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View Full Version : New symptoms - are they related to SM, liver, IBD or another issue?



Teri
22nd October 2012, 01:18 AM
Hi everyone, it has been a crazy couple of weeks and was hoping to get some insights on if any of my SM girl's new symptoms are new SM signs or something else. Please excuse the length of this message as a lot has happened recently and I didn't want to leave anything out in case it was important.

My nine year old Cavalier, Sadie, was first diagnosed with SM and hydrocephalus when she was five years old after having an MRI, and was classified as severe but with mild symptoms. She has been on 100mg Gabapentin 3x/day along with Omeprazole and Furosemide, with occasional increases in the Gabapentin during flareups such as when we are traveling with altitude changes. She has been stable for several years and she seemed happy. She would dance and jump and spin in the air and give happy barks while I was preparing her dinner or when she knew she was going for a ride in the car. She loved her food and lived for figuring out ways to get treats, both at home and at the vet. She has had no loss of motor skills. Her symptoms when she would have them would be some air scratching and some yelping. Once she had fast breathing and screaming when it is real bad (only had one episode of that so far thank goodness).

Now fast forward to two weeks ago. Sadie is now nine years old. I noticed her belly was quite round. She wasn't fat, I could feel her ribs, but she was quite round underneath. I was familiar with bloat from my cocker spaniel that had it a few times years ago and this didn't seem quite like it. Sadie still acted normal, eating, drinking, peeing, pooing normally, seemed her happy self with no loss of motor skills. I got her in to see our regular vet immediately just to be sure. Nope, not bloat. But she was retaining water in her belly. They drained a small amount of it for a sample, did a blood test where they found her albumin and protein to be quite low and said she needed to be seen by her internist for an ultrasound. We got her in to see her internist by going through the ER in her hospital in the city 1.5 hrs away the next morning at 7am since we didn't have an appointment. Btw, Sadie's neuro is also located in this same hospital. By this time, her stools were soft and getting less shape to them. ER got her vitals and had her set up by 8am for when the internist arrived. The ultrasound was done at noon. Nothing conclusive and she recommended doing a biopsy thru endoscopy to rule out or confirm her suspicions. This wouldn't be done until the following afternoon so we left her there overnight and waited to hear from them the next day. At 2pm the following day they called to say that the biopsy was done and she would be released in a couple hours and we could talk to the internist at that time. So we made our way back to the hospital. We were told it was confirmed that she has Inflammatory Bowel Disease (IBD) as primary with Lymphangectasia as secondary. We met with the internist who explained what was going on and where we go from here. Her absorption of fat is impaired and causes further problems when fat is in in her diet, so Sadie has to be on an ultra low fat diet such as Royal Canin Low Fat prescription food or a home cooked diet referred to as a "white diet". Her stools are now quite bad diarrhea. She also has some medications she needs to be on to reduce the fluid buildup in her abdomen, and to help with the inflammatory response. She is on Prednisone, Metronidazole, and Cyclosporine. She was taken off of her furosemide and Omeprazole because they said the other drugs would do the same thing. I questioned it and asked that they inform her neuro (in the same hospital) about the changes. Sadie was only allowed this food and anything with no fat in it such as vegetables like carrots. She has been eating the Royal Canin food, enthusiastically at first.

After being on the diet and medications for one week, her stool has improved to very soft but formed light colored stool, and we brought her in for a blood test. The test showed an improvement in the albumin and protein, although still not where they should be, but now her liver values were quite high and not in the normal range. Was told to start reducing the prednisone and continue everything else for another week and then do another blood test. Did the blood test last Tuesday, finally getting someone to give me the results on Thursday. The albumin and protein continue to improve. Liver values were much much higher!!! Very disappointing. She had an appointment for Saturday morning to be seen by her regular vet again (she hadn't seen her since we started with the internist) but by Friday morning Sadie didn't seem as eager to eat, only licked at her food but ate more when I put it on my fingers or had the competition of Joey standing there waiting to eat it if she didn't. But still she didn't eat half of it. I kept an eye on her the rest of the day. I noticed things like tripping over the lip of the dog door or a small hesitation before climbing the two steps up to the sofa. She slept and laid around a lot but that really isn't unusual for her as she has always been a couch potato. That night she again only half ate her dinner and not that enthusiastically. She was a bit more enthused about the carrots and dry version of the food that I offered her. She also didn't have that sparkle in her eye. She would stand there and just look around with no emotion. Obviously she wasn't feeling well and I wondered if she was in pain. At about 8pm I walked into the room and looked over at her on the sofa and thought she looked strange. She was laying flat on her side, eyes wide open and not blinking or moving. I talked to her, touched her face, blew in her face, no reaction. She was breathing but fast & shallow. She finally came around, gave a big sigh, sat up and fell back down. She tried to get back up and walk and her legs kept going out from under her, either buckling or sliding on the sofa. She was also panting with her tongue hanging out. My husband came running when I called to him and he stayed with her while I got on the phone and tried to get in touch with the internist. Luckily she was still there in the hospital! She got on the phone and I described what was happening. She said it sounded like a focal seizure. Sadie has never ever had a seizure of any kind in her life. After a few minutes Sadie was better, she seemed stronger and able to walk on her own without falling down. She did some pacing at first and later went outside and went potty. A little wobbly but not bad. I sometimes see a slight head tremor but wasn't sure if it was due to weakness. I brought her in to see the regular vet early Saturday morning. She was pleased to see that the water fluid was gone and her abdomen was back to normal, and was of course very concerned about what had happened. She also saw a dog who lost her sparkle, very lethargic and weak. One who didn't care that there were treats in the jar up on the counter or that she was going in the back room to see her favorite techs. She was not alert at all. They ran a bile acids test ordered by the internist and that should be back Monday or Tuesday.

