Liver shunt

[Tammyh]

Hello All

I've attempted to get Bella spayed twice now but because of blood work issues that's on hold. Yesterday they did a Bile Acid test and the vet left a vm message last night confirming that the results were abnormal and it shows abnormal liver function and to give them a call to discuss the next step (she did mention ultrasound which I've read on this site is only 60% - 80% accurate). I'd like to be prepared to ask the right questions when they call back. I've seen both LS and MVD mentioned on this site when talking about this issue. What does MVD stand for and what is it? I've also seen a recommendation for a Protein C test? Any advise that can be given would be greatly appreciated. I don't know much about LS either. Bella acts completely normal and healthy, she's had no signs that anything is wrong other then the blood work results that were done as a routine before her surgery. Thanks for any help you can offer

[Ellie May]

MVD is microvascular dysplasia. It is microscopic shunting throughout the liver that is managed by diet and supplements instead of surgery.

Can you post the blood work results?
How did the vet have the bile acid test results back so quickly?
did they do it in-house?

A Protein C test in normal range suggests MVD and in abnormal range suggests a shunt. If it is normal, you can go to diet and supplements. If abnormal, the next step is scintography. If you want a positive diagnosis for MVD, a liver biopsy has to be done. This can be done while they are in there for the spay, however, there is some concern that the risks outweigh the benefits. I'm not sure there is a right or wrong answer here because there is a bit of a risk but a positive diagnosis is always good.

She is completely asymptomatic?
Circling, seizing, head pressing, drooling, staring, gastrointestinal problems, bladder problems, shaking, lethargy, depression, inappetance...

[Tammyh]

Originally Posted by Ellie May

MVD is microvascular dysplasia. It is microscopic shunting throughout the liver that is managed by diet and supplements instead of surgery.

Can you post the blood work results?
How did the vet have the bile acid test results back so quickly?
did they do it in-house?

A Protein C test in normal range suggests MVD and in abnormal range suggests a shunt. If it is normal, you can go to diet and supplements. If abnormal, the next step is scintography. If you want a positive diagnosis for MVD, a liver biopsy has to be done. This can be done while they are in there for the spay, however, there is some concern that the risks outweigh the benefits. I'm not sure there is a right or wrong answer here because there is a bit of a risk but a positive diagnosis is always good.

She is completely asymptomatic?
Circling, seizing, head pressing, drooling, staring, gastrointestinal problems, bladder problems, shaking, lethargy, depression, inappetance...

As soon as I get the bloodwork results I'll post it. I believe the test was in-house because they had the results by the end of the day, I'll ask them that when they call back.

She is completely asymptomatic, she shows no signs that anything is wrong. She's very active and playful, eating normal, no bladder problems.

Thanks for your quick response. I'll keep you posted

[Ellie May]

Originally Posted by Tammyh

As soon as I get the bloodwork results I'll post it. I believe the test was in-house because they had the results by the end of the day, I'll ask them that when they call back.

She is completely asymptomatic, she shows no signs that anything is wrong. She's very active and playful, eating normal, no bladder problems.

Thanks for your quick response. I'll keep you posted

In-house bile acids testing is pretty much a waste of money. It only goes up to 30 and 25 can be considered normal. So you wouldn't know if the result was really 30 or 250 or 275, etc. It needs to be sent to an outside lab.

[Tammyh]

Originally Posted by Ellie May

In-house bile acids testing is pretty much a waste of money. It only goes up to 30 and 25 can be considered normal. So you wouldn't know if the result was really 30 or 250 or 275, etc. It needs to be sent to an outside lab.

So if it was done in-house should I request they send the tests to an outside lab for further testing? Would they need to do another test on her? This 2nd test was done for free because they weren't confident with the first lab test results. My poor little Bella has been put through so much just trying to get spayed

[Ellie May]

Originally Posted by Tammyh

So if it was done in-house should I request they send the tests to an outside lab for further testing? Would they need to do another test on her? This 2nd test was done for free because they weren't confident with the first lab test results. My poor little Bella has been put through so much just trying to get spayed

I wouldn't be satisfied with in-house results.
She should get blood drawn, eat, then get blood drawn again in two hours and it should be sent to somewhere like Idexx or Antech. She will have to have more blood drawn. To know the exact numbers is quite important because if it is really only 30 or 40 it is likely MVD. If it is over 100 it is more likely shunt although there are tons of exceptions.

[Tammyh]

Originally Posted by Ellie May

I wouldn't be satisfied with in-house results.
She should get blood drawn, eat, then get blood drawn again in two hours and it should be sent to somewhere like Idexx or Antech. She will have to have more blood drawn. To know the exact numbers is quite important because if it is really only 30 or 40 it is likely MVD. If it is over 100 it is more likely shunt although there are tons of exceptions.

As soon as I hear back from them I'll let you know what they say. I do know that she fasted for over 12 hours, they took blood, fed her and then two hours later took more blood. I'll just have to ask if the lab work was done in-house or not. I don't even know the numbers yet because by the time I listened to my vm message they were closed so they didn't leave details. I've left a message this morning to have a vet call me. The vet that did this last test is out of town starting today so they're handing it over to another vet which I'm not too worried about because the other vet started this whole process in the first place. I guess for now I'll wait to get more details from the vet and let you know what they say.

Thanks so much for all the great info!

