ADVERSITY

1. ADVERSITY “Adversity causes some men to break, others to break records.” -William A. Ward

2. Liver Diseases High regenerative capacity; damage must be severe for signs to appear Drug/Toxin induced Liver Disease Acute liver failure requires >70% of liver to be affected Susceptible to toxin ingestion (portal circulation) Some drugs have a Hx of liver toxicity Acetaminophen Phenobarbital others

3. Drug/Toxin Induced Liver Disease Signs Acute onset Anorexia vomiting/, diarrhea/constipation PU/PD Jaundice (maybe) Melena, hematuria, or both CNS signs (depression, ataxia, dementia, coma, seizures)

4. Dx Hx of drug administration Painful liver on palpation Chem panel ↑ ALT (alanine aminotransferase) ↑ Total bilirubin, ↑ blood ammonia ↑ Serum bile acids Hypoglycemia, coagulopathy Radiographs show enlarged liver Liver biopsy (unless coagulopathy suspected) Drug/Toxin Induced Liver Disease

5. Rx Antidotes Induce vomiting Activated charcoal IV fluids Vit K for clotting Antibiotics Special diets (Hill’s k/d or u/d) Drug/Toxin Induced Liver Disease

6. Liver Tumors Metastatic tumors are more common than primary tumors of liver Signs Anorexia, lethargy, wt loss PU/PD Vomiting/diarrhea (?) Abdominal distension, hepatomegaly Jaundice Dx Anemia Chem Panel Abnormal liver enzymes and liver function tests

7. Liver tumors Dx X-ray: Heptomegaly, Ascites (?) Biopsy of liver Abdominocentesis may show tumor cells Rx Surgical removal is preferred treatment Single masses have good Px Multiple nodules/Diffuse disease have poor Px Chemotherapy doesn’t help primary tumors; better for metastatic lesions Client info Guarded to poor Px generally Survival time: 6 mo-3 y

8. Portosystemic Shunts Shunts form between portal circ and systemic circ allowing blood to bypass liver; Function of liver—detox blood Congenital or acquired By-passing liver, allows many toxins into systemic circulation CNS is most affected by the circulating toxins

9. Portosystemic Shunts

10. Signs Dumb/numb, lethargic, depressed Ataxia, staggering Head-pressing (against a wall) Compulsive circling, apparent blindness Seizures, coma Bizarre behavior (esp cats) Signs often more pronounced shortly after a meal Portosystemic Shunts

11. Dx Chem panel ↓ serum protein, albumin (liver is usually small) ↓ BUN (liver converts ammonia → urea) ↑ ALT (alanine aminotransferase), ALP (alkaline phosphatase) ↑ blood ammonia (from protein) X-rays Small liver Contrast material Inject into splenic vein By-passes liver Portosystemic Shunts

12. Rx Medical management seldom very successful Low protein diet Sx Ligation of shunt Total ligation often causes ↑ liver BP Partial ligation may be more practical A second Sx can be performed after few months to close off shunt totally Client info Px often very good following ligation For best results, Sx should be performed before 1 y old Collateral circulation may develop, with relapse of signs Portosystemic Shunts

13. Feline Hepatic Lipidosis Idiopathic (IHL) – cause unknown Most common hepatopathy in cats Obese cats of any age, sex or breed Stress may trigger anorexia Diet change, Boarding Illness, Environmental change

14. IHL Anorexia prolonged for 2 weeks causes imbalance between breakdown of peripheral lipids and lipid clearance within liver Lipids accumulate in liver Other mechanisms proposed Early diagnosis and aggressive treatment important 60-65% of cases => complete recovery

15. IHL

16. IHL

17. IHL Clinical Signs Anorexia Obesity Wt loss (as much as 25% of body weight) Depression Sporadic vomiting Icterus Mild hepatomegaly +/- coagulopathies

