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My 2 y old little dog presented suddenly with hepatic encephalopathy

and was diagnosed with hepatic...
My 2 y old little dog presented suddenly with hepatic encephalopathy and was diagnosed with hepatic shunt in and outside the liver on usltrasound, not operable. Responded well to treatment and discharged on Lactulose and Metronidazole and low protein diet, Hills Science diet l/d canned food. Developed severe ascites that needed draining within 2w of discharge. Low blood albumine, half of normal level. Drained fluid did not contain protein. Happy and full of energy and very very loved. Told today to let her go... can't do it. Why the sudden ascites? Low protein diet causing it? What would be "high quality protein " to add to her liver diet? Told Spironolactone won't help much. Please advise.
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Answered in 1 minute by:
10/7/2013
Dr. G.
Dr. G., Veterinarian
Category: Dog
Satisfied Customers: 2,064
Experience: Private Practice Veterinarian
Verified

Dr. G. :

Hello, my name isXXXXX am a licensed veterinarian and I will try and help you as best as I can.

Dr. G. :

I am sorry to hear Tinkerbell is not doing well

Dr. G. :

liver shunts can be very hard to manage and often do not respond well to treatment

Dr. G. :

The ascites is from the low albumin

Dr. G. :

The low albumin is because the liver is not functioning properly, not related to the diet

Dr. G. :

The low protein diet is helping to minimize signs of hepatic encephalopathy

Dr. G. :

For that reason, you don't want to add protein to her diet

Dr. G. :

Spironolactone would be the next treatment, to try to pull fluid out, however it may not work for a very long time given how low her albumin is. The belly will continue to fill with fluid because of the low albumin.

Dr. G. :

I would give the Spironolactone a try if you are not ready to let go right now, but it is only a temporary fix unfortunately

Customer:

How do we get the blood albumin up to stop the ascites if adding protein to the diet won't work? Plasma infusion? Anything else we cant try? She is so young and so full of life

Dr. G. :

The only other thing you can do would be plasma transfusions. They would need to be regular: multiple transfusions a week, which can get very cost prohibitive after a few weeks

Customer:

And to just drain off the liquid every week or two?

Dr. G. :

Typically we will start with once every 7-10 days, then sometimes increase to as much as every other day

Dr. G. :

depending on her signs (mainly respiratory difficulty)

Customer:

What would be the easiest protein for her liver to turn to albumine?

Dr. G. :

unfortunately the particular protein source is not relevant in this case. The problem is the liver itself and its ability to work normal which is not dependant on the protein source. I would stick with the l/d diet, it is the best available for this disease

Customer:

She was completely well before,no ascites until the low protein diet, that's why I thought changing the diet may help.

Dr. G. :

A high protein diet will not alter the albumin levels, it will however increase the ammonia levels in the blood, which the liver is currently unable to eliminate well, which will make the signs worse. I think the timing here is just a coincidence

Dr. G. :

A transfusion is the only thing that will increase the protein levels in the blood (albumin)

Customer:

So if we drain the fluid depending on her respiratory signs what will happen next?

Dr. G. :

Essentially, you continue to do that until she declines enough and you are ready for humane euthanasia. The belly will continue to fill with fluid, she will slowly worsen as far as becoming lethargic and dehydrated, she will lose muscle mass, and eventually the protein levels will get so low that she will be full again within 24 hours after draining.

Customer:

What if the external shunt can be operated? How does one know if the liver is cirrhotic or fibrotic without a biopsy? The uss was done by a vet specialist who said the liver was smaller than it should be, in keeping with shunting, there is a small external shunt which may be operable but the internal shunts are multiple and not operable. Is it a congenital issue with shunting causing the liver damage or is liver damage for some reason the cause of the shunting?

Dr. G. :

The shunt is a congenital problem and is breed related. The external shunt can be operated on, but the internals cannot. Given the internal shunts, it is likely signs would not improve with surgical closing of the external shunt. A biopsy is indeed needed for definitive diagnosis, however given the age, breed, clinical signs, and ultrasound findings, it is a pretty easy diagnosis

Customer:

I need to know that I have done everything possible, is there nothing else? What about the liver's regeneration potential?

Dr. G. :

The liver will not regenerate with a shunt present due to the abnormal blood flow. You are doing everything you can, but unfortunately this is a disease that in this case you really can do nothing to affect long term outcome. The spironolactone and plasma transfusions may help in the short term, but you will never be able to cure this disease or regenerate lost liver. I'm sorry

Customer:

Thank you for explaining everything, it's just so hard, I love her so much, she's given me so much joy, I just didn't expect her life to be so short. I 'll see how she goes and take her to sleep when she deteriorates again. Thank you.

Dr. G. :

You're very welcome.


I wish you the best with little Tinkerbell. It sounds like she has a great home and a wonderful owner. Please feel free to contact me again if you need any further information, otherwise please feel free to leave positive feedback for this conversation. My goal is 100% customer satisfaction. If you do not believe you have received this, please reply back before rating and I will help you further. Thank you and have a great day.

Dr. G.
Dr. G., Veterinarian
Category: Dog
Satisfied Customers: 2,064
Experience: Private Practice Veterinarian
Verified
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Hi Ria,

I'm just following up on our conversation about Tinkerbell. How is everything going?

Dr. G.
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