Interesting Case No.5

Pyometra (Uterus Infection)

Under construction. Maggie is a 5 year old Labrador cross, female desexed dog. She presented to our clinic on the 3rd of May 2008, having been off her food for 4 days and vomiting throughout this time. Examining Maggie she was found to be quite jaundiced. That is, a yellow discolouring of her gums and conjunctiva. In itself this raises concern over liver disease of some kind. She was in fact still reasonably bright, despite the last 4 days.

Bloods were taken for a full general profile whilst initiating anti-biotic cover in case of bacterial hepatitis. The blood results returned the next day revealed significant liver disease. The following are 5 general liver enzymes, showing Maggies' level and in brackets the normal values:

Bilirubin 341 (2-15)
Alk Phos 651 (10-120)
ALT 1407 (5-80)
GGT 31 (1-10)
AST 522 (10-80)

As can be seen from these values we have significant liver disease. Now, liver disease is one of the most complicated organ diseases our pets can suffer. Bloods can tell us we have liver disease, but cannot tell us what is causing the disease. Generally speaking the broad categories of most likely causes include the following:

Bacterial hepatitis
Toxic hepatitis
Inflammatory
Cancer
Viral

The trick is to try to ascertain which of these it is, and the only way is via a biopsy. That is, we need to take a piece of the liver itself and send it to a pathologist to look at it under a microscope. Now, here's the complicated part about liver disease, and in fact liver biopsies. Most times we take a section of tissue for pathology we have a very high chance that will give us a very specific diagnosis. Liver biopsies are different. The various diseases listed above don't necessarily have completely distinguishing features, and often we may not get a specific diagnosis. The frustration for client and clinician alike is that this must be understood before the client goes to a liver biopsy.

Biopsies of the liver can be done two main ways. Firstly, via a sedation, ultrasound and needle biopsy through the skin. The second way is via surgery, actually anaesthetising the patient, opening into the abdomen, visualising the liver and surgically taking a piece. There are pros and cons of both methods but ultimately I prefer surgery. Via surgery we can not only get a much larger piece, we can actually view the whole abdominal contents, reducing the chance of not finding something on ultrasound. Interestingly, the total cost is actually cheaper than compared to sedation and ultrasound.

Maggies owners decided to go ahead with a surgical exploratory and biopsy. Upon inspection of the liver during surgery, we found a diffuse nodular appearance to the liver. A section was taken for histopathology and the rest of the abdomen was inspected. Sometimes cancer is obvious just on inspection of the liver. However, often times cancer may not be obvious until we get the biopsy results. Fortunately for Maggie, the results were not cancer but was in fact a condition called chronic active hepatitis.

Hence the biopsy of Maggies liver did in fact give us a fairly specific diagnosis of inflammatory hepatitis. In itself this is a liver disease which we are not exactly sure what causes it. It in fact may be caused by the immune sytem over reacting and as such often responds to high doses of cortisone to reduce the inflammation in the liver and reduce the immune system.

At least now we had ruled out infectious causes and cancer, and we could safely trial the high doses of cortisone that are needed to treat this condition.

Maggie was started on high doses of cortisone which were tapered down as the weeks went by. Very quickly, within days, Maggie's energy levels and appetite returned. Within about 10 days, the severe jaundice was subsiding.

Maggie has her liver enzymes monitored regularly and within six months she was doing well on a very low dose of cortisone. She will possibly need this for life, however she is living a very active happy life.

SUMMARY OF MAGGIES LIVER DISEASE:

Blood tests can tell us that we have liver disease, but not what's causing it.

Biopsy may give us a definitive diagnosis of what the cause is. There may or may not be treatment options once we have a diagnosis.

In Maggies case we had a treatment option that she fortunately has responded very well to and now lives an active normal life.