Today (Sunday) Sadie is still off her food, I can barely get her medicine in her (I hide it in her canned food like little meatballs). She is very very weak, can't/won't climb any steps (although goes down the steps fine at times), and we are now carrying her outside to potty, bringing her the water dish filled to the brim so she doesn't have to bend over to drink it, and carrying her up to the sofa and watching her so she doesn't fall off or slip between the cushions since she doesn't have the strength to pull herself out. When she is laying down I sometimes see the C in her spine. She has no yelping or whining. Sometimes her foot folds forward at the ankle and she doesn't correct it. She is very restless at night, does not want to sleep in her crate (has a thick pillow type pad in it, maybe she needs a pad that is firmer?), and so she is now sleeping on our bed between us so we can keep an eye on her all night and so she doesn't fall off. She could very well be still experiencing more seizures too as they are hard to notice, especially when she is sleeping or resting so maybe that is why sometimes she seems worse than other times throughout the day.

Okay, so here is my question (finally!). Could the focal seizures be a symptom of worsening SM? Can seizures be part of SM? How much of the symptoms we're seeing is a sign of pain or related to SM versus due to liver disease, IBD, not eating, or something else? Is it common for SM patients to get liver disease? Because she was acting fine before we started on the new medicine and made the changes to her SM meds, I am thinking the changes in meds for her IBD have made her SM worse and that is what we're seeing. Especially with being off of her Furosemide and Omeprazole. I am just sick thinking that this one change could have started this horrible downhill motion. I plan to call her neuro first thing on Monday morning but am wondering whether I should be increasing her Gabapentin in the meantime if she is indeed in pain. I am hoping the neuro will talk to the internist and get Sadie back on her Furosemide and/or Omeprazole now that her abdomen is back to normal and remove the other drugs. My neuro has said that I can increase her Gabapentin as needed.

It is killing me to see her like this. She was a happy sweet silly girly girl who lived for food, treats, playing outside on the grass, and car rides, and now she has lost her light and happiness. Any information, insight opinions or support would be most appreciated!!! Thank you so much!

Furrfoot
22nd October 2012, 05:30 AM
This is the only thing I know to ask is how are her calcium levels? Here's what I found: http://ahdc.vet.cornell.edu/clinpath/modules/chem/hypocalc.htm

"Clinical signs of hypocalcemia in dogs include muscle tremors, convulsions, ataxia, and weakness..."

I did find it through wikipedia, so I don't know how reliable it is, but you may want to ask your vet(s) about it?
http://en.wikipedia.org/wiki/Lymphangiectasia
"Diagnosis Diagnosis is through biopsy. The presence of hypoproteinemia, decreased blood lymphocytes (http://en.wikipedia.org/wiki/Lymphocyte), and decreased cholesterol (http://en.wikipedia.org/wiki/Cholesterol) support the diagnosis. Hypocalcaemia (http://en.wikipedia.org/wiki/Hypocalcaemia) (low calcium (http://en.wikipedia.org/wiki/Calcium)) is also seen due to poor absorption of vitamin D (http://en.wikipedia.org/wiki/Vitamin_D) and calcium, and secondary to low protein binding of calcium. Medical ultrasonography (http://en.wikipedia.org/wiki/Medical_ultrasonography) may show striations (http://en.wiktionary.org/wiki/striation) in the intestinal mucosa (http://en.wikipedia.org/wiki/Intestinal_mucosa) indicating dilated lacteals.[8] (http://en.wikipedia.org/wiki/Lymphangiectasia#cite_note-7)"

Teri
22nd October 2012, 08:12 AM
Hi! I checked my copy of her lab results and her calcium levels are normal, right in the middle of the normal range actually. Thank you so much for looking into a possibility I hadn't thought of though! It is much appreciated!

murphy's mum
22nd October 2012, 10:24 AM
I'm sorry I can't help you Teri, but just wanted to say we're thinking of you and Sadie, and all fingers and paws are crossed for Sadie to make a speedy recovery.

Kate H
22nd October 2012, 11:46 AM
I can't answer a lot of your questions (though stumbling as you describe was one of Oliver's first SM symptoms, and he still doesn't put as much weight on his right front leg as he does the others), but liver disease can be the result of being on a diuretic such as frusemide over a long period. Neurologists usually recommend regular blood tests to check the liver and kidneys in SM dogs. If your neuro feels Sadie needs to go back on a diuretic, it might be worth discussing with him/her using Zitac (cimetadine) rather than frusemide, as it is gentler on the stomach.

