- 2 and 1/2 year old asymptomatic male neutered Chihuahua
- Chronically elevated ALT=248 U/L initially detected on predental labwork, all other chems are normal
- Bile acid test shows pre=5.1 mcmol/L, post=65.9 mcmol/L
- Elevated prothrombin time =14.7 sec
- PTT and platelet count are normal
- 2 and 1/2 year old asymptomatic male neutered Chihuahua
- Chronically elevated ALT=248 U/L initially detected on predental labwork, all other chems are normal
- Bile acid test shows pre=5.1 mcmol/L, post=65.9 mcmol/L
- Elevated prothrombin time =14.7 sec
- PTT and platelet count are normal
- Abdominal US exam showed a slightly decreased liver size, no aberrant portal vessels, normal CVC:AO ratio at the hilus and normal PV:CVC ratio at the hilus as well as well defined right and left portal branches. The left kidney showed one minor 2mm mineralization.
- US guided liver biopsies showed no significant inflammation or neoplasia. The pathologist states there is no evidence to suggest intoxication, degeneration or other metabolic condition. There is a single small focus of macrophages noted along one margin, however, because of the small size of the specimen, its significance is uncertain.
- My options for the client include referral for CT scan to completely rule out a shunt (for owner’s peace of mind), exploratory surgery to get a bigger liver biopsy (dog weighs <5 lbs), or nonspecific supportive treatment for potential liver pathology (metronidazole, Denamarin, L/D diet or novel protein diet) and continue to monitor liver enzymes/bile acids.
- What do you all think?
Comments
With the elevated
With the elevated post-prandial bile acids, small liver shunt or primary portal vein hypoplasia would be possible etiologies. How bad is the dental disease?, as that can elevate ALT activity.
Further assessment would be, as you mention, CT and liver biopsy. However, as the patient is completely asymptomatic, this may not be indicated as it would be likely that you would diagnose the cause of the elevated ALT and bile acids but not be able to rectify it.
In consultation with the owner, I would go for supportive therapy and monitor liver enzymes/bile acids as the risk of liver biopsy outweighs the benefit. If needed sort the teeth out and see what happens to the ALT/bile acid activity.
With the elevated
With the elevated post-prandial bile acids, small liver shunt or primary portal vein hypoplasia would be possible etiologies. How bad is the dental disease?, as that can elevate ALT activity.
Further assessment would be, as you mention, CT and liver biopsy. However, as the patient is completely asymptomatic, this may not be indicated as it would be likely that you would diagnose the cause of the elevated ALT and bile acids but not be able to rectify it.
In consultation with the owner, I would go for supportive therapy and monitor liver enzymes/bile acids as the risk of liver biopsy outweighs the benefit. If needed sort the teeth out and see what happens to the ALT/bile acid activity.
Thanks Remo. If this
Thanks Remo. If this asymptomatic dog had an extrahepatic vascular shunt, would you go ahead and recommend surgery?
Thanks Remo. If this
Thanks Remo. If this asymptomatic dog had an extrahepatic vascular shunt, would you go ahead and recommend surgery?
Probably not as medical
Probably not as medical management can be just as effective as shunt ligation/attenuation but would give the owner the final say.
Probably not as medical
Probably not as medical management can be just as effective as shunt ligation/attenuation but would give the owner the final say.
The liver looks relatively
The liver looks relatively normal size, inflammatory hepatopathy and portal hypoplasia most likely which is medical.
The liver looks relatively
The liver looks relatively normal size, inflammatory hepatopathy and portal hypoplasia most likely which is medical.