Possible Shunt/Liver Disease

[ladyjane]

I am going to once again recommend that vet hospital. At this point, might be good to get a second opinion.

I would be freaked by exploratory as well...BUT I would not want to wait too long. I have seen people on YT hold off and hold off until their dogs were inoperable after throwing more shunts.

I am so sorry you are having to deal with this. If it is a shunt, it is fixable. I know surgery is scary but these things are done all of the time on even smaller pups.

[Ellie May]

OP: Is there a reason to believe that the IMS isn't recommening the best possible route? You could get a second opinion. Chances are that with bile acids this high still after a month, diagnostics and/or surgery will be needed. If it's an intrahepatic shunt (inside the liver instead of outside - not as common in Yorkies), they won't see it when exploring.

Find a vet that you trust and help them guide you to an IMS that you trust and do what they feel is best.

If I am shelling out money for a specialist, they will be ACVIM/ACVS. It is also important to me to know how successful previous LS surgeries have been for the specialist doing it (in case they decide that's the problem). Not all surgeons are alike in their ability to correct these issues.

[ladyjane]

Originally Posted by Ellie May

OP: Is there a reason to believe that the IMS isn't recommening the best possible route? You could get a second opinion. Chances are that with bile acids this high still after a month, diagnostics and/or surgery will be needed. If it's an intrahepatic shunt (inside the liver instead of outside - not as common in Yorkies), they won't see it when exploring.

Find a vet that you trust and help them guide you to an IMS that you trust and do what they feel is best.

If I am shelling out money for a specialist, they will be ACVIM/ACVS. It is also important to me to know how successful previous LS surgeries have been for the specialist doing it (in case they decide that's the problem). Not all surgeons are alike in their ability to correct these issues.

[kjc]

Originally Posted by ladyjane

I am going to once again recommend that vet hospital. At this point, might be good to get a second opinion.

I would be freaked by exploratory as well...BUT I would not want to wait too long. I have seen people on YT hold off and hold off until their dogs were inoperable after throwing more shunts.

I am so sorry you are having to deal with this. If it is a shunt, it is fixable. I know surgery is scary but these things are done all of the time on even smaller pups.

I have seen people on YT who had the surgery done right away and their dogs still threw multiple shunts. It happens, depending on the dog, and the issues that each individual dog has.

[aproctor]

My Vet spoke to Dr Myers who works at a Vet Hospital which has BC surgeons. If this were a shunt then why does she look like a happy, healthy dog who has had NO symptoms at all for almost 6 weeks?
I know the BAT shows that there is an issue but is it possible that it was a toxin or that she was getting too much people food treats from my mother?
I am going to call him again tomorrow to discuss the diet and order the L/D and Denemarin and when I do I am going to ask him some more questions.

I know some of you will not agree but for now we are going to try the diet and have her blood work and Bile Acids re-tested again in 6 weeks and then if they are not better we will explore one of the other procedures.

I know you said some have waited and it has disastrous results but I have also heard and read many stories where changing the diet was a success and completely turned the numbers around so I want to give Lucy that chance before we consider some huge procedure that will be hard on her and possibly not necessary.

I thank you all for your guidance, support and your opinions and I am very appreciative for ALL of you!!
Keep up the support as I know I will need it and I will keep you updated on how she is doing!

[ladyjane]

Originally Posted by kjc

I have seen people on YT who had the surgery done right away and their dogs still threw multiple shunts. It happens, depending on the dog, and the issues that each individual dog has.

Please show me the research that states this is a common thing. I have never heard of anything like that. Perhaps it is possible..............but..... Am I not correct in saying that putting off surgery for a long time puts a dog at risk for multiple shunts?

Is it not true that it is more likely to happen to a dog who has NOT had the surgery? I mean, seriously, are you recommending AGAINST liver shunt surgery? What do you suggest...that an owner ignore a shunt and not do surgery because the dog might throw more shunts? Seriously?

[ladyjane]

I am quite sure as I have been since I PMd you that you are following another lay person's advice. That, of course, is your prerogative. I hope that works better for you than it has others.

I will pray for Lucy and hope that all goes well for her.

