Liver Disease in Dogs - Hepatic Nodular Hyperplasia

Hepatic nodular hyperplasia and Choleangiohepatitis

Question: I am a new subscriber who discovered your helpful site while researching information on liver problems in dogs. My 5 year old German Shepard/Chow mix recently had been losing weight and not eating, so I took him in to the vet,where they discovered his abdomen was full of fluid. They did an ultrasound guided liver biopsy, and the likely diagosis according to our vet was liver cancer. Thankfully, the biopsy results came back negative for cancer cells but the doctor wanted to try to get a better sample. He said that Riley's liver was so bumpy and abnormal looking and cancer was the only thing he knew to cause that. They did a second liver biopsy, and the results came back the same- no cancer cells. They have concluded that it is choleangiohepatitis, either caused from a bloodbourne infection or food allergy. It seems to me that it would be fairly easy to distinguish the cause- wouldn't an infection be able to be figured out from the biopsy? And wouldn't a food allergy have presented with other symptoms as well? They want to start him on a hypoallergenic diet after he finishes his course of meds. Wouldn't it be better to determine if a food allergy is even the problem first? Just wanted your opinion. Thanks! Sally-

Answer: There is a condition in dogs, hepatic nodular hyperplasia, which causes lumps on the liver that look just like cancer but are benign lesions. It is usually possible for the pathologist to identify this condition from a biopsy sample, but the sample does have to come from an affected area, which is one of the problems with needle biopsies -- they produce small samples. I have worried over the possibility of cancer after examining a liver with these hyperplastic nodules so I assume this probably happens to other vets, too. Unfortunately, it is also possible to miss a tumor in the liver with a needle biopsy, even an ultrasound guided one. Sometimes it is necessary to do an exploratory surgery to get a larger biopsy sample. If there is still some confusion about other possible disorders, it would be possible to biopsy other organs at the same time. I do think it is a good idea to try to rule out disorders other than liver disease prior to doing an exploratory surgery, or to do testing that is more specific for liver function, such as bile acid response testing, to try to be sure that the liver is not functioning well. The only way to tell if a food allergy is present is to feed a diet that isn't likely to cause an allergic reaction. Most of these diets are not truly hypoallergenic, they just contain ingredients that the dog isn't likely to be currently allergic to (foods that haven't been eaten at any prior time). There are newer hydrolyzed protein diets that really are hypoallergenic -- actually unlikely to ever cause an allergic reaction. Feeding one of these diets long enough to see if clinical signs disappear is the test for food allergies. It usually takes six to eight weeks to be sure that a food allergy is not present but it may take less time if one is present -- the dog will get better before six weeks in many cases. The causes of fluid accumulation in the abdomen include heart failure, liver disease, disorders causing low protein in the bloodstream (inflammatory bowel disease, parasites, kidney disease) and cancer. Sorting through these possible problems can be difficult. It is important to try to rule out causes that aren't related to the liver, too, though. Analyzing the fluid from the abdomen can be helpful in determining what it is. Once in a while, heart problems lead to ascites without any obvious sign such as a heart murmur. This is one of those situations in which it can take a concerted effort to figure out what is going on. It may take a concerted effort on your part and on your vet's part to get to a diagnosis but it is usually possible to eventually get one. Mike Richards, DVM 8/29/2000

