Liver Disease 1 Flashcards by Marin Low

ALP is a ______ enzyme and ALT is a _____ enzyme

cholestatic

hepatocellular damage

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which liver enzyme can become increased via steroids or phenobarb in dogs?

ALP

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why is ALP high in young animals?

bone growth

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why is an increase ALP or ALT of ANY degree in a cat significant

because the half life is so short, so if it’s above reference range, it is something to worry about

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what are the markers of liver dysfunction and what is important to remember about them?

hyperbilirubinemia
hyppcholesterolemia
low BUN
hypoglycemia
hypoalbuminemia

**these are neither sensitive nor specific for liver dysfunction, aka, for these to happen the liver has to be REALLY sick

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the ‘best’ liver function test we have is _____ , and it is performed via…

bile acid test

12h fasted preserum bile acid, then feed high calorie meal, then 2h later post serum bile acid

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a bile acids test is not sensitive but is specific for liver dysfunction, however there is one exception which is:….

it is sensitive for portosystemic shunts

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why does liver disease cause a decreased USG

because the kidney filters all the crap that the liver could not break down and all this crap brings water with it!

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in _____ bilirubinuria is ALWAYS significant, but in _____ it can be normal

cats NEVER NORMAL

dogs can be normal

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what are some CBC findings that are consistent with liver disease

anemia: chronic disease, GI bleeding, coagulopathy

microcytosis

leukocytosis

thrombocytopenia

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large breed dogs get ______ PSS and small breeds get _____ PSS

large breeds get intrahepatic

small breeds get extrahepatic

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what did serge refer to as “portosystemic shunt’s nice cousin”?

portal vein hypoplasia (microvascular dysplasia_

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with extrahepatic PSS, it is usually _______ that shunts blood to the azygous vein or caudal vena cava instead of the liver

one vessel

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a 5 month old yorkie named Lady Snugglebutt von Wigglepaws presents for: PUPD, ataxia, and “weird” behavior per the owner, like random barking and growling. Owner says it’s really bad after she eats food. Number one ddx? what diagnostics do you wanna do?

EHPSS

CBC: microcytic normochromic NR anemia
Chem: decreased BUN, low albumin, hypoglycemia, low cholesterol, high ALT and ALP
UA: isosthenuria, urate crystals
Bile acids: if over 100, this is EHPSS, if lower than 100, microvascular dysplasia

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true or false: small breeds are prone to hypoglycemia

true

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Lady Snugglebutt von Wigglepaws is diagnosed with an EHPSS. what treatment option is best for her?

surgery to close the shunt

medical treatment: liver food, metronidazole, lactulose, ompeprazole **BUT this is not recommended as sole therapy, it’s better done pre surgery rather than instead of surgery. if the client has no money you can go with this option

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how do clinical signs of portal vein hypoplasia differ from PSS?

dogs are usually the same breeds and same age, but they usually have no clinical signs and no consequences!

might have a high ALT and ALP

bile acids will be below 100

dont need treatment

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hepatic lipidosis os secondary to

catabolism in anorexia

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hepatic lipidosis can happen in _____ in cats and it does not have to be caused by full anorexia, it can be _______

days

decreased appetite over several days

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the two causes of hepatic lipidosis are

primary: complete loss of appetite like someone forgets to feed the cat on vacatrion

secondary: something else makes them not want to eat OR things that cause insulin resistance like pancreatitis, GI disease, diabetes, etc

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Countess Fuzzypaws McWhiskerface the cat presents for vomiting, yellow skin, and lethargy. The owners said they were out of town for the weekend and their brother was supposed to come feed the cat but forgot. Based on your number 1 ddx, what would you expect to see on your diagnostic test results and how could you make a confirmatory diagnosis?

CBC: non regenerative anemia
chem: high ALP and ALT, high bilirubin, hypokalemia and hypophosphatemia sometimes

PT/PTT: can be increased

rads: hepatomegaly
ultrasound: bright, rounded liver

FNA can rule out lymphoma

hepatic biopsy would give diagnosis but this is often not done

Countess Fuzzypaws McWhiskerface is diagnosed presumptivley with hepatic lipidosis. What treatment will you offer?

NURTITION RIGHT AWAY!!!!

do not rely on appetite stimulants!!!

NG tube in hospital, esophageal tube when more stable for home if needed

start slow with a high caloric diet and give 1/4 RER and divide that into 4-6 feedings a day

other meds into the tube: anti nasuea meds, vitamin K, appetite stimulants, potassium, SAMe, etc

Countess Fuzzypaws McWhiskerface is hispitalized and you place an NG tube and give her slow feedings frquently with Hills recovery. What things would you like to monitor?

