Elevated liver enzymes...need advice!
 

So I took Toki in for a physical and a routine blood test this past Wednesday. The results of the blood test came back with high liver enzymes (the only value I remember was the ALT being 312...I can get more specific values Monday when I ask for a copy of her bloodwork results). The following day we got a bile acid test performed and her post-fast value was was 63 so now we have an ultrasound scheduled for Monday to check for a liver shunt.

This is all really surprising to me...we go in for a routine exam visit and now there is the possibility of liver issues. Toki's bloodwork was completely normal back in September/October when she had her FHO surgery and she has been asymptomatic, to my knowledge.

The vet gave me an antibiotic and a liver support supplement to give her in the meantime and I've switched her food to a kibble lower in protein and fat. Depending on the results of the ultrasound (which I know isn't the most reliable way to detect a shunt), my vet is going to discuss treatment and management plans with me.

I was just looking for similar experiences or any advice/recommendations or stories you all could share with me. I suppose it is better that we found out about potential issues before Toki started presenting outward signs/symptoms. I just hope we are able to pinpoint a specific cause for her elevated liver enzymes and BAT values.

I'm sorry to hear this and I wish Toki and you the best, and praying this will turn out to be something that can be controlled with diet and meds. While I don't have any experience in this department, I wanted to bump your thread up for others to see. I do recall from previous threads mention of scintigraphy for diagnosing shunts.

Post #8... http://www.yorkietalk.com/forums/sic...h-ast-alt.html

My dog recently has been suspected to either have MVD or Liver Shunt. Scheduling a appointment with a specialist this week. He was perscribed Royal Canine Hepatic dog food, and also is on Luctralose. Hope everything turns out OK with your dog, as this is costing me a fortune.

My yorkie had elevated bile acid levels at his last checkup. He also has seizures. I took him to a specialist and he told me that levels less than 100 are more likely to be MVD than an external shunt. We did an ultrasound - no external shunt, no gallbladder issues. The specialist said it could be MVD but it would be better to switch his diet and see if he improves than to do an invasive liver biopsy. He's doing just fine so far but we're waiting on a 6 month retest.

Liver Shunts and Gall Bladder issues don't always show on Ultrasound. Sludge can develope in the bile duct from the liver to the GB, and cause similar test results as a Liver Shunt, including high BAT results.

Thanks for thinking of us, Kristin. I do believe that a scintigraphy will most likely be our next step. I too am hoping for something that can be controlled without surgical intervention (I'm willing to do whatever is necessary regardless)...fingers crossed.

I had actually come across that thread you mentioned...it has a ton of interesting information, especially with regards to different liver/gallbladder disorders and corresponding bloodwork values. I've been combing through that article you linked. It's so hard to even know what Toki has going on... her BAT values were under 100 and she has no symptoms...what if they don't find anything with the ultrasound? Will we have to do a biopsy? Or will they just give her medication and retest her values later on to see if anything has changed? Monday seems forever away. More time to do research though so that I can ask my vet appropriate questions and not spaz out on her.

Please keep me updated. Has his seizure frequency decreased since changing his diet?

It certainly isn't cheap going through the steps of figuring out what is wrong...now I'm rethinking getting the pet insurance and glad that I have a savings account for her to help out. I was looking at your thread and it seems like we're going through a similar process ...please let me know how your appointment with the specialist goes.

Many times if no tests are definitive, they will opt to retest in 1-3 months, sometimes after being on a low protein diet and/ or meds to see if there's any changes, esp with a dog with no symptoms. Also depends on her liver enzyme bloodwork.... Sometimes if it's just the ALT, it could be a toxin that was ingested (or toxic to the liver) (Tink ate rancid grease). The Denamarin (liver supplement) will be a great help there. A biopsy is best done during surgery to fix something else, ie: spay, LS, clear bladder stones, etc.

I went through this last October with Taycie, through Biopsy she was diagnosed with MVD. Taycie has always had slightly elevated liver enzymes her entire life.. but nothing to scare me at the time. It was like 2 -5 points out of "normal range". I was always told this could be because stress at the vet office.

About a year prior to her diagnosis with MVD she had already has been diagnosed with SIBO or small intestinal bacteria overgrowth.. she was placed on tylan powder and I had already put her on lower protein food because she just simply could not tolerate anything with higher protein levels. Now.. looking back.. I think this bought us time.. and pacified the problem for the time being.

