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High ALKP and bile acids.

Species: Dog
Breed: Jackapoo
Age: 5-8 years
Hi Dr. Marie

I value your opinion so much and I do respect and understand that your opinion is just that, an opinion and it cannot be substituted for the advice of my regular veterinarian.

As you may recall, I was in touch with you regarding Oreo's elevated liver enzymes and Bile Acid test results a few weeks ago.

Although his post meal test results were not that bad, the first post meal of 26.9 and the second one a month later, 46.0 I decided it was time to take it to the next level and I took him to the University of Wisconsin-Madison vet school. What a great place! :-) So happy I did so.

Oreo has had issues with his ALKP liver enzymes on and off throughout his 6 years. But never anything seriously high. So as you can see, I sent you a document with his results, way too many for me to post on here, he had a good going over. Again his liver enzymes on the ALKP were up even more than a month ago and his post meal bile acid had risen also in a months time to 61 from a 46.

The internist was not alarmed really by any of his test results and feels most likey he has Microvascular Dysplasia. I am still shook up that his post meal is rising every time we take it. And that his ALKP had risen to 374 from 217 a month earlier. Again the internist was not concerned.

He was put on Denamarin, he had been on SAM-e. He was also put on an antibiotic in case there was a low grade type of infection going on in his intestines causing the up and down levels. I am to recheck blood levels in 3-4 weeks while he is still on his antibiotic.

He had an ammonia test done, that was normal. Protein C test done and that was normal. Basically everything was darn near perfect except those darn liver enzymes and the BAT post meal.

A friend of mine suggested that up and down ALKP is indicative of bone disease. This is not something I asked the internist because I was not aware of it at the time I saw her. The internist told me they have a motto they go by and that is "Treat the dog, not the lab values." They stresed to me that he is bright, happy and presents darn near perfect on examination. She told me that he most likely has had MVD his whole life and for most part has thrived. He isnt scrawny, his color is perfect, he is 3 pounds overweight, all those thing she told me are great signs.

I am glad she is not worried about his results but yet there has got to be a reason for these fluctuating liver values. And it worries me. Oh yes, there was some kind of break down too in the collection of his blood cells. I forget the name of it, but I guess that can affect results?

I am an opinion seeker and wondering how you feel about the documents I sent to you. Feel free to post them on your website if that is possible but appreciate if you can leave out my name, address and phone number.

Many thanks to you!

Suzie


Online vet, Dr. Marie

Dr. Marie replied:

Hi Suzie. Thanks for sending me that report. That gives me a lot more insight about Oreo's case. And you know what? If he was my patient I would not be worried about him at all.

It's true that he has some elevation in his ALKP, but in my books these elevations are very minor. Almost every dog I see that is over the age of 5 has some mild increase in ALKP. I once spoke with a pathologist about this and her thought was that most dogs develop some mild Cushing's disease as they mature. She feels that the disease in most dogs never gets to the point where we are seeing clinical signs and we don't ever have to do anything about it.

With that being said, when I do see an elevation in ALKP I generally do recommend doing a liver workup or tests for cushing's. Even though many dogs have elevations that are nothing to worry about, there is the odd one that has an underlying problem. If those tests are normal then I simply keep an eye on the liver enzymes every 6 months or so. If I start seeing ALKP numbers of 800 or so or higher then I get more serious about looking for actual disease again. Or, if I have a dog that is losing weight, not eating and not feeling well then we revisit the situation. (If Oreo is 3 pounds overweight I can almost guarantee you that there is no active liver disease!)

I recently talked to a specialist recently about a dog who had a really high ALKP (like 1200 or so) and I couldn't find any disease present. He said in his experience dogs with high increases in ALKP and no other symptoms usually end up being diagnosed with Cushing's disease down the road. Now, Oreo's ALP is not even close to me wondering about Cushing's, but if the level keeps going up and gets to high levels then we could consider retesting for Cushing's. With that being said, we don't treat Cushing's unless we have clinical signs of increased thirst and urination.

