Cosmo presented to the Tufts NEVMC emergency service on 8/7 with a possible Advantix toxicity. Cosmo went to our Summer house on 8/1 and was lethargic and anorexic for the first few days (which is usually normal for him in a new environment). Cosmo received a dose of Advantix on 8/3 and his lethargy never improved. He did continue eating until 8/6 but on 8/7 he was incapable of moving and was cold with shallow breathing. Cosmo was quickly slipping into a coma. Cosmo was immediately transported to a veterinarian near the summer house where Cosmo’s temperature continued to drop down to 96 degrees, (dog normal temp is 101.6 degrees) then began rising again that afternoon. This was with the aide of heating pad and constant attention from the veterinarian’s assistants. After calling the vet office every hour on the hour the good news finally came that his temp had returned to 101.6 and it was advised that he continue to receive veterinary care over night. Much to our surprise we found that very few veterinary offices have 24 hour care. Our options were limited to 3 distant locations Tufts in Grafton Massachusetts was the furtherest away from home but we knew he would receive the best care there. So Cosmo was then referred to Tufts for further monitoring and care.
On physical examination, Cosmo was lethargic and had a mildly increased respiratory rate, though there were no other abnormalities. Cosmo was started on IV fluids and a complete blood count (CBC), chemistry panel and urinalysis were run. He chemistry panel showed increased liver enzymes and bilirubin, suggestive of liver disease. The CBC showed a high neutrophil count with low lymphocytes (both of these are white blood cells; this pattern suggests stress) as well as a mild anemia with small red blood cells. The urinalysis had no abnormal findings. Te finding on blood work suggested the presence of a portosystemic shunt (PSS), so a bile acids test was run; the results were high, further supporting a PSS.
When Tufts spoke with us about this diagnosis, we commented that the most recent episode did seem to begin after Cosmo had eaten some steak. This again would support the findings. On the ultrasound done on Monday afternoon a PSS was confirmed (exrahepatic – outside of the liver and calculi (stones) in the bladder were also seen. (This would explain the piddle accidents Cosmo was having at home on occasion). The stones in the bladder were large enough that they would not pass through the urethra without causing problems so the plan was to remove them .
In normal animals, nutrients are absorbed by the intestines and into the bloodstream. This blood then travels to the liver through the portal vein, where the nutrients are processed and toxins can be neutralized. In dogs with a portosytemic shunt, there is an extra blood vessel in the body, one which connects the portal vein to another major vein in the body (the vena cava in Cosmo’s case). By doing this, much of the blood that is supposed to go to the liver to be detoxified goes to the rest of the body instead. The brain is particularly susceptible to the excess toxins floating around in the blood, so during an episode of Cosmo’s illness, you will see neuralgic signs such as altered behavior, depression, or even coma. We call this hepatic encephalopathy (HE). HE is most commonly seen after a high protein meal because the toxins that are formed from proteins (such as ammonia) seem to have the greatest effects on the brain.
Cosmo was taken to surgery on 8/12 for his PSS and bladder stones. In surgery an ‘ameriod constrictor ring’ was placed around his abnormal blood vessel which slowly contacts around the vessel to eventually fully occlude it. Cosmo’s bladder was also opened during surgery and numerous stones were removed; analysis on the stones is still pending. The stones were removed to prevent future urinary problems or blockages. A liver biopsy was taken during surgery, which revealed changes consistent with a PSS but no other significant or permanent abnormalities.
While in the hospital for 8 days, Cosmo was maintained on IV fluids. He was also given lactulose (to help draw ammonia out of the bloodstream and into the intestinal tract) and cefazolin (an antibiotic to help decrease the bacterial load in the intestines). Post-surgically Cosmo has received opioids (pains killers) to control his pain and has recovered quite well from his surgery. His appetite is great and her continues to eat Hills K/D canned dog food, which has low levels of protein to minimize ammonia production. His blood has been tested quite regularly and remains quite normal. Post-surgically his sodium blood levels were mildly low, so high sodium-containing fluids were given and his sodium has improved. Cosmo has not vomited or had episodes of diarrhea and remains bright and alert (especially when he is walked outside).
Also during Cosmo’s stay it was discovered that he has a yeast infection in his ears so he is also being treated for that.
On 8/15 Cosmo was ready to go home. He has made steady improvement and is eating and drinking normally. When we picked Cosmo up we were given 12 cans of Hills K/D and 5 medications to help Cosmo with his recovery. Upon receiving Cosmo we learned that he has an incision from the top of his chest all of the way past his penis. The instructions for his Post surgery recovery were very specific. No excitement, no jumping, no other food other then the hills K/D.
8/18 Cosmo is vomiting bile. Tufts instructed us to take him to our Vet for a IV fluid injection and bloodwork to see how the liver is doing. All test results showed that the liver is no longer malfunctioning and his blood levels were now normal.
8/20 Cosmo is eating, drinking and having normal bowel and bladder movements. His spirit and energy levels are at the highest levels ever.
Cosmo returns to the Vet on 8/22 to have the staples removed from his belly.
8/22/03 Cosmo has his stitches removed and a blood test run things are looking good.
10/22/03 Cosmo has his annual physical and last blood test on the liver and all test came back normal. The surgery was a success!
Post surgery photo, for larger pic click on image.