[aproctor]

Originally Posted by ladyjane

I am quite sure as I have been since I PMd you that you are following another lay person's advice. That, of course, is your prerogative. I hope that works better for you than it has others.

I will pray for Lucy and hope that all goes well for her.

Thank you for your prayers!!! Regardless of who I am or am not speaking to I have taken what everyone has said to heart and I am doing what I feel is best at this point.
Have you ever came upon a case like this where the blood work came out so well but the BAT came out elevated AND the dog had NO symptoms for several weeks?
All cases are different and if I felt that I should continue testing then I would but I just don't think at this point I am going to go any further. I may ask for an x-ray because that has never been done.

[ladyjane]

You have already been advised by two vets that further testing should be done. Personally, I would be at a third vet...one that is board certified as I said. Then, I would be in a better place in terms of a decision. That's just me.

As to your question about whether I have ever seen a case like hers...... I am not a vet!! I cannot say I have seen it....or not. No one can do that online! No one here has seen your dog ... has the qualifications to diagnose or compare to other dogs. I have not advised you to do ANY testing...I have advised you to go to professionals with board certification. I don't go to my vet and tell them what tests and/or xrays to do. I might ask them if something is appropriate...but I seek out the best and trust them to explain why or why not to do them.

I don't sit online and attempt to diagnose people's pups no more than I try to diagnose my own. I go to professionals for that. I pay a lot of money, yes, but that is in my mind the appropriate thing to do for a living being that is in my care. They did not choose to live with me...I chose them and I offer them the same treatment I would give to myself....and always provided for my son. I just don't try to diagnose...I am a retired RN and know a lot of medical stuff...but I still don't try to guess what my dogs have or other peoples' dogs either. It is simply stepping outside my boundaries. I seek out good vets and trust them with my pups.

[107barney]

Originally Posted by aproctor

Thank you for your prayers!!! Regardless of who I am or am not speaking to I have taken what everyone has said to heart and I am doing what I feel is best at this point.
Have you ever came upon a case like this where the blood work came out so well but the BAT came out elevated AND the dog had NO symptoms for several weeks?
All cases are different and if I felt that I should continue testing then I would but I just don't think at this point I am going to go any further. I may ask for an x-ray because that has never been done.

You are doing what you feel is best, but you are not doing what Dr. Myers thought was best. I manage my dog with diet alone, but she does NOT have a single shunt, was much older at diagnosis, and her FIRST plan was dietary management and not surgery. Please do not use Daisy's case, what limited info you know of it, to compare to Lucy for her sake. Best wishes.

[Ellie May]

My dog had near normal enzymes when we realized she had a liver problem. Her bile acids (post) were high. She had no symptoms on a daily bases. Looked healthy.

Medical management was approved as appropriate for her by her IMS. She felt that Ellie was in no danger and that we should watch what drugs are given very carefully, give Denosyl if we felt like it, etc. Her regular vet agreed that she did not appear to be in danger. Her preprandial bile acids were only slightly elevated once. She had a liver biopsy. So while, yes, her bile acids were up and she appeared to be totally healthy, her IMS felt that she was okay. That can't be said for Lucy, unfortunately.

So if the bile acids go down in 6 weeks, are you supposed to assume that they are going to stay down or do you keep retesting? By the time put all that money into continuously testing bile acids, you could have a diagnosis... If they do come down some and it's decided to retest in 6 months, what happens if they went back up and were elevated all that time (all the while the IMS thinks more needs to be done).

L/D and Denamarin are not wrong, but they are probably wrong for Lucy if the IMS has recommended otherwise. They don't recommend invasive procedures for no reason. I'm confused why this protocol wasn't started last month. It also doesn't seem that the specialist has done anything more than a regular vet could have so far, so why dish out the money for a specialist and not do what they suggest?

[Ellie May]

Originally Posted by aproctor

Thank you for your prayers!!! Regardless of who I am or am not speaking to I have taken what everyone has said to heart and I am doing what I feel is best at this point.
Have you ever came upon a case like this where the blood work came out so well but the BAT came out elevated AND the dog had NO symptoms for several weeks?
All cases are different and if I felt that I should continue testing then I would but I just don't think at this point I am going to go any further. I may ask for an x-ray because that has never been done.

