Hepatitis In Dogs And Cats

Ron Hines DVM PhD

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Hepatitis means inflammation of the liver. Your pet's liver is a very complex organ that processes nutrients soon after they are absorbed through it's intestines. This makes it the first organ to come in contact with toxins and harmful products absorbed from your pets foods. The liver plays a major role in metabolism, detoxification, energy storage and blood protein synthesis. It also produces bile, which aids in digestion. Your pet's liver has a very large reserve capacity - so it has to be severely damaged before any signs of illness will become apparent to you. The following information relates to some of the more common causes of hepatitis in dogs and cats there are many more, lessfrequent, causes that I do not discuss here.

How Is Liver Disease Diagnosed In My Pet?

Until liver problems are quite advanced, the signs of the disease are rather vague and non-specific. The key to diagnosis is measuring the level of liver enzymes that circulate in your pets blood. The most commonly elevated enzyme is ALT (Alanine Aminotranferase or SGPT). Elevated ALT tells your veterinarian that your pet has hepatitis but it

does not tell what kind of hepatitis it is. Other enzymes that are often elevated in hepatitis are AST (Aspartate Transaminase SGOT) , GPT(Glutamate Pyruvate Transaminase), and Alkaline Phosphatase. A metabolite called bilirubin may also be elevated and blood albumin may be low. You can read the normal values for these tests here. None of these test will tell your veterinarian what type of hepatitis your pet has or what caused it. To do that usually requires a biopsy of your pets liver. Using an ultrasound apparatus as a guide, the veterinarian will extract a small snippet of liver tissue using a specially designed needle. This is sent to a veterinary pathologist who will tell your veterinarian the type of hepatitis present, how severe it is and, perhaps, what caused it.

Infectious Canine Hepatitis Of Dogs (ICH, CAV-1)

This disease is caused by a virus. It is part of a group called adenovirus (CAV-1). This disease is not infectious to people or cats, but foxes, wolves and bears also catch and carry it. Dogs catch this disease by inhaling or eating the virus that is present in the urine, nasal and eye secretions of other infected dogs. Dogs can carry and pass on the virus for up to a year after recovering. Canine Adenovirus is part of the vaccine combinations your puppy receives when it is 12 -16 weeks old. Although the virus in the vaccine is Canine Adenovirus 2, it protects against type 1 as well. After receiving this vaccination at 12 and 14 weeks of age, your dog will be immune to CAV-1and CAV-2 for many years - probably for life. So booster vaccinations are not needed. Because of the effectiveness of this vaccine, Canine Infectious Hepatitis has become very rare in dogs in the United States. After entering the blood stream, this virus attacks the cells of the liver, eyes, kidneys and the inner linings of blood vessels throughout the body. Most cases of CAV-1 are not serious. Many dogs have little or no symptoms after they are infected. In some dogs, only a cough develops. In this mild form, dogs simply loose their appetite, or are

mopy and run a low fever for a few days. One or two weeks later, a few develop a temporary bluish discoloration of the cornea of the eye called blue eye. All these dogs that recover from ICH are immune to the disease for the rest of their lives. A few puppies, , do become severely ill with infectious canine hepatitis. They can develop liver disease, internal bleeding, tonsillitis, and inflammation of the mouth and eyes. This can lead to shock and death. After the virus gains entry to the dog, it localizes in the cervical lymph nodes and tonsils before traveling throughout the body. It takes approximately five days for infection to become apparent to the owners. By that time symptoms relate to virus in the liver, eyes, kidneys brain and lungs. Infected dogs shed the virus in their stool, saliva and urine. Over the next two weeks, the dog either dies from the disease or goes on to develop chronic hepatitis and cirrhosis of the liver. A few dogs develop chronic kidney disease (pyelonephritis), glaucoma or circulatory abnormalities (vasculitis, disseminated intravascular coagulation). Once a dog has become infected with CAV-1 there is no treatment that will destroy the virus. The best one can do is to support the dog with good nursing care, intravenous fluids and medicines to lighten the workload on the liver. Antibiotics are also included in treatment to prevent additional infections.

Chronic Active Hepatitis (CAH):

This disease is sometimes called Chronic Canine Inflammatory Hepatic Disease. Chronic active hepatitis is more common in dogs than in cats. It can occur in any breed dog, male or female, and at any age, although most or the pets are middle-aged or older. The fact that is chronic means that the disease has been going on for weeks or months as opposed to acute hepatitis that comes on suddenly and then ceases. A pet with this problem is in Liver Failure.

