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Liver disease and diarrhea?

Species: Dog
Breed: Boston Terrier
Age: 8-11 years
Hi Dr. Marie
My 11 y.o. Boston Andi (about 14 pounds) has been a healthy girl all her life. The only thing she's ever had has been occasional diarrhea, maybe once or twice a year, sometimes years go by without even that. Andi had a short but severe bout of diarrhea about 2 1/2 months ago. Middle of the night, blood, awful. I fasted her and fed very bland stuff, and it was not so bad but not resolved completely in 2 days so we went to the vet. She did a blood test and discovered elevated GGT and Total Bilirubin and low protein (I have scanned all results and will try to email to you.) She gave her a B12 shot, and we started her on Metronidazole (125 mg 2x daily) and Denamarin. Andi was completely recovered and normal acting. We went back for a follow up (again no fasting) blood test and Bilirubin was up from .6 to 1.3; GGT up from 17 to 47. The doctor recommended a liver biopsy.

I took Andi down to my sister's place for a week to see her vet for a second opinion, as my sister has great respect for him. We saw somebody different. A bile acids test was done, an ultrasound and blood tests repeated. Bile acids pre:6.6; post 54.1. Ultrasound showed enlarged adrenals, with sludge seen in gallbladder. Cushing's was ruled out after an LDDS was normal. Recommended food change which I did. No other hypotheses. Told me to see local vet and get a urine test for creatinine/cortisol ratio. Local vet puzzled by Cushing's hypothesis and urine analysis. An ordinary urine analysis was done. NEW blood work and bile acids test showed GGTP at 20;Platelet Count 423; Pre meal bile acids 23; post meal bile acids 29.9. Liver biopsy was attempted but abandoned as the liver was quite vascular and the procedure deemed unsafe.

It has been 2 1/2 months since the diarrhea that started all this and yesterday I began to notice the symptoms of another attack starting -- gas, esp. at night, getting BAD, is the big sign. she's not a gassy girl ordinarily. The next day sure enough, there was diarrhea, but it wasn't the explosive kind. I fasted her and started her back eating slowly, while starting her on 125mg. of metronidazole morning and night, plus a famotidine before bed because she seems to have acid reflux as her tummy gets emptier. This morning stool is pasty but formed, and she eats well (always!) and gas disappears after eating. I will try to send the scans of test results; please don't display these. I don't know what to do -- whether this bland canned food is doing something, or I should keep her on metronidazole forever or what. Any thoughts? needless to say I love this dog, and don't want to put her through treatments that have little chance of helping, at her age. I would appreciate your thoughts. Thank you very much for reading all this. Kathleen

Online vet, Dr. Marie

Dr. Marie replied:

Sorry to hear of all of the trouble you and Andi have been through. Cases like this sure can be frustrating.

It sounds like the main question here is whether or not Andi has a problem with her liver. Sometimes it can be so hard to tell. She has had some elevated liver enzymes, but nothing that I would call outrageously high. The most important test to determine if the liver is functioning properly are the bile acids. If a dog has normal bile acids, especially post prandial, then the liver is generally functioning ok. The post is the test that tells me the most. When the post was 54.1 I would be starting to wonder if there were issues and would want to do the test again a week or two later. But, given that the following test had a number of 29.9 that really isn't that high. Usually when there is serious liver disease we see a number that is >100 or so.

Ultimately the way to know if there is something going on with the liver is to biopsy, but if the vet felt that biopsying was not safe then unfortunately not much can be done. But, I can tell you that often in cases like this when we biopsy we still get inconclusive results.

If a LDDS test is normal then this is not cushing's.

So, if this were my case, I would be treating the diarrhea. If the metronidazole is working you could talk to your vet about possibly using a medication called tylosin which is quite effective when antibiotics are needed long term to control diarrhea. You can also talk to your vet about the possibility of inflammatory bowel disease.

Intestinal issues are frustrating too because short of doing intestinal biopsies, it's hard to know what the problem is.

It sounds like your vets are doing the right things though. I hope you get some answers soon!

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Disclaimer: Although Dr. Marie is a qualified veterinarian, the information found on this site is not meant to replace the advice of your own veterinarian. and Dr. Marie do not accept any responsibility for any loss, damage, injury, death, or disease which may arise from reliance on information contained on this site. Do not use information found on this site for diagnosing or treating your pet. Anything you read here is for information only.

Customer reply:

Thank you Dr. Marie
I appreciate your prompt and thorough answer. I will follow up with my local vet re tylosin and IBS.

Is there a test for IBS? Is it undesirable to continue very long on the metronidazole? And is there a food you would recommend, or types to avoid? I was also wondering if smaller, more frequent meals would be helpful. Sorry about all these questions! I won't abuse your good nature any further. I am grateful for your "voice in the wilderness" so to speak. Many thanks for a much needed service.

Online vet, Dr. Marie

Dr. Marie replied:

If this is inflammatory bowel disease (IBD) usually, the only way to get an accurate diagnosis is to biopsy the intestines.

I have had some patients who stay on metronidazole long term. There is some concern that long term metronidazole could cause a dog to be predisposed to cancer, but no one has proven this. If it is working then you can talk to your vet about possibly using it long term or sporadically as needed.

Food is debatable. For dogs with recurrent diarrhea issues I have had good success with Royal Canin Gastro Diet. This is a prescription food and you can ask your vet for recommendations. Just as a side note, this is unlikely to be a food allergy. I have many clients who want to feed all sorts of strange holistic diets when something like this happens and it probably won't help.

Don't worry at all about the questions! That's why I'm here!

Oh, and thanks so much for the bonus. :)

Dr. Marie.

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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.

Is an online vet visit just as good as a trip to your veterinarian? No! But, many times, asking an online veterinarian a question can help save you money. While Dr. Marie can't officially diagnose your pet or prescribe medications, she can often advise you on whether a vet visit is necessary. You can also ask Dr. Marie for a second opinion on your pet's condition.