Neb. Pre-anesthesia Liver puzzle.
09/29/09 (date written)
Neb was a rescue dog. He showed up at our clinic for his exam and he was full of energy. He has an all Terrier attitude and is a white blur of motion. He was been adopted by parents that adore him. As you will find out, they are going the extra mile to ensure the best for him.
Neb came in at the end of November of 2008. The records that accompanied him listed his basic deworming and first set of puppy vaccinations. I examined him and found a robust very active puppy full of sass and vinegar. Just the type of puppy you need to keep your eye on or he will be into something the second your back is turned. He went through basic vaccinations, distemper, leptospirosis, hepatitis, parvo, parainfluenza, and rabies vaccination. Neb was de-wormed three times at the appropriate three-week interval. He started on a monthly heartworm preventative that removes or controls intestinal worms (round, hooks, and whipworms). He came at 16 weeks (4 months) of age with an Ideal body condition score of 5/9 using Purina's weight chart weighing 7.4 pounds. Jan 17, 2009 he received his rabies vaccine. His owners due to expected lifestyle declined vaccinating for Lyme disease and Giardia. Do you see or spot any abnormalities? I used to say sound as a dollar, looking like apple pie, motherhood and the American way. There was no outward clinical sign of any problem.
I started this article to reinforce why we veterinarians recommend presurgical blood testing prior to surgical procedures. In older geriatric animals, we also need to know what is going on inside where the organs are. Are there kidney, pancreas or liver issues that can interfere with breaking down or metabolizing the anesthetic agents we use to get to a surgical plane of anesthesia or not. We need to know before a procedure what the odds are the animal is going to wake up. Veterinarians are cautious by nature, training and being in practice. Caring veterinarians do not want to make the dreaded bad news after procedure call.
Neb came in for his neutering appointment June 18, 2009 13.2 pounds of swagger. Body condition score still an ideal 5/9, No heart murmur, good pink mucous membranes and no abnormal lung sounds. He was premeditated so his day cage would seem more comfortable and quiet to him. Presurgical blood tests were done. Everything was fine except for two liver enzymes, Alkaline Phosphatase (Alk Phos) and Alanine aminotransferase (ALT). The results were Alkphos 514 U/L (23-212) normal range (NR) and ALT 891.0 (10-100) NR. These two are big warning flags for veterinarians. An elevated ALT indicates some type of liver damage. This enzyme is detectable only if there is pressure, squeezing the cells and releasing elevated levels in the blood serum. Types of injury may include trauma from physical force (hit by a car), internal pressure from an enlarged gall bladder, liver tumor, abscess or a hematoma (blood clot bruise). The uptake mechanisms with developmental abnormality or circulating blood may develop a vascular shunt, processing of digestion materials or received substances in need of processing for elimination are other examples of other hepatic disorders.
When these numbers are elevated, I will not put an animal under anesthesia. I need to wake them up. I called Neb's owner and told her he needed a bile acid test done and evaluation of liver size by radiographs and an ultra sound exam for soft tissue evaluation. We did the bile acid test. Neb was fasted already so we could draw a pretest (zero hour) serum sample. We fed him a can of A/D dog food (high in fat content). We got a two-hour post pyramidal (eating) sample.
We shipped serum to Michigan State University, Diagnostic Center for Population and Animal Health (DCPAH). The results were pretest sample 3.2 umol/L (0.58-8.7) NR two-hour post feeding sample 22.9 (0.5-23.4) these results are normal. If there was a significant elevation, it would support a diagnosis of portal systemic shunt (PSS) or in small breeds such as Neb, they refer to it as a microvascular anomaly (MVA). This is a real puzzle and an emotional rocker for the owners. It is many confusing data points to process with a very active adolescent canine. I gave the owners an option to have an ultra sound done with Dr Fulton at the Animal Emergency Clinic in Ann Arbor. He does a very thorough exam, gets great liver biopsies and the close proximity is a plus. The other options were Michigan State University VTH or one of the specialty practices in the Detroit area. I started Neb on doxycycline and a product called Denamarin. Denamarin is milk thistle and S-adenosylmethionine (SAMe) an empirical treatment for damaged livers.
Neb went to MSU VTH and was examined by the Internal Medicine Veterinarians. They went over the same discussions I had with the owners they repeated liver enzymes, included testing for leptospirosis and recommended a nuclear scintigraphy (radioactive isotopes) that are an extremely sensitive "mapping" of the circulatory system in the liver. This would rule in or out a portal shunt. The scintigraphy showed him clear of a shunt. They scheduled the liver biopsy and neutering was done at the biopsy procedure also. They were as puzzled as I was. Their diagnosis was undetermined at this point also.
The biopsy results were very reveling. Dr Todd Carter, Internal Medicine Resident at MSU VTH, reported Neb has copper (Cu) storage disease. The liver results were Cu >2,000 parts per million (ppm). This condition is toxic above 300 ppm. Due to the inflammation and pressure, he started him on a medication called tetramine tetrahydrochloride (Trientine). It is given every 12 hours. The basis for use is that it is a chelating process. This medication has an affinity or attracts copper to it and binds it for elimination out of Neb's liver. Neb is to have a follow up liver biopsy and enzymes tested in a month. Thirty-seven years in practice and the first documented mineral storage disorder in a non Bedlington Terrier. Veterinary Medicine always has an interesting case just around the corner. Neb is lucky his owners went the extra mile. For me it reinforces the importance of checking the inside of an animal prior to anesthesia. True this is an unusual case but I have stopped many procedures until out of range test results are confirmed. It is the safe way to be.
For more information about a specific case, consult your veterinarian.
The outside of a pet is good for the inside of a human.