Case Of the Month

The Shunt Hunt…Part II

The Shunt Hunt Revisited. A Jack Russel Terrier from Yankee nation has to be named “Jeter.” But Does Jeter have a shunt and can it be corrected in time for the playoffs?
Case Imaged by Eric Lindquist DMV, DABVP. Patient managed by Abe Van Beveren DVM of Madison VH, Madison, NJ & Tom Scavelli & Staff at Garden State VS, Tinton Falls, NJ, USA.

Sonogram: (Liver, 7/26/10): “Jeter”

History: (Kelly Vasquez RVT): A 3-year-old MN Jack Russell Terrier with history of elevated ALT activity; treated with Ursodial in Japan, was presented for an initial visit. Physical examination was unremarkable and the owners were advised to stop giving the Ursodial. The patient was presented for vomiting for 3 days shortly after his initial visit. Physical examination and survey radiographs were both within normal limits. Blood chemistry revealed moderately elevated ALT activity and elevated pre-and post-prandial bile acids (175.9 and 449.1 umol/L, respectively). The patient was treated with Pepcid and Cerenia, and discharged with Gastro calm. The patient was recommended for treatment with Denamarin, Flagyl, Lactulose, and a low protein liver diet.

Outcome

The patient was recommended for urinary bladder lavage, ameroid constrictive placement upon the extra-hepatic spleno-azygos shunt, and concurrent liver biopsy. On exploratory surgery, a large splenoazygos shunt was identified and attenuated with an ameroid constrictor, liver biopsies were taken, a cystotomy was performed, and a culture from the bladder wall was obtained. The patient was discharged with Clavamox, Tramadol, and recommended for a special low protein liver diet. At last communication the owner reported the patient doing well.

Comments

Special thanks to Dr. Abe Van Beveren & Staff at Madison Veterinary Hospital, Madison, NJ, USA (http://www.vcahospitals.com/madison) and Dr. Tom Scavelli & Staff at Garden State Veterinary Specialists, Tinton Falls, NJ, USA (http://www.gsvs.org/) for the medical and surgical management of this case. Regarding shunt diagnostics via ultrasound and other studies, see our ECVIM abstract from Toulouse, France 2010 in our resources tab.

Clinical Differential Diagnosis

(Remo Lobetti BVSc, MMedVet, PhD, DECVIM):
http://www.sonopath.com/Specialists_Lobetti.html:

Vomition – infectious (viral, bacterial, helminths), diet, toxins, garbage disease, liver disease
Liver disease – congenital (MVD, PSS), cirrhosis

Sampling

Full-thickness surgical biopsies of the liver showed hepatic microvascular dysplasia. Culture of the bladder wall yielded no growth.

Sonographic Differential Diagnosis

(Lindquist DMV, DABVP): Extra hepatic shunt bypassing the vena cava consistent with splenoazygos shunt. Surgically correctable. Potential for concurrent microvascular dysplasia.

Image Interpretation

(Lindquist DMV, DABVP)