Introducing my dog Marcus to k9

[marcus]

Hello, I am Ian and I own Marcus a beautiful 9 year old Chocolate Lab and Rhodesian Ridgeback mix. Marcus has been showing signs of what I now consider Cushing from atleast 2 years ago.
I have gone to my local vet, and then without satisfactory explanations I have taken him to Mississauga vetenarian full function hospital to have him checked out there.

Over the last two years all they have been able to say is that his heart lungs mind and body seems to be just fine. Ultrasounds and x-rays revealed no outstanding issues. Yet over this period mark has become much worse.

His symptoms are larger than 2 years ago, but I have been adamant in all that time that he was not being himself. He has gone from a fun loving happy physically active pup(of 9 years) to an old dog. His tongue is out and he is panting from the first few minutes of his 2 daily walks and now part of our routine it to include a shady spot for him to lie down and rest. That during what is no more than a 10 minute very very slow paced walk.
I accept he is slowing down with age, but it has been my conviction that this tiredness and panting is/was and will be not normal. He will still swim for 20 minutes as long as the lake is cold and he is not been badly fatiqued by his over heating.
As of the last 2 weeks I have noticed his hind legs are getting shaky. He has to try hard to jump onto the bed at night. And today twice he slipped getting in/out of the cars back seat.
He has a fan on him all the time. One on his side of the bed, one by the couch where he is during the day, or on the floor if/when his panting makes him look for cooler places like the floor.
The whole time the crux of the attention from the vet was to question his drinking habits. And in the worst situation he is not drinking large volumes of water. He has no trouble waiting to be outside to pee. And his appetite is not getting voracious though he is always waiting in advance for his meals , something this picky eater never did before.

I just convinced my vet to give him a low dose dexamephism test. which was done on Monday with blood samples taken at 9:00 and the drug too, then samples of blood taken 4 hrs later(13:00) and again at 4 hrs later(17:00).
I hope to have the results of this test on Thursday when I go back to see the vet. She is still calling it early stage Cushings and is continuing to propose nothing get done until it progresses. I don't agree and from what the K9 web sites has shown me, it is not advisable to leave Marcus untreated. I know the effects of treatment can be less than perfect, but his illness (if it is cushings) is getting worse and I don't want to wait. So I am considering taking the results of the test with me to Guelph, where there is a teaching hospital for animals(dogs an others I am not sure), and I will hopefully find more intuitive vets to look at him there.

Thursday I will ask for a referral as the Guelph hospital only services animals that come by referrals.

I hate to call myself desperate but I am so worried for my dog that I am admitting to being very much worried that I am missing the mark, in getting him treated while he still has some chance to recover.

Also his belly is fatter but not pot bellied in any outrageous degree, though his whole body looks less muscular and I don't consider it appropriate for the way he and I have always kept each other fit.

I have to go for a cancer meeting as I too have my own illness to deal with. I hope this introduction was appropriate and I will be home later tonight(Tuesday) and I will check to see if there is any feedback.

I know I have some prior blood work results to include if that is what will be helpful. I just wanted to quickly introduce Marcus and myself and to hopefully be in a position to receive some help/guidance/thoughts/support.

We would be very grateful for any and all questions and comments.

P.S. I only found this site over the weekend past and I am not sure what is the best place to begin. If I have mistakenly directed this introduction please advice and I will make corrections later this evening.

Thank you....Ian and Marcus

[spdd]

I had my dog at both the Mississauga hospital and to Guelph. If you have any questions whatsoever, please contact me. I don't want to alarm you, but with the regular testing done by my vet (which was not Mississauga) and then referral to Guelph... Guelph was NOT thorough enough other then giving him an ultrasound. Make sure that you have Guelph perform all tests that need to be done. I know it is expensive, but worth it. In my case both the vet and Guelph were wrong. It's a long story..... and I ended up getting all my money back as a result. Guelph concurred with my vet... trouble was my vet wasn't educated enough and performed all the tests incorrectly. Thanks to this forum, I caught it... and things were rectified. Don't let Guelph concur... make them do their own independent testing... just to be on the safe side.

[marcus]

Hi,

I am pretty much shooting in the dark. I don't have any ideas about Guelph, other than folklore had it that as a teaching hospital it would be all things for all problems.

It would be so easy to stick with my own vet who is close but she keeps implying that Marcus is at early stages, and it took some push just to get this Endocrine Function Test done.

