Transcript adversity - Dr. Roberta Dev Anand

ADVERSITY
“Adversity causes some men to break,
others to break records.”
-William A. Ward
Liver Diseases
High regenerative capacity; damage must be
severe for signs to appear
Vague signs early: anorexia, vom/diar, wt loss,
PU/PD, fever
• 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
Drug/Toxin Induced Liver Disease
• Signs
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Acute onset
Anorexia
vomiting/, diarrhea/constipation
PU/PD
Jaundice (maybe)
Melena, hematuria, or both
CNS signs (depression, ataxia,
dementia, coma, seizures)
Drug/Toxin Induced Liver Disease
• Dx
– Hx of drug administration
– Painful liver on palpation
– Chem panel
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↑ 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
• Rx
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Antidotes
Induce vomiting
Activated charcoal
IV fluids
Vit K for clotting
Antibiotics
Special diets (Hill’s k/d or u/d)
Liver Tumors
Primary and metastatic tumors are not uncommon in
dogs and cats
Metastatic tumors are more common than primary
tumors of liver
• Signs
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Anorexia, lethargy, wt loss
PU/PD
Vomiting/diarrhea (?)
Abdominal distension, hepatomegaly
Jaundice
• Dx
– Anemia, usually non-regenerative
– Chem Panel
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↓ serum albumin
↑ serum bilirubin, bile acids
↓ serum glucose
Azotemia (↑ BUN, creatinine; esp in cats)
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
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
Portosystemic Shunts
Portosystemic Shunts
• Signs
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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
• Dx
– Chem panel
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↓ 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
• 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
Feline Hepatic Lipidosis
• Idiopathic Hepatic Lipidosis (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
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
IHL
IHL
IHL
• Clinical Signs
– Anorexia
– Obesity
– Wt loss (as much as 25% of body weight)
– Depression
– Sporadic vomiting
– Icterus
– Mild hepatomegaly
– +/- coagulopathies
IHL
• Diagnosis
– CBC – nonregenerative anemia, stress
neutrophilia, lymphopenia
– Biochem panel – Increased ALP, ALT, bilirubin, Low
albumin, Increase serum bile acids
– X-rays – mild hepatomegaly
– US liver hyperechoic
– Liver biopsy – severely vacuolized hepatocytes
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
IHL
• Treatment
– IV fluids
– Metoclopramide SQ 15 min prior to feeding
– Monitor weekly
• CE
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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
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
Pancreatic Dysfunction (Exocrine)
• 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
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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
Pancreatitis
• Dx
– CBC, Chem panel
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Leukocytosis
↑ PCV (means what?)
Hyperlipidemia
↑ serum amylase, lipase
• Rx
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IV fluids, electrolytes
NPO 3-4 d
Antibiotics
Butorphanol for pain
Start back on low fat diet 1-2 d after vom stops
• Client info
– Avoid obesity/overfeeding
– Feed low-fat treats
– Px is difficult to assess
Exocrine Pancreatic Insufficiency
The pancreas stops making dig enzymes
May occur spontaneously (G Shep) or due to chronic pancreatitis (cats)
• Signs
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Wt loss
Polyphagia
Coprophagia, pica
Diarrhea, fatty stool
Flatulence
• Dx
– Normal CBC
– ↓ total lipids
Exocrine Pancreatic Insufficiency
• 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
Perineal Hernia
Intact male dogs; atrophy of levator ani muscle; rectum herniates
• Signs
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Reducible perianal swelling
Tenesmus (feeling of full colon)
Dyschezia (difficult defecation)
Urethral obstruction
• If bladder is herniated
• Dx
– Rectal palpation reveals hernia sac
Perineal Hernia
• 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
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
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Intact male, older (>8 y)
Tenesmus
Dyschezia, pain on exam
Fecal incontinence
Bleeding, foul odor of perianal area
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Perianal Fistula
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 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
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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