Hope you get Sadie sorted out soon and back to her lively self.

Kate, Oliver and Aled

Karlin
22nd October 2012, 12:04 PM
Hi -- So sorry you are dealing with this. I think you are right to talk to her neurologist as fast as possible.

Unfortunately yes, meds for SM can rarely, cause problems -- bloods should be done every 6-12 months or so to check them. I don;t know if they can cause a sudden shutdown. Frusemide is generally now avoided by neurologists following most research -- it also has unwanted side affects and other CSF inhibitors work as well or better -- eg cimetidine.

Clare no longer even lists it for this condition:


Start CSF pressure reducing drug e.g. cimetidine (5-7mg/kg orally 3 times daily) or omeprazole (0.5-1.5 mg/kg PO q 24hr)

Increasing gabapentin may make this problem worse if it is gabapentin causing the problems. But I would surely want her to have painkillers to see if that would help her collapse -- perhaps steroids (which also can help IBD). Omeprazole has occasional side effects in some dogs including making them quite sick and diarrhea BTW especially if the dog has been on it non stop-- don't know if this has also been considered if she has been on this. Cimetidine can rarerly cause problems so needs to be monitored.

From Clare Rusbridge's treatment algorithm:


Haematology and biochemistry should be monitored on at least a 12 monthly basis for any dog receiving long term medication.
Cimetidine is rarely associated with hepatotoxicity, nephrotoxicity and thrombocytopenia.


Seizures might be related to SM as might the collapse as both are symptoms -- but a neurologist really needs to consider the details. If she was diagnosed with severe SM four years ago she could very well have just reached the breakthrough point where her system cannot cope. I am really sorry to be suggesting that but I think you do need to be considering the whole picture of what might be going on. Most dogs with severe SM don't seem to continue with moderate symptoms. If she is bent in a C then I would be inclined to think this is a severe SM breakthrough and would really want to medicate for that. There are a lot of meds for managing high level pain and as noted, steroids sometimes will quickly help this kind of pain.

At age 9 -- is her heart definitely OK? Most cavaliers by this age will have MVD and many will start retaining stomach fluid as part of that (though obviously could be many other things too...).

If she has IBD -- I would also consider looking at prepared raw diets.. I have read many times how much difference raw or cooked diets could make for ill animals. I do give my dogs a mix of both (generally avoiding raw bones except for ground in bone in prepared raw). But I have an elderly cat that has had explosive diarrhea for several months and had not had a truly solid normal stool in several years. I'd tried various things to no avail. For about 6-9 months my vet and I had really thought she had shifted to palliative care as she was listless, no clear test results indicating a specific problem. She'd become alarmingly thin though kept her appetite. I tried some tinned and dry special foods; no joy. My vet felt she had IBD as everything else was coming back negative. I switched her and all the cats to a raw diet as a 'last ditch'. Within two days she had a normal stool. The first in years! From then on she started gaining weight and her old mischievous personality returned. She has since regained over a third of her starting weight. My vet would not have believed it if he hadn't seen the results and it has changed his view on prepared raw diets.

Given current research on the role of diet and gut flora on overall health in humans (actually first demonstrated in lab animals) -- I think it is deeply wrong now to feed any animal a diet of only or mostly processed foods, especially kibble, no matter how good the quality. All evidence is pointing to gut flora as a major influencer in an extraordinary range of diseases and good flora do not flourish without a fresh, varied diet. So would just consider trying a prepared quality raw rather than the dry diet, too.

Best of luck with Sadie. Teri; I hope you can get this under control. :(

RodRussell
22nd October 2012, 01:19 PM
... At age 9 -- is her heart definitely OK? Most cavaliers by this age will have MVD and many will start retaining stomach fluid as part of that (though obviously could be many other things too...).

A rounded belly and retaining water bring advanced heart valve disease to my mind. Did that ultrasound include checking her heart?

Teri
22nd October 2012, 08:10 PM
Thank you all for your good wishes as well as your suggestions. I talked with the coordinator for her neurologist, told her what was going on, and she is going to relay it to the doctor. He will touch base with the internist, look at her test results, and then give me a call back today.

We have just been happily going along with her regular protocol once she was stable for all these years, and I admit that I didn't stay on top of the latest research so I didn't realize that Clare had suggested a change in protocol away from the furosemide. Our neuro never mentioned it either but she was stable and doing well. Yikes! I will ask him about Cimetidine. Is there a recommended dosage?

We have gotten Sadie's bloodwork checked twice a year since she was first put on SM meds and her liver values have always been solidly normal. Even when she first got the fluid in her belly, she acted totally normal and aside from her albumin being low, her liver values were still normal at that time. It wasn't until a week after being taken off the furosemide and Prilosec and being put on the other drugs, that her liver values suddenly started to shoot up quickly. Ugh!

Heart disease and cancer/tumor were their first thoughts with the water in the belly and they said they ruled it out. I know they listened to her heart (both regular vet and internist) and it was totally normal sounding. They did the ultrasound of the abdomen, I don't believe they did the heart though. That is something I will ask about to get clarification. Thank you!

