Rising ALT and elevated post bile acids (40) in an asymptomatic patientR/

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Rising ALT and elevated post bile acids (40) in an asymptomatic patientR/

  • 11 year old FS Boston Terrier with chronically elevated ALT, ALKP, and Post Bile Acids=40
  • Patient is asymptomatic
  • Abdominal ultrasound shows a small normal liver with some very slight micronodular changes in the left liver and mild splenomegaly with multiple echogenic foci.  The portal hilus appears normal as do the adrenal glands.
  • The dog is not on any meds and does not appear Cushingoid.  Urine specific gravity=1.030

    • 11 year old FS Boston Terrier with chronically elevated ALT, ALKP, and Post Bile Acids=40
    • Patient is asymptomatic
    • Abdominal ultrasound shows a small normal liver with some very slight micronodular changes in the left liver and mild splenomegaly with multiple echogenic foci.  The portal hilus appears normal as do the adrenal glands.
    • The dog is not on any meds and does not appear Cushingoid.  Urine specific gravity=1.030
    • Why does this dog have elevated live enzymes AND bile acids? My rule outs include chronic hepatitis, microvascular dysplasia, shunt (none seen), occult IBD, less likely neoplasia
    • I usually assume that echogenic nodules in the spleen are benign but this dog has multiple and splenomegaly so I aspirated them just in case.
    • The patient is asymptomatic but the owner wants an answer.  I biopsied the liver and performed fna’s on the liver and spleen.  Results are pending.

Comments

rlobetti
September 6, 2014 at 11:58 am -

How elevated are is the

How elevated are is the ALT/ALP activity? The micronodular changes can account for the liver enzyme and BA changes. Other possiblities would be vacuolar hepatopathy and nodular regeneration. With that urine SG Cushing’s most unlikley but consider doing an ACTH stimulation test if everything else is fine. The splenic nodules are most likley lipogranulomas and incidental. Always a good idea to FNA any abnormal findings.

rlobetti
September 6, 2014 at 11:58 am -

How elevated are is the

How elevated are is the ALT/ALP activity? The micronodular changes can account for the liver enzyme and BA changes. Other possiblities would be vacuolar hepatopathy and nodular regeneration. With that urine SG Cushing’s most unlikley but consider doing an ACTH stimulation test if everything else is fine. The splenic nodules are most likley lipogranulomas and incidental. Always a good idea to FNA any abnormal findings.

Electrocute
September 6, 2014 at 12:38 pm -

Thank you Dr.Lobetti.  I am

Thank you Dr.Lobetti.  I am in the process of getting a copy of her labwork.  As I recall, the ALT has been slowly climbing the past 2 years but it is still only mildly elevated (low 200’s). Can vacuolar hepatopathy and benign nodular hyperplasia cause elevated bile acids?  

Electrocute
September 6, 2014 at 12:38 pm -

Thank you Dr.Lobetti.  I am

Thank you Dr.Lobetti.  I am in the process of getting a copy of her labwork.  As I recall, the ALT has been slowly climbing the past 2 years but it is still only mildly elevated (low 200’s). Can vacuolar hepatopathy and benign nodular hyperplasia cause elevated bile acids?  

rlobetti
September 6, 2014 at 1:02 pm -

Not really – need to think of

Not really – need to think of gall bladder/bile disease, congenital, GI disease.

Have the BA remained stable or are they also climbing?

rlobetti
September 6, 2014 at 1:02 pm -

Not really – need to think of

Not really – need to think of gall bladder/bile disease, congenital, GI disease.

