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.
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.
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.
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.
EPO (exocrine pancreatic insufficiency) is easily ruled in or out by a TLI test done at Texas A&M.
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.
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.
My best wishes to you for a rapid turnaround for Sadie.
Spot on, Pat.
Originally Posted by Pat
And Teri, pardon my lapse on Twitter.
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.
So glad she seems to be on the mend and has improved -- wonderful to hear! :)
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:
Here's a pretty good summary written by a vet:
David Twedt is the "liver guru" in the veterinary teaching world. I've attended five or six of his lectures; he is fantastic:
You can go to 360 vet site and find many articles that he has written.
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!
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! :)