Her belly is totally back to normal by the way, no more fluid there. So that part is much better. But I think I'd rather have her looking bloated but happy than have this! She still has soft shiny poo's but there is some shape to them. Last night she seemed more alert for awhile, was sitting up on the sofa after I went into the kitchen to make their dinner. I looked over in time to see her on the edge of the sofa watching me with a happy eager face (one I used to see all the time but hadnt in a few days), and then saw her turn to head towards the steps, but her foot started sliding and she was too weak to recover and before I could get there, she had fallen (head first) off the sofa onto the hardwood floor. Ack!!!! She immediately jumped up and started walking around, but her mood quickly changed and the cloud was back as she paced and walked it off. She wanted outside to potty, and then couldn't get back up the two steps to the house so I picked her up and she immediately started quietly crying and squirming in my arms so I quickly got her up to the top step onto the deck so she could walk into the house. I gave her a bit more gabapentin as I was sure she was having a lot of pain at that point, especially after the fall. She did gobble down her dinner though which was a relief since she hasn't been eating real well for awhile. But then she started to go back downhill again, and this morning she isn't even lifting her head, didn't eat her breakfast, and I had to put the pills in her mouth so she could swallow them as she only half heartedly licked at them when I offered them to her (wrapped in food).

I am not a big fan of a lot of the commercial foods either and prior to this happening had been looking into making my own. I was told I could also do home cooked as long as it met the requirements for very low fat and protein as well as dealing with the other nutritional requirements she would need, and I was looking into changing her over to that once I got it figured out. But I haven't had a lot of time to look into that since she started failing. I did start her on the canned prescription food and had just picked up a sample of The Honest Kitchen's Preference mix to mix with the canned for now as a quick and easy way to work her towards that. But now she's not eating and not stable so I am not quite sure what to do at this point!

Thank you all again for taking the time to respond to my very long message! It means a great deal to me that you are all here and so supportive and so willing to share your wealth of knowledge. Thank you so much! I will let you know when I hear back from her neurologist and what he has to say.

Karlin
23rd October 2012, 01:22 AM
Gosh I sure hope you can figure out what is going on. Poor Sadie and this must be very hard on you too. :(

On frusemide: it was more a gradual move away and not really I think widely discussed -- because it can be hard on the heart if taken all the time in advance of a dog actually needing it for heart disease (oddly enough). There were some discussions on the specific reasons here a while back. I can't remember the detail. I moved from frusemide to cimetidine myself fairly quickly before it was actually recommended to use other CSF inhibitors, simply because Leo had to pee all the time on frusemide; it was just a hassle to manage it.

Karlin
23rd October 2012, 04:04 PM
One other thought: has she been thoroughly checked for pancreatitis? Sadly this is another condition that appears to be increasingly seen in cavaliers -- we have many owners dealing with it here. It tends to be an emergency and the kind of listlessness and bowel problems you are seeing certainly could fit this -- if so this would be a larger issue than simply IBD and diet will be critical to management. She should be in hospital til she stabilises. Pancreatitis and pancreatic tumours can cause seizures.

See:

http://www.cavaliertalk.com/forums/showthread.php?41297-Information-about-pancreatitis

http://www.cavalierhealth.org/pancreatitis.htm


Symptoms

Classic signs of chronic pancreatitis include abdominal pain, vomiting, and loss of appetite. The pain can be severe and may cause the dog to take a “praying” position. The affected dog may also pass diarrhea or voluminous feces, with small amounts of fresh blood and/or mucous.

The clinical signs of pancreatitis will vary with the severity of the disease. Low-grade cases may not show all of the classic symptoms and may be confused with inflammatory bowel disease. In severe cases, the dog may become dehydrated, may collapse, be in shock, and may even suffer renal shutdown and distressed breathing.

http://www.cavaliertalk.com/forums/showthread.php?30611-Tummy-probs-Higher-pancreatitis-risk-in-cavaliers

http://www.ivis.org/proceedings/wsava/2008/lecture16/114.pdf?LA=1

Margaret C
23rd October 2012, 06:52 PM
I would like to note that a dog can have pancreatitis without it showing up on tests & without them having diarrhoea or vomiting.

Earlier this year Tommy was about to be PTS because of what appeared to be uncontrollable SM pain. ( he was also diagnosed when five years old ) It was only when I mentioned he had just changed to a high fat renal diet that it was realised that he had a very painful stomach and that he was suffering from an acute attack of pancreatitis. All this had exacerbated his SM symptoms. He had always had perfectly formed stools and no sickness at all.

I brought him home armed with strong painkillers and with orders to keep him sedated until the pain lessened. He now has a specialy devised fish & rice diet from a veterinary nutritionist to take into account the problems of kidney disease, pancreatitis and MVD.

The last few months have been a little fraught due to the need of emergency dental treatment for a broken tooth and urinary tract infections due to prostatitis ( 6 weeks of antibiotics )

Tom was twelve last week, I don't know how much longer I will have him as he is frail and his back legs are very weak, but he does seem comfortable and he still loves his daily walk and our smoochy goodnight sessions before we go to sleep.