Have the BA remained stable or are they also climbing?

rlobetti
September 6, 2014 at 1:08 pm -

Some details about BA and

Some details about BA and liver disease:

The 3 main pathologic processes that may result in an increased BA are  abnormalities of the portal circulation; decreased functional hepatic mass and a decreased bile acid excretion into the bile. This means that a variety of liver diseases may lead to increased BA concentrations, such as portosystemic shunting, cholestasis, cirrhosis, necrosis, hepatitis, hepatic lipidosis (cats) and neoplasia. Exaggerated increases in postprandial BA concentration are most consistent and marked with portosystemic shunting. It is not possible to determine the type of liver disease based on increased BA concentration alone.

rlobetti
September 6, 2014 at 1:08 pm -

Some details about BA and

Some details about BA and liver disease:

The 3 main pathologic processes that may result in an increased BA are  abnormalities of the portal circulation; decreased functional hepatic mass and a decreased bile acid excretion into the bile. This means that a variety of liver diseases may lead to increased BA concentrations, such as portosystemic shunting, cholestasis, cirrhosis, necrosis, hepatitis, hepatic lipidosis (cats) and neoplasia. Exaggerated increases in postprandial BA concentration are most consistent and marked with portosystemic shunting. It is not possible to determine the type of liver disease based on increased BA concentration alone.

mjweisman
September 6, 2014 at 1:25 pm -

Thanks Eric.  This is the

Thanks Eric.  This is the first time that bile acids have been checked on this patient as she is clinically normal.

 

mjweisman
September 6, 2014 at 1:25 pm -

Thanks Eric.  This is the

Thanks Eric.  This is the first time that bile acids have been checked on this patient as she is clinically normal.

 

EL
September 6, 2014 at 1:43 pm -

 
 
Actually that was Remo

 
 

Actually that was Remo wiht all that great info but I agree and here are some causes of bile acid elevations that are not shunt related: This is an excerpt form the upcoming book that remo and I coauthored wiht Drs Frank and Modler… The curbside guide:

http://sonopath.com/products

Nonhepatic Causes

  • ·               Inflammatory bowel disease/intestinal dysbiosis
  • ·               Spontaneous GB contraction
  • ·               Hypertriglyceridemia
  • ·               Ursodeoxycholic acid treatment
  • ·               Severe disease or resection of the ileum (site of bile acid reabsorption)
  • ·               Cholecystectomy
  • ·               Prolonged anorexia
  • ·               Hyperadrenocorticism
  • ·               Pancreatitis
  • ·               Other nonhepatic pathology
  • ·               Transient elevation in Irish wolfhound puppies, other breeds?

 

Hepatic Causes

  • ·               Diffuse hepatocellular disease
  • ·               Cholestatic disease
  • ·               Primary portal vein hypoplasia/Microvascular dysplasia

 

 

 
EL
September 6, 2014 at 1:43 pm -

 
 
Actually that was Remo

 
 

Actually that was Remo wiht all that great info but I agree and here are some causes of bile acid elevations that are not shunt related: This is an excerpt form the upcoming book that remo and I coauthored wiht Drs Frank and Modler… The curbside guide:

http://sonopath.com/products

Nonhepatic Causes

  • ·               Inflammatory bowel disease/intestinal dysbiosis
  • ·               Spontaneous GB contraction
  • ·               Hypertriglyceridemia
  • ·               Ursodeoxycholic acid treatment
  • ·               Severe disease or resection of the ileum (site of bile acid reabsorption)
  • ·               Cholecystectomy
  • ·               Prolonged anorexia
  • ·               Hyperadrenocorticism
  • ·               Pancreatitis
  • ·               Other nonhepatic pathology
  • ·               Transient elevation in Irish wolfhound puppies, other breeds?

 

Hepatic Causes

  • ·               Diffuse hepatocellular disease
  • ·               Cholestatic disease
  • ·               Primary portal vein hypoplasia/Microvascular dysplasia

 

 

 
mjweisman
September 8, 2014 at 1:47 pm -

Thanks Remo and Eric.  Wow,

Thanks Remo and Eric.  Wow, that is great info.  When will your book be out?

mjweisman
September 8, 2014 at 1:47 pm -

Thanks Remo and Eric.  Wow,

Thanks Remo and Eric.  Wow, that is great info.  When will your book be out?

EL
September 17, 2014 at 7:12 am -

Its in final editing should

Its in final editing should be a couple of months now hard copy and downloadable format

EL
September 17, 2014 at 7:12 am -

Its in final editing should

Its in final editing should be a couple of months now hard copy and downloadable format

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