Signalment:
Canine, Shepherd cross, 11 years old, female spayed, 46.8 lbs.
Clinical history:
The dog presents with vomiting and icterus. Therapy has included Actigall, metronidazole, Baytril and prednisone.
Physical examination:
The findings include rectal temperature 101.6° F, heart rate 110/min, pink mucous membranes, and normal capillary refill time.
Normal heart and lung sounds are heard.
Laboratory results:
A complete blood count, serum chemistry profile, and urinalysis were performed and are as follows.
Ultrasound examination:
Thorough abdominal ultrasonography was performed.
Table 1: Results of laboratory tests
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My comments:
The liver is echobright and has irregular margins and shows hypoechoic areas in its parenchyma. Fine needle aspirations of
the liver for cytologic examination are obtained. The gall bladder is mildly distended, and its walls are not thickened or
hyperechoic. The common bile duct is slightly dilated. The spleen shows a uniform echogenicity in its parenchyma - no masses
noted. The left and right kidneys are similar in size, shape and echotexture. No masses or calculi were noted in either kidney.
The urinary bladder is distended with urine and contains some urine sediment material - no masses or calculi noted. The stomach,
left adrenal gland, small intestine and pancreatic region are normal.
Liver cytologic examination:
The smears contain numerous large clusters of well-preserved hepatocytes. These hepatocytes show mild to moderate cytoplasmic
fine vacuolar degeneration and intracellular accumulation of bile pigments. There are several extracellular bile casts. Multiple
focal areas of hepatocytes show moderate to severe cytoplasmic fine infiltration – suggesting benign nodular regeneration.
There is moderate infiltration by inflammatory cells composed of a mixture of neutrophils in good morphological condition,
small lymphocytes, medium-sized lymphocytes and occasional plasma cells.
There is no evidence of sepsis or neoplasia. The cytologic diagnosis is moderate mixed suppurative and lymphocytic hepatitis
with severe cholestasis and multifocal benign nodular regeneration.
Image 1 and 2.
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Case management:
In this case, chronic liver disease is the clinical diagnosis. This dog's liver disease is chronic hepatitis with regenerative
nodules. These cases of chronic hepatitis usually have a long history of increased serum liver enzymes. Fluid and antibiotic
therapy is important in the clinical management of severely icteric dogs. I generally will feed these dogs Prescription Diet
L/D and daily administer Denosyl SD4 (18 mg/kg PO SID), milk thistle (silymarin, 4-8 mg/kg PO SID) and/or vitamin E (400-800
units PO SID).
Periodic use of prednisone (1-2 mg/kg BID for 5-7 days) and oral lactulose (0.25-0.5 ml/kg PO BID) are needed to get the dog
back to eating again and improve the dog's activity.
I suspect that the liver disease in this dog may be controlled but will not be cured. I would from here on be careful with
any drug use in this dog that requires metabolism by this dog's liver. Therapy of special diet and antioxidants is probably
for a lifetime.
Image 3 and 4.
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Review of treatment of chronic hepatitis in dogs
The treatment of chronic hepatitis in dogs remains speculative as controlled clinical trials with large numbers of dogs have
not been performed. The necroinflammatory response is usually progressive, and most dogs do not go into spontaneous remission.
If cirrhosis is present, the likelihood of successfully managing the case is low. Therefore, the prognosis is poor in severe
cases, and most of these dogs die within several weeks to months despite appropriate treatment.
Early detection is important. The basic goals in treating dogs with chronic hepatitis are to arrest inflammation; resolve
fibrosis; and correct nutritional imbalances and treat hepatic encephalopathy with dietary management.
Although there are no controlled trials involving glucocorticoids in the treatment of dogs with chronic hepatitis, many veterinarians
have had success using them as part of the therapeutic regimen. The starting dosage of prednisone is 1 to 2 mg/kg/day. Once
clinical remission is achieved (usually three to four weeks), the dosage of prednisone is gradually tapered to a low maintenance
dosage (approximately 0.25 mg/kg daily or about five to seven days every four to six weeks). During the tapering process,
animals may be monitored with serum chemistry profiles for relapses.
The use of the hydrocholeretic drug ursodeoxycholic acid (ursodiol; Actigall or Urso) may be helpful. It is believed that
ursodeoxycholic acid has anti-inflammatory, immunomodulatory and choleretic effects. Use of ursodeoxycholic acid may be considered
as either primary or adjunctive (in combination with immunosuppressive or anti-inflammatory drugs) treatment in animals with
chronic liver diseases. A safe and effective dose is 15 mg/kg daily, administered either once daily or divided twice a day.
The drug should be given with food. Studies need to be performed to substantiate its efficacy and dosage in the dog.
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