PCV, liver values, phosphorus, potassium, return of appetite and energy

true or false: it can take a cat weeks to recover from hepatic lipidosis

true

the ultimate state of liver dysfunction is

hepatoencephalopathy: trash in circulation causes neurologic signs

the 3 broad categories of feline cholangitis are

lymphocytic neurotrphilic chronic

compare and contrast lymphoctyic feline cholangitis and neutrophilic feline cholangitis

neutrophilic: more common, older cats, much more sick, anorexic, icteric, fever, globulins normal, neutrophilic inflammation, ascites not common, IBD and pancreatitis possible, - cause is ascending bacteria - treatment is ANTIBIOTICs lymphocytic: usually younger cats, not as sick, might be icteric, elevated globulins, hyperechoic liver, ascites possible, treatment is IMMUNOSUPPRESSION

a 12 yo DSH cat named Jellybean presents to the emergency room with a fever, icterus, anorexia, and a high ALT & ALP.. When you read the history for this cat you see that he is also suspect to have IBD. based on your top ddx, what treatment do you need to initiate for jellybean?

neutrophilic cholangitis nutrition clavamox + metronidazole or enrofloxacin until culture, treat for 6-8 weeks SAMe, vitamin K, pain meds prognosis good but recurrance common definitive dx is a biopsy

a 2 yo Persian cat named Shart Nugget presents for routine wellness exam and vaccines. the owner says he is eating more than normal recently and maybe seems a little bit lethargic over the past few months, but otherwise seems normal. On PE he seems to have a little of of ascites and you think his skin looks a little bit jaundiced. you run blood work to find a high ALT and ALPT, elevated globulins, and a lymphopenia. based on your top ddx what treatment does Shart Nugget need?

lymphocytic cholangitis definitive dx is a biopsy immunosuppressive dose of prednisolone (2mg/kg) and ursidiol prognosis is guarded

what is triaditis? why does serge hate it?

concurrent inflammation of the liver, pancreas, and GI. there isnt a lot of evidence for it, and only 30% seem to get it. IBD and cholangitis seems to be together, but the pancreas part is less clear in research

canine chronic hepatitis is _________

a condition associated with progressive hepatic inury, hepatocyte apoptosis and necrosis, followed by fibrosis and possibly failure

list some possible causes of canine chronic hepatitis?

idiopathic, drugs and toxins leading to acute liver injury, infectious agents, copper accumulation, immune mediated

never ignored an elevated _____ in a dog

ALT

what are the clinical signs of chronic hepatitis in dogs?

often nothing until its too late, no signs until damage has progressed: hyporexia, lethargy, icterus, ascites, PUPD, vomiting, diarrhea, etc it is usually subclinical but can show changes on biochem

a 6 yo yellow lab named Libby presents for routine dental and on the pre-anesthetic bloodwork you find an increased ALT. the dog seems completely healthy on PE. What is the most approrpiate next step?

this dog could have chronic hepatitis... do imaging and then a biopsy ( a liver aspirate is not good enough) other tests like bile acids are not sensitive enough

NEVER ignore an elevated ALT in a dog, especially in these breeds:

cocker spaniel, doberman, lab

6 yo yellow lab named Libby, who you think could have chronic hepatitis, gets a liver biopsy. The owner asks you how this disease is treated. What treatment does Libby need?

it depends on the cause... immunomodulatory meds like prednisone hepatoprotective drugs like Ursidiol, SAMe, milk thistle nutrition, anti nauseua drugs copper chelation

what is SAMe?

an anti oxidant that REALLY WORKS according to serge ***must give on empty stomach

SAMe and milk thistle combined (Denamarin) is a

antioxidant

what is ursidiol?

stimulates gallbladder contractions and gets rid of the nasty bile acids

milk thistle by itself is called

silymarin

what is N-acetyl cystine

its a liver med with cytoprotective and anti inflammatory effects, most often indicated for acute liver toxicites

1/3 of dogs with chronic hepatitis have an issue with

copper accumulation aka copper hepatopathy liver accumulates copper and for some reason it can't eliminate it, and it destroys the liver

why is treatment of of copper accumulation and storage disease often unsuccessful

because the treatment, D-penicillamine, tastes awful and dogs hate it, it can cause vomiting, diarrhea, and anorexia. you also need a second liver biopsy to know if the treatment is working. also a low copper diet (but this has to be after the copper is reduced in the liver)

if copper is >1000ug/g DW, this means.... if copper is <1000ug/g DW, this means...

the dog has copper associated chronic hepatitis-->D-penicillamine, low copper diet, biopsy in 6 months the dog has either idiopathic or immune mediated chronic hepatitis-->consider immunotherapy, biopsy in 6 months

gold standard patient monitoring of all chronic hepatitis includes...

repeat biopsy at 6 months to document if the liver is improving serial evaluation of liver values, mostly ALT, monthly for copper storage hepatitis and if on pred for immune-mediated hepatitis, at 2 weeks and then monthly

what is vacuolar hepatopathy?

a hepatic lesion characterized by hepatic vacuolization, usually filled with either fat, glycogen, or water. often secondary to diabetes mellitus, cushings, or chronic steroid use "steroid hepatopathy" or "endocrine liver" are other terms commonly used for this disease

does vacuolar hepatopathy require treatment?

no it doesn't cause any major issues but maybe an ALP elevation, EXCEPT in scotties, this will kill them

nodular hyperplasia is a common benign lesion in older dogs. what signifigance does this have?

it can look like neoplasia on imaging it can cause an increased ALP (this is why people say you can ignore an ALP increase in dogs)

if ALT is higher than ALP, then you'll likely need ______ to get a full diagnosis

liver biopsy