Bailey - 8.5 y/o Beagle - Need Urgent Advice

[jeffmi]

Hi Folks,

I am hoping someone here can lend us some advice on our beloved four daughter.

Back in November 2013, Bailey wasn't acting right. She was sleeping a ton and seemed to stop hoping up on the couch etc. After a few days of this we found that she had hook and whip worms. We believe that she go a hold of a field mouse or rabbit droppings. After the first set of deworming pills, Bailey seemed better however was still not jumping on the couch so we returned to the vet. The vet dx her with possible muscle strain and also draw a full senior dogs blood panel. It was noted that her Alk phos was 219, but her ALT was normal. The vets thought was ALP was elevated due to a muscle strain. She was given a second round of deworming pills as well as carprofen and tramadol for 14 days.

Around the second week of December she was back to her old self, in the trash, hoping up to watch tv, etc. Fast forward to last week, she was seen for her 8 year old physical and the vet stated she was in great health, other than being overweight which she has been for a while even though we are working on it. The vet asked to repeat the liver enzymes since the Alk Phos was high in November. This past Saturday we got a call from the vet stating that her ALP was now 475 and her ALT was now elevated to 134. The vet asked us to take her to the referral center for a abdominal US. We did that on Tuesday and they noted the following:

- Enlarged Liver
- 10 nodules on the liver
- asymmetric enlargement of the left adrenal, the cranial pole is enlarged, and the right adrenal gland is middy enlarged.

The US Vet wants to rule our cushings, and our normal vet is onboard with that as well. However, the normal vet also wants to do a full outright liver biopsy, not needle.

I made an appointment with a internal med vet @ Angell Memorial Hospital here in Boston. Our vet also first wanted to perform the urine cortisol, but then called last evening asking to have the low Dose Dexamethasone Suppression Test done this Thursday.

As you can imagine we are simply a wreck, as well as our 10 & 13 year old children. Bailey really doesn't show any of the symptoms that i have read. She has never been a big drinker, and has always asked to pee every time you turn around. She does pant when excited or nervous, but other than that i don't really see anything else.

I am looking for advice from others on what to do as far as ruling this out, as well as how to move forward ensuring our Bailey is healthy and happy. Our kids and us picked Bailey out of the litter, and this is simply killing me to think that our baby maybe sick. Any help is greatly appreciated.

Jeff

[Renee]

Hi Jeff,

Glad you joined here.

First, it sounds like you have done a lot of things right. Getting the ultrasound was very smart, as is seeing the IMS. I agree with your regular vet about doing a liver biopsy, after speaking with the IMS.

In my opinion, I would not do any cushings testing. The reason I say this, is because the liver is obviously compromised in some way, with those nodules, and any test you give for cushings will be impacted by the nodules and the stress they are causing on the liver, causing a false positive. It may well be that Bailey *could* have cushings, but it is much, much more likely that her issues and adrenal gland abnormalities are caused by the liver. The stress in the body from the liver will raise cortisol. This doesn't mean she has cushings, this means she has something else causing the cortisol to rise (i.e. the liver).

I hope that makes sense. Others will be by to offer their opinion and advice as well.

[molly muffin]

Hello and welcome.

I agree with Renee, the cortisol could be high due to the liver nodules. Which might need to be removed. We have a member whose dog, Flynn, has had 2 operations to remove liver nodules in addition to an adrenalectomy, successfully.

Typically with cushings you will have strong hunger, drinking buckets of water and peeing a fountain, so to speak. The concern is of course the mildly enlarged one adrenal which might have a nodule on it too.

The risk is that an LDDS will have a false positive, but it is very hard to say if it would or not. An ACTH would likely be high if there is a problem with the liver.

We all come here a wreck and worried sick. However, you'll find that it is a very good support group with a lot of knowledgeable people who live cushings and liver issues, every day.

Hope this helps. Others will also be by to chip in their comments.

Sharlene and molly muffin

[lulusmom]

Hi and welcome to you and Bailey.

With Bailey having no symptoms commonly associated with cushing's, I personally would not incur the expense of running diagnostics unless the internal medicine specialist recommends it. You did not post the normal reference ranges for the liver values but even without them, the increases seem to be rather mild. Hepatic nodular hyperplasia is not uncommon in older dogs and it doesn't usually cause symptoms and liver enzymes are usually higher than Bailey's. Liver biopsies are very invasive so if it were my dog, I would absolutely not consent to a liver biopsy before consulting with an internal medicine specialist. If it were me, my next step would be to get Bailey in to see the internal medicine specialist at Angell Memorial and let him/her discuss what your next move should be. Just my two cents worth.

Glynda

[molly muffin]

Yes, what Glynda said, go with the IMS appointment.

Those liver enzymes are not high at all compared to what we normally see in both cushing dogs and dogs with serious masses. We see ALPs in the 1000's.

Sharlene and molly muffin

[Trish]

Hi Jeff

I am wondering if you did a typo on Bailey's latest ALP, you have written it as 219 same as the earlier one but said it had gone up?? Can you just confirm what it is now?

Did the US report give any indication what they think the liver nodules are likely to be? Often the get a fairly good idea whether they are nasty ones or not.

I don't think I would be happy letting your local vet do an open liver biopsy either. That is a very invasive test, I would also want the IMS advice before proceeding.

