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Hepatitis Case
Histories
Anne Jones RN, BSNE
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Hepatitis is the name given to
inflammation of the liver; it takes many forms and can be from
various causes. The following case histories represent how this
disease can manifest itself from different triggering mechanisms but
makes – in each instance – a very sick dog.
Sue was about 14 years old when she was found to have a recurrence
of mammary cancer. Her previous surgery about 3 years prior had
removed tumors and her recovery was fast and without consequence.
When her owner noticed evidence of more cancer, she was taken to her
veterinarian for examination and surgery quickly followed. The
second surgery revealed an aggressive form of cancer and the vet
recommended that she have more surgery to scrape away all remaining
mammary tissue. This would hopefully provide more years for Sue so
her owner quickly approved the surgery. Both were done within less
than two weeks time. Recovery was relatively fast.
Or so her owner thought until Christmas Eve when Sue began vomiting
and was soon clearly in a life threatening illness. The Veterinary
Emergency Hospital was the only option in a holiday week and she was
admitted. Test results showed that Sue was in liver crisis with
extremely elevated liver enzymes and the diagnosis was metastatic
liver cancer, spread from the mammary tumors. Both the owner and the
regular vet later disputed the diagnosis of cancer because she had
been so healthy prior to surgery and had recovered so easily. Time
was to prove them correct.
Regardless this was a very sick Bichon and treatment with
intravenous fluids was the first step toward recovery. She was
hospitalized through Christmas Eve, Christmas Day and night, then
taken to her regular vet for follow up treatment. Sue recovered and
lived more than two more years, dying at age 16 years plus. However
her liver was compromised and she paid a price. The final
determination on what caused the hepatitis was overload to her
system from her surgeries with two anesthesias, two series of
powerful antibiotics, systemic stress and, in Sue’s case, the
inability to tolerate a drug given to her for pain during her
hospitalization. The drug was Rimadyl, at that time a new product,
which has since been proven not to be well tolerated by some dogs
and some breeds.
Aimee has a different history. While Sue was bred by a known and
respected breeder with a long history of breeding and exhibiting
Bichons, Aimee came from a kennel with a connection to a “for
profit” breeder. She is a beautiful little nine year old Bichon but
has a long history of illness and behavioral problems. She is self
destructive, chews on her feet, exhibits a tendency to calcium type
crystals in her urine with no clearly defined indications of
inherited calcium oxalate stone formation. She has had seizures,
some clearly a reaction to stress. Unfortunately the most stressful
location for her is her veterinarian’s clinic so he has made house
calls rather than put Aimee through the stress of visiting him in
his office. We should all have a vet who is so sympathetic to the
needs of our dogs! Her history has been one of ongoing health
problems and temperament issues.
Aimee’s liver health has been in question for a long time and
consideration was given to possible liver shunt (aka portal systemic
shunt). Bile acid studies, the test for this condition, were done
but were normal. While on phenobarbital for seizure control, her
liver enzymes were elevated to the level expected while on this
medication but were not excessive. Yet two months after her most
recent monitoring blood chemistry, Aimee was admitted to the
hospital in liver failure. She has a history of mushy yellow stools,
very runny and smelly, and occurring in no particular pattern. In
fact, it is difficult to explain how Aimee’s symptoms vary from day
to day without seeming confused. She has, in fact, been called “the
puzzle dog” on occasion because of the unpredictable nature of her
disposition and her health.
The current illness began with signs of deteriorating health but
without any pattern. Her veterinarian saw nothing alarming, given
her erratic behaviors in the past. This changed when her she was put
on a course of prednisone. She was already taking metronidizole,
hydroxyzine and the phenobarb. The prednisone was an attempt to
control some of her issues that might have been related to
autoimmune conditions. Within 3 weeks, Aimee was clearly ill and
went into a crisis, resulting in hospitalization for 8 days. Her
liver enzymes were extremely high and she required constant
intravenous fluids and a steady regimen of antibiotics and other
drugs appropriate for liver failure. After days of no food by mouth,
she slowly began hand feedings but it was touch and go. Even when
she returned home after 8 days, her condition was precarious. The
outcome is not known at this writing but her medications seem to be
sustaining her with some ups and downs. Because she is so fearful of
the clinic situation, every effort is made to maintain her at home
and this has worked so far.
In both these dogs, the costs were extremely high in dollars and
cents but both owners felt their dogs deserved a chance for
recovery.
What is hepatitis?
Hepatitis is any inflammation of the liver. It may be secondary to
other disorders or other diseases, it may be drug induced, it may be
viral and it may be transmitted from blood donation or organ
transplantation, a particular concern in humans. The first signs may
be poor appetite or vomiting. Fever usually is present and there is
marked tenderness in the area of the liver with enlargement of that
organ. Often there is an odor of ammonia to the breath.
In Sue’s case, her illness was probably drug induced and was also
secondary to her surgery in that her system was already stressed.
For Aimee, there is some consideration of underlying and undiagnosed
liver disease although she has been tested for the obvious
congenital portal systemic shunt. In her case, a tentative diagnosis
of autoimmune hepatitis has been made. Any autoimmune disease stems
from the reaction of the body to itself. (see Definition of
Autoimmune Disease ).
