HISTORY / CLINICAL SIGNS: Several month Hx of fatigue, weight loss, decreased appetite, diarrhea, occasional vomiting, urinary accidents in the house, and increased thirst. Not up-to-date on DHPP vaccine. Not on consistent flea/tick/HW preventives. No other pets in the household. No known toxic insult.
PHYSICAL EXAM FINDINGS: BCS 2/9. QAR, weak. TPR: WNL. mm yellowish/tacky. CRT 2 sec. Delayed skin tent. Sclera icteric. Grade 2/6 left-sided heart murmur. Bronchovesicular sounds normal. Muscle wasting. Pendulous abdomen with mild fluid ballotment. Abdomen non-painful. Liver palpates firm and slightly enlarged. Poor coat quality. Mild pitting limb edema. Hematochezia.
What diagnostic tests would you order? Any other questions?
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DIAGNOSTIC TESTS & RESULTS:
- CBC: HCT 29%, normocytic, normochromic, non-regenerative. Occasional target cells. Platelets normal. Stress leukogram.
- Chemistry: Serum yellow. Glu 71 (88-121mg/dL). BUN 6 (8-30mg/dL). Crea 1.8 (0.4-1.8mg/dL). Ca 6.9 (9.4-10.7mg/dL). P 5.1 (1.9-4.4mg/dL). TP 4.3 (5.3-7.8g/dL). Alb 1.3 (2.8-4.3g/dL). Glob 3.0 (2.1-3.8g/dL). ALT 247 (16-75U/L). AST 101 (13-48U/L). ALP 281 (8-70U/L). GGT 6 (1-5U/L). TBil 3.2 (0-0.4mg/dL). Chol 62 (129-332mg/dL). Normal Na & Cl. K 3.0 (3.4-4.5mEq/L).
- โBonus Question 1 of 4: Would you have expected the liver enzyme values to be higher in this case or not? (answer below)
- Coagulation panel: ACT 89 (60-100 sec). PTT 26 (11-19 sec). PT 14 (5-12 sec). FDPs >1:5, <1:20 (<1:5).
- Serum ammonia: declined by owner
- Bile acids: not performed
- โBonus Question 2 of 4: Why is this test unnecessary for this case? (answer below)
- Urinalysis: Yellowish-orange color. USG 1.015. 1+ protein. 2+ bilirubin. Bilirubin crystals.
- UPC ratio: declined by owner
- Imaging โ Abdominal radiographs: Mild diffuse hepatomegaly with free abdominal fluid. Abdominal ultrasound: declined by owner
- Abdominocentesis: declined by owner
- Fecal flotation: NOPS
Based on this patientโs signalment, clinical signs, physical exam findings, and test results, what is your diagnosis, recommended treatment, and prognostic outlook?
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DIAGNOSIS: Chronic Liver Failure
Unfortunately, the exact cause of this patientโs liver disease was not determined as financial constraints prohibited the owners from consenting to an abdominal ultrasound and liver biopsy. Cirrhosis is suspected but not confirmed. Additionally, the abdominal fluid detected upon PE and X-rays is most likely ascites based on the Dx of liver disease and the presence of hypoalbuminemia and limb edema; however, without fluid analysis, this cannot be confirmed. Other risks for this patient are hepatic encephalopathy, spontaneous pulmonary edema/pleural effusion due to low albumin, as well as hemorrhage as suggested by the increased clotting times.
โBonus Question 3 of 4: What does the albumin concentration need to be in order to cause spontaneous ascites and pulmonary edema/pleural effusion? (answer below)
This patient has evidence of protein-losing enteropathy (PLE) with hematochezia, which can occur with hepatic disease. The most likely causes of this patientโs end-stage liver failure include diffuse neoplasia or chronic/active hepatitis.
โBonus Question 4/4: Would infectious canine hepatitis caused by adenovirus-1 be a possible differential in this case? Why or why not? (answer below)
EMPIRICAL TREATMENT: This patient was initially stabilized in-hospital with IVF (0.45% NaCl + 2.5% dextrose + K โ Hetastarch also considered), antiemetics, amoxicillin, & parenteral vitamin K1. Pressure wraps to reduce limb edema were applied. A blood transfusion to restore clotting factors was declined. Upon discharge, the patient was then managed with Denamarinโข (SAMe + silybin), immunosuppressive prednisone, and famotidine. The use of a prescription liver support diet, D-penicillamine, and ursodiol was discussed but ultimately declined by the owner.
PROGNOSIS: After several weeks of at-home care with some improvement, this patient was brought in on emergency, suspected to be in disseminated intravascular coagulation (DIC). She was ultimately euthanized. A necropsy was declined.
Any other questions, comments, or suggestions?
BONUS QUESTION ANSWERS:
โBonus Question 1: Would you have expected the liver enzyme values to be higher in this case or not?
- Answer 1: Not necessarily; this patientโs liver values were only mildly/moderately high. As more and more hepatocytes die off with progressive liver failure, there are not enough liver cells to produce or leak enzymes that would otherwise cause elevations seen on blood chemistry. Instead, liver enzyme values may not look as high as expected and may even be normal with end-stage failure.
โBonus Question 2: Why is this test [bile acids] unnecessary for this case?
- Answer 2: If a patient is icteric (as in this case), there is no need to run a bile acids test because the answer is known: bile acids will be elevated if a patient is icteric.
โBonus Question 3: What does the albumin concentration need to be in order to cause spontaneous ascites and pulmonary edema/pleural effusion?
- Answer 3: <1.0-1.5 g/dL
โBonus Question 4: Would infectious canine hepatitis caused by adenovirus-1 be a possible differential in this case? Why or why not?
- Answer 4: No. Despite causing liver disease, infectious canine hepatitis (ICH) does not cause icterus in infected dogs because cholestasis does not result. The patient in this case was jaundiced, so ICH is unlikely to be the cause of liver disease despite the fact that she was not up-to-date on her DHPP vaccine.
Unless otherwise stated, these clinical cases are real-life cases that I have managed as a veterinarian in general small animal veterinary practice or else assisted with as a student in vet school. These cases are a great real-world learning tool for vet students and other veterinary professionals. They shall be used for learning purposes and collaboration of knowledge only. These cases are not intended to diagnose or treat any disease by pet owners. – Maranda Elswick, DVM