I am battling liver nodules with my dog, he has had surgery twice to remove them. They were massive though, up to 8cm in a fox terrier. He had fine needle biopsy at the IMS. Maybe your local vet cannot do that as they do not usually have the high power ultrasound machines the IMS usually have at their disposal to do it that way. There are pluses and minuses for both methods, obviously an open biopsy gives a better look at the liver and they can make sure they get a better sample. The sample from FNA can sometimes miss the target. Flynn to this day has a number of nodules in his liver, so they can do well with them. It is now 2 1/2 years since the first big one was removed. He also developed an adrenal tumour which was also removed nearly 18 months ago. He had x2 LDDS tests, both negative. So don't give up hope, it is amazing what they can do these days with both surgical and medical options.

But I do agree with the others in getting the IMS review first before proceeding with other testing, they may want to do a CT or MRI to get a better view of what is going on in Bailey's tummy.

[goldengirl88]

I agree with Glynda about that nodules are seen in older dogs as the vet told me that about Tipper. However I also agree with what Renee said about the liver raising the cortisol. I personally would not want someone doing such an invasive procedure on my dogs liver without a second opinion from an IMS, but that's just me. Not sure if they would have a hepatologist available for a dog where you would go or not. Blessings
Patti

[jeffmi]

Thanks Trish for pointing out the typo in the ALP level, I have corrected the post. Her ALP last week was 475, as far as the normal limits i will need to get a copy of the test results as the copy i had i provided to the vet who did the ultrasound. We called our vet last night to cancel the LDDS testing for today, however they said that the Internal Med doctor wanted it done prior to coming to see her in the next few weeks. So Bailey is having the test done as we speak. If i understand the testing process and results correctly from reading numerous post here, if it comes back negative we may need to repeat? And if it comes back positive we will most likely be told by the Internal med doctor to move forward with the high dose test?

At this point i really don't know what we should be hoping for, no cushings and just watch her hoping that the tumors are not cancer? As far as the nodules go we know that there are ten of them and there is only one size noted on the US which is 3.2 mm. As you all know this is some of the hardest news to handled and at this point we just feel so lost and confused since she seems to be normal.

[molly muffin]

If the LDDS comes back positive they might want to either start on a cushing med or go to an ACTH test, which measures cortisol in body and reserves.
I wouldn't start anything until you talk to the IMS and discuss the liver nodules. At 3.2cm, they might recommend that one at least be removed. It is hard to say, depends on what they think it is doing.

Sharlene and Molly muffin

[flynnandian]

p.s. sharlene the nodule is 3.2mm, not cm. so still very small.

[molly muffin]

Oh yes, you are right Iris very small so they probably wouldn't do anything

Sharlene and molly muffin

[Trish]

Hi Jeff

Ahh that makes more sense now! Still that ALP is not too high, I think others have said with cush pups can easily go into 1000's. My little liver nodule dog has levels at intial diagnosis close to 2000. His IMS also wanted LDDS done prior to adrenalectomy, it was negative. So I can understand why they are doing it, make sure you get the numbers from the test and post them here. There are people on the board who are real experts in interpreting those numbers so they will be able to help you out. Glad your IMS is on board and communicating with your vet so that when you do get in to see them, they will have a lot of that leg work completed. Why is it taking so long to get appointment, are they booked out?? 3.2mm are teeny tiny, its not meant to be cm is it?

"At this point i really don't know what we should be hoping for, no cushings and just watch her hoping that the tumors are not cancer?" That is exactly what I would be hoping for, I am kinda in the same boat, ongoing watch on liver nodules + an adrenal nodule!!

[goldengirl88]

Just to throw this into the mix, my Tipper never had the alp in the thousands either, she was barely over normal range as Dr. Bruyette said she was not the typical cush dog with her numbers, so not sure why but I know her liver has never been enlarged if that is the cause for her low number I am not sure. Blessings
Patti

[jeffmi]

Hi Folks,

Thanks for all the great information. The reading on Baileys liver was in mm, so yes they are small and we hope they stay that way :)

Our LDDS test that was to be taken yesterday, now needs to be repeated due to a "new vet" at our normal vets office. The doctor draw the baseline and then injected her IM. Shortly after we left the doctors office to come home in between draws we received a call that she had given bailey the high dose, not the low. As you can imagine we nearly lost it on them. This vet office has been great up until they moved bailey to this new doctor. So all of that aside i have decided to have the test repeated on Monday as to not effect the testing.

As far as why we are waiting until the 12th to see the IMS, they stated as soon as we have the LDDS test results we could move the appointment sooner. We also started Bailey on Denamarin this morning to hopefully bring her levels down a bit. As i continue to read and go over the symptoms of cushings i don't really see them in bailey so i guess only time will tell.

I really appreciate everyones input as it is helping to not only educate us, but also to settle my nerves a bit.

[goldengirl88]

So sorry that test was no good. I think they would be paying for the mistake as the testing is not cheap. Sometimes it just takes a while to get answers. Cushing's is one of the hardest diseases to diagnose, so I understand how you must be feeling. All the pieces don't match up all the time and it can get frustrating. Just know we are always here if you need us. Hope it all gets figured out. Blessings
Patti

[molly muffin]

Well That was frustrating for you and for Bailey.

Any chance they would move you back to another vet, not the new one? I ask because it sounds like there are things going on with Bailey that will need a vigilant vet working with you IMS to keep on top with. Cushings itself is often gotten wrong by vets who don't see it every day, so the more experience the better, as long as the experience is the right kind. By that I mean, up to date on medication, testing protocols, etc. Getting the LDDS wrong, which is pretty basic, sort of sets of my alarm bells. (they do go off quite often though, so it's just a caution bell at the moment) ;)

Sharlene and molly muffin