I do hope you can find out the reason for Sadie's deterioration, get her comfortable and stabilised so you can have a little more time with her.

I'm thinking of you both.

Teri
24th October 2012, 08:59 AM
Thank you Karlin and Margaret for your responses and valuable information. It has really helped me to be an informed caregiver for Sadie. Margaret, I am so glad that you were able to figure out what was going on with Tommy in time! How scary that had to be for you!

This has certainly been a whirlwind here trying to figure it all out and coordinate all the doctors involved in her care right now. I was able to speak with the internist and neurologist last night, and then my regular vet had a conference call with them today and they worked out a treatment plan that everyone seems happy with that will cover each vet's concerns. They had checked her heart when she was first admitted to ER with the fluid but found nothing. They did not do an ultrasound on the heart however, but did around the abdomen area looking for possible tumors which they did not find. When they did the biopsy they had a positive diagnosis of IBD with Lymphangiectasia. Then for some unknown reason (so far) her liver started failing. She now also has Hepatic Encephalopathy (HE) which they believe may be caused by an infection. The HE is what is believed to have caused the seizures and other neuro symptoms we have been seeing. Our neurologist does not feel that her seizures and other neuro type symptoms are SM related at all and he put her back on the furosemide and omeprazole in addition to the gabapentin which she was still on. They took her off one of her newer medications for now to see if it might be possibly causing the liver issue. This medication reduced her fluid (the fluid is all gone) so now we have to watch her closely that the fluid doesn't build up again. Right now she is very close to being in total liver failure. We are in a race against time with her liver so this just has to work. She is on a special diet and medications for the IBD and Lymphangiectasia. She is on several medications to treat a possible infection, as well as to treat the bacteria and liver function issues. If we can just get her stable, then we can do some other things but she is quite fragile right now and they were afraid of introducing too many new things into her system at once in case there is a reaction. So they went for the main issues first. She seemed to have a better night tonight though. She actually ate her dinner, doesn't seem spacey anymore, and while she is staying in her crate most of the time, she isn't nearly as wobbly as she was and is walking up and down the two steps again to potty. I divided her meal up throughout the day into smaller meals and about mid-afternoon she started eating (she didn't eat her breakfast). She usually gets that fluid med in the evening and soon afterwards she seems to go downhill, so we are hoping we can turn things around for her by removing it from the protocol.

Please keep her in your thoughts.

Karlin
24th October 2012, 11:55 AM
I'm so sorry there remain so many challenges with her.

An excellent veterinary specialist has read your story here and she said she believes too that this is pancreatic. She said they should check immediately for pancreatitis as well as pancreatic insufficiency.

BTW the swollen stomach is a common symptom of pancreatitis. Pancreatitis can destroy the liver.

If it is pancreatitis she possibly should not be getting any food at all and then after only small amounts -- resting the pancreas would be critical.

Best of luck and hope you can manage this.

Pat
24th October 2012, 05:01 PM
Pancreatitis can be fairly easily ruled out by performing a Spec cPL test and also by abdominal ultrasound. The pancreas will "light up" on ultrasound in the presence of pancreatitis, and this can be clearly ruled in or out. The "old fashioned" way to diagnose was by looking at the amylase and lipase values on blood chemistry, and indeed, those values can be misleading. The newer Spec cPL is pretty definitive.

http://www.idexx.com/view/xhtml/en_us/smallanimal/reference-laboratories/testmenu/innovative-tests/spec-cpl.jsf?SSOTOKEN=0

EPO (exocrine pancreatic insufficiency) is easily ruled in or out by a TLI test done at Texas A&M.

http://www.epi4dogs.com/

I don't suspect either of these in this case, and I think the internist seems to be doing the right diagnostic and treatment procedures. (Remember that the biopsy confirmed this diagnosis.)

Have you read up on lymphangiectasia? This is a very serious PLE (protein-losing enteropathy). It is very common in Yorkies; I've only heard of one other Cavalier (in Alabama) with this. Ascites (fluid in the abdomen) is a classic sign of this disease. Can you give the exact values (with normal range) for all of the liver values and for the TP and albumin? When albumin drops to about 2 or below, very bad things happen, including the ascites. I've written extensively about this in a yahoo group; I'll try to find that to cut and paste here. Read the link below and note the connection between albumin and PLE and liver disease.

http://www.marvistavet.com/html/body_intestinal_lymphangiectasia.html

The HE would be the cause of all of the neurological symptoms and not SM. The question, of course, is WHY is her liver failing? She never took NSAIDS for her SM, right? Those can cause liver failure, but you haven't mentioned that she has taken any of them either present or in the past.

I don't have time to write a lot more at the moment, but these links above should be helpful. I lost a 16 year old Cavalier years ago to a PLE - intestinal lymphoma. If I had a dog with liver disease or a PLE, I would definitely feed home-cooked (NOT raw) meals. You can google and look for Dr. Jean Dodds' liver diet or look on Dr. Donald Strombeck's website where you'll find a lot of home prepared recipes suitable for various chronic diseases. They are very easy to prepare. I have fed home-cooked diets for many dogs with kidney disease over the years. I really hate the vet script kibbles - including Hill's and Royal Canin - they are very poor quality.

http://dogcathomeprepareddiet.com/

My best wishes to you for a rapid turnaround for Sadie.

