Elevated liver enzymes...need advice!

[ladyjane]

I have had three pups with bladder stones over the years and every one of them had surgery. I did not think that they ever left them because they can cause severe problems.

My Teddy Bear had bladder stones recently and they blocked his urethra...he ended up with a tiny rupture in his bladder that thankfully actually repaired itself. Anyway...he was taken to surgery and the vet was suspect of a shunt and did an exploratory and found one large portosystemic shunt. They called me and I gave the ok to repair it. He is doing fine....just went for his one month appointment and blood work, including BATs.
I have had Teddy Bear for 7 years and he never had a symptom at all...and all of his labs were within normal limits over the years. I test my pups yearly, sometimes more often. So, this was a shock to me. I did not realize that it is actually not surprising at all to find this.

As for gall bladder sludge, I have had many pups with it which were picked up on ultrasound. One specialist told me it is common and usually not a concern. I have two right now who have it and it really is not causing any issues at all. The interists are not concerned. I suppose it makes a difference what else is going on with the pup.

Hope all goes well with your pup whatever course you decide to take. Will keep you and Tokie in my thoughts and prayers.

[LuvTaycieGirl]

Keeping you both in my prayers!

[kjc]

Some links:

The diagnostic approach to asymptomatic dogs with elevated liver enzyme activities - Veterinary Medicine=

http://radfileshare.cvm.ncsu.edu/RIS...20mucocele.pdf

An update on gallbladder mucoceles in dogs - Veterinary Medicine=

[ladyjane]

Curious as to why they are doing a scintigraphy? If they feel that surgery is needed for the bladder stones, why not do that and then explore and check the liver? They could repair a shunt if there and if not, then biopsy the liver. Seems to me that would save dollars???

Of course they would probably biopsy the liver anyway. Teddy Bear had one, but they are holding the sample until the BAT results come in. To send that out is a tad bit pricey and they said it really is not necessary if his BATs are ok.

[tokipoki]

I appreciate all of your thoughts and prayers. Toki is in for her scintigraphy this morning and I'll be discussing options with the vet tomorrow when she is discharged.

Originally Posted by kjc

Some links:

The diagnostic approach to asymptomatic dogs with elevated liver enzyme activities - Veterinary Medicine=

http://radfileshare.cvm.ncsu.edu/RIS...20mucocele.pdf

An update on gallbladder mucoceles in dogs - Veterinary Medicine=

Thank you so much for the articles. They did a more complete blood workup yesterday and didn't mention anything about suspecting gallbladder issues but I will certainly mention it, especially if it turns out that she doesn't have a shunt.

Originally Posted by ladyjane

Curious as to why they are doing a scintigraphy? If they feel that surgery is needed for the bladder stones, why not do that and then explore and check the liver? They could repair a shunt if there and if not, then biopsy the liver. Seems to me that would save dollars???

Of course they would probably biopsy the liver anyway. Teddy Bear had one, but they are holding the sample until the BAT results come in. To send that out is a tad bit pricey and they said it really is not necessary if his BATs are ok.

The scintigraphy seemed like it would be a much cheaper option (and much less invasive) than exploratory surgery although if it turns out that Toki does indeed have a shunt that must be surgically repaired anyway, then the cost of the scintigraphy will just be one that I have to eat. I keep re-reading your thread about Teddy Bear. That is incredible that they didn't detect a shunt until he was ~8 years old and that he was pretty much asymptomatic. I'm so glad to hear that he is doing well and hope that his BATs come back normal. When my first vet mentioned the bladder stones, I honestly didn't know much about how they were treated or what they were caused by. I am going to go ahead and ask about having them surgically removed so that they can figure out the type of stone and also perform a biopsy on the liver.

YT is amazing! I really do appreciate you ladies sharing your experiences with your own pups...you really can't find this type of support and guidance anywhere else

[ladyjane]

Oh, don't get me wrong...I am not a fan of exploratory surgery...someone would have to do a LOT of convincing to get me to agree to that. BUT....If a pup is already being operated on and the stones look to be urates, it makes sense to me to do it. I just thought that you had said that the university vets said that bladder stone surgery was needed here. That is why I asked about the scintigraphy. More out of curiosity about why they suggested that.
HOpefully all is going to turn out very well and won't end up costing a small fortune as it actually did in my case because of the way it came down. I was in the EC prior to going to the specialist and when all was said and done I had spent right at $8,000

[tokipoki]

Originally Posted by ladyjane

Oh, don't get me wrong...I am not a fan of exploratory surgery...someone would have to do a LOT of convincing to get me to agree to that. BUT....If a pup is already being operated on and the stones look to be urates, it makes sense to me to do it. I just thought that you had said that the university vets said that bladder stone surgery was needed here. That is why I asked about the scintigraphy. More out of curiosity about why they suggested that.
HOpefully all is going to turn out very well and won't end up costing a small fortune as it actually did in my case because of the way it came down. I was in the EC prior to going to the specialist and when all was said and done I had spent right at $8,000

Ah, I see what you're saying. I'm not entirely sure what exploratory surgery entails (kinda just looking around the area of interest for a problem that you cannot find through other tests?) but it sounds like a more expensive option than just paying $250 for them to rule out an external shunt through scintigraphy even though the exploratory surgery could be done at the same time as her stone removal. They drew out a flowchart of how we narrow down and diagnose the issues at hand and they actually never even mentioned performing exploratory surgery while she was under for the bladder stones. They recommended a liver biopsy at the same time but not the exploratory surgery.

