Liver shunt?

[threedogpack]

I took my 6 month old Papillon puppy to be spayed today. I always do pre-op bloodwork. Vet just called and said liver values are off the chart, Alt-p (?) was 656, normal is 10-100. Alt was so high it was unreadable by her machine.

She thinks due to some intermittent diarrhea we could be looking at a liver shunt.

Puppy does not display any other symptoms…just the intermittent loose stools, lack of interest in eating and tiny size (3.8# right now). From what I understand, she should also be lethargic (is DEFINITELY not), and have some lack of coordination (runs up and down stairs w/no problem)

Next step is to do a fasting bile test, which will be sent over night, and go from there.

anyone here have any experience with liver shunts?

[Alex_and_Bodie_s_Mom]

No advice, just jingles to you and your puppy!

[tweeter]

One of the military pugs that we’ve fostered over the years (his mom has been deployed 4 times and we get them each time) had a liver shunt.

It was the first time we’d fostered him, he was 2 years old. For a while he’d been ok with just a very strict diet, but she knew the chances were he’d need surgery eventually. We noticed that when he went out, he acted like he had to pee, but didn’t actually pee. Took him to the vet, and his bladder was full. Spent the night at the urgent care place…did a bunch of tests and after a consult with the vets at State, it was decided he needed to have his shunt fixed.

We took him to NC State for the procedure. They used the band method, and other than trying to keep him quiet while he healed, and all the meds he needed for a while, it went very well.

It made a HUGE difference in him! He grew, his energy level went from about a 5 to a 10 (and 8 years later, it’s still a 10, LOL) He just looked so much happier. Funny thing was, his vet was actually an army vet doing a rotation up there, and he wrote to the owner (she was in Iraq) and kept her up to date too.

He definitely wasn’t lethargic and his coordination was just fine. Looking at him you’d never have know there was anything wrong with him. He was first diagnosed when he was in Germany, I think he was about 6 months old then.

[SquishTheBunny]

Yep, lots. Extrahepatic shunts are common in smaller breed dogs, particularly yorkies. Do the bile acid test, and if those come back high there are several next diagnostic steps.

1.) Protein C - this can help rule in/out shunt vs. other liver function disease.
2.) Abdominal ultrasound, done by a radiologist. To confirm portal pressures and visualize the shunt.
3.) IF the shunt cant be seen on ultrasound (on occasion it cant), other diagnostic tests are a CT angiogram or microbubble transplenic cardiac study. However…if you have a good ultrasonographer the majority of the time you can see the shunt.
4.) Then the surgery, where the ameroid constrictor is placed over the shunting vessel, slowly closing it off over time.

Most young dogs with corrective shunt surgeries do quite well. Intrahepatic shunts are more difficult and have less positive outcomes…these require coiling procedures. Dogs with extrahepatic shunts can often live a full lifespan once corrected. Most do not do well for long with just medical management.

[threedogpack]

Bile acid came back normal, not just normal but low normal. First test needs to be under 10, hers was 1. Second needs to be under 20, hers was 7.5

Based on these numbers, we are going to worm her with the big guns, put her on milk thistle and recheck in 4-6 weeks. If things have not gone down hill, we will spay her using a portal protocol.

Squish, you are a gem. Thank you so much for chiming in here. If there is something else we should look at, please speak up. I was told by a human doc they would do a biliruben test before bile acid in people, to check for a blocked duct but apparently this is not normal protocol in dogs.

[CrowneDragon]

@threedogpack;7197744

Based on these numbers, we are going to worm her with the big guns, put her on milk thistle and recheck in 4-6 weeks. If things have not gone down hill, we will spay her using a portal protocol.

No experience with liver shunts, but tons with other canine liver disease. If you need a place to get more info, the Canine Liver D group on Yahoo is quite helpful.
I’d be careful aggressively deworming a dog that shows hepatic distress of unknown etiology.
Good luck.

[threedogpack]

[QUOTE=CrowneDragon;7197778]

I’d be careful aggressively deworming a dog that shows hepatic distress of unknown etiology.
Good luck.[/QUOTE]

thanks. The vet is the one who is making the decision to deworm her.

[CrowneDragon]

[QUOTE=threedogpack;7198247]
thanks. The vet is the one who is making the decision to deworm her.[/QUOTE]

My vet recommended putting my dog on heartworm preventative and he ended up hospitalized for 3 days.

[SquishTheBunny]

Great news!!!

I would recheck the bloods in a few months to make sure they are stable, or trending down. We do a lot of ultrasounds on puppies with increased liver values and the vast majority do not have shunts, just microvascular dysplasia (or completely normal).

Worming can certainly help if the cause of liver inflammation is due to a high wormload or infection (it can be), sometimes antibiotics can help if its simply infectious. Milk thistle wont hurt at all. Those values you mentioned aren’t crazy for either ALT or ALP so I wouldn’t worry too much about the worming. Just keep an eye on your pup for any abnormal behaviour such as anorexia, diarrhea, jaundice etc. And definitely repeat the liver panel in a few months.

And in regards to bilirubin - usually not terribly significant in liver shunts, commonly high with severe pancreatitis which blocks common bile duct or gallbladder mucoscoeles/stones. Key signs (non liver realted) with liver shunts are bladder stones and mineralization in the kidneys, low BUN.

[threedogpack]

thank you again Squish. I always look forward to your posts. You explain things well and I can understand what you are telling me.

Have you ever run into the vast difference(s) between the pre op blood work and the bile acid results?