It is true that ALKP can be elevated in a growing puppy because the bones are growing, but it is pretty rare that I would attribute an increase in ALKP in an adult dog to bone disease.

The only thing that seems a slight bit abnormal to me is the elevated bile acid. However, the specialist's comment that we treat the dog and not the lab results is so true. What I see here is a slight elevation and again, nowhere near the levels that I would worry about. I think it's a great idea to cover all bases and treat with the liver protectant and antibiotics just to be sure. But, likely there is really not much we can do. Remember that no test is 100% accurate...we use them as guidelines.

What I can see on Oreo is a slight elevation in liver enzymes (which is often normal) and a dog that is happy and healthy and overweight. If this was my patient I wouldn't be worried at all, but I would occasionally be doing some blood tests just to be sure that there is not something looming. You will likely see a mild increase in ALKP each time and possibly variation in bile acid results. If you start to see a really high increase then I would be more vigorous in looking for disease.



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Customer reply:

Hi Dr. Marie

I am very relieved to read your reply. It means alot to me.

The post meal bile acid result has climbed from the original 26.9 up to 61 now. So does this mean his might jump around a bit for rest of his life? I will be retesting him in 3 weeks and almost dred the day. My heart will sink if it rises even more.

I asked the internist about Lactulose and she said no to it for now. From what I have read about that, it sounds like you have to be on the poop watch to make sure the stools are the way they are suppose to be. What are your thoughts on Lactulose? Does Oreo seem like a candidate for that yet?

An option for me if the biles come back elavated will be laparoscopic liver biopsy and gall bladder fine needle aspiration with culture. The vet made light of the liver biopsy saying it was no big deal. His clotting panel is good so it doesnt look like he would have a problem if he bled. I've read one should never put a dog through liver biopsy so if it comes to my having to decide, will that deffinately tell me more about what is causing Oreo's elevating post meal biles? I am one that wants a deffinate diagnosis on things but is that really necessary I wonder? What is recovery like for dogs who have undergone the biopsy? Do they bounce back alright or could I harm Oreo by having this done?

And where does the gall bladder come in with all of this? I wonder why the vet would suggest the fine needle aspiration of that?

I have the finances to persue this further but I dont want to put his life in jeopardy either by putting him through all of that unless necessary.

I also have a question about the Cipro antibiotic he is on. He will be on it for about 3 or so weeks. Will that cause him any harm for that long? The bottle says to make sure he gets plenty of water. Well, I cant force him to drink, I can only have it available for him. I havent seen him drink any water lately. But his dog food has water in it so is that good enough? He just doesnt seem thirsty.

When those labs are repeated in a few weeks, and if they arent better, I just dont know how far to persue this and it causes me grief. Like I said, I dont want to harm in by having liver biospy and gall bladder poked and proded.

I hate to ask you this but if Oreo were your dog, and his labs came back higher, what would you do?

Thank you for looking over his report!

Suzie


Online vet, Dr. Marie

Dr. Marie replied:

You're right that the bile acids may jump around a bit. I don't think a slight increase or decrease will mean much, but if suddenly we are seeing a level like 120 or something like that then this tells us that we need to start being concerned.

Lactulose would only be necessary if there were signs of hepatic encephalopathy. You need a really diseased sick liver for this and this is not the case with Oreo!

If a clotting panel is normal then I have very few concerns in doing a liver biopsy, but really, I don't think it is necessary at this point. The only reason to do one would be to satisfy your need to put a name on Oreo's condition. But, often if there are mild liver elevations we could do a biopsy and STILL not have an answer. At this point, doing a biopsy won't change Oreo's quality of life at all. I'd hold off on this. If the bile acids or liver enzymes have a dramatic increase or if he is not feeling well then the vet may be more keen to do it.

The gall bladder is just part of the whole liver enzyme thing. There are some conditions that we can diagnose by aspirating the gall bladder. But again, this seems extreme to me at this point. But, if/when it comes the point where you are going to do a biopsy of the liver you might as well be thorough and look at the gall bladder too.

