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

  1. #1
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    Question New symptoms - are they related to SM, liver, IBD or another issue?

    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!
    -Teri
    Mom to Sadie (11 yr old Blenheim)
    and Joey (at the Bridge)
    Utah, USA

  2. #2
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    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...m/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, and decreased cholesterol support the diagnosis. Hypocalcaemia (low calcium) is also seen due to poor absorption of vitamin D and calcium, and secondary to low protein binding of calcium. Medical ultrasonography may show striations in the intestinal mucosa indicating dilated lacteals.[8]"

  3. #3
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    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!
    -Teri
    Mom to Sadie (11 yr old Blenheim)
    and Joey (at the Bridge)
    Utah, USA

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    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.
    Paula - mum to Murphy(6) & Misty(7), and Jerry our cat.

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    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

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    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.
    Karlin
    Cavaliers: Jaspar Lily Tansy Libby Mindy
    In memory: Lucy Leo
    Cavalier SM Information site:www.smcavaliers.com

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    Quote Originally Posted by Karlin View Post
    ... 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?
    Rod Russell

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    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.
    -Teri
    Mom to Sadie (11 yr old Blenheim)
    and Joey (at the Bridge)
    Utah, USA

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    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
    Cavaliers: Jaspar Lily Tansy Libby Mindy
    In memory: Lucy Leo
    Cavalier SM Information site:www.smcavaliers.com

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    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/s...t-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/s...k-in-cavaliers

    http://www.ivis.org/proceedings/wsav...6/114.pdf?LA=1
    Karlin
    Cavaliers: Jaspar Lily Tansy Libby Mindy
    In memory: Lucy Leo
    Cavalier SM Information site:www.smcavaliers.com

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