Pat

RodRussell
24th October 2012, 05:37 PM
... Have you read up on lymphangiectasia? This is a very serious PLE (protein-losing enteropathy). It is very common in Yorkies; I've only heard of one other Cavalier (in Alabama) with this. Ascites (fluid in the abdomen) is a classic sign of this disease. Can you give the exact values (with normal range) for all of the liver values and for the TP and albumin? When albumin drops to about 2 or below, very bad things happen, including the ascites. ...

Spot on, Pat.

And Teri, pardon my lapse on Twitter.

Teri
24th October 2012, 07:15 PM
Thank you everyone for taking the time to respond to this thread and offer information, suggestions, thoughts, and support. You are a valuable resource and lifeline right now and we appreciate having you all on our team to help get Sadie feeling better again.

Rod, it was wonderful of you to check on us when I posted on Twitter. It meant a lot to me. You and your website are such a valuable service to the Cavalier community. I refer to it often, so thank you for all you do.

I asked the vets about pancreatitis last night and they said it didn't quite fit. Ultrasound checked her pancreas at the very beginning of the onset (altho her only symptom as the time was the ascites and all blood values incl liver were normal except for the albumin which was 1.1 at that time) and the pancreas looked fine at that time. Also, she has never had any vomiting and does not arch her back. I will request an additional blood test for this however, just to cover all bases. Thank you for the suggestion because I want to be sure we don't overlook anything.

Pat, thank you so very much for weighing in and it is a relief that you support the vets diagnosis. Yes, I have a copy of all her blood test results here. Her latest liver values (as of Saturday) are as follows:

TP: 4.7 (normal 5.4-7.6)
Albumin: 1.8 (normal 2.3-4.0)
ALP: 1201 (normal 10-84)
GGT: 388 (normal 0-10)
ALT: 276 (normal 5-65)
AST: 162 (normal 16-60)
Cholesterol: 516 (normal 150-275)

So, everything is off the charts. I'm not sure what all the drugs are that are classified as NSAIDS but the only drugs she has ever taken for her SM are Gabapentin, furosemide and omeprazole. She had some other drugs when she was on an IV when she was in the ER for two days and had her ultrasound and biopsy. The drug that they just took her off of is Cyclosporine. The list of drugs to treat this thing, in addition to her SM drugs listed above, are: Prednisone, Amoxicillin, Metronidazole, and Lactulose Syrup.

Last night she seemed to feel better. She was alert, not foggy. She ate. She walked without falling over and didn't seem excessively tired. It always seemed like she'd rally in the afternoon and early evening and then crash again in the evening until afternoon. She is still fine this morning and ate her small meal and walked normally, went up and down the two steps in and out of the house and hopped over the lip in the dog door. Also her poo was actually almost normal looking in shape and firmness, although color is still a light brown/orange. She is still tired though (but not excessively like before and doesn't act weak) and is still choosing to go back to bed in the bedroom rather than lay on the sofa and watch what is going on. Hopefully that will change soon. I was giving her the Cyclosporin in the evening and stopped it so she didn't get a dose last night... we wondered if it was the culcript and causing some side effects that it can be known for. So I'm glad they are stopping it if that is indeed the case. But now we have to keep a close eye on her that her ascites doesn't return.

Thank you everyone for your help. I will certainly let you know how she is doing with regular updates.

Karlin
24th October 2012, 08:42 PM
So glad she seems to be on the mend and has improved -- wonderful to hear! :)

Pat
24th October 2012, 08:48 PM
What is her bilirubin? That is the most important blood serum indicator of liver disease as it reflects the actual "state" of the liver, whereas liver enzymes can be elevated for many reasons other than primary liver disease (including pancreatitis and other diseases).

Just off the top of my head (all my vet reference texts are at home and I'm not), the liver enzymes don't alarm me terribly. Alk phos can be extremely elevated in senior dogs with no identifiable cause and with no ill consequences. (Been there, done that.) Albumin of 1.1 is very scary; I'm glad it's up to 1.8 but I'd like to see it over 2.0. Is she jaundiced? Is her urine orange as well as her stool?

What about her CBC (complete blood count)? Is hematocrit (HCT or PCV) normal? That would indicate anemia if low. Elevated WBC would indicate an infection. I presume she's had a urinalysis to make sure that there is no protein loss from the kidneys versus from the gut. (PLN is protein losing nephropathy versus PLE which is protein losing enteropathy - one is protein/albumin loss from the kidneys and the other is loss from the gut/intestines.)

I'd probably run a Spec cPL just to totally rule out pancreatitis since it isn't super expensive.

Has anyone mentioned doing a lepto test as a rule-out? Anyone suspicious of TBD (tick borne disease)?