Based on info I read about Atypical Cushings disease I asked to have all hormone levels tested. That got her to add an ALP lab test. Now I have to read up and see if that is enough checking for Marcus's case. I guess it will depend on the results.

Marcus's cortisol levels have been high, and the ultra sound did not that one of his adrenal glands was larger than the other. So it has been 6 months later and maybe now if they re-do the ultra sound it will show up something on his adrenal glands.

Can you please suggest where I should be reading/reviewing info to get a better understanding of the best tests to have done. I don't know what exactly to ask for and I would like to.

If the blood samples are sent to the lab. Will they not be consistent in how they are reviewed ? The first date for his tests were postponed and then I read that some reviewers requested 12 hr fast first and then others said it wasn't necessary. Non the less I didn't give Marcus any food since the prior evening because no one said fasting would be bad, and some in fact said it was necessary.

I am sorry for all the info that I am putting out here. I am just hoping that if I try harder and know/do more I can help promote his chances. I would prefer to sit back and just follow the vets recommendations but several articles, and your reply, somewhat state that Vets don't all know the best thing to do. I can't leave his health to chance.

I am not rich but I will do and pay anything that will bring back any advance to his health. I cannot handle the thought that he is sicker yet and it was on my mind that "had I only done more".

Thank you for your reply. I would like and appreciate any more help and or suggestions.

Ian

[Harley PoMMom]

Hi Ian,

Welcome to you and Marcus! So sorry for the reasons that brought you here but glad you found us.

Cushing's is probably the most difficult canine disease to diagnose. Physical symptoms associated with Cushing's are shared by many other diseases, blood and urine abnormalities are shared with other other diseases and the diagnostic tests to measure circulating cortisol are flawed and can yield false positive results in the face of non adrenal illness or even stress. All of these things make it very challenging to correctly diagnose Cushing's which makes it one of the most misdiagnosed canine diseases. There isn't one test that can accurately diagnose Cushing's so multiple testing is required to validate a diagnosis of Cushing's.

Strong symptoms are a huge part of a diagnosis and the goal of treatment is not to cure but to remedy the symptoms. Cushing's is a very graded disease, taking a very long time to do damage to internal organs or shut down the immune system, so there is time to get a proper diagnosis.

Atypical Cushing's is when other adrenal hormones are elevated but the dog's cortisol is not. As far as I know the only lab that tests for these elevations is the University of Tennessee at Knoxville and their recommendation for treatment for Atypical is lignans and melatonin.

Could you get copies of all tests that were done on Marcus and post those results here? With respect to the blood chemistry and complete blood count (CBC), you need only post the highs and lows and please include the normal reference ranges. For that low-dose dexamethasone suppression (LDDS) test there are 3 numbers to post and we are especially interested in those results...thanks! Regarding the fasting for the LDDS test, from what I have read, most labs do recommend that a dog be fasted before running that test.

Kudos to you for wanting to educate yourself about Cushing's, the key to facilitating safe and effective treatment is an experienced vet and an educated pet owner. If either of these are missing, the risk of misdiagnosis and overdose is greatly increased. I am providing a link to our Resource forum where you will find some great reference material to help you understand the steps in diagnosing a dog, the treatments used, adverse reactions to those drugs and even a great deal of information on concurrent diseases like diabetes and hypothyroidism. It also includes articles written by some of the most renown veterinarians that specialize in endocrinology: http://www.k9cushings.com/forum/forumdisplay.php?f=10

If you have any questions please do not hesitate to ask them and know that we are here to help in any way we can.

Hugs, Lori

[marcus]

Thank you Lori,

I have asked to give me all the blood work results when I take Marcus back on Thursday. I do have some info on me and I will include them later on today.

I will not jump to conclusions but as you said this disease mimics the signs of age.

I have had dogs move their legs while sleeping and it was cute to think that the dog might be dreaming of chasing a cat, or something cute like that. But Marcus has much more aggressive shaking, best described as tremors. I have to shake him awake a bit, because he looks like its suffering not cute. When he does this I see his eyes rolled back in his head and when I do gently get his attention, he seems so out of it. Not just waking from sleep, but like returning to this world from some place else. After a short time he seems to get over it , recognizes me at last and wags his tail.

Again, I can't prove what going on at these times (almost every sleep time) but it is maybe nothing, maybe just dreams but I just know it isn't the way he has ever been before.

Sorry just adding thoughts here.

I will add the blood work soon.