Understanding liver function is key to understanding how hepatitis
can alter the efficiency of the liver. Other than skin, the liver is
the largest organ of the body. While a liver can, for a time, be
maintained in the presence of major damage, quality of life will be
altered. Early treatment of any liver disease is essential to
preserve liver function. The liver is responsible for metabolism of
fats, carbohydrates and protein. Detoxification is a critical action
that the liver shares with the kidneys. It synthesizes those
proteins that maintain ability of blood to clot through a complex
biochemical process and it removes old or damaged red blood cells,
stores iron and is a part of the process that breaks down
hemoglobin. To maintain whole body health, a vital and functioning
liver is critical. Fortunately the liver is one organ of the body
with ability to regenerate damaged cells which does sometimes allow
a diseased liver to return to normal function.
The liver produces virtually all body proteins, with the primary
protein being albumin, which controls and maintains fluid pressure
in arteries and veins. Failure to control this pressure allows
buildup of fluid and when fluids leak into the abdominal cavity, a
buildup of abdominal fluids occurs, distending the belly. This fluid
is called ascites. Fluid can also build up in the thoracic cavity
creating pressure on the lungs (pleural effusion). Albumin also aids
in transporting compounds through the bloodstream, including
vitamins, hormones, drugs, calcium, fatty acids and bilirubin.
Since the liver plays a vital function in metabolizing
carbohydrates, a diseased liver has difficulty controlling blood
glucose level. Stored blood sugar is called glycogen. Abnormalities
can result in the development of low blood sugar or elevated blood
sugar (diabetes mellitus).
Signs of liver disease may develop slowly. Poor appetite, loss of
weight, lethargy, thirst and frequent urination, light color of the
stool from the absence of bile in feces, dark (orange) colored urine
and a yellow tinge to the skin (jaundice), distended abdomen from
fluid buildup (ascites), vomiting and/or diarrhea, abdominal pain,
poor clotting of blood, anemia and behavioral changes – these are
all or individually signs that disease may be developing. Often
there is an odor of ammonia to the breath. Clearly one or two of
these signs may not be significant but when several are present in
the dog, he is probably sick. Unfortunately, it is only when the
more advanced disease signs are noted that his owner understands
that his pet is ill. When the dog presents with seizures, this is a
clear indication of whole body sickness.
Diagnosis will be made primarily through blood testing for elevated
liver enzymes. Disease signs in a young dog are more likely to be
related to liver shunt (portal systemic shunt) and will be diagnosed
through bile acid test. In hepatitis, testing will start with a
complete blood count and blood chemistry panel. Chronic disease may
present lower levels but elevated nonetheless. In acute disease, you
may hear your vet say “they are off the chart”, which is not a
veterinary diagnosis but an indication that the levels are extremely
elevated and that immediate care is directed first toward reducing
toxicity in the blood stream. Alkaline phosphatase, ALT (SGPT) and
AST (SGOT) and total bilirubin will be the first values looked for.
Prothrombin time, having to do with blood coagulation, and white and
red cell counts, dealing with anemia, are tests that will present a
picture to the vet that liver disease is present. The more these are
skewed from the normal, the more likely that this pet may not
survive. However immediate hospitalization and intensive treatment
has saved many dogs that were critically ill with hepatitis and
other liver diseases. The dog may expect to be hospitalized from 24
hours to a week or more, depending on general condition and the
severity of the disease.
There are a number of drugs which can be used today to treat
hepatitis. In all forms of hepatitis, some treatment will be the
same or very close to the same. The first action will usually be
administration of intravenous fluids to flush the system of toxins.
Some medications are specifics for liver treatment while others are
directed to controlling immune issues or to aid the digestive system
in tolerating medication. If seizures occur, medication will be used
to control them until toxicity can be reduced and may be needed
after recovery if seizures continue to occur. Most veterinarians
will follow a very similar protocol of treatment and will usually
start with intravenous fluids. Medications may be added to IVs, such
as an antiemetic, especially since vomiting is most likely a part of
the illness. Once there is control of the emergency situation,
reestablishing intake of solid foods can begin. It will most likely
consist first of very small amounts, handfed as necessary to get him
to tolerate food intake.
While some dogs will be able to leave the hospital in 24 to 48
hours, it may take a longer time to establish and maintain
stability. Remembering the complexity of liver action in maintaining
health will aid the owner in understanding that this disease is
serious, requires extended and intensive treatment and monitoring
for failure to thrive or for relapse to occur. An enlarged liver
will require careful handling of the animal, will be painful and
will be slow to heal. Rest is vital, good nutrition essential to
recovery and fluid intake important. There can be complications in
terms of developing secondary problems so this dog must be seen on a
regular schedule so that his veterinarian can monitor his progress
and his owner should be alert to any changes in behavior or signs of
developing problems.
Sue was my Bichon. She did make a good recovery and had another two
years of life. However she exhibited signs of liver failure at the
end and required further treatment. We enjoyed her presence in our
lives until she died of natural causes. Today her granddaughter lies
at my feet as I tell her story. Aimee is still making progress and
her owner is hopeful that she will have her for many years to come.
She reports that Aimee is getting into mischief again and resuming
her role as mistress of the household. That is a good sign!
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