This is not a site I use often, but here is a good explanation of bilirubin:

http://www.justanswer.com/pet-dog/0g1s6-elevated-bilirubin-levels-dogs.html

http://www.petwave.com/Dogs/Dog-Health-Center/Digestive-Disorders/Liver-Disease/Diagnosis.aspx

Here's a pretty good summary written by a vet:

http://www.canine-epilepsy.com/liverdisease.htm

David Twedt is the "liver guru" in the veterinary teaching world. I've attended five or six of his lectures; he is fantastic:

http://www.dcavm.org/09sep.html

You can go to 360 vet site and find many articles that he has written.

http://www.dvm360.com/


Pat

Teri
24th October 2012, 09:50 PM
I am hoping that we keep seeing this improvement for the next 24 hours and then build from there. Pat, I have the numbers you asked for.

Bilirubin, Total: .6 (normal 0-.5)
HCT: 44.7 (normal 37.0-55.0) Yay, normal!!!
WBT: 23.0 (normal 6.0-17.0) and why they added Amoxicillin to help with infection)

She is not jaundiced and I have been instructed to look for it daily as well as also look to see if the fluid builds up around her abdomen again. I don't know if her pee is orange. She is so small and low to the ground (she's a petite 10 lbs) that it is difficult to see it or to even get anything under her that will fit to catch it. I will look around for an old saucer I can use and do that the next time she pees. I was told that she wasn't losing protein from the kidneys, it was coming from the gut.

Sadie is up to date on all her vaccines. No one has mentioned Lepto to me. No mention of TBD either, she is mostly indoors and we don't see ticks here, have not seen one on her ever. We only see ticks in the deep woods quite a few miles away and she has never been to the woods.

They also did a bile acids test but to do the test properly you fast them for the first test (which we did except for the tiny amount of food we need to give her meds), and then for the second test you have to feed them a high fat diet and we can't do that due to the IBD/lymphangiectasia. So the tests aren't really true.

Pre-bile acids: 93 (normal 0-10)
Post-bile acids: 136 (normal 0-20)

If there are any other numbers you need, I can pick them off the lab sheets, so just let me know which ones are needed. Thanks again!

Teri
25th October 2012, 07:25 PM
Just wanted to give an update. First, I got a sample of her urine and it was not orange. Just a normal yellow color. :)

Sadie has been doing better for over 24 hours now. No stumbling, no seizures, no spacey stares. Even her poo is firming up! She is alert, she is eating more, she is walking around without falling over, she goes out and in the doggy door and down and up the two steps by herself without any help. She is still more tired than usual and goes into her crate to nap when I'm not fixing her meal (normally she would choose to nap on the sofa). Previously she was so lethargic she could barely stand, and she would be so exhausted after squatting to potty that she would just stand there and not have the energy to make it back inside the house on her own. She now walks closer to a normal pace and with more purpose than she did, although still slightly more careful and slower than before she got sick. Still no sign of jaundice or fluid buildup. So overall, she is doing better. We will know for sure when we do the next blood test. I am waiting to hear from the vet to see when they want the next blood test. I assume we'll do that in the next few days since they are keeping a close eye on her.

So anyways, just wanted to report that so far so good! :)

Karlin
25th October 2012, 11:57 PM
On lepto -- it is fairly widespread across the US (and most places) including city parks etc. Someone here posted a while back about someone with a cavalier in a suburb that got it and died and had only been just on normal street walks. :( So may be worth checking. Ticks also can be picked up almost anywhere. Our pyrenees used to get them from who knows where when I lived in a California central valley town. So not just rural areas pose a risk. Both might may be worth exploring as a cause.

So glad she is doing so much better!! You must be so relieved.

Teri
26th October 2012, 05:16 AM
I am cautiously relieved but can't relax just yet. Sadie goes in on Saturday for another blood test so we should get that back on Monday or Tuesday. I will bring up lepto and TBD and see about testing for that as well as the pancreas test just to cover any other possibilities. Thanks everyone for your help!

Teri
30th October 2012, 08:53 PM
I received Sadie's latest blood tests and after one week, her liver values have improved! Yay! They're not back to normal, but they have turned around and made significant improvement so I am very encouraged. We stopped the Cyclosporin so it looks like it was the right thing to do. Her abdomen is normal and no fluid buildup, eyes are still white, gums still pink. So far so good. As of yesterday, they have now taken away the Lactulose Syrup so I'm watching to make sure she stays alert and doesn't get foggy and lethargic again. One new thing popped up on her blood test, she is slightly anemic. They have added in a B-12 shot once a week. Sadie also is getting tired of that prescription food so I am looking into making her food, the internist gave me some guidelines for the white diet, but its a bit confusing to make sure she gets all the nutrients she needs without causing new problems that will make things worse for her.

