ADVERSITYADVERSITY

“Adversity causes some men to break, others to break records.”

-William A. Ward

Liver DiseasesLiver Diseases

High regenerative capacity; damage must be severe for signs to appear

Drug/Toxin induced Liver Disease◦Acute liver failure requires >70% of liver to be

affected◦Susceptible to toxin ingestion (portal circulation)◦Some drugs have a Hx of liver toxicity

Acetaminophen Phenobarbital others

Drug/Toxin Induced Liver DiseaseDrug/Toxin Induced Liver DiseaseSigns

◦Acute onset◦Anorexia◦vomiting/,

diarrhea/constipation◦PU/PD◦Jaundice (maybe)◦Melena, hematuria, or

both◦CNS signs (depression,

ataxia, dementia, coma, seizures)

Dx◦Hx of drug administration◦Painful liver on palpation◦Chem panel

↑ ALT (alanine aminotransferase) ↑ Total bilirubin, ↑ blood ammonia ↑ Serum bile acids Hypoglycemia, coagulopathy

◦Radiographs show enlarged liver◦Liver biopsy (unless coagulopathy suspected)

Drug/Toxin Induced Liver DiseaseDrug/Toxin Induced Liver Disease

Rx◦Antidotes◦Induce vomiting◦Activated charcoal◦IV fluids◦Vit K for clotting◦Antibiotics◦Special diets (Hill’s k/d or u/d)

Drug/Toxin Induced Liver DiseaseDrug/Toxin Induced Liver Disease

Liver TumorsLiver TumorsMetastatic tumors are more common

than primary tumors of liverSigns

◦Anorexia, lethargy, wt loss◦PU/PD◦Vomiting/diarrhea (?)◦Abdominal distension,

hepatomegaly◦Jaundice

Dx◦Anemia◦Chem Panel

Abnormal liver enzymes and liver function tests

Liver tumorsLiver tumorsDx

◦X-ray: Heptomegaly, Ascites (?)◦Biopsy of liver◦Abdominocentesis may show tumor cells

Rx◦Surgical removal is preferred treatment

Single masses have good Px Multiple nodules/Diffuse disease have poor Px

◦Chemotherapy doesn’t help primary tumors; better for metastatic lesions

Client info◦Guarded to poor Px generally◦Survival time: 6 mo-3 y

THINGS THAT MAKE THINGS THAT MAKE YOU GO HMMMMMM…..YOU GO HMMMMMM…..

“Is it good if a vacuum really sucks?”

Portosystemic ShuntsPortosystemic ShuntsShunts form between portal circ and systemic circ

allowing blood to bypass liver; Function of liver—detox blood

Congenital or acquiredBy-passing liver, allows many toxins into

systemic circulationCNS is most affected by the circulating toxins

Portosystemic ShuntsPortosystemic Shunts

Signs◦Dumb/numb, lethargic, depressed◦Ataxia, staggering◦Head-pressing (against a wall)◦Compulsive circling, apparent blindness◦Seizures, coma◦Bizarre behavior (esp cats)◦Signs often more pronounced shortly after a meal

Portosystemic ShuntsPortosystemic Shunts

Dx◦Chem panel

↓ serum protein, albumin (liver is usually small) ↓ BUN (liver converts ammonia → urea) ↑ ALT (alanine aminotransferase), ALP (alkaline

phosphatase) ↑ blood ammonia

◦X-rays Small liver Contrast material

◦ Inject into splenic vein◦By-passes liver

Portosystemic ShuntsPortosystemic Shunts

Rx◦Medical management seldom very successful

Low protein diet◦Sx

Ligation of shunt◦Total ligation often causes ↑ liver BP◦Partial ligation may be more practical◦A second Sx can be performed after few months to close off

shunt totally

◦Client info Px often very good following ligation For best results, Sx should be performed before 1 y

old Collateral circulation may develop, with relapse of

signs

Portosystemic ShuntsPortosystemic Shunts

Feline Hepatic LipidosisFeline Hepatic Lipidosis

Idiopathic (IHL) – cause unknownMost common hepatopathy in catsObese cats of any age, sex or breedStress may trigger anorexia

◦Diet change, ◦Boarding◦Illness, ◦Environmental change

IHLIHL

Anorexia prolonged for 2 weeks causes imbalance between breakdown of peripheral lipids and lipid clearance within liver◦Lipids accumulate in liver

Other mechanisms proposedEarly diagnosis and aggressive

treatment important◦60-65% of cases => complete recovery

IHLIHL

IHLIHL

IHLIHL

Clinical Signs◦Anorexia◦Obesity◦Wt loss (as much as 25% of body weight)◦Depression◦Sporadic vomiting◦Icterus◦Mild hepatomegaly◦+/- coagulopathies