Cipro is generally safe. There are some rare cases where dogs have gotten bladder crystals after a long course of these antibiotics. It's not enough risk to stop the meds though. If we can encourage him to drink this lessens the risk, but as the risk is tiny I wouldn't be too worried.

If Oreo was my dog I would do no further testing on him for at least 6 months. Perhaps I may do it sooner if he was losing weight or not feeling well. Then, in 6 months I would repeat liver enzymes and bile acids. It wouldn't surprise me if there was a slight increase. If there is a large increase then I would consider doing the biopsy. And, at any point if he develops symptoms of cushing's disease (drinking and urinating more) then I would re test for that.

Dr. Marie.



Customer reply:

Hi Dr. Marie

Thank you so much for your detailed reply back, I value your opinion very much!

Wow, so do no testing for 6 months...? I'm so neurotic that might be hard, lol. So it wouldnt surprise you if there was a slight increase, even being on the Denamarin? I would hope the numbers would go down. What makes you say that?

I am concerned a little about the Cipro Oreo is on. The plan was for him to be retested at about the 3 week mark of being on the Cipro. But meds can affect test results, cant they? I would deffinately expect an increase with him being on the Cipro. He was given a 40 day course of that and I worry being on an antibiotic that long could do more harm than good? I have also noticed he has been coughing since he began it and has had some bouts of reverse sneezing too. That wasn't present before he began the Cipro. I wonder if that could be a side affect? There was no list of side affects that came with the prescription. If by chance there was some type of infection going on that was causing his biles to be up, would being on it for 2 weeks be adequate time for the infection to clear? I'm a bit concerned with him being on it for 40 days. I try to get him to drink more water but he isn't interested. I always have it available for him.

Since you viewed the documents, what are the chances of him really needing to be on the Cipro? Based on his other labs, would other numbers be off if he had an infection going on? I am wondering if I should take him off of the Cipro and see if his coughing and reverse sneezing stops? Might there be another antibiotic you could recommend I ask my vet about or would the Cipro be your drug of choice too?

A friend and I were talking and she wondered if Oreo could perhaps not have a liver problem but still have biles that are all over the map? The vet internist we saw has now moved on to another rotation I am told so she is very hard to get ahold of.

Well we are getting close to Christmas and I know you are busy so there is no hurry for a reply. Just as your schedule permits is good for me and thank you again Dr. Marie! Merry Christmas :-)

Suzie


Online vet, Dr. Marie

Dr. Marie replied:

Thanks for the bonus Suzie. It's greatly appreciated.

About the increases and decreases all I can say is that these numbers are not absolute. They are averages. You could do a test today and repeat it tomorrow and the numbers could be significantly different. What we look for are continuing trends upwards or dramatic increases. You will drive yourself crazy worrying about minor changes like this.

The best advice I can give you is to trust your vet. It sounds like they are doing an excellent job. They wouldn't put him on Cipro if it wasn't safe. And no, the coughing/sneezing is not a side effect of cipro. If that continues you may need to have him checked again, but it doesn't really fit with his liver elevations.

I can't comment on which drugs are best. Trust your vet. They have Oreo's best interests in mind.

It really sounds like he is fine and now we need to work on getting mommy not to worry so much. :)

Dr. Marie.



Customer reply:

Hi Dr. Marie

You are very welcome for the bonus! :-)

I am working hard at calming down about this all. My local vet told me she wants to see Oreo today because it sounds like he has kennel cough. So that doesn't alarm me really and makes sense since he was kenneled with a group of other dogs last week at the vet school and he has been nowhere else since then, so imagine that! I am not worried about that. I know it will pass.

I do appreciate all of your replies and cant thank you enough.

Happy Holidays!

Suzie


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Dr. MarieDr. Marie is a veterinarian who practices in a busy animal hospital in Ottawa, Ontario. She created Ask A Vet Question as a resource for good, accurate veterinary advice online. Dr. Marie treats dogs, cats, hamsters, guinea pigs, and rats. She has been a vet since 1999.

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