Here's a comparison of her test results from a week ago and now:

TP: was 4.7 (normal 5.4-7.6); now 5.3 Close!
Albumin: was 1.8 (normal 2.3-4.0); now 2.5 Yay!
ALP: was 1201 (normal 10-84); now 1432 (vet said not unusual to increase due to increasing the prednisone when took off the cyclosporin)
GGT: was 388 (normal 0-10); now 152
ALT: was 276 (normal 5-65); now 175
AST: was 162 (normal 16-60); now 86
Cholesterol: was 516 (normal 150-275); now 325
Bilirubin, Total: was .6 (normal 0-.5); now .3 Yay!
HCT:was 44.7 (normal 37.0-55.0); now 31.1 Oops!
WBT: was 23.0 (normal 6.0-17.0); 21.5

So far she is back to acting close to normal. She is just a bit tired, and sometimes she has trouble getting her foot up and over the lip in the dog door, and she is still choosing her crate to sleep over curling up in one of the floor beds or going up the two steps up to the sofa where she usually hangs out during the daytime. But other than that, she is alert, seems happy, wags her tail, checks Joey's dish for any tiny morsel he may have left behind, and loves her treats. Poo's are soft but formed so that has improved as well. As long as things go along well, she will have another blood test again on Saturday. Hoping the numbers will be back to normal, or at least very close.

Thank you all so much for your help and support through this very stressful time!

RodRussell
30th October 2012, 09:18 PM
It all sounds very promising, Teri.

Pat
30th October 2012, 10:47 PM
What are the rest of the numbers on the CBC that reflect anemia - hemoglobin, RBCs? You may need to do another (cheap) test to see if this is regenerative or nonregenerative anemia if the anemia turns out to be chronic. The B-12 injections sting - so be prepared. B-12 generally won't do anything to improve chronic anemia; I've been down that road with lots of dogs with kidney failure (which causes nonregenerative anemia), although I did give B vitamins in subq fluid (made me feel better, anyway).

WBC is still high - is she still on antibiotics? What kind of what dosage and what does she weigh? What do they say about her still fighting infection? What other meds is she taking still?

Forgot to ask earlier - is she taking liver supplements such as a product with milk thistle and SAM-e? That would be something that could be very helpful and certainly won't hurt. Google Jean Dodds and read about liver diet and liver supplements.

I would def homecook a "white diet." It is really pretty easy and you shouldn't stress about it being perfectly "balanced" at this point. Dogs with chronic illness can do fine on an "unbalanced" diet - I have been feeding a 15 year old a kidney diet for years, and she is doing well on an "unbalanced" diet. You often can't do "complete and balanced" for a dog with a chronic illness such as liver or kidney disease, and it doesn't matter short term anyway.

I have the nagging feeling that something (infection?) caused this and that there is no chronic IBD or PLE or primary liver disease.

Pat

Teri
31st October 2012, 12:12 AM
The RBC is now 4.26 (normal 5.50-8.50)
HGB: 10.6 (normal is 12.0-18.0)

They did an additional test:
Reticulocyte 5.2%
Absolute Reticulocyte: 221,520/ul
Because it is greater than 150,000/ul the anemia is considered regenerative.
Vet said it is possibly from the IBD/lymphangiectasia and hoping that the anemia is short-term.

Yes, she is still on antibiotics. She was on Amoxicillin but it is difficult to get here so after the one week supply ran out they switched her to Clavamox tabs for another week. The tabs are 125mg tablets, 1 tablet by mouth every 12 hrs. She weighs around 10 lbs. They said they are suspecting that she has an infection.

Other meds she is on:

Prednisone: 7.5mg daily
Metronidazole (50mg tab): 1-1/2 tabs daily
Clavamox (mentioned above)
Vitamin B-12: 0.5 ml injected sub-q once a week for 5 weeks
plus her SM drugs.

No, she is not currently taking liver supplements. I asked about milk thistle and SAM-e, and while they were open to it and do use it for liver issues, they felt they had so much going on right now that they wanted to hold off on that for now. Sounded like they didn't want any more variables involved right now as they figured this out, but were certainly open to adding in the supplements soon.

White diet. They gave me a piece of paper and said I need to choose a protein source (choice of chicken, turkey, fish, low or non-fat cottage cheese, egg whites) and a carbohydrate (rice, potato, low fat plain pasta). Also calcium and vitamins should be added such as a Tum's per day and a dog multi-vitamin. Also recommends adding Fortiflora (probiotic supplement). When I look at the Fortiflora (sold at the vets) it comes in box full of little packets. Instructions just say to give a packet a day with no regard to size of dog. Seems wrong to me that I'd give the same amount of that and the Tum's to my 10 lb dog as to a 100 lb dog! Also, the multi-vitamin that I got (Canine Plus chews) has calcium in it, so not sure if that was taken into account or if I will end up giving her too much. Also, I was told to stay away from fish since that was the protein she was on when she first got sick, they wonder if she has a sensitivity to fish, and I should choose a protein that she has never had before. Maybe I'm just overthinking it, but she has come through so much I don't want to mess it up for her. They were hoping that I wouldn't have to switch to a home-cooked diet until she was stable as it is another new variable they will have to take into account if there are any more problems.

Yes, the vets are thinking that the liver disease isn't permanent yet and can be reversed once the cause is known. Possibly due to the Cyclosporin. Although they seem to stand by their initial diagnosis of Primary IBD and secondary intestinal lymphangiectasia. But we'll see how this all plays out. I am hopeful that her liver is turning around and will be normal or very close to normal in another week, and that the IBD and lymphangiectasia is stabilizing. Pat, I hope your nagging feeling is true and we get to the bottom of it soon!