Unfortunately full recovery is more likely after an acute hepatitis rather than the chronic condition. The term active means that liver cells are continually becoming inflamed and dying. In CAH, continuous liver inflammation and cell death eventually lead to the replacement of the normal liver tissue with scar tissue. This is called cirrhosis. In most cases the exact cause of your pet's problem will remain unknown. Certain breeds are predisposed to Chronic Active Hepatitis, these include Bedlington Terriers, Doberman Pinschers, Skye Terriers, Standard Poodles, Cocker Spaniels and West Highland White Terriers. In many of these cases, copper is found in excessive quantities in the dogs liver. Other diseases that can lead to chronic active hepatitis are infectious canine hepatitis, leptospirosis, autoimmune disease and drug and chemical toxicities. Aflatoxins found in moldy grain especially corn can cause this disease. High quality dog foods test the grains they use for this toxin. You can read about some of the problems associated with these high-corncontent products here. What Are The Signs of Chronic Active Hepatitis? Symptoms of chronic active hepatitis are quite variable because the liver does so many things. The most common signs are increased lethargy, loss of appetite and diarrhea. Pets often drink and urinate more. As the disease progresses, many cases develop a swollen abdomen that is filled with fluid (ascites) and yellowish (icteric, jaundiced) gums, eyes and skin. In some cases the disease attacks the nervous system and the dogs become blind and obtuse. This can progress to seizures, coma and death. How is Chronic Active Hepatitis Diagnosed? Diagnosis relies on blood chemistry results that show an increase in the level of hepatic enzymes and on biopsies of the liver. Physical examination of the dog can suggest the disease when jaundice is

present. Dogs with chronic active hepatitis have smaller than normal livers. This can sometimes be seen on x-rays and ultrasound images of your pet. The texture of the liver with serious cirrhosis also changes. This is quite visible using these imaging techniques. How Can My Pet Be Helped? Treatment of cirrhosis is quite difficult because we have no medicines yet to encourage regeneration of the liver. Hospitalized dogs usually receive intravenous fluids and general supportive care. We often place them on antibiotics, anti-inflammatory agents and low protein diets.

Copper-Associated Chronic Hepatitis of West Highland White and Bedlington Terriers

Both these breeds sometimes inherit a defect in the metabolism of copper within their liver which causes a disease called copperassociated chronic hepatitis (CACH). Some of the dogs that develop this problem become depressed and jaundice. When it occurs in Bedlington terriers, they may also become severely anemic and pass red urine. If they survive this crisis, they suffer periodic bouts of hepatitis - particularly when stressed. Blood tests show elevations in all the enzymes associated with hepatitis. In the form seen in Westies, liver levels of copper build up to toxic level by six months of age and then sometimes decline and the overall concentration of copper in the liver is lower than in Bedlington terriers. Westies do not appear to suffer the hemolytic anemia that is common in Bedlington terriers with this disease. Treatment in both breeds consists of a low copper diet and drugs that bind and lock up copper (chelating agents), vitamin C to help flush

copper out through their urine and zinc acetate to block its absorption. We see two types of Bedlington Terriers with this condition. The first are young dogs less than six years of age that suddenly develop liver failure. Most of these dogs pass away quickly in spite of intensive treatment. A few do recover but are plagued with liver problems for the rest of their lives. The second group are older dogs that develop a slower, less severe form of the disease. They sicken very gradually and loose weight but the can live a long time. West Highland Terriers that develop this disease tend to have lower levels of copper in their livers and a less severe form of the disease. We estimate that 25% of Bedlington terriers suffer from this disorder and half the rest carry the genetic code for the defect but do not become ill. This is because two defective genes must be present for the disease to appear. These dogs can, however pass the disease on to their offspring. In these pets copper accumulates within the cells of the liver due to the presence of an abnormal binding protein. These dogs failure to excrete toxic copper through their bile slowly leads to hepatitis or cirrhosis of the liver. Clinical signs include enlarged liver, vomiting, depression, lack of appetite, jaundice, hemolytic anemia and hemoglobin in the urine. Treatment includes feeding diets low in copper and administering compounds that lower body copper stores. One of these compounds, D-penicillamine, binds with copper causing it to be voided in the urine. Another compound, trientine hydrochloride, decreases the amount of copper absorbed through the intestine. Prednisone anti-inflammatory treatment is also often helpful. Ursodeoxycholic acid (ursodiol; Actigall or Urso) is another antiinflammatory and bile facilitating drug that has been helpful. Sadenosylmethionine (SAMe) is an antioxidant compound that appears to help some of these dogs. Milk thistle herb is yet another compound used to treat liver disease. It was thought that its active ingredients, which include antioxidants, might protect liver cells and

facilitate liver repair (unfortunately, the only recent scientific study of milk thistle's
"active" ingredient, silymarin, found it of no value in humans with one form of chronic hepatitis ref. Silymarin is one of the two "active" ingredients in Denamarin).

Some veterinarians suggest these dogs receive vitamin E to protect against oxidative damage to liver cells. Dogs with this condition should not be bred, as they will pass on the disease through their genes.

Hepatitis Of Unknown Origin:

Hepatitis of unknown origin or idiopathic or periportal hepatitis sometimes occurs in dogs. It is most commonly seen in middle aged dogs. All breeds and both sexes are susceptible. Signs include vomiting, diarrhea, weight loss, jaundice, ascites, depression and weakness as well as increased thirst and urination. Lab work shows an increase in the enzymes ALT and AP as well as increases in bilirubin, bile acids and globulin and a decrease in blood albumin and red blood cells. We treat this disease with supportive care, antibiotics, low-protein diets and sometimes immunosuppressants. How the disease progresses or resolves depends on the amount of functional liver tissue that can be saved.Chronic hepatitis of Doberman Pinschers: This is s a perplexing disease. Some of these cases suggest copper storage disease similar to West Highland and Bedlington Terriers but we are uncertain if excessive copper causes the condition or if the disease simply causes excess copper to be stored in the liver. Female dogs are more commonly affected than males. This disease can occur at any age. Signs include weight loss, diarrhea, jaundice, vomiting and drinking and urinating excessively. Dogs may also be disoriented due to increased blood ammonia and they may bleed excessively due to blood clotting defects. Liver enzymes, bilirubin, blood ammonia and serum bile acids are usually elevated. Ultrasound studies will reveal a shrunken liver. Treatment for this disease includes supportive care, anti-inflammatory drugs and azathioprine and ursodeoxycholic acid. Chances for a long life after this disease has been diagnosed are quite poor. Hepatic Lipidosis in Cats: This disease occurs in cats that will not eat for a variety of health

reasons. Cats that are affected were often overweight. These cats may have stopped eating because of a change made in their diets or because of a stressful situation at home such as moving, kenneling or health problems in their owners. Secondary hepatic lipidosis also occurs in cats that suffer from diabetes, intestinal disease, pancreatitis or any other serious systemic disease. No mater what the cause, all cats develop an over-accumulation of triglycerides (fat) within their liver which blocks normal liver activity. Signs of this disease include weight loss, vomiting diarrhea, listlessness, drooling and jaundice. Laboratory tests reveal elevated liver enzymes and anemia. In treating this condition we try to address any underlying disease in order to get the cat to eat. Until this is done, cats need to be tube-feed energy-rich, high caloric foods.Inflammation Of The Biliary System In Cats: This condition is common in cats but rare in dogs. Suppuration is the accumulation of white blood cells called neutrophils in an organ. In the suppurative form (called Suppurative Cholangitis or Cholangiohepatitis) bacterial, fungal or protozoal infection of the livers system of ducts that transport bile result in the diseases. In the non-suppurative or lymphocytic form of the disease, blood cells called lymphocytes and plasmacytes accumulate around inflamed bile ducts. In biliary cirrhosis fibrous tissues surround and occlude the biliary system. A similar condition, lymphocytic portal hepatitis, is an inflammatory condition that is probably an underlying autoimmune disease. You can read more about these chronic inflammatory conditions of cats here. Hepatitis Due to Feline Infectious Peritonitis Of Cats: Feline infectious peritonitis or FIP is a deadly disease caused by a coronavirus that affects only cats. It causes inflammation of tissues throughout the body including the liver. Signs of this disease include weight loss, depression, abdominal fluid, jaundice, vomiting, diarrhea and fever. Mortality from this disease is a withering 100%. Affected cats are usually less than two years old or older than 10years. Many of these cats are also infected with the feline leukemia virus. Despite my intensive efforts cats with FIP do not live long.

Hepatitis Definition The liver is the main filtering and clearing house of the body. All blood supply travels through the liver to be detoxified. Hepatitis is a general diagnosis for a number of illnesses where there is inflammation and death of liver tissue. Types of hepatitis include Infectious Hepatitis, Chronic Active Hepatitis, and Leptospirosis Hepatitis. Affected dogs and cats develop a slowly progressive liver disease. There are many possible causes including viruses, bacterial infection, and some drugs (such as high doses of aspirin). Leptospirosis can actually be transmitted between animals and humans, whereas infectious hepatitis can be transmitted only between animals through contact with blood, feces or mucus membranes of an infected animal. Symptoms Listlessness, lethargy, depression Increased drinking and urination Fever Loss of appetite Vomiting Inflamed nostrils Pale mucus membranes Convulsions in young puppies Discharge from the nose Coughing Bloody stools and vomit Diarrhea Abdominal pain and/or enlarged stomach

How using ThePetCheckup regularly can help ThePetCheckup is a simple, in-home early detection test that may help to detect health problems at an early stage in your dog or catbefore symptoms appear. Because liver damage can be extensive before hepatitis is diagnosed, early detection is critical.

Hepatitis in dogs and cats is normally treated with antibiotics, IV fluids, dietary change, corticosteroids, and possibly copper-reducing medications. Hepatitis can be controlled when caught early, however, because liver damage is often advanced before the disease is diagnosed, prognosis is not always good.

Liver Disease: Signs, Symptoms, and Diagnosis

Column written by: Dr. Fleming, Sherwood Animal Clinic (Regina, Saskatchewan, Canada)

This topic is as big as the states of Alaska and Texas combined. I really cannot do it justice in a short essay, but I think it deserves some mention, if only to give the pet owner some understanding as to the difficulties involved when a veterinarian is faced with a case of possible liver failure. If you asked ten people on the street what they knew about "liver", I would bet that the only consistent answer you would get is that it tastes really bad unless the cook really knows his stuff. The best description of the liver I can give you is that this organ is the main industrial centre of the body. The liver processes raw materials, manufactures the building blocks of the body, recycles the old to make new, and detoxifies the industrial waste of the body. In short the liver is involved in just about every biochemical process required to run e body. As a result of this relationship, liver disease can affect just about any other part of the body and thus the symptoms of liver disease are typically unpredictable and non- specific. Furthermore, because the liver acts as a "biochemical cross roads" for the body, it is affected by a wide range of diseases, including viral and bacterial infections, degenerative and neoplastic disease, and toxic insults. It is estimated that three per cent of all disease seen by veterinarians is liver based. The liver has a double edged nature which, while being life preserving, makes diagnoses and treatment of liver disease extremely difficult. The liver has a tremendous reserve capacity, which means that it can easily perform it's duties with up to 70 to 80 per cent of the liver mass affected by disease. While it certainly is a benefit that our liver can keep us alive despite an overwhelming infection or a massive tumour, it also means that the disease is well advanced and possibly untreatable before any symptoms are noted. We all know that disease is most easily conquered early, but the very nature of the liver makes this an impossible task. One thing about livers though: they are the only organ in the body which is capable of complete regeneration and thus is we do manage to successfully treat the disease, there is a chance of complete recovery. Because of the complexity of this topic, I am going to cover it using very abbreviated point form. I will try to skip over the experimental theories and the more esoteric points and keep to the meat of the topic.

Common Presenting Symptoms:

All, some, or only one of these signs may be present. 1. Intermittent recurrent abdominal or gastrointestinal upsets. loss of appetite, vomiting, diarrhea, constipation. 2. Progressive depression or lethargy. Does not want to play anymore or refuses to go for walks. 3. Swollen belly with a "fluid filled" look. This is also known as ascites and is actually fluid accumulation in the belly due to circulation alterations in the abdomen. 4. Pale gray feces. Bile pigments are what gives poop it's characteristic brown colour and if the liver is not processing bile properly, the feces will not get their colour. 5. Orange urine. The improper processing of bile results in the excretion of bilirubin in the urine in high amounts, thus orange urine. 6. Jaundice, also known as icterus. Any pale or white skin or visible tissue takes on a yellow hue. Again the biliary pigments are accumulating in the body because the liver is not processing them. 7. Rarely: bleeding problems. Many of the proteins required for proper blood clotting are created in the liver. Remove these proteins and blood clotting decreases. 8. Hepatic encephalopathy, or severe neurological signs. behavioural changes, seizures, aimless pacing or circling, head pressing. May be associated with meal time. 9. Pain associated with the abdomen. This is due to the stretching of the liver capsule. May be noted when the dog is lifted around the belly or when the veterinarian probes (palpates) the abdomen. The veterinarian may also notice a swollen liver while palpating with some of the more acute liver diseases. 10. Chronic weight loss or wasting. The liver processes all the building blocks. If it fails to process, the body fails to maintain itself. 11. Increased water consumption and urination. Most likely due to dramatic shifts in serum and kidney salt balances. May be behavioural too.

Points on notable symptoms:

1. Bile pigment processing. Bile is a complex mixture of organic and inorganic compounds. It is primarily responsible for alkalizing the intestinal contents (acidic from the stomach),emulsifying the dietary fat, and prevention of putrefaction of digestive material. Bilirubin, one of the bile pigments, is derived from the break down of hemoglobin, the oxygen carrying molecule carried in our red blood cell. Bilirubin is quite toxic, but it usually binds to a protein called albumin, which harmlessly carries it to the liver for detoxification and excretion. Albumin is made in the liver. Liver failure results in poor bilirubin processing and decreased albumin manufacturing, which results in a dangerously high level of free floating bilirubin. The liver excretes the bilirubin after binding it to an amino acid into the bile duct system. Eventually the conjugated bilirubin enters the digestive tract, where the intestinal bacteria break it down to a harmless product called urobilinogen. Urobilinogen, after complete digestion in the intestines, is brown, therefore the feces tend to be brown. Jaundice, also known as icterus, results from the accumulation of conjugated and unconjugated bilirubin in the body tissues. This becomes visible to the veterinarian, especially around the whites of the eyes and on the pale areas of the gums. 2. Important biological functions: a. hormone metabolism. The liver is both the target organ for many of the body's hormones and the recycling centre for most of the hormones. Some of the symptoms stemming from liver failure may mimic a major hormonal imbalance. b. vitamin metabolism. Practically all the vitamins consumed in our diets are either directly involved in liver function or require liver aided transformation to be used in the body. This includes Vitamin C, the B vitamins, Vitamins A, D, E and K. Vitamin K is important to maintain blood clotting and requires hepatic transformation from the inactive form to the active form. c. Red blood cell maintenance. In the mature dog the liver plays an active role in the removal of aged or damaged red blood cells from circulation. It is also active in the metabolism of hemoglobin and the storage of iron. Abnormalities in red blood cell structure is one of the harbingers of liver disease. Anemia may be present in chronic liver disease. d. Hemostasis or blood clotting ability. Most of the proteins involved in the creation of a functional blood clot are made in the liver. The clotting system is an extremely complex, interlocking system ; remove some of the factors involved and you end up with a tendency to bleed or hemophilia. e. Carbohydrate and fat metabolism: Sugars, or carbohydrates are the basic fuel of the body. The liver is the primary centre for processing of the sugars into the form immediately required. The liver is also responsible for the destruction of insulin, the hormone directly involved with the cellular absorption of blood sugars.

Alterations in liver function often do not affect blood sugar levels until much of the liver has been destroyed. Fat metabolism is extremely complex due to the vast number of functions fat carries out in the body. The liver sits at the centre of those many functions. Cholesterol is probably the most common fat based product in the body, being the major component in the cell wall, the basis for the steroid hormones and bile pigments, and the precursor of vitamin D. Any disease in fat metabolism can adversely affect the liver, and any disease in the liver can result in problems in fat metabolism. An example of this is the "fatty liver syndrome" we see in cats, whereas the rapid mobilization of fat stores during starvation results in an overtaxed liver and eventually liver failure.

Protein synthesis:
The liver manufactures many of the proteins involved in the body functions. The major protein is albumin, which is required for transport of many nutrients and toxins (i.e. bilirubin). Albumin is also responsible for keeping the serum concentration constant, which is important with regards to serum fluid and salt balance. (also known as "oncotic pressure") Also synthesized in the liver is the globulin series, which are responsible for numerous biochemical reactions throughout the body. Elevations of select globulins may indicate a particular hepatic pathology. The building blocks of proteins are the amino acids. The liver is also primarily involved in processing of dietary amino acids to modify them into required or useful forms. Some of the amino acids require direct hepatic metabolism, while others can be used by the body unchanged. Experimental efforts have been made to diagnose and track liver disease based on the relative proportion of the various amino acids to each other. In liver failure the amino acids requiring hepatic alterations prior to use should climb in concentration as compared to those amino acids unaffected by the liver.

Important Liver Enzymes:

Traditionally the medical practitioner has measured the relative concentration of several enzymes which may indicate alterations in liver health. The following enzymes typically change values in the face of liver failure: Alanine Aminotransferase: ALT. Liver specific in the dog and cat. Cell damage will cause elevations of A-LT due to leakage. The elevation of the enzyme correlates with the number of cells damaged. Falling levels of ALT may indicate recovery or may indicate a failing number of functional liver cells. Rapid increases in ALT may indicate an acute process, while slow increases may indicate bile duct obstruction. Aspartate Aminotransferase: AST, an enzyme seen in the liver, heart, kidney, skeletal muscle and brain. The half life of the AST in the blood stream is much shorter than that of ALT,

therefore the values of AST tend to drop more rapidly once liver function is resumed. AST elevations and ALT elevations should parallel each other in liver disease. Alkaline Phosphatase. This enzyme is present in many tissues, therefore it is not very specific in liver disease, but it appears very early in the progress of liver disease, therefore it is considered quite sensitive. ALP tends to be slightly more specific in the cat, but not quite as sensitive. A similar enzyme or isoenzyme is secreted as a result of high levels of cortisone, therefore an effort must be made to separate Cortisole induced ALP or CALP and normal ALP. Liver ALP is released from the liver when many anticonvulsant drugs are administered to the dog. A similar sensitivity has not been noted in the cat.. This must be taken into account when evaluating ALP levels. ALP levels typically are greatly elevated in the young, growing animal and therefore a veterinarian should not mistake any elevations as disease in a young animal. Gamma Glutamyltransferase GGT: This enzyme is has it's highest concentration in the kidneys and pancreas, but it is also found in the liver and other organs. The major proportion of GGT in the serum seems to come from the liver. Elevations of GGT in disease seem to stem from new synthesis rather than leakage, therefore the changes seen due to disease are not spectacular. Large elevations of GGT are more commonly associated with pancreatitis and bile duct obstruction.

Bile Acids:
These series of organic acids circulate almost entirely in the localized blood flow between the intestines and the liver (a.k.a.: the Portal system). The flow is typically from the liver, into the bile duct system, then excretion into the intestines to aid digestion after a meal, to be reabsorbed into the portal system and recycled by the liver. Very little of the bile acids escape form the portal circulation system into the rest of the body. Leakage is considered abnormal and is a sure sign of a liver abnormality. This is one of the most sensitive tests available to diagnose liver disease. While the liver does actually manufacture this product, it has tremendous reserve capacity and can easily meet the bodies demand for bile acids despite severe disease. As a result of this reserve, the bile acid levels do not typically drop due to liver disease.

Ammonia and Urea:

Ammonia is a by product of digestion of protein in food and the catabolism of nitrogen based organic materials in the body. Eighty per cent of ammonia is delivered to the liver and converted to urea. In patients with liver insufficiency the ammonia is not detoxified to urea, but enters the circulation to act as a central nervous system depressant. In patients with a severely reduced liver function we may see a true intolerance of ammonia and thus neurological signs after a heavy protein meal or we may see substantially reduced urea levels. This is a late sign in liver disease, only seen after 60 to 70 per cent of the liver function is gone.

Ascites development:

This is the accumulation of fluid in the abdominal cavity and results from several factors. Simply put liver disease tends to alter the blood pressure in the portal system, the albumin and salt concentration in the serum, the water retention in the body, the function of the surrounding organs and the permeability of the portal vessels. As a result of all these factors, fluid tends to build up in the abdomen and the animal gets a big, swollen, fluid filled belly. Electrolyte and Acid-Base disorders. Common side effect of liver disease due to a multiple of factors leading from metabolic disorders. Enough said.

Gastrointestinal Ulceration and Hemorrhage:

Again a sequellae to liver disease which may confuse the veterinarian. He may think he is treating a simple ulcer and miss the liver disease. Hepatic encephalopathy. Simply described as severe neurological dysfunction due to advanced liver disease. Has been linked to the accumulation of biological toxins, including ammonia, alterations in the blood brain barrier, alterations in the neuroreceptors in the brain, and decreased blood sugar.

Diagnosis of Liver Disease:

Having gone into such detail prior to this, I hope this section will be short and to the point. I hope most of my statements here will naturally flow from points made above. 1. Examination, specifically noting signs which may indicate liver disease. Periodic ascites, intolerance of a high protein diet, icterus, chronic weight loss, abnormally coloured feces or urine, bleeding disorders, chronic illness, and all that has been mentioned above. Sometimes urinary crystals formed from the improperly metabolised proteins and amino acids may indicate liver disease. 2. Extensive blood work:

A complete blood count to check for anemia and blood cell abnormalities. A complete chemistry screen, including ALT, ALP, AST, bilirubin, glucose, urea, electrolyte levels, albumin, globulin and bile acid levels. The bile acid levels should be checked on a empty stomach and two hours after feeding. All these values , with the exception of the bile acids, usually are included on a standard Small Animal Data Base Screen. A complete urine analysis. Check urobilinogen levels, bilirubin levels, glucose levels, protein levels. Again all this is usually on a standard urinalysis panel. Radiograph the abdomen. X rays can show increased liver size, decreased liver size liver abscesses, abnormal mineralization , and circulatory abnormalities (using special dyes)

Ultrasound the liver. Perfect technique for visualizing the circulation of the liver, the bile duct system, the density of the liver tissue, the size of the liver. Biopsy of the liver. While this is a surgical technique, it is the ultimate for diagnoses, since it allows us to directly examine and test liver tissue, give an absolute diagnoses and hopefully a final treatment regime. Biopsies can be taken by full laparotomy, where the surgeon actually looks at the liver and removes a small piece, or they can be done by a biopsy needle guided by ultrasound through the body wall. The liver will regenerate any piece removed, therefore liver biopsy is usually a low risk procedure in capable hands.

Specific Diseases of the Liver:

Infectious Hepatitis. Typically caused by either an adenovirus or a herpes virus. Transferred from dog to dog by oral contact and ingestion. Usually only causes a transient non specific illness characterised by lethargy vomiting, diarrhea and fever. Sometimes develops into a full blown case of severe hepatitis with many of the symptoms previously noted. Treatment is geared to support while the body fights off the bug. Prevention is by vaccination. Another syndrome has been seen in England called Canine Acidophil hepatitis. Typical signs of hepatitis are present, but the case may take a very chronic course, lasting over a period of years. No specific viral organism has been identified, therefore no vaccine or treatment is available. No specific virus causes hepatitis in cats, but the feline corona virus responsible for Feline Infectious Peritonitis will cause a hepatitis in some cases. Diagnoses by biopsy. No treatment. Mediocre vaccine. Several bacterial causes of hepatitis are known. Treatment is based on a proper diagnoses and appropriate antibiotic use. There is good proof that the bacteria is a normal inhabitant of the liver and only becomes a problem when the liver is injured form other causes. There are notable exceptions. Blastomycosis, histoplasmosis and coccidiomycosis are fungal infections seen in various parts of the country (usually associated with river systems) Difficult to treat. Leptospirosis is a bacterial infection common in wildlife and transferable to domestic animals and people through contaminated water. Dangerous, possible fatal, but the vaccine is quite good for prevention. Tuberculosis is still around and is considered transmissible to humans. Certain parasites will infect the liver. Typically the likelihood of parasitic infestation depends on the area you live in. Diagnoses is often based on symptoms, fecal examination, and standard diagnostic techniques for liver disease. Treatment is the use of appropriate parasiticides.

Liver Disease Secondary to other Disease:

Acute pancreatitis: the close proximity of the pancreas to the liver and the bile ducts results in some degree of hepatitis whenever there is a case of pancreatic inflammation. Treat the pancreatitis and the liver disease will regress. c bowel disease: the chronic inflammation of the bowel allows portal absorption of toxic intestinal products and bacteria. treat the colitis. Shock, anemia, and congestive heart failure. All these result in severe loss of blood circulation to the liver and lack of oxygen. The liver disease is rarely of primary concern as the primary causes of the problem are most likely going to kill the animal prior to liver failure. Abdominal trauma: tears, bruising, biliary leakage, hepatic bleeding. Correction of these problems would require surgical intervention, assuming a timely diagnoses. Simple bruising of the liver will heal unaided, with only a transient increase in the hepatic enzymes. Feline Hyperthyroidism: many of the symptoms of hyperthyroidism and hepatitis are the same and in fact the hyperthyroidism will cause elevations in the liver enzymes. The thyroid level of any cat presenting with symptoms suggestive of liver failure should be checked. The hepatitis will resolve once the hyperthyroidism is treated.

Chronic Hepatitis:
Copper storage diseases in Beddlington terriers, Doberman pinschers, and West Highland white terriers. These are all genetically inherited diseases which result in abnormal and toxic levels of copper to be stored in the liver. The course of the disease is variable, some presenting with acute hepatitis, many presenting in end stage cirrhosis of the liver. Diagnoses is based on liver biopsy. Treatment requires the use of copper binding drugs, anti inflammatory to decrease liver inflammation, dietary modification to limit copper uptake. Chronic Active Hepatitis: In humans there is a chronic form of hepatitis characterised by chronic elevation of liver enzymes and biopsy samples showing scarring and active inflammation. The underlying cause for this entity falls into one of three categories: viral induced, toxin induced, and immune mediated. There is some question as to whether a similar syndrome exists in dogs. There has been cases which did show chronic elevation of the liver enzymes over weeks to months), symptoms characteristic of liver disease ill defined malaise), and a response of anti inflammatory treatment to limit the ongoing inflammation and scarring of the liver. At this time recommendations for treatment are that moderate or intermittent disease should only receive supportive therapy or basic nursing, while deteriorating chronic cases should receive steroid based anti inflammatory. If the case shows poor response, biopsies should be referred to a pathologist for evaluation in an attempt to find the underlying cause. In some cases it may be necessary to use strong immune suppressant drugs to stop the destruction of the liver. Leptospirosis associated chronic hepatitis: An example of bacterial infection leading to chronic disease. Diagnoses by biopsy and identification of the pathogen. Treatment by antibiotics.

Infectious Canine Hepatitis associated chronic hepatitis. Exposure to the virus responsible for ICH leads to chronic active hepatitis due to an ongoing immune system malfunction. Diagnoses by biopsy and the use of special stains to demonstrate the viral antigens in the liver. Lobular dissecting hepatitis: rare disease diagnoses by biopsy. Hepatoportalfibrosis: Disease primarily of the blood supply to the liver. Diagnosed by very specialized radiograph techniques which measure and visualize the blood flow through the liver. Biopsy critical for diagnosing location of lesion. Toxic liver injury: Primary disease is caused by the ingestion , injection, or inhalation of a toxic substance which adversely affects the liver. Due to the central nature of the liver with regards to detoxification of chemicals, it is no surprise that many are harmful to the liver. Factors contributing to the disease are: females more susceptible, fatty diets more dangerous, continuous exposure, high levels of exposure to toxins. Exposure results in death and inflammation of the liver cells, followed by replacement of damaged tissue by fibrous scarring. This can be a self perpetuating cycle, resulting in cirrhosis of the liver. Toxins include many common drugs, such as acetaminophen, ASA, anabolic steroids, chemotherapy drugs, some antibiotics, glucocorticoids, anaesthetics, parasite control drugs, and phenylbutazone. Some of the drug induced hepatitis is a predictable side effect of the drug, while other incidences of hepatitis are considered an unpredicted or abnormal side effect of the drug. This is difficult to diagnose unless there is a known exposure to the drug or toxin and the appropriate tests are taken. Biopsy will confirm liver destruction, inflammation, and fibrosis, but it will not single out the causative agent. Glucocorticoid Hepatopathy dogs seem abnormally sensitive to glucocorticoid drugs ("cortisone") and will develop typical lesions in the liver after multiple dose therapy or long term over production of intrinsic cortisone by the adrenal gland (Cushing's disease). Lesions are fairly typical and the rare animal which shows liver associated symptoms during glucocorticoid therapy will improve with the removal of the steroids. Liver associated lesions may take weeks to months to heal. Anticonvulsant associated hepatopathy; Phenobarbital, primidone, phentoin. May cause liver disease in 6 to 15 % of all dogs on anti-convulsant therapy. Inflammation seems related to dose. Degree of disease is variable and unpredictable. Diagnoses based on history, symptoms, laboratory tests, and biopsy. Treatment is removal of offending agent. Cirrhosis: This is the end point of chronic, active hepatitis. The cycle is one of liver cell death (due to insult, either toxic, viral, or immune mediated), followed by inflammation and scarification. The end requires all previously noted techniques. No treatment is possible and ongoing palliative and dietary care is the only treatment option..