I wanted to come back to this post for a minute.

It is, of course, no business of mine who you are and are not privately talking to. But for Lucy's sake, I do want to say this.

Nobody on YorkieTalk has publicly stated that they hold their DVM; therefore, nobody here should be attempting to diagnose your pet or provide a treatment plan. First, even a licensed veterinarian doesn't usually do this without examining the animal. Second, it is attempting to practice veterinary medicine without a license and isn't exactly the most legal thing to do.

There are vet techs, vet assistants, and pre-vets here. These people do not have their DVM and it is not okay to trust them (me included) with your pup's medical care (diagnosis and treatment plan).

There are many owners and breeders here who know a heck of a lot about dog health. They are not vets and it is not okay to trust them with your pup's medical care.

In the end, it is your dog that will suffer if one of us gives you bad advice. There have been quite a few cases of liver issues on YT over the years. They have not all been managed correctly. In fact, there isn't even a diagnosis here, so how do you know what you are managing...

My dog could have been stuck on a very restricted protein diet and Denamarin too. That, however, was not indicated "for her" long term. A little bit of testing made the decision clear that such a restriction long-term was not needed. There is no protocol that fits all seemingly healthy dogs with high bile acids. There is nobody on YT that knows more about this than an internal medicine specialist. There is a ton of information all over YT about veterinary medicine that is just plain wrong. I mention some of the stuff to my vet and we have a good laugh over it because it's not based in science at all. Just because somebody online says something, that doesn't make it so.

Listen to Lucy's doctors and talk to them about your concerns. If you are going to hand them a chunk of cash for a surgery, then I do suggest that it is somebody with the right credentials.

[kjc]

Originally Posted by ladyjane

Please show me the research that states this is a common thing. I have never heard of anything like that. Perhaps it is possible..............but..... Am I not correct in saying that putting off surgery for a long time puts a dog at risk for multiple shunts?

I didn't say it was 'common', I said I saw people on YT who have had to get 2nd LS surgeries for their dogs.

http://www.yorkietalk.com/forums/yorkie-health-diet/228696-food-after-liver-shunt.html

http://www.yorkietalk.com/forums/sick-injured-emergencies-talk/52419-second-liver-shunt-my-indy.html

http://www.yorkietalk.com/forums/2283685-post9.html

The best time for LS surgery is when the pup is less than one year of age. Older dogs, such as Lucy, 3 Years old, or my Tink, who was diagnosed at 3 years old are already at a higher risk from not being diagnosed and surgically repaired as puppies.

Originally Posted by ladyjane

Is it not true that it is more likely to happen to a dog who has NOT had the surgery? I mean, seriously, are you recommending AGAINST liver shunt surgery? What do you suggest...that an owner ignore a shunt and not do surgery because the dog might throw more shunts? Seriously?

I don't know, I haven't seen any statistics. I think it happens at the genetic level, and the gene or genes that control the formation of the liver shunt (which is present in all dogs at birth) is damaged and malfunctions. No, I don't think a shunt should be ignored. But I do think owners need to be aware that surgery can't always correct the problem, and that the liver can produce more shunts after being repaired. And owners also need to be aware that sometimes LS surgery does work.

Acquired Shunts occur when the pressure in the liver becomes too great, and rather than have the liver burst, it produces shunting to relieve the pressure. When a shunt is repaired, it can cause more pressure in the liver, and the pressure is measured during LS surgery to determine what the liver can handle, so the decision is then made as to how much to close off the shunt, or to only partially close it off. So I guess it again depends on the exact problem of each individual dog, whether multiple shunting is more likely to occur in dogs that have shunts that are or are not repaired.

The liver produces and stores bile for the gall bladder, and if the bile gets too thick (called sludge) then this can also increase the pressure in the liver and cause it to throw multiple acquired shunts. These are different than Congenital Liver Shunts, they are smaller and more branched in appearance. (I suspect that this is Tink's problem as her surgeon prescribed Ursodial, which is supposed to thin the bile out.)

Originally Posted by aproctor

I did call to make sure Dr Myers was there and the tech I spoke to was very nice and she understood my anxiousness and said that she was in today and that she was going to review and speak with my Vet as soon as she could.