How it was presented to me, the results of the scint. seemed to be what would determine the following course of action (a "yes" reading would lead to CT scan and most definitely surgical interventions to treat a shunt which they didn't discuss with me at the time. A "no" reading would lead to deciding how to medically treat). If Toki didn't have the bladder stones and they determined that there was no shunt, I don't know that I would necessarily get a tissue sample ASAP, just to avoid putting her under. We'd probably just treat her as if she did have MVD through diet and medically etc.

By the way, I got a call this afternoon about Toki's scintigraphy results and they did not find a liver shunt which is good news but of course leaves MVD as the most likely issue. I'll post more tomorrow afternoon after Toki is discharged and I get more information.

[ladyjane]

Originally Posted by tokipoki

Ah, I see what you're saying. I'm not entirely sure what exploratory surgery entails (kinda just looking around the area of interest for a problem that you cannot find through other tests?) but it sounds like a more expensive option than just paying $250 for them to rule out an external shunt through scintigraphy even though the exploratory surgery could be done at the same time as her stone removal. They drew out a flowchart of how we narrow down and diagnose the issues at hand and they actually never even mentioned performing exploratory surgery while she was under for the bladder stones. They recommended a liver biopsy at the same time but not the exploratory surgery.

How it was presented to me, the results of the scint. seemed to be what would determine the following course of action (a "yes" reading would lead to CT scan and most definitely surgical interventions to treat a shunt which they didn't discuss with me at the time. A "no" reading would lead to deciding how to medically treat). If Toki didn't have the bladder stones and they determined that there was no shunt, I don't know that I would necessarily get a tissue sample ASAP, just to avoid putting her under. We'd probably just treat her as if she did have MVD through diet and medically etc.

By the way, I got a call this afternoon about Toki's scintigraphy results and they did not find a liver shunt which is good news but of course leaves MVD as the most likely issue. I'll post more tomorrow afternoon after Toki is discharged and I get more information.

If they did a liver biopsy they would actually be right there and see a shunt if it was there.

No matter now anyway...at least you do have your answer! MVD is manageable...glad you have your answer!

[kjc]

Great news!

[tokipoki]

Thanks! I am able to exhale now!

[107barney]

So what is the plan for Toki? Is she going on a lower protein diet? I'm glad there was no shunt

[ladyjane]

I am also wondering what they are going to do about the bladder stones...

[Maximo]

Originally Posted by tokipoki

By the way, I got a call this afternoon about Toki's scintigraphy results and they did not find a liver shunt which is good news but of course leaves MVD as the most likely issue. I'll post more tomorrow afternoon after Toki is discharged and I get more information.

Wonderful news! I am very happy and relieved for you. How is Toki doing today?

[tokipoki]

Thanks ladies!

So the folks at NCSU Vet School have determined that Toki does not have a liver shunt (yay!) and that she possibly has a mild case of MVD. They said that since she doesn't have any symptoms and doesn't displays signs of encephalopathy that it's not necessary to have her on a prescription diet or even a protein-restricted diet.

They recommended that she just eat a regular dog food and that we can give her the liver support/protectant supplement. We are supposed to recheck the bloodwork every few months or so and keep an eye out for anything unusual.

And the bladder stones...oh man! They found 2 stones (through ultrasound so there could potentially be more, of course) small enough for Toki to pass through urinating. My general vet and the internist both did not seem concerned with dealing with the stones immediately. I did press the issue and the folks I spoke with at the internal medicine department did suggest urohydropropulsion as an appropriate method to remove these stones (since they are so small) but I would like to discuss it with my general vet to see if she could do the removal in the same manner (it seems less invasive than surgically removing them). I'd appreciate any thoughts or suggestions in terms of the bladder stones. I don't want them to develop into a bigger problem and it'd be nice to know what type they are so that I can potentially prevent them in the future.

Goodness! We've been so busy running back and forth to different vets on top of packing so that we can move this weekend. This in addition to work and life! I just want everyone happy and healthy (and a quiet, napping day at some point would be nice too!).

[tokipoki]

Originally Posted by Maximo

Wonderful news! I am very happy and relieved for you. How is Toki doing today?

Toki is doing fabulous! She had a nice breakfast and we went on our usual walk... Things are back to normal for at least one more day! We are moving tomorrow but I'm sure she'll be fine...Toki is quite resilient! She did sleep the entire afternoon yesterday when she got back from NCSU (from what I heard she is quite vocal and a character when they put her in a crate and turn their attention away from her lol I'm sure that's exhausting demanding love from everyone ) but she is back to her normal self today!