by Anne Jones RN, BSNE
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!