[cowboymom]

I hope she’s totally fine, threedogpack, I’m sure it’s been a nervous few days!

Thanks for the prompt on pre-op BW…

[threedogpack]

I learned my lesson a long time ago with a foster. Pre op bloodwork catches a lot that would not show because the dogs act fine. One dog I had, needed some minor surgery, and when we did the bloodwork, his platelet count was WAY down. The vet told me he would have died on the table. The few extra dollars can save your pet. I’m certain that a friend lost her cat on the table because she didn’t do the pre-surg bloodwork (I’m know for a fact that vet office does not routinely offer or suggest it).

[RdEventer]

[QUOTE=threedogpack;7196464]
I took my 6 month old Papillon puppy to be spayed today. I always do pre-op bloodwork. Vet just called and said liver values are off the chart, Alt-p (?) was 656, normal is 10-100. Alt was so high it was unreadable by her machine. [/QUOTE]

Well I’m glad the bile acid test was negative! As for the pre-op bloodwork…

Were all the liver values elevated or just the ALP (also abbreviated ALKP; stands for alkaline phosphatase)? ALP can be released in case of a liver shunt, but it’s also produced elsewhere in the body. For example, puppies often have elevated ALP because of rapid bone growth. So that may account for the 656 value.

Had puppy been fasted before the blood was drawn? In my experience, unreadable results are almost always due to lipemia (although it depends on the analyzer; sounds like this was an in-house one). If the bloodwork was sent out the laboratory will have instruments that dilute the samples so that the analyzer can read them. Our goal is to put out at least an approximate number so that the veterinarian can know if the value is truly high or if the sample quality was bad.

Lastly, puppies have different normal chemistry ranges than adult dogs since their bodies are changing so quickly. The analyzers default to adult ranges. If you have a list of the actual values, you can look up what the normal ranges are for a puppy.

[SquishTheBunny]

Yes threedogpack, high liver values can indicate a lot of things, including microvascular dysplasia http://en.wikivet.net/Hepatic_Microvascular_Dysplasia

I have seen a lot of these dogs where Bile Acids are not elevated, as the microvascular shunting is minimal.

However…before you move forward with surgery I would recheck the bloods. If they are the same, or higher then get an ultrasound done with potential biopsy or FNA.

FWIW, we do a lot of these on small dogs who are otherwise asymptomatic - and the vast majority come back as normal or MD.

[CrowneDragon]

While helpful, bile acids are not a reflection of all liver issues. My dog has had 3 BA tests and all have been normal, yet all of this other diagnostics indicate severe cirrhosis.

[threedogpack]

@RdEventer;7199772

Well I’m glad the bile acid test was negative! As for the pre-op bloodwork…

Were all the liver values elevated or just the ALP (also abbreviated ALKP; stands for alkaline phosphatase)? ALP can be released in case of a liver shunt, but it’s also produced elsewhere in the body. For example, puppies often have elevated ALP because of rapid bone growth. So that may account for the 656 value.

this being in house labs, were printed out for me as follows below:

alkp: 656 u/l
alt: - (no value)
Bun: 24 mg/dl
crea: .08 mg/dl
GLU: 107 mg/dl

Had puppy been fasted before the blood was drawn? In my experience, unreadable results are almost always due to lipemia (although it depends on the analyzer; sounds like this was an in-house one).

yes, she had been fasted for over 8 hours.

If the bloodwork was sent out the laboratory will have instruments that dilute the samples so that the analyzer can read them. Our goal is to put out at least an approximate number so that the veterinarian can know if the value is truly high or if the sample quality was bad.

the blood for the bile acids were drawn on the same fast, and they came back normal.

Lastly, puppies have different normal chemistry ranges than adult dogs since their bodies are changing so quickly. The analyzers default to adult ranges. If you have a list of the actual values, you can look up what the normal ranges are for a puppy.

thank you!

[threedogpack]

[QUOTE=SquishTheBunny;7199780]

However…before you move forward with surgery I would recheck the bloods. If they are the same, or higher then get an ultrasound done with potential biopsy or FNA.

FWIW, we do a lot of these on small dogs who are otherwise asymptomatic - and the vast majority come back as normal or MD.[/QUOTE]

We are going to wait 4-6 weeks and retest. For what it’s worth her stools have firmed up as well so I’m guessing she picked up some sort of parasite here when she first came.

[threedogpack]

note: RdEventer…she has grown much taller (tho not heavier) in the last few weeks so knowing that can change ALT ranges is a good thing. Thank you!

[SquishTheBunny]

I would request out of house labs on your repeat test. ALT value should not come back as a 0. Many in house labs can be wonky as quality control isn’t often attended to. At an outside lab they have strict qc’s to follow and usually more accurate blood analyzers.

For puppies I would be more worries about an increased ALT than ALP.

[SkipHiLad4me]

@CrowneDragon;7197778

No experience with liver shunts, but tons with other canine liver disease. If you need a place to get more info, the Canine Liver D group on Yahoo is quite helpful.

Ditto what CrowneDragon said. I’ve tapped into the vast wealth of knowledge on the Canine Liver Disease group on Yahoo and it has been very helpful. My senior Boston does not have a shunt but has chronic liver disease and I feel like the information I’ve used from that group to support her nutritionally has bought her additional time with us. (She turned 15 this summer!) Not to mention there is a lot of good discussion/explanation of what the terminology and lab numbers mean in terms of your dog’s health and prognosis.

Good luck with your pup!