A couple of hours later my Vet did call and I just got off the phone with him and the summary of what he said is this: Because of the BAT's coming back elevated it indicates that there is still inflammation due to either hepatitis or possibly a shunt. Because of her not having any symptoms, and her blood tests being as good as they are they gave me these options:

Exploratory surgery/Biopsy (If there is a shunt they would repair it and if not they would just get the biopsy)
*Dr Myers feels this is the best route to go(to get a biopsy) because if there is a bleed they can control it and if there is a shunt then she would only end up with one surgery.
Laparoscopic biopsy
Ultrasound guided biopsy
OR
L/D Diet and Denemarin (sp?) and testing again in 6 weeks to see if her BAT's improve.

As of this moment my head is spinning and I need to talk to my hubby, I ordered the L/D and Denamarin because either way I think to start her on this diet would be best and then we will make our decision from there.

It just freaks me out to think of her under the knife because she is sooo little!
I think it would be different if she actually seemed sick or had any symptoms at all then I would not hesitate.
If we do anything at all I think we would do an ultrasound because I don't want to have her go through any type of surgery that may or may not be necessary.

As your dog is not a puppy under one year old, I don't believe 6 weeks will make any difference in her diagnosis or prognosis, unless the diet and meds (as also recommended by the vet) work, and her BAT returns to normal. I'm sure they would have pushed the surgery option more had she appeared ill in any way during her exam.

Many dogs with Liver Shunt do not show any symptoms. They are frequently suspected of LS when pre-op bloodwork is done just prior to having a spay or neuter done, and the liver enzymes results are elevated.

I am just wondering if her BAT result isn't more indicative of a gall bladder issue, as the involuntary contraction of the gall bladder in the middle of the night (common in small breeds) can cause the preprandial result to be elevated higher than the postprandial result.

An xray may be a good option, as it can show the vet the size of the liver. The liver in most dogs with Liver Shunt tends to be undersized, and appears small in comparison with the body size on the xray.

The high ALT on her earlier bloodwork is 3x higher than what is seen in most dogs with LS. The higher elevations are more frequently associated with some form of toxicity. The fact that this number came down so quickly makes me think she has a fairly efficient liver. When Tink ingested an unknown amount of grease, it took her liver over 6 months for the ALT to start decreasing. Certain drugs can affect the BAT, so I am assuming certain toxins can affect it too.

I would definitely discuss everything with your vet. It is accepted protocol to make diet changes and redo the BAT in 2-3 months, when abnormal results are obtained the first time.

I would also ask your vet to contact the University of Tennesee. Vets there are more than willing to discuss cases over the phone to help with diagnoses. My vets contacted them during Tink's treatment to be sure nothing was missed or overlooked.

[ladyjane]

Originally Posted by Ellie May

I wanted to come back to this post for a minute.

It is, of course, no business of mine who you are and are not privately talking to. But for Lucy's sake, I do want to say this.

Nobody on YorkieTalk has publicly stated that they hold their DVM; therefore, nobody here should be attempting to diagnose your pet or provide a treatment plan. First, even a licensed veterinarian doesn't usually do this without examining the animal. Second, it is attempting to practice veterinary medicine without a license and isn't exactly the most legal thing to do.

There are vet techs, vet assistants, and pre-vets here. These people do not have their DVM and it is not okay to trust them (me included) with your pup's medical care (diagnosis and treatment plan).

There are many owners and breeders here who know a heck of a lot about dog health. They are not vets and it is not okay to trust them with your pup's medical care.

In the end, it is your dog that will suffer if one of us gives you bad advice. There have been quite a few cases of liver issues on YT over the years. They have not all been managed correctly. In fact, there isn't even a diagnosis here, so how do you know what you are managing...

My dog could have been stuck on a very restricted protein diet and Denamarin too. That, however, was not indicated "for her" long term. A little bit of testing made the decision clear that such a restriction long-term was not needed. There is no protocol that fits all seemingly healthy dogs with high bile acids. There is nobody on YT that knows more about this than an internal medicine specialist. There is a ton of information all over YT about veterinary medicine that is just plain wrong. I mention some of the stuff to my vet and we have a good laugh over it because it's not based in science at all. Just because somebody online says something, that doesn't make it so.