Noninflammatory Liver Diseases:

Portal vascular abnormalities Usually a portal-systemic shunt which allows blood to pass from the digestive tract directly into the general circulation without being detoxified by the liver first. Usually a congenital defect restricted to young dogs and puppies, but can be the result of hepatic cirrhosis. Symptoms are never consistent, but many dogs are young, malnourished, chronically sick, poorly tolerant of toxins, drugs, and anaesthetics, and tending to eat strange items (pica). Diagnoses is based on physical exam, history, laboratory tests, and specialized X rays showing blood flow through the liver. Treatment is surgical correction of the circulatory abnormality to force the blood into the liver prior to it entering the general circulation. Hepatic Lipidosis Most common form of severe liver disease in cats. Most often seen in obese cats suddenly subjected to dietary deprivation. May also be associated with diabetes mellitus, drug injury and toxicity. Thedisease seems to result from the sudden mobilisation of the bodies fat stores which quickly overwhelms the liver's ability to process the raw fat into useful nutrients. The fat accumulates in the liver rapidly and causes acute liver failure. The end result is a swollen, greasy liver which is fragile and yellow to see. The cats present with complete lack of appetite and many signs of acute liver failure. Treatment is based on the provision of a highly nutritious diet to provide the energy required to run the body, stop the ongoing mobilisation of the fat stores, and drive the liver to decrease the fatty accumulation in the liver. Treatment is difficult and a long process. Hepatic Cancer (Neoplasm) Falls into two categories: primary or originally stemming from liver tissue or secondary; originating in some other part of the body and spreading to the liver through the circulation system. Primary liver cancers can stem from exposure to toxins (oncogenic compounds) which attack the liver full strength, since the liver is the primary detoxification centre of Secondary cancers may stem from any part of the body, but the liver is a favourite destination for metastatic cancer because of it's central function in the body and the micro- capillary network which makes up the circulation passing through the liver. Primary liver cancer is usually quite advanced prior to diagnoses and tends to metastasize to the rest of the body very early in the course of the disease. Keep in mind the liver can function with less than one third of it's volume still operating, therefore liver cancer can be very advanced before any symptoms are noted. Treatment is usually pointless, but would be based on diagnoses of the specific cancer and the use of appropriate chemotherapy agents.

Basic Points for Treatment of Liver Disease

1. Removal of toxic agents. Identify and remove any drug or toxin which may potentially hurt the liver.

2. Rest and confinement. This will help divert body resources to the healing process at the liver and reduce discomfort caused by inflammation of the liver such as painful belly, nausea, malaise. 3. Dietary management: Extremely important. The goal is to provide all the necessary nutrients which may be lost due to failure of liver processing without overtaxing the liver with regards to processing of dietary intake. High levels of top quality protein to provide the essential amino acids in an easily digestible carrier which will not produce high levels of ammonia during digestion. Cottage cheese is good, meat tends to produce high levels of ammonia. High level carbohydrates to drive the metabolism of the body, essential fatty acids not less than 6% of the daily intake, and a good mineral and vitamin supplement. Force feeding may be necessary. 4. Control of ascites and water retention. Reduce sodium intake. Diuretics will help in resistant cases. 5. Control concurrent infections with antibiotics. 6. Deal with the concurrent medical problems as they crop up. Remember that the dog may develop bleeding problems, malabsorption problems, and neurological problems. Each separate problem has to be dealt with both individually and as a part of the whole disease entity. Neurological symptoms such as coma need to be addressed aggressively with a combination of therapies. I realise that this is a long, possibly boring paper that is far from complete. I cannot emphasize too strongly how difficult this topic is. I gleaned this information from a single source Textbook of Veterinary Internal Medicine edited by Stephen J.Ettinger 1989.