In June, 2012 she had a dental done. This time bloodwork was done her liver enzymes were 50 points above normal. My vet at the time, ( not my current vet now) told me we need to watch this.. Lets retest in 3 months and then schedule an ultrasound.

In October, it all came to a head she would get up in the night and pace.. and act very strange. I would find her curled up in the kitchen in the middle of the night.. Her stomach would be tight.. and she would be starting at nothing.. I scheduled the ultrasound..

Ultrasound results were inconclusive... A scintigraphy for us was not an option.. no one does this in Salt Lake:(

So.. back to the vet we went and at this point her enzymes were 100 points above normal. I requested a BAT and her pre meal was 24 post meal was 109.

Taycie at the time got extremely sick and was hosptilized for 3 days.. She was sent home on a feeding tube for a week and then a week later went in for exploratory surgery.. She had a biopsy of her small intestine and liver. This is finally when we were able to rule out a shunt.

Her Biopsy report came back with MVD. Taycie is on Metronidazole and Lactulose. She is also supported with a Homecooked Diet Formulated by Dr. Remillard. On the positive side she is doing VERY well now! I am so happy with her progress! I will keep Toki in my prayers. I know how much YT helped me when I went through all of this.

Thanks for sharing your experience and keeping us in your thoughts. I'm really glad that Taycie is doing well now and it makes me hopeful...it seems like most of these pups fare well with a closely monitored diet and medication, even if surgery is not an option. I take my baby in for an ultrasound tomorrow morning so hopefully we will have more answers then. I'm assuming that we will be able to get a scintigraphy (if that is the next step) since we are right down the road from the NCSU vet school...I imagine they have lots of resources and specialists.

I am really hoping that we do not have to go through the process of exploratory surgery/biopsy though. I'm not sure what to expect with this ultrasound but I'll keep you all posted and give an update tomorrow. I am of course hoping that they don't find a large shunt although that result will lead to even more questions and options we'll need to explore. Thanks everyone for the information and support.

Thinking about you today! Hope all goes well, and you get some answers. I so envy people that are nearby a vet school that is wonderful you can take her there.

Keep us posted!

Well it is too late for most pet insurance if the dog has already been evaluated for the symptoms so check carefully before signing on...

I hope you find out what is wrong. MVD can indeed be managed with a lower protein diet and sometimes medications/supplements. My dog has been a long time survivor, is almost 13, and runs around like a puppy. Even if it is a shunt, it is a pretty easy fix these days for most dogs that have an external shunt. LadyJane's 8 year old TeddyBear just had surgery for one and did fine.

Best wishes, I'll keep an eye out for your update.

I just picked up Toki from her ultrasound appointment. They were unable to detect a liver shunt but they did find some bladder stones (the vet said that there were stones but no crystals...not sure what the significance of that is). She didn't seem so concerned about it and said we could have them surgically removed and sent off to be tested or see if they improve with a change in the diet. I also chose to have them take a blood sample and send it off to Cornell for them to do a Protein C panel.

My vet suspects MVD based on the ALT and BAT values which she said will not require surgery and can be treated medically (as you've all mentioned). She said if I wanted to, we could do the scintigraphy at NCSU. I have an appointment tomorrow with an internist at the vet school where they are basically going to do an exam and redo bloodwork and I will have to schedule another appointment for the scintigraphy. I'm not sure if I should keep it or wait for results from the Protein C panel to come back or wait a few months after having her on the RC Hepatic and milk thistle.

I don't know what to do. The lady I spoke with on the phone said that a basic liver workup could be as high as $1500 (before the scintigraphy). I want to do what is best for Toki but I'm trying to balance that with not having unlimited funds. After running all of these tests, they may come to the same conclusion as my general vet that we just need to change her diet. I hope I don't sound like a terrible person :(

I would proceed with ncsu.

:thumbup::thumbup:

I would also proceed with NCSU.

I am so sorry to hear about Toki, we have been through the shock and feeling of helplessness by learning our Toby has LS/MVD also. In our case he was showing some symptoms with pre/post BAT (65/170). We are waiting for a vet school appointment for ultra sound also. Medical management has turned Toby around completely and he is now on a balanced home made diet (Hilary's Blend) and lactulose and is doing very well.

