Need advice for high ALT levels

[CaponeTheYorkie]

Capone is 8 years old and has has had high liver enzyme levels for several years now. A previous vet kind of shrugged it off and said if he had a liver shunt he would of had symptoms by now and said some dogs just have higher
levels.

So, about two months ago I took him to to get his teeth cleaned and opted to do an ultrasound with it, given his past history of elevated levels. The vet tells me everything from the ultrasound seems normal (he had some sludge in his gall bladder though) and he told me to put him on a senior diet. His ALT levels are at 390 so he perscribes me Denamirin to see if that helps. I take him back after a month on the medicine and his levels are even higher 420. He now recommends a BAT and then a biopsy. I have scheduled another month of the medicine. I just need some time to do research and decide what to do now. I’m planning on doing the BAT in a month.

My question is should I now ask to be referred to a specalist? He told me for the biopsy he would need to call in a specialist to do an ultrasound and then after reviewing the results move on to the biopsy. I’m just nervous to do such an invasive precedure on my little baby. But at the same time I’ll do whatever is the best thing for him.

[Lovetodream88]

One of our other members had a yorkie that was older when diagnosed with liver shunt. I personally don’t have experience or to much knowledge of liver shunt. I know my almost 12 year old has higher liver numbers and has for awhile and she ended up having Cushings which can mess with liver numbers. I also had a friend who was feeding beneful dog food and suddenly had sky high liver numbers that went down after stopping the food. I think I would go with the specialist in my opinion. Please keep us updated.

[CaponeTheYorkie]

Thank you for your reply. I’ve been doing so much thinking and worrying about him. I’ll be doing the BAT test soon but after that I’ll ask for a referral to a specialist. I trust my vet and he always tells me what he would do if it was his dog which makes me feel more at ease but I want to make sure I make the best decision on such a serious procedure.

[ladyjane]

ALT is weird...can be elevated and then come down for no explained reason. As to a liver shunt, you can actually have an older pup with a shunt that has never had elevated enzymes...happened to my Teddy Bear. I will post his link at the end of this post in case you might want to read it. They also don't always have typical symptoms...it is all dependent on the size of the shunt and how much blood flow actually goes through the liver to be filtered.

I would do the BATs with your vet as it is a simple, inexpensive test and then go from there. I personally would not do a liver biopsy for just an elevated ALT. That is an invasive test. I would go to an internal med specialist if I was concerned. Not sure where you are in Texas but there is a great hospital here in the Houston area. There are others in other parts of the state as well. You can find an internal med specialist at: www.acvim.org I am happy to tell you about the local one if you are in this area.

As for gall bladder sludge...super common and I have never seen a problem because of it.

Here is Teddy's link:

http://www.yorkietalk.com/forums/sic...ver-shunt.html

[CaponeTheYorkie]

Wow, thank you LadyJane for your reply, after researching the forum on this topic, I have read quite a few of your post. I currently live in the Austin area and I’m from Houston. My family lives in Tennessee close to the UT campus and I’ve read that is the best place to go if my puppy does have a liver shunt, but I don’t want him to have to travel via plane a week after his surgery. I’m very open to any reputable places in Texas if there are other options. Capone’s ALT levels have slowly gone up since 2014. It just concerns me because the vet mentioned he would have seen a liver shunt in his ultrasound but he said his liver looked fine. I’m also curious about a low protein diet to make it easier on him in the meantime do you have any recommendations ?

[ladyjane]

Originally Posted by CaponeTheYorkie

Wow, thank you LadyJane for your reply, after researching the forum on this topic, I have read quite a few of your post. I currently live in the Austin area and I’m from Houston. My family lives in Tennessee close to the UT campus and I’ve read that is the best place to go if my puppy does have a liver shunt, but I don’t want him to have to travel via plane a week after his surgery. I’m very open to any reputable places in Texas if there are other options. Capone’s ALT levels have slowly gone up since 2014. It just concerns me because the vet mentioned he would have seen a liver shunt in his ultrasound but he said his liver looked fine. I’m also curious about a low protein diet to make it easier on him in the meantime do you have any recommendations ?

I personally go to Gulf Coast Vet Specialists in Houston....they are amazing! www.gcvs.com There really is no reason to travel to UT ... yes, Dr. Tobias is a leading researcher in the field, but liver shunt surgery is not all that complicated and many vets have studied there. GCVS has a surgeon who did her residency at UT. I am not familiar with specialists in the Austin area, but you could search for internal med at www.acvim.org and for surgeons at www.acvs.org

As for the comment about ultrasound not showing a shunt....they often are not seen on an ultrasound. The fact that his liver looks good is encouraging because with a shunt, they are usually smaller; but, of course, nothing is ever etched in stone.

I know lots of people would jump to a low protein diet...I have never done that nor have I been advised to with pups who had elevated ALT. ALT is a fluky enzyme ... I think if it were me, I would just do bile acids and then take it from there. I would stick with a regular diet for now if it were me until they get to the bottom of the elevated ALT.

Here is a link to a brochure that is really good. It was written by Dr. Tobias at UT. You may have already seen it ......

https://vetmed.tennessee.edu/vmc/Sma...D-Brochure.pdf

[ladyjane]

Just checking in to see if there are any updates on Capone..

[CaponeTheYorkie]

So, I just got the results from the BAT today the pre was 4.5 and post was 45 . This indicates that it is elevated. My vet said it’s not elevated enough to indicate a liver shunt that is operable. He is still pushing for the liver biospy.

At this point, I asked for a recommendation for a specialist. I was not aware you could choose your own specialist and ask your vet for a refferal. I just feel like I need a second opinion. As much as I want to do everything I can to find out what is wrong with Capone, I would hate to put him through any unnecessary surgeries.

One positive is that his ALT levels have dropped from the 500’s that they were in April to 280 so that’s something, not much but something.

[ladyjane]

The brochure I posted above has a section on MVD which is what Capone most likely has.

You can find a specialist at www.acvim.org Most of them will do a lot of testing. That is just the way of internal med vets. I personally would probably not do a biopsy .. there really isn't a "treatment" for MVD. Some people think these pups should be on low protein food and some don't. My Teddy Bear had a shunt repaired and now has MVD .. he was on a regular diet until we found out he also has IBD. Many of the liver pups have IBD. He is on Hill's Ultra ZD and doing well.

There is an interesting quote from Dr. Tobias in that brochure : "Don’t bother to ask whether lactulose, diet, yogurt, SAM-e, milk thistle, antibiotics, or anything else will be helpful to your ‘asymptomatic’ dog; the fact is, nobody knows! All we can tell you is that many of our “normal” Yorkie patients have mildly increased bile acids and live long lives without any special treatment, as long as they don’t get sick from something else."
—Tobias