18. IHL Diagnosis CBC - stress Biochem panel – Increased ALP, ALT, bilirubin, Low albumin, Increase serum bile acids X-rays – mild hepatomegaly US liver hyperechoic Liver biopsy – severely vacuolized hepatocytes

19. IHL Treatment High protein, calorie dense diet Feeding tube usually required NG tube for short term liquid diets Gastrostomy tube best Esophagostomy tube Tubes can remain in place For up to 3-6 weeks

20. IHL Treatment IV fluids Metoclopramide SQ 15 min prior to feeding Monitor weekly CE Avoid stress in obese cats Early intervention is essential Any cat that stops eating is at risk Cats do not respond well to frequent diet changes

21. Pancreatic Dysfunction (Exocrine) Main function of Exocrine Pancreas → secretion of dig enzymes Located along duodenum Dig enzymes secreted in an inactive form to protect pancreas tissue

22. Pancreatitis—Inflammation of pancreas May be chronic or acute Develops when dig enzymes are activated within gland → autodigestion More common in obese animal; high-fat diets may predispose animal to it Unpredictable results; some recover well, others worsen and die Signs Older, obese dog or cat with Hx of recent high-fat meal Depression, anorexia, vomiting ± abdominal pain Shock, collapse may develop Often seen post-holiday Table scraps of ham, gravy, etc Pancreatic Dysfunction (Exocrine)

23. Pancreatitis Dx CBC, Chem panel Leukocytosis ↑ PCV Hyperlipidemia ↑ serum amylase, lipase Rx IV fluids, electrolytes NPO 3-4 d Antibiotics Butorphanol for pain Start back on low fat diet 1-2 days after vomiting stops Client info Avoid obesity/overfeeding Feed low-fat treats Px is difficult to assess

24. Exocrine Pancreatic Insufficiency The pancreas stops making dig enzymes May occur spontaneously (G erShep) or due to chronic pancreatitis (cats) Signs Wt loss Polyphagia Coprophagia, pica Diarrhea, fatty stool Flatulence Dx Normal CBC

25. Rx Supplement pancreatic enzymes with each meal Pancrezyme Viokase-V Low fiber diet Client info EPI is irreversible; life-long treatment Pancreatic enzyme replacement is expensive With enzyme replacement, dog will regain weight, diarrhea will stop Must be given with every meal Exocrine Pancreatic Insufficiency

26. Perineal Hernia Intact male dogs; atrophy of levator ani muscle; rectum herniates Signs Reducible perianal swelling Tenesmus (feeling of full colon) Dyschezia (difficult defecation) Urethral obstruction If bladder is herniated Dx Rectal palpation reveals hernia sac

27. Rx Stool softeners (Colace) Enemas Surgical repair Castration Client info Keeping stool soft may help reduce straining True for all dogs Castration recommended testosterone is suspected as a predisposing factor Perineal Hernia

28. Perianal Fistula Exact etiology unknown; thought to start as an inflammation of sweat and oil glands around anus Bacteria grow well in the moist, warm region of these glands Infection invades into deeper tissues Most commonly affects G Shep (84% of dogs diagnosed) Signs Intact male, older (>8 y) Tenesmus Dyschezia, pain on exam Fecal incontinence Bleeding, foul odor of perianal area

29. Dx—PE to r/o anal sac disease/perirectal tumor Rx Medical—usually not successful Clip hair, keep clean Flush with saline Antibiotics Surgical—difficult because of nerves/blood vessels Remove infected tissue Cryosurgery Laser surgery Cautery Client info Painful—be cautious of biting many complications of Sx Fecal incontinence Anal stenosis Perianal Fistula

30. Perianal Gland Adenoma Signs Intact male, older Single or multiple masses that may ulcerate Not metastatic Pruritis in anal area Bleeding Firm nodules in perianal skin Dx—PE, biopsy Rx Surgical removal Radiation Cryosurgery Castration—causes regression of tumors Client info Gently cleanse area daily with baby wipes Castration at early age helps prevent it