May I ask you how invasive was the ultra sound? Did Toki need to be shaved and sedated? Also, how invasive is scintigraphy and what does it involve for the dog? I ask these questions because Toby can no longer tolerate anesthetic or even vaccinations.

All the very best, our thoughts and prayers are with you! Please let us know the results!

I am currently at NCSU and have just spoken with a 4th year student and waiting for the specialist to come speak with us. From what I've read scintigraphy is not invasive but I'm sure the other ladies here will know more.

The ultrasound was not invasive at all. They did shave her underside (she looks a lot slimmer haha) but she didn't even need to be sedated. Relatively quick procedure.

Good luck Toki! We have our fingers crossed for you ;)

Good Luck Toki! You both are in my thoughts!

I've given this a lot of thought... I can't recall ever hearing of letting bladder stones resolve on their own or with diet change. I've always been told that this is quite serious as the stones could block the bladder which is life threatening.

If this were me, I'd have the stones surgically removed, and at the same time have an exploratory done and see if there's a shunt or not, repair it if there is one, and get the liver biopsy at the same time.

In older dogs (over 2YO), there is also the problem of Gall Bladder sludge, which causes the same symptoms as Liver shunt, and often does not show on xray or Ultrasound. It can show up in the liver enzyme bloodwork, if the vet knows to look for it. It will also be evident during an exploratory surgery, and the bile duct can be cleared at that time, or be put on a medication that helps to disolve the sludge and restore normal pressure in the liver..

Although any dog may feel and act better on Lactulose, Denamarin, and antibiotics, none of this helps or solves the problem of Gall Bladder sludge. This condition creates pressure in the liver and causes multiple tiny shunts to form to alleviate the building pressure.

Also a complete Urinalysis should be done, as various bacterias, one being E Coli, can cause the Gall Bladder to develope sludge. It takes at least a 30 day course of antibiotics to clear E coli, and may need to be repeated.

Diagnosis of Portosystemic Shunts

Nuclear scintigraphy is a noninvasive means of evaluating dogs for portal venous shunting. In dogs 99mtechnetium pertechnetate is extracted from the circulation primarily by the liver. In animals with shunts, the pertechnetate rapidly circulates to the heart and lungs. Normal dogs have a shunt fraction of less than 15% on scintigraphy; most dogs with shunts have fractions greater than 60%.
Magnetic resonance angiography (MRA) and CT scans have also been used to diagnose portosystemic shunts.
The ultimate diagnostic tool is laparotomy. Once experience is obtained, most extrahepatic shunts and approximately half of intrahepatic shunts can be identified on exploratory.

I had actually been thinking about those bladder stones last night too and was thinking it might be a good idea to just have them surgically removed and analyzed and at the same time get a biopsy done on her liver (the vet at NCSU recommended that).

Anyway, I just got back from NCSU. I ended up dropping her off. Today, they will be re-doing her bloodwork, performing a UA, and doing an ultrasound on her urinary tract (a board certified radiologist performed the ultrasound yesterday but I wanted them to get another look at her bladder stones). Then we will bring her back tomorrow early in the morning to have the scintigraphy performed... she'll end up spending the night and coming home Thursday morning. It already feels like it's been such a long day! Poor Toki...she always knows that something is up when I don't give her breakfast and then pack her up in the car. I'll keep you all posted.

I think you're doing the right thing. Best wishes.

Buddy, my silkie yorkie has been a pickie eater since I adopted him last March. I have tried so many kibble, organic, grain free, etc and he never seemed to settle on one. I tried roasted chicken, I know thats not the best thing, but at one point he would eat that and nothing else, now he turns his nose up at that. I had been giving him AllerG3 for his coat and itching and reliably could put it in chicken pill pockets and he would gobble that down, now he turns his nose up at that. Recently had his dentil done and the usual checkup. He is/was fine. Two days later he had bloody diarhea they said was worms, despite being on Trifexis. So now I have to give him an antibiotic every 12 hrs and worm him a week and a half after they gave him worm meds in the office. The antibiotics went down ok in a pill pocket until 3 days ago, now he refuses them. He wont even consider the peanut butter pockets. His wt was down about 1/2 lb from his prior wt, but still at 8.5. Tried waiting him out, just at my wits end. He is lethargic and I worry. Any ideas?

Please keep us posted. You are your pup are in my prayers.

I'm glad you are working with NCSU. Keeping Toki in my prayers.

Praying your all goes well and I can see you are getting great advice :hands: