Animal Health Trust
Lanwades Park
Kentford
Newmarket
Suffolk
CB8 7UU
Tel: +44 (0)8700 502424 Internal Medicine Unit
Fax: +44 (0) 8700 502425 Centre for Small Animal Studies
E-mail: info@aht.org.uk Tel: +44 (0)8700 502540
Web Site: www.aht.org.uk Fax: +44 (0)8700 502541

Discharge notes
Case #: 06/2506 Investigation performed
Haematology, biochemistry, coagulation analysis, radiographs, ultrasound examination, vascular studies

Findings
Twiggy has an extrahepatic portosystemic shunt and severe liver dysfunction. She has severe protein malnutrition and her liver is unable to maintain normal levels of glucose, cholesterol or proteins.

We have two main options – to treat her medically with a combination of diet, lactulose and antibiotics for life. This will help control her clinical signs of neurological upset (hepatic encephalopathy) but will not treat her liver. The prognosis with medical treatment is guarded – in studies about half of dogs treated medically are euthanased due to persistent neurological disease or liver failure with an average time of 10 months from diagnosis. Remaining dogs live an average of 4 years with medication but the age of diagnosis is often younger than Twiggy. Surgical management offers a better chance of correcting the problem and allowing her liver a chance to function normally but there is a risk of peri-operative mortality (on average about 10%). Complete surgical correction is not possible in about half of dogs with portosystemic shunt sand in these dogs partial ligation of the abnormal vessel is usually attempted. In such cases about half of the dogs undergoing partial ligation still have persistent clinical signs requiring medical treatment. A second operation is sometimes required. So essentially medical management runs the risk of missing the opportunity to surgically treat the disease and surgical management runs the risk of perioperative mortality. In general dogs that undergo surgery are best operated on under two years of age, but have the better longer term outcome than dogs treated medically.

Presently Twiggy is not an ideal candidate for surgery – her liver function is unable to keep her glucose or protein levels normal which are very basic liver functions and which would make her recovery from anaesthesia and tissue repair after surgery poor.

Current treatment
Lactulose – initially 3 mils orally three times a day but this will need to be adjusted to effect. Twiggy needs to be given enough lactulose to make her stools a little loose without causing them to be runny. She may have some slightly loose stools after sedation for ultrasound but this should settle down quickly. If this dose makes her too runny drop down to 1 ml orally three times daily initially.

Amoxycillin 100mg (1/2 tablet) orally twice daily
Diet – 180-190g of Canine Dry Royal Canin / Waltham Hepatic diet in 4 divided meals / day with the addition of low-fat cottage cheese 1/4 of a small tub with each meal.

Discharge notes
I would like Twiggy to be weighed and her serum protein levels assessed by your vet every 2 weeks initially. They can fax the results through to me and I can keep an eye on whether progress is being made. We would want Twiggy to gain at least a kilo in weight and for her serum albumin level to increase before considering her a suitable surgical candidate, and for her to have been stable for a month.

Suggested follow-up
Please call me with an update / progress report in 3-4 weeks and we can discuss further whether to consider surgery or not.

Jon Wray BVSc DSAM MRCVS
RCVS Diplomate in Small Animal Medicine