.

 

[pgg]

Thanks all.

We did ask about the liver findings, but I wasn't really pushy ... as an MD I generally defer to the specialty-trained judgment of other MDs who know more than I do, so I'm doubly reluctant to try to apply my people-medicine knowledge to something a DVM's judged as not a big deal. If that makes any sense.

She mentioned that an ultrasound might be helpful, but once the the UA came back showing a UTI, she kind of changed gears toward treating that and watching him as opposed to further tests. We talked about Cushings briefly, but she thought that was unlikely.

He has a followup scheduled in few days so we'll see how that goes.

Make sure you mention you heard about it on an internet message board. We love it when clients say that.

I'm an anesthesiology resident - a couple weeks ago, I took care of a healthy kid having a tonsillectomy. Mom had printed out the Google Scholar search results for "tonsillectomy" and gave them to me. Not any actual articles, mind you, just the first page of search results.

She pointed to search result #2 on the list (which is still "Dexamethasone decreases vomiting by children after tonsillectomy") and then said words to the effect of, "You're going to give him some dexasskjslkawhatever so he doesn't throw up, right?"


Maybe someday I'll be this DVM's story to tell about a stupid pushy people-doctor who got all worked up over his dog's alkaline phosphatase level.

 

[chris03333]

Maybe someday I'll be this DVM's story to tell about a stupid pushy people-doctor who got all worked up over his dog's alkaline phosphatase level.

ALP is not very specific in dogs. Is it in human?

 

[pgg]

ALP is not very specific in dogs. Is it in human?

No, but it's also not something that would be dismissed after finding a UTI. Elevated liver enzymes carry a long, long differential in people and the initial workup often includes more (different) LFTs, screens for various flavors of viral hepatitis, ultrasound (these days probably more likely to go straight to CT skipping the US), detailed history (which I'd imagine is quite a bit harder to get from a dog), etc. If it was just ALKP I'd be unconcerned.

But there I was, playing with my dog, thought "hmm that feels like ascites and he doesn't like me poking his RUQ" ... went to the vet where labs & films showed an abnormal liver ... and left with abx for a UTI.

 

[chris03333]

No, but it's also not something that would be dismissed after finding a UTI. Elevated liver enzymes carry a long, long differential in people and the initial workup often includes more (different) LFTs, screens for various flavors of viral hepatitis, ultrasound (these days probably more likely to go straight to CT skipping the US), detailed history (which I'd imagine is quite a bit harder to get from a dog), etc. If it was just ALKP I'd be unconcerned.

But there I was, playing with my dog, thought "hmm that feels like ascites and he doesn't like me poking his RUQ" ... went to the vet where labs & films showed an abnormal liver ... and left with abx for a UTI.

You should really get a second opinion...

 

[alliecat44]

Speaking as a vet student here, so take my "advice" with a grain of salt...

I'd be curious to know what his BUN, cholesterol, and albumin were. If any of those were low, I'd be tempted to start with a bile acids +/- ACTH stim +/-ultrasound +/- ultrasound-guided aspirate. There are tons of rule-outs for elevated liver enzymes in dogs, though, so difficult to say what the proper course would be (as I'm sure you can appreciate!). Also, much of it is dependent on his history, as again I'm sure you can appreciate. Radiographically, could you appreciate a loss of detail that would support your concern regarding ascites (vs. fat/organomegaly)?

FYI, if it comes to this in order to obtain a diagnosis--and hopefully it doesn't--it is possible and increasingly common to perform a laparoscopic liver biopsy. Advantages and disadvantages over an open procedure, just like in people, and depedent upon what else is going on with your dog, but just wanted to make you aware of it. (So many MD clients are surprised at what specialty veterinary medicine can offer!)

It sounds like you're uncomfortable with what your vet is telling you. For that reason alone, I'd pursue a second opinion. If this were my mother's dog, I'd also pursue a second opinion. Hope that helps.

P.S. If it's cholangiohep, at least he's already on abx...
Also, hilarious anesthesia story. I'm hoping to specialize in anestheiology myself. You must love it when they're asleep and can't talk to you.

 

[PAThbrd]

Please don't stray too close to the line of medical advice or Ill have to close the thread

Good luck with your dog!

 

[pgg]

Thanks again, it's been very interesting to hear from all of you on the animal side. We'll just take him back for his followup appointment, and if the answers still don't make sense we'll visit another vet.

You must love it when they're asleep and can't talk to you.

Ha, we all joke about it, but there's more than a grain of truth to that. I'm not the only one who wound up in this field because I'd rather do something for a patient than talk to him about it.

 

[alliecat44]

Please don't stray too close to the line of medical advice or Ill have to close the thread

Good luck with your dog!

Sorry! Eep!

pgg, best of luck with your dog...let us know how it turns out!

 

[Weazlebub]

No, but it's also not something that would be dismissed after finding a UTI.

Bingo! (p.s. the ultrasound would rule in or out ascites.. more reason to follow up if you think you feel fluid)

 

[Bill59]

Ha, we all joke about it, but there's more than a grain of truth to that. I'm not the only one who wound up in this field because I'd rather do something for a patient than talk to him about it.

Now if you could only get the surgeons to be quiet.