Liver problems in older Golden -Nodular hyperplasia or Cushing's possible

Question: Dear Dr. Richards, I have a 13 year old golden retriever, named Kirby, who had intermittent diarrhea for about 2 weeks. We kept thinking about taking him to the vet, but then it would clear up for a day or two before it came back. Finally, it got much worse and he became nauseous, and we brought him in. Since Kirby had gone swimming in the Chattahoochie River here in Atlanta about two weeks ago the vet suspected giardia. Two fecal flotations were negative for giardia, but did show a bit of blood in his stool. He was put on flagyl, and when that didn't help after 48 hours, also on ampicillin. We also did a full blood workup. It came back with some bad liver values, as the vet put it. In fact, she called us in for emergency x-rays, which she said did not show anything immediately life threatening, but said his liver was smaller than it should be. The abnormal values are as follows: total protein - 4.8 (L) alkaline phosphatase - 522 (H) calcium - 8.3 (L) CPK - 54 (L) Magnesium - 1.4 (L) T4 - 0.4 (L) some other values, like cholesterol and triglycerides look borderline bad as well. After being on these antibiotics for a week Kirby's appetite is back to normal, and he is acting alert and happy. However, he still has abnormal stools that are loose and bloody. My vet wants to try using panacure, in case there are worms. I see no evidence of these in the stool, and he is on a heartworm preventative that has dewormer in it. He is also scheduled for an ultrasound, but it can't be done for a week. I could insist on a reference and maybe get the ultrasound done sooner, but my vet seems to think that if they find that this is being caused by the liver, there will be no real treatment options anyway, since it would be digestive cancer. Are there any tests that we should have done to figure out the cause of this, or is treating with medicine and seeing if it responds the best way to do things? Are there diet and medicine options for Kirby's reduced liver function that I should be implementing now? I have had four goldens who have all lived to past 15 years. I think with a little care, attention, and luck that this is not an unreasonable age expectation. However, every time I walk into a vet's office everybody acts amazed that I have an old, healthy dog! Thanks for your time, and sorry this was so long. sincerely, Debra

Answer: Debra- When there is a rise in alkaline phosphatase, without a rise in other liver enzymes in an older dog, the two most common causes are probably hyperadrenocorticism (HAC, Cushing's disease) and nodular hyperplasia of the liver. There can be other causes, though. Nodular hyperplasia can be seen on ultrasound exam sometimes, but not always. Liver biopsy, which can be done in association with the ultrasound exam (ultrasound guided biopsy) is often necessary to confirm this diagnosis. I have to admit that I am not too excited about doing liver biopsies in patients that just have elevated alkaline phosphatase (SAP) levels, when they feel well and show no other signs of liver disease. It is the only way to be sure of the diagnosis that I know of, though. This is a benign condition that causes dogs to have high SAP levels but usually liver function tests like bile acid response testing and other liver enzyme levels are normal. Cushing's disease is always a consideration in older patients but it usually causes other signs, like hair loss, increased drinking and urinating, pendulous abdominal muscles, muscular weakness and/or panting. The low protein levels could be a result of liver disease, can occur with kidney problems and with intestinal inflammation. In this case, I think I'd worry about intestinal inflammation the most, but that opinion might change if I was evaluating the patient and not the history alone. Panacur (tm) is pretty safe and it kills giardia as well as hookworms, whipworms and roundworms, so I we use it in situations like this, sometimes, too. I don't think that you know at this point whether or not Kirby actually has reduced liver function. You know that there is something that is causing a rise in alkaline phosphatase and something, possibly liver disease, leading to decreased protein levels. The calcium level is low only because the protein level is low. Calcium rides around in the bloodstream attached to protein --- when the protein is low, the total calcium level will be low. Ionized calcium (the active form) is usually still normal in these cases. T4 levels drop in many instances in which there is any systemic illness, so right now, this value is not meaningful. Once the problems are under control it might be a good idea to retest to see if there is a true hypothyroid state. To find out if Kirby has decreased liver function, the best test is a bile acid response test. This is easy to do and any general practice using an outside lab should be able to do it. If this test is normal, which is very likely, then there isn't much reason to make dietary changes. Sometimes ursodiol (Actigal Rx) is helpful when there are alkaline phosphatase rises, milk thistle seems reasonable to use and SAMe (Denosyl SD4 tm) is also recommended frequently for liver diseases. It might be worth considering using one or more of these medications. It is nice to see older healthy dogs and we make a fuss over them, too. We see a number of older dogs with chronic health problems of one sort or another and it is just good to see one that is doing well. It isn't that we think it is really unusual or that we are expecting bad things right away --- it is just really nice to see someone doing well! Hope this helps. Mike Richards, DVM 8/10/2000