[Ladymom]

A twelve hour fast is not even the proper protocol for a bile acids test. Samples should be paired around a meal.

Here is an article from Dr. Center, the developer of the bile acids test:

PSVA and MVD Research Summary

Are you close to a vet school? Most vets don't see enough liver disease to have much experience diagnosing it. You can waste a lot of time and money on tests not performed correctly or worthless tests like an ultrasound.

Here are a couple more good articles for you:

Hepatic Vascular Disorders - WSAVA 2006 Congress

Portosystemic Shunts FAQ

Please post the BAT results when you get them back.

[Tammyh]

Originally Posted by Ladymom

A twelve hour fast is not even the proper protocol for a bile acids test. Samples should be paired around a meal.

Here is an article from Dr. Center, the developer of the bile acids test:

PSVA and MVD Research Summary

Are you close to a vet school? Most vets don't see enough liver disease to have much experience diagnosing it. You can waste a lot of time and money on tests not performed correctly or worthless tests like an ultrasound.

Here are a couple more good articles for you:

Hepatic Vascular Disorders - WSAVA 2006 Congress

Portosystemic Shunts FAQ

Please post the BAT results when you get them back.

They tested her 12-hr fasted and 2-hrs after eating which according to what I've read is proper protocol.

Thank you so much for the great links, I've printed them all out so I can take my time reading through them.

I really appreciate everyone's help. I'll keep you all posted.

[Ellie May]

Originally Posted by Tammyh

They tested her 12-hr fasted and 2-hrs after eating which according to what I've read is proper protocol.

Thank you so much for the great links, I've printed them all out so I can take my time reading through them.

I really appreciate everyone's help. I'll keep you all posted.

That used to be proper protocol but not anymore.
i'm not sure it would skew the results though.
It's just that that long of a fast isn't needed as far as I know.

[Ladymom]

Originally Posted by Tammyh

They tested her 12-hr fasted and 2-hrs after eating which according to what I've read is proper protocol.

It's outdated protocol. Dr. Center revised it a few years ago. This is from page 7 of Dr. Center's 2007 seminar handout:

7. Random "Fasting" Bile Acids ARE NOT reliable for RULING OUT liver dysfunction or abnormal portal circulation. Rather, you need PAIRED SAMPLES AROUND A MEAL. We no longer collect 12-hr fasting bile acids but instead collect a bile acid sample before a meal (pre-meal) and 2 hours after a meal (post-meal or postprandial)." (all emphasis was added by Dr. Center, not me)

[Tammyh]

Originally Posted by Ladymom

It's outdated protocol. Dr. Center revised it a few years ago. This is from page 7 of Dr. Center's 2007 seminar handout:

7. Random "Fasting" Bile Acids ARE NOT reliable for RULING OUT liver dysfunction or abnormal portal circulation. Rather, you need PAIRED SAMPLES AROUND A MEAL. We no longer collect 12-hr fasting bile acids but instead collect a bile acid sample before a meal (pre-meal) and 2 hours after a meal (post-meal or postprandial)." (all emphasis was added by Dr. Center, not me)

Boy there's so much information out there it's confusing, LOL!

The first Bile Acid test they did she had eaten that morning so hadn't fasted for 12 hours, it had probably been a couple of hours before the first sample was taken. I guess the first test results were confusing which is why they asked to do a 2nd test with her fasting. I'll ask for the first test results also as well as this 2nd one. I'm feeling that if they suspect LS I need to have them do a Protein C test so we can see if it could be MVD?

So when they call back what are the questions I should ask?

What the BAT results are? Was the testing done in house? Anything else?

[Tammyh]

OK, so the vet called back and he said the pre-test was 3 and the post-test (2hrs after she ate) was 91. They gave me 3 options.

1 - They said they could go ahead and do the spay with minimal drugs (could still be risky)

2 - Do the spay with minimal drugs and do a liver biopsy

3 - Refer me to a Board Certified vet that would have more experience with this then they do.

I'm going with option 3. In some of the literature I read it said that dogs with LS will usually be over 100. Bella is close to that but I'm still hopeful that it's not LS, especially since she acts completely healthy and has no signs of LS. Another said that dogs with PSVA often have at least one bile acid value >200.

I guess I just need to get another vet with experience dealing with this issue and go from there. If anyone has any other suggestions I'd love to hear from you. Thank you all for your input. I'll keep you posted.

[Ellie May]

I definitely agree with option 3 but it looks hopeful that it's MVD.
They must have sent it out to a lab because the postprandial was above 30.
Ninety-five percent of dogs with a shunt have elevated preprandial bile acids, so it looks hopeful to me.

I would wait and talk to the internists about the spay but it really isn't terribly risky if done right.

[TLC]

Roxy's first BAT was pre 43 and post 100.9
She really has such minimal symptoms: just some blahness to her

We went to a Internal Medicine Specialist. Did a full blood panel, urinanalysis, coagulation test and we did do a u/s (which showed a normal size and normal shaped liver). Roxy was already spayed at the time and also had been thru 2 LP surgeries and 1 dental plus her spay, I figured that was enough for her little body, plus they wanted about $3000 for the liver biopsy.
In the end, after everything was normal (except the BAT) her Vet and the Specialist are leaning towards MVD.

Anyway, she is doing well on a special diet and supplements