 

[amborchesk]

i have a similar problem...

my pet is a 3yr old female shih tzu, who suddenly had difficulty getting up monday morning after a couple days of shivering episodes (which we attributed to thunder). she passed out a greenish-mucoid stool. we brought her to the vet and on physical exam, we were told that she had hepatomegaly and was somewhat pale. lab workups done were cbc (pcv 28%, wbc 12.8, neutro 78, lymphos 22, plt 1-3/ioi), bun (51.4), normal crea, sgpt and sgot. stool exam was normal, with no red blood cells noted. she is currently on liverolin and anti-diarrheal agents. our vet thinks it's just arthritis due to her high protein diet (dog food, 27% protein).

i came to this forum to ask for your opinions. i had 3 dogs who died of what the vets thought was blood-parasite. they too presented with intermittent limping, anorexia before they got too sick. i don't want that to happen again so i'd value any thoughts and opinions you professionals could have on my pet's case. thanks in advance.

 

[sunshinevet]

i have a similar problem...

my pet is a 3yr old female shih tzu, who suddenly had difficulty getting up monday morning after a couple days of shivering episodes (which we attributed to thunder). she passed out a greenish-mucoid stool. we brought her to the vet and on physical exam, we were told that she had hepatomegaly and was somewhat pale. lab workups done were cbc (pcv 28%, wbc 12.8, neutro 78, lymphos 22, plt 1-3/ioi), bun (51.4), normal crea, sgpt and sgot. stool exam was normal, with no red blood cells noted. she is currently on liverolin and anti-diarrheal agents. our vet thinks it's just arthritis due to her high protein diet (dog food, 27% protein).

i came to this forum to ask for your opinions. i had 3 dogs who died of what the vets thought was blood-parasite. they too presented with intermittent limping, anorexia before they got too sick. i don't want that to happen again so i'd value any thoughts and opinions you professionals could have on my pet's case. thanks in advance.

I think that is asking for veterinary advice. We are not professionals - we are students. You need to ask a veterinarian.

That said, Pgg, the vet may just want to clear the UTI and see how the dog is after - I'm sure you know, funny things happen. Also, unless you seemed quite keen-bean for further workup, the vet may have thought it would be best to treat the UTI first and let the liver slide for now - a lot of people decline expensive work-ups, especially in older pets, and the vet may not have known where you stood. Another factor - your dog is 11 - and quite a large breed by the sounds of things. Your vet may not be too worried as this tends to be one of the things we accept as they get older, and is more interested in treating the easily treatable problems.

Unfortunately, most of the time veterinary medicine tends to be a bit more of a vague area that human medicine - we dont get to do all the workups, and get to the bottom of all the cases like you guys do. So make it clear to your vet that your keen to get to the bottom of the liver issues - she might have thought, from your lack of input, you wanted to go with a conservative workup.

Hope this helps!

 

[pgg]

Was just using the search function to see if anyone had replied to threads I'd posted in recently, and this one popped up.

pgg, best of luck with your dog...let us know how it turns out!

He did pretty well through early/mid 2008 - had some repeat blood work. Two vets were not especially impressed by the liver issues I was all worked up about and neither felt compelled to do anything other than monitor him. Later in the year he had a few recurrent UTIs and began to develop some urinary incontinence. Ultrasound showed a bladder tumor. He did OK for about 6 months with phenylpropanolamine - was his usual self. Always hard to tell with animals if they're just silently enduring chronic pain, but he seemed happy. Some time in April 2009 he finally started acting like an old, sick dog so in May our vet came to our house to put him down.

Thanks again for the discussion way back then.

 

[meadow36]

Sent you a PM ... good luck with your dog!

 

[alliecat44]

Was just using the search function to see if anyone had replied to threads I'd posted in recently, and this one popped up.



He did pretty well through early/mid 2008 - had some repeat blood work. Two vets were not especially impressed by the liver issues I was all worked up about and neither felt compelled to do anything other than monitor him. Later in the year he had a few recurrent UTIs and began to develop some urinary incontinence. Ultrasound showed a bladder tumor. He did OK for about 6 months with phenylpropanolamine - was his usual self. Always hard to tell with animals if they're just silently enduring chronic pain, but he seemed happy. Some time in April 2009 he finally started acting like an old, sick dog so in May our vet came to our house to put him down.

Thanks again for the discussion way back then.

Sorry to hear about the bladder cancer--it's a bad disease. I'm glad you had more time with him, though. Take care and I hope that eventually another dog will be lucky enough to find its way into your heart and home.

 

[amborchesk]

i was kindda hoping to get an opinion from those who are in the field of veterinary medicine, whether you are a student or a practicing vet already. this thread is for current DVM students and graduates right?

 

[Angelo84]

Yes this forum is for vet students and vets. What you are asking for is medical advice which we cannot give by both the rules of this forum and the law. If you are uncomfortable with your vets opinion get a second opinion either at the same practice or elsewhere. Good luck with your dog I hope she does well.

 

[Bill59]

i was kindda hoping to get an opinion from those who are in the field of veterinary medicine, whether you are a student or a practicing vet already. this thread is for current DVM students and graduates right?

Anyone who would give medical advice about a specific patient they have never examined would be acting irresponsibly. It doesn't matter if they are a DVM or not.

And any pet owner who would act on such advice instead of getting an opinion from a veterinarian who has actually examined the patient would be acting irresponsibly.

 

[chris03333]

Anyone who would give medical advice about a specific patient they have never examined would be acting irresponsibly. It doesn't matter if they are a DVM or not.

And any pet owner who would act on such advice instead of getting an opinion from a veterinarian who has actually examined the patient would be acting irresponsibly.