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ADVERSITY “Adversity causes some men to break, others to break records.” -William A. Ward Liver 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 Disease Signs ◦ Acute onset ◦ Anorexia ◦ vomiting/, diarrhea/constipation ◦ PU/PD ◦ Jaundice (maybe) ◦ Melena, hematuria, or both ◦ CNS signs (depression, ataxia, dementia, coma, seizures) Drug/Toxin Induced Liver Disease 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 Disease Rx ◦ ◦ ◦ ◦ ◦ ◦ ◦ Antidotes Induce vomiting Activated charcoal IV fluids Vit K for clotting Antibiotics Special diets (Hill’s k/d or u/d) Liver Tumors Metastatic tumors are more common than primary tumors of liver Signs Dx ◦ ◦ ◦ ◦ Anorexia, lethargy, wt loss PU/PD Vomiting/diarrhea (?) Abdominal distension, hepatomegaly ◦ Jaundice ◦ Anemia ◦ Chem Panel Abnormal liver enzymes and liver function tests Liver tumors Dx ◦ 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 YOU GO HMMMMMM….. “Is it good if a vacuum really sucks?” Portosystemic Shunts Shunts form between portal circ and systemic circ allowing blood to bypass liver; Function of liver—detox blood Congenital or acquired By-passing liver, allows many toxins into systemic circulation CNS is most affected by the circulating toxins Portosystemic Shunts Portosystemic 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 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 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 Feline Hepatic Lipidosis Idiopathic (IHL) – cause unknown Most common hepatopathy in cats Obese cats of any age, sex or breed Stress may trigger anorexia ◦ ◦ ◦ ◦ Diet change, Boarding Illness, Environmental change IHL Anorexia prolonged for 2 weeks causes imbalance between breakdown of peripheral lipids and lipid clearance within liver ◦ Lipids accumulate in liver Other mechanisms proposed Early diagnosis and aggressive treatment important ◦ 60-65% of cases => complete recovery IHL IHL IHL Clinical Signs ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Anorexia Obesity Wt loss (as much as 25% of body weight) Depression Sporadic vomiting Icterus Mild hepatomegaly +/- coagulopathies IHL 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 IHL Treatment ◦ 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 place For up to 3-6 weeks IHL 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) Main function of Exocrine Pancreas → secretion of dig enzymes Located along duodenum Dig enzymes secreted in an inactive form to protect pancreas tissue Pancreatic Dysfunction (Exocrine) Pancreatitis—Inflammation of pancreas May 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 Pancreatitis Dx Rx Client info ◦ CBC, Chem panel Leukocytosis ↑ PCV Hyperlipidemia ↑ serum amylase, lipase ◦ ◦ ◦ ◦ ◦ IV fluids, electrolytes NPO 3-4 d Antibiotics Butorphanol for pain Start back on low fat diet 1-2 days after vomiting stops ◦ Avoid obesity/overfeeding ◦ Feed low-fat treats ◦ Px is difficult to assess Exocrine Pancreatic Insufficiency The pancreas stops making dig enzymes May occur spontaneously (GerShep) or due to chronic pancreatitis (cats) Signs ◦ ◦ ◦ ◦ ◦ Wt loss Polyphagia Coprophagia, pica Diarrhea, fatty stool Flatulence Dx ◦ Normal CBC Exocrine Pancreatic Insufficiency Rx ◦ Supplement pancreatic enzymes with each meal Pancrezyme Viokase-V ◦ Low fiber diet Client 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 Perineal 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 herniated Dx ◦ Rectal palpation reveals hernia sac Perineal Hernia Rx ◦ Stool softeners (Colace) ◦ Enemas ◦ Surgical repair Castration Client info ◦ Keeping stool soft may help reduce straining True for all dogs ◦ Castration recommended testosterone is suspected as a predisposing factor Perianal Fistula Exact etiology unknown; thought to start as an inflammation of sweat and oil glands around anus Bacteria grow well in the moist, warm region of these glands Infection invades into deeper tissues Most 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 Perianal Fistula 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 Gland Adenoma Signs ◦ Intact male, older ◦ Single or multiple masses that may ulcerate Not metastatic ◦ Pruritis in anal area ◦ Bleeding ◦ Firm nodules in perianal skin Dx—PE, biopsy Rx Client info ◦ ◦ ◦ ◦ Surgical removal Radiation Cryosurgery Castration—causes regression of tumors ◦ Gently cleanse area daily with baby wipes ◦ Castration at early age helps prevent it