Dr. Marie, I have a now 14 year old yorkie with some complex medical issues and I’m hoping you can shed some light on his most recent test results.
We first noticed Scooby had elevated liver enzymes six months ago when he had a blood test for another reason. At that point his ALT was around 250 and the ALP at around 1500. In spite of our – and our vets – best efforts to figure this out and bring the enzymes down, they continued to rise at an alarming rate. In the past six months, we’ve had numerous blood tests, two ultrasounds, tested him for Cushings (negative), and ran a bile acid test. Bile acids were slightly elevated (pre level was 15.6 and post level was 35). The ultrasound in September showed a slightly enlarged liver, no shunts or anything that would suspect cancer, and all the other organs looked normal including his gall bladder and pancreas. We have changed his diet to Royal Canin Hepatic (with some homecooking – Dodd’s diet), he has been on Denamarin and fish oil for now six months. We have tried two different types of antibiotics (Amoxycillin and then Clamavox – both very long courses), and he has been on Flagyl. In November, his ALT had risen to around 500 and the ALP to 4500. The rest of his blood work has been and continues to be in the normal range. Clinically, he looks great. Eats well, is active and playful and has not lost any weight.
By the end of January, his ALT had risen to 600 and the ALP at a whopping 7000. That is when we did the second ultrasound, which when compared to the one in September did not really show any change. The second ultrasound in February was read by a board certified radiologist and the report said that his liver was slightly enlarged and had some areas which could be significant for inflammation, changes due to Cushings disease or even cellular regeneration. The same areas were noted on the first ultrasound in September but not defined. Then we did the Cushings test (negative) and the bile acids. Throughout all these tests and trying one thing and another, no definitive reason has been found for the issue with his liver.
At the end of January, he was put on Actigall, not because a problem was noted with his gall bladder but because there was not much else to try and he is not a very good biopsy candidate because of the very high liver enzymes. We also discontinued all the antibiotics and Flagyl. Thirty days later I was shocked that his liver values had drastically dropped. His ALT is now back in the high normal range at 104 and his ALP has dropped to 3900. The rest of the liver panel still looks good. Our little guy has been a puzzle trying to figure out because he does not have any typical symptoms of the liver problem except the two elevated enzymes.
My question is, could Actigall have made that much difference and that quickly? And have you ever seen a dog with ALT and ALP that high make a good recovery? I haven’t had a chance to speak to my vet and the blood test results were emailed to me over the weekend, so at first I thought it was awesome news. Then I jumped on the Internet and scared myself silly when I read that a drastic and unexplained drop like that can also signify even worse news…such as liver failure?? What are your thoughts on that?
Dr. Marie replied:
Wow. You and Scooby have sure been through a lot. Liver conditions like this can be extremely frustrating to figure out. I have had several cases very similar to yours where we can't find an answer but all we know is that there is *something* going on with the liver.
It sounds like your vet is doing an excellent job. Sometimes we just have to try different things and see what works. If the numbers have come down after starting the Actigall, then it certainly is possible that there is a bile duct problem and the Actigall is working. It is a safe drug and I would keep it going.
I would not worry at all about the fact that the numbers are dropping. What you mentioned about a drop in enzymes being a problem is really not applicable in Scooby's case. If a dog is in liver failure they are SICK...I mean, really sick...vomiting, not eating and lethargic. If the liver is extremely diseased then it can stop producing the enzymes that it has been over producing and then we can see a drop in numbers. But it sounds like he is actually feeling quite well.
I know it is frustrating not knowing what the problem is, but if it helps at all, this is unfortunately very common in liver issues. I would say to trust the advice of your vet and keep doing what you are doing. When you find something that helps, then stick with it.
I hope he continues to do well. Let me know if you have more questions!
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Have you ever had a dog in your practice, with elevations that high over a period of time, actually make a decent recovery?
I realize that he is likely to need the meds and supplements for the rest of his life, which doesn't bother me. I mean he's 14 and I know that is old for a dog, but I'm curious about a prognosis. Since my vet can't give me a diagnosis, I don't know what to expect.
And is Actigall known to work that quickly? It seems like a drastic drop in just 30 days, especially since they've been climbing at an astonishing rate for six months now.
Thanks for giving me a little peace of mind.
Dr. Marie replied:
I have seen many dogs recover from high liver enzymes. However, there are probably hundreds of different reasons for liver enzymes to be high, so we can't really generalize that all dogs are going to do the same. For example, I had a dog who ate toxic mushrooms and had severe liver failure with numbers much higher than Scooby's. After treatment they came back down to completely normal.
But Scooby's issue is not likely to be a toxin. There is likely an age related condition that is more chronic in nature than acute. I would expect that whatever this is, he will never be completely cured, but the hope is to keep him active and happy for as long as possible. You are right, that it is pretty much impossible to give a prognosis as we don't have a diagnosis.
I can't recall having a case where there was a dramatic improvement after giving Actigall but that doesn't mean that it didn't work for Scooby. I think that it is very likely that the Actigall is what is helping him the most.
Thanks. I guess we're in a wait and see mode then. Our vet wants to retest in 30 more days.
One more question, if the elevations do continue to drop significantly and making him a better surgical candidate, would you think a biopsy would still be beneficial?
Dr. Marie replied:
A biopsy is always a good idea (provided your vet feels it is safe.) It doesn't always give an answer but sometimes it can give a very definite answer.
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Dr. 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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