[Harley PoMMom]

I'm wondering if Marcus is having some kind of seizure or epilepsy episode. If you could tape him while this tremor/shaking is happening it may give the vet a better understanding of what is going on.


Sorry just adding thoughts here. No need to apologize, discussions, opinions, they are welcomed here, add as many thoughts as you want, we are here to listen and help in any way we can. ;)

Hugs, Lori

[marcus]

That is a good thought. I have had friends with epilepsy and I have witnessed seizures in humans but I haven't recognized any seizures/twitching/eye rollings when he is awake. I read other owners say tremor so I chose that to imply more than the usual odd foot kicking etc.

FYI: I have had dogs every year of my life as mom was the neighborhood go to for lost animals. We had up to 4 adopted strays for most of my childhood. I am aware of dogs and I was there for old age, and end of life for most of them. I am okay with Marcus growing older and dealing with all the typical sign symptoms of growing older( we are slowing down together). But suffering is not one I can watch and leave alone.

I will definitely take a video of him, and see what the vet thinks, and thank you for the recommendation.

[marcus]

Hello,
I have included the lab results for the low dex testing which indicates Marcus has has cushings.
It states that additional testing to id exact type of cushings (adrenal vs pituitary-dependent) I have asked for a referral to an internal medicine specialist and have had 2 offerings a private emerg. clinic near me, and A teaching hospital in Guelph a 2 hr drive away. The thought was the teaching hospital might be more attentive as it includes teachings to students. Does this site have a preferred clinic/specialist in Toronto are or any other within 100 miles of. There are alot of fields under Chemistry but all of which are within ref range(ie. normal). If any others are useful I would like to know ? And lastly it seems the next step is to have Marcus given another Ultra sound. It has been over a year since his last one which did not reveal anything. Maybe this time it might be more noticeable ?

I look forwards to any thoughts on Marcus. Thanks in advance,

Ian





September 22nd, 2015
BIOCHEMISTRY
Test : Alkaline Phosphataze(ALP) , Result : 596 , Reference : 5-160 , Units : IU/L

ENDOCRINOLOGY
Test :Cortisol (0 hr ) , Result : 56 , Reference : 28-120 , Units : nmol/L
Test :Cortisol (4 hr Dex) , Result : 46 , Reference : 28-120 , Units : nmol/L
Test :Cortisol (8 hr Dex) , Result : 56 , Reference : 28-120 , Units : nmol/L

at 8 hr: > 41 nmol/L , and at 4 hr: > 50% baseline Interpretation : consistent with hyperadrenocorticsm

Comment : further testing is required to differentiate adrenal tumour from pituitary-dependent hyperadrenocorticism

July 28th, 2015
BIOCHEMISTRY
Test : Alkaline Phosphataze(ALP) , Result : 567 , Reference : 5-160 , Units : IU/L
Test : Alanine Transaminase(ALT) , Result : 83 , Reference : 18-121, Units : IU/L


May 21st, 2015
BIOCHEMISTRY
Test : Alkaline Phosphataze(ALP) , Result : 836 , Reference : 5-160 , Units : IU/L
Test : Alanine Transaminase(ALT) , Result : 174, Reference : 18-121, Units : IU/L

[Squirt's Mom]

Thanks for the test info! The LDDS does seem to certainly indicate Cushing's and this test can be used to determine if it is adrenal or pituitary based....but I don't know how that is done. Some of our other members can help with that, I just bet! ;) I'm sure others will be along soon to chat with you.

Good news the liver values are going down, especially that ALT! I get nervous when any of the liver values other than the ALP are elevated. Just one of my thangs! :D

[labblab]

Just wanted to pop in to add that although the LDDS is consistent with Cushing's, the pattern of his results could occur with either the pituitary or adrenal form. That's why the lab report says that further testing would be necessary.

I agree that it's great that the ALP and ALT decreased between May and July, but that's somewhat unusual for those values to improve in an untreated Cushdog, so that does leave me scratching my head a bit in terms of the overall diagnosis. But I see that the ALP is still elevated above normal, so that part is indeed consistent with Cushing's.

Marianne

[molly muffin]

Hi, I'm in Mississauga also, and I took my dog to the Vet Emergency Hospital in Oakville/Mississauga, it's over on Bristol circle. She is being treated for cushings, urine loss protein, and has an eye specialist through their ophamologist and would recommend them.

I took Judi over there too and she wasn't as satisfied with the experience I don't think, but I have a different vet now, who is unfortunately going to be on maternity leave for 4 months, but they do understand cushings and it might be worth making an appointment there. They have a couple Internal Medicine Specialist and are able to do many tests in house and I get my results usually next day.

[marcus]

Hello I have some new info as of October 26th 2015:

I took Marcus to Guelph small animal companion Hospital. The place has a different name every time I connect with it, that I will just call it Guelph and hope that directs attention to the Vet teaching hospital.

Monday's Oct 19th was a intro meeting for Mark and the internal medicine dr. The scheduled Ultra Sound was cancelled because they said triage patients from the weekend. So it was a non productive meeting and another trip home.

Wednesday Oct 21 we arrived for our scheduled Ultra Sound. Marcus was examined and found a very small tumor on one of his adrenal glands (<2 centimeters). It did however show up and appears to be 1 cm in size.

He was then given an ACTH (I think that the acronym) to id whether it was pituitary or adrenal based Cushings. The result was a low value which they said indicate the pituitary gland is functioning ok, and indicates that this Cushing is adrenal based.

Next Mark had his blood pressure tested to see if it was okay so we could continue a discussion re: surgery. Marcus had good BP with no indications of problems there.

The surgeon requested that Marcus begin medical treatment to get him stabilized for a proposed surgical operation.

Wednesday Marcus was given his first does of Trilostane 30 MG. based on his weight which is 43 kg. This was the beginning of his twice daily 30 mg. dose (60 mg / day) and was defined as conservative based on the dr's experience with Trilostane and large dogs and the need to start off at a lower than the calculation would indicate (2.2-6.7 mg/kg)

Thursday began Marcus's first full day of Trilostane with him given his med with food twice during the day.

Marcus began to have diarrhea, and it was in the park at dark so I only could tell it was watery. Marcus had to relieve himself every 2 hrs for the whole night. I kept waking up to run him to the back door. I realized the next morning that I didn't catch each time as he had left some accidents in the basement. It was then it was evident that it was bloody stools and I say stool, but it was mainly wet watery blood pools.

I gave Marcus his final 30 mg does on Friday morning before deciding to stop this medication(I was slower than I should have been), because I thought diarrhea wasn't bloody and thought it was his system adjusting to the medication.

I contacted his vet in Toronto, and picked up medication antibiotics to deal with his upset stomach .He is now receiving (200 mg *2) Tylosin twice a day. After the first does on Friday night, Marcus had one more episode of diarrhea and then he was over that problem. By Sunday he had eaten a little bit of food, and had a regular bowel movement. Thank god the poor boy could stop the upset.

Monday October 26th: Mark is eating and going to the bathroom in a normal fashion, as he was before the Trilostane treatment began.

What to do next ? I am going to continue his Tylosin medication for the full 7 days because that was the prescription direction. I am wanting to proceed to surgery to get him past this severe reaction to the medications and the the initial disease Cushings.

1) Will surgery be possible if he isn't pre-treated with Trilostane ?
2) With such a severe reaction to this drug, is it sensible to get him back on the medication ? I am shaking from the thought of his reaction and the thought of him/me going through a similar situation again.
3) If not Trilostane then what are the options ?
4) Is surgery worth doing ? I have heard that the board certified surgeon is interested in performing an adrenelrectomy using laparoscopic technique. I don't know if that indicates Marcus is a GREAT candidate or the surgeon is looking to have more practice at this surgical procedure.
5) I have adjusted to the thought of the financial cost of surgery. Now it is just overcoming the obstacles and insuring the feasibility of doing the surgery. I am hoping that Marcus can have whatever is the best solution to his illness. And doing whatever we can to get him better and let him get past this disease.

I have not heard back from the internal medicine Dr. RE: what to do next. I am hoping to hear from the K9 community to help me gain insight and help make the proper next move(s).
Any remarks, comments, directions would greatly be appreciated. I know that it is very hard to read through the documentation and reports to help me discover what makes proper sense. It is between a rock and a hard place right now. Can't stay without some form of treatment and not sure what would be a safe treatment.

Thank you in advance for any help.... Ian and Marcus

[Harley PoMMom]

I only have a moment to post, to me it sounds like the Trilostane dose was too high for him. Some dogs are more sensitive to it than others so with keeping this in mind I wouldn't cross out trying the Trilostane again BUT starting it at a lower dose.

One of our members, Trish, has had a successful adrenalectomy performed on her furbaby, Flynn. I'm including a list of questions she prepared for others debating adrenalectomies for their dog:
Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

Hope this helps.

Hugs, Lori

[marcus]

Hi, Just a reply to the referral to Vet Emergency Hospital in Oakville/Mississauga. Mark was there a year ago for his first examination to diagnose why he was exhibiting signs that now are known to be cushings related.

I chose Guelph, because I was told that being a teaching hospital they might have been able to do a bit more on Mark's behalf. I was already aware of the Vet Emerg and I wanted to experience Guelph.

As a comment, I find that the trip to Guelph is hard on me and Mark. He hates cars and 2 1/2 in stop/go traffic doesn't make him warm up to travel. And I was very surprised that after waiting a few weeks for the appoint for the scan/visit to arrive and then being bumped was very disappointing. I tried to negotiate the Resident doing the intake try to negotiate a different option than rescheduling. I offered to hang around for hrs if needed to try and work around the backlog but didn't get any help. It was clearly easier to just bump us than to fight another option. In my place it wasn't an option to argue harshly when Mark's well being is in their hands.

One tip, to anyone traveling far for an appointment. Avoid Monday bookings. They said that that day(more than any other) is often bumped because of other unscheduled events following the weekend Triage problems left over from both Sat and Sunday's.

Had that been understood (my referring vet had no idea) we could have easily booked Tue-Friday and increased the odds of being done.
Second to that they also said that early morning appointments are less prone to being bumped. My Monday Ultra Sound was booked for 2:45 P.M. (found out after followup with admin).

I would suggest getting the earliest appt, in hopes that you get taken care of before scheduling demands steal your place.

It is amazing what you learn after the problems are experienced. Like everyone else my thoughts are "WHO KNEW ?" I wish the Guelph Website had a tips and tricks section in their FAQ section. Not that I would have looked or thought to check.

I am hoping to get a second opinion re:surgical adrenalectomy from Vet Emergency Hospital in Oakville/Mississauga. I would like to boost the odds of success and maybe having Marks file reviewed by a second hospital might be the right move ? I don't want to experience any more "WHO KNEW's" ..

Cheers... Ian & Marrcus

[marcus]

Hello Lori,

I had just printed off Trish's post re: Adrenalectomy or Medical Management. It seems like a very good list and I will need to read it over a few times to let it all sink in.

I am thinking that if Marcus has to try Trilostane again, that he needs to be given a tiny does to prove it isn't going to harm him . If it takes some time to work up to a meaning dose then so be it.

By the way when I first thought of costs $3,500 estimate seemed huge. But when you consider $100.00 a month for trilostane and ACTH quarterly review. The cost of medical treatment seems to overtake the large outlay that a surgical solution entails if Marcus is around in 2 years. That is not even thinking of quality of life if (WHEN!) the surgery proves to be curative.

Thank you for the post
... Ian

[molly muffin]

So Mark weighs 94lbs and the dose they tried him on was 60mg split into 30am and 30pm. That is in line with the newest dose recommendations.

http://www.dechra-us.com/Files/dechraUSA/downloads/Client%20Literature/Treatment%20and%20Monitoring%20of%20Hyperadrenocor ticism.pdf

Do you have a copy of the ACTH so you can let us know what the pre and post value was? Usually it is the LDDS test, that takes 8 hours which helps tell you which type is prevalent, adrenal or pituitary. It is possible to have a nonfunctioning adrenal nodule, which my dog does also.

I wish my IMS at Oakville/Mississauga was available, but she is on maternity leave until March, 2016 I think. I am currently seeing Dr. Prosser at the Oakville/Mississauga, but not sure how much experience she has with cushings. There are a couple other IMS, Dr. Hasselman I have seen before, so that could be an option for you there.

[marcus]

October-30
Hello, I have a lot or doc from Mrk's visit. Some are billing and directions for Trilostane, and -->

Date:2015-Oct-21 16:30 ,ACTH specimen type:Plasma EDTA, Test:ACTH, Result:3.4 L, pmol/L Reference interval:7-40 Test method:CLP-556

Done by Animal Health Laboratory..

Other page info..-->
Diagnostics tests performed today:
Abdominal Ultrasound:
1) Right Adrenal nodule cranial pole
2) Mild diffuse hepatopathy with subtle nodules and small hepatic cyst.
3) Solitary small and subtle splenic nodules
4) Cystic mesenteric lymph node
Given the reported suspicion of Cushing's disease, and the unilateral findings the differential diagnosis for the right adrenal nodule should include a secreting adenoma; however occasional unilateral changes are seen with adenomatous hyperplasia and therefore the possibility of pituitary dependent hyperadrenocorticism cannot be fully excluded. Other differentials for the right adrenal nodule would include a non-secreting adenoma and much less likely, carcinoma or phaeochromocytoma as these latter differentials are typically much (>2cm) and distort the normal shape of the adrenal gland. The differential dignosis for the mild hepatopathy, or chronic hepatitis. The differential diagnosis for the faint hepatic and splenic nodules primarily include lymphoid hyperplasia or extramedullary hematopoiesis.

Endogenous ACTH:
3.4 pmol/L (Ref interval 7-40)
Blood Pressure Measurement:
Systolic Pressure - 162
Diastolic Pressure - 102
MAP - 116

[marcus]

Assesment:
Marks abdominal ultrasound combined with his endogenous ACTH level were consistent with functional (cortisol secreting) adrenal tumor on the right side. Functional adrenal tumors account for ~15% of the cases of hyperadrenocorticism. These tumours secrete cortisol, among other steroids, resulting in the clinical signs of Hyperadrenocorticism(Cushings Desease). This causes a negative feedback to the pitui and low levels of circulating endogenous ACTH. Adrenal adenomas and adneocarcinomas are equally likely causes of adrenal tumors. bilateral functional adrenal tumors are rare. another type of adrenal tumor (e.g. pheochromocytoma that secretes epinephrine and other hormones). Median survival times for surgical excision or an adrenal adneocarcinoma without metasttases are repotedly 17.5-36 months.

In Marks case, surgical prognosis could exceed these reported times as the tumor currently is small and no meststtases were suspected.
Three view thoracic radiographs are recommended prior to surgery if excision is elected. A CT scan is recommendedf should surgery be pursued to screen for thrombi (blood clots) in the greater vessels, which may complicate surgical options such as laparoscopic assisted surgery. The risk of surgery primarily include hemorrhage perioperatively , but thromboembolic events (blood clots that travel to other organs or vessels) postoperatively are also a concern. Pretreatment with Trilostane is recommended to reduce the risk of adrenalectomy. Additionally, pre-treatement with phenoxybenzamine 1 week prior to surgery is recommended in case a concurrent pheochromocytoma.


My questions & concerns are:

1) Mark did very poorly with 60 mg Trilostane /day (bloody diarrhea every 2 hrs for 1.5 days. I am sure the suggestion will be to reduce the dosage and try again. I am really hesitant to cause & witness Mark going through such a bad thing yet again.
2) There is suggestion to procure a CT scan. I am not getting caught up in the costs where necessary, but the fee for a CT scan is 1.5 thousand(I have heard) and that is alot when added to all other costs. I hope some others can speak up, because I know that being owners we are in love with our dogs but also need to keep the rest of our lives from poverty. I want to distinguish between the nice to have's and the need to haves. And I will of course want to ask the surgeon directly. I am passing my thoughts to an intern that then talks to the surgeon. I am not saying the info isn't correct. But I owe it to my dog, to get the info directly from the surgeon. And from other owners who have open viewpoints without factors that may cloud other thoughts.
3) It seems that surgery may be okay, and then once healed Mark's live would be greatly improved. I want him to get better, and not to develop Addison's or stomach ulcers etc from the pre-surgery treatment from Trilostane. I don't want him to die from unforseen blot clots etc.


When I have time at the weekend and I will go through all marks test to see if I can supply other results that have been mentioned in Mark's posts.

One more concern I have is the thought of getting a 2nd opinion regarding surgery, and the pre-surgical requirements IE Trilostane, etc). Any ideas of how to go about this ? Just call and request an appointment with ?

I have to get back later,. I never had to type so many 30 letter words in the non-english MD language. I upset spellcheck to no end and I hope it ends up being readable. Ian & Mark

[molly muffin]

I don't know if they feel it is necessary to have a CT prior to surgery or not or if they need to be on trilostane before surgery. They might want the cc due to needing to see a clear picture of the tumor before going in. That is something you can ask the actual surgeon about.

There is always risks with surgery, just as there are risks with medicating or not medicating. The key is to evaluate those risks and what is an acceptable risk level (when none are actually acceptable at all)

I'm not sure where you would get a second opinion at about surgery around here, because every vet, even the ER vets send you to Guelph for the surgeries. Makes it very difficult to get a second opinion.