IHLIHL

Diagnosis◦CBC - stress◦Biochem panel – Increased ALP, ALT, bilirubin,

Low albumin, Increase serum bile acids◦X-rays – mild hepatomegaly◦US liver hyperechoic◦Liver biopsy – severely vacuolized

hepatocytes

IHLIHLTreatment

◦High protein, calorie dense diet◦Feeding tube usually required

NG tube for short term liquid diets Gastrostomy tube best Esophagostomy tube

◦Tubes can remain in placeFor up to 3-6 weeks

IHLIHL

Treatment◦IV fluids◦Metoclopramide SQ 15 min prior to feeding◦Monitor weekly

CE◦Avoid stress in obese cats◦Early intervention is essential◦Any cat that stops eating is at risk◦Cats do not respond well to frequent diet

changes

Pancreatic Dysfunction (Exocrine)Pancreatic Dysfunction (Exocrine)Main function of Exocrine Pancreas → secretion of

dig enzymesLocated along duodenumDig enzymes secreted in an inactive form to

protect pancreas tissue

Pancreatitis—Inflammation of pancreasMay be chronic or acute Develops when dig enzymes are activated within gland →

autodigestion More common in obese animal; high-fat diets may predispose

animal to it Unpredictable results; some recover well, others worsen and die

◦Signs Older, obese dog or cat with Hx of recent high-fat meal Depression, anorexia, vomiting ± abdominal pain Shock, collapse may develop Often seen post-holiday

◦Table scraps of ham, gravy, etc

Pancreatic Dysfunction (Exocrine)Pancreatic Dysfunction (Exocrine)

PancreatitisPancreatitis

Dx◦ CBC, Chem panel

Leukocytosis ↑ PCV Hyperlipidemia ↑ serum amylase, lipase

Rx◦ IV fluids, electrolytes◦ NPO 3-4 d◦ Antibiotics◦ Butorphanol for pain◦ Start back on low fat diet 1-2 days after vomiting

stopsClient info

◦ Avoid obesity/overfeeding◦ Feed low-fat treats◦ Px is difficult to assess

Exocrine Pancreatic InsufficiencyExocrine Pancreatic InsufficiencyThe pancreas stops making dig enzymesMay occur spontaneously (GerShep) or due to chronic

pancreatitis (cats)Signs

◦Wt loss◦Polyphagia◦Coprophagia, pica◦Diarrhea, fatty stool◦Flatulence

Dx◦Normal CBC

Rx◦Supplement pancreatic enzymes with each meal

Pancrezyme Viokase-V

◦Low fiber dietClient info

◦EPI is irreversible; life-long treatment◦Pancreatic enzyme replacement is expensive◦With enzyme replacement, dog will regain

weight, diarrhea will stop◦Must be given with every meal

Exocrine Pancreatic InsufficiencyExocrine Pancreatic Insufficiency

Perineal HerniaPerineal Hernia

Intact male dogs; atrophy of levator ani muscle; rectum herniates

Signs◦Reducible perianal swelling◦Tenesmus (feeling of full colon)◦Dyschezia (difficult defecation)◦Urethral obstruction

If bladder is herniatedDx

◦Rectal palpation reveals hernia sac

Rx◦Stool softeners (Colace)◦Enemas◦Surgical repair

CastrationClient info

◦Keeping stool soft may help reduce straining True for all dogs

◦Castration recommended testosterone is suspected as a predisposing factor

Perineal HerniaPerineal Hernia

Perianal FistulaPerianal FistulaExact etiology unknown; thought to start as an

inflammation of sweat and oil glands around anusBacteria grow well in the moist, warm region of these

glandsInfection invades into deeper tissuesMost commonly affects G Shep (84% of dogs diagnosed)Signs

◦ Intact male, older (>8 y)◦ Tenesmus◦ Dyschezia, pain on exam◦ Fecal incontinence◦ Bleeding, foul odor of perianal area

Dx—PE to r/o anal sac disease/perirectal tumor Rx

◦ Medical—usually not successful Clip hair, keep clean Flush with saline Antibiotics

◦ Surgical—difficult because of nerves/blood vessels Remove infected tissue Cryosurgery Laser surgery Cautery

◦ Client info Painful—be cautious of biting many complications of Sx

◦ Fecal incontinence◦ Anal stenosis

Perianal FistulaPerianal Fistula

Perianal Gland AdenomaPerianal Gland AdenomaSigns

◦ Intact male, older ◦ Single or multiple masses that may ulcerate

Not metastatic◦ Pruritis in anal area◦ Bleeding◦ Firm nodules in perianal skin

Dx—PE, biopsyRx

◦ Surgical removal◦ Radiation◦ Cryosurgery◦ Castration—causes regression of tumors

Client info◦ Gently cleanse area daily with baby wipes◦ Castration at early age helps prevent it