Listen to Lucy's doctors and talk to them about your concerns. If you are going to hand them a chunk of cash for a surgery, then I do suggest that it is somebody with the right credentials.

And now, I am off to raise money for the yorkies in need that are in the care of YHR.

Wishing everyone a nice day.

[aproctor]

Originally Posted by Ellie May

My dog had near normal enzymes when we realized she had a liver problem. Her bile acids (post) were high. She had no symptoms on a daily bases. Looked healthy.

Medical management was approved as appropriate for her by her IMS. She felt that Ellie was in no danger and that we should watch what drugs are given very carefully, give Denosyl if we felt like it, etc. Her regular vet agreed that she did not appear to be in danger. Her preprandial bile acids were only slightly elevated once. She had a liver biopsy. So while, yes, her bile acids were up and she appeared to be totally healthy, her IMS felt that she was okay. That can't be said for Lucy, unfortunately.

So if the bile acids go down in 6 weeks, are you supposed to assume that they are going to stay down or do you keep retesting? By the time put all that money into continuously testing bile acids, you could have a diagnosis... If they do come down some and it's decided to retest in 6 months, what happens if they went back up and were elevated all that time (all the while the IMS thinks more needs to be done).

L/D and Denamarin are not wrong, but they are probably wrong for Lucy if the IMS has recommended otherwise. They don't recommend invasive procedures for no reason. I'm confused why this protocol wasn't started last month. It also doesn't seem that the specialist has done anything more than a regular vet could have so far, so why dish out the money for a specialist and not do what they suggest?

No offense but I think you all read what you wanted to read but skipped the part about what the IMS said:
Exploratory surgery/Biopsy (If there is a shunt they would repair it and if not they would just get the biopsy)
*Dr Myers feels this is the best route to go because if there is a bleed they can control it and if there is a shunt then she would only end up with one surgery. *****When I said Dr Myers feels this is the best route - I meant between any of the PROCEDURES not the best route to take all together
Laparoscopic biopsy
Ultrasound guided biopsy
OR
L/D Diet and Denemarin (sp?) and testing again in 6 weeks to see if her BAT's improve.

I am going to have a consult with my Vet today and then I am also going to ask to speak with Dr Myers myself later today after I talk to my Vet.

When I talked to him he didn't say "Dr Myers said you should do one of these procedures" he just told me what my options were just as they told me those options before and both times they said I can wait because of her specific case where the enzymes have gone down they don't think there is a rush to do any of the procedures.
Maybe I should have made that more clear when I wrote my first comment regarding this but I had just gotten off the phone with the Vet and was just trying to process the information again.

I also want to clear this up:
**When Lucy was first sick I went to the closest Emergency Vet I could find to help her which is the Vet that ended up doing the FIRST blood tests and BAT.
**Then I went to Blue Pearl to see Dr Myers who told me after examining her and doing a repeat blood test (NO BAT) which came out normal that if it was HER dog she would wait and repeat the tests in 4-6 weeks because she felt Lucy was in NO IMMEDIATE DANGER!
**During the waiting period I researched and found a different Vet that I was more comfortable with for Lucy because I felt the first place I went with her was not a good fit as I think they didn't deal with many small dogs. So, then I found my new Vet and after having a consultation with TWO Vets at the new clinic I felt much more comfortable with them and so I called BP and asked if it was a problem to have the BAT's repeated at the new Vets clinic and they said it was not a problem at all. So, I took Lucy there for the THIRD BT and SECOND BAT. The Vet also examined her and found her to be in very good shape - the physical exam came out perfect (and also when DR Myers saw her)!
**After getting the results my Vet called Dr Myers at BP and discussed it with her and that is now where we are at ABOVE........

I am not comparing my Lucy to anyone else and I want and will do what is best for her. The IMS has never to my knowledge said or recommended that I should do one of the procedures so I think that is where we all got a little confused.

I am 100% comfortable with my new Vet and 100% comfortable with Dr Myers at Blue Pearl (which is a hospital that has BC surgeons). I will continue to consult with them and do what they think is best for Lucy and I will update you on how she is doing.

Again, I thank ALL of you for your support and I appreciate all of the input that I have gotten.