Vet School 101 Portsystemic (liver) shunts, their resolution and their more rare, extended realities

One of my patients will die within weeks. Her congenital portosystemic shunts, presumably the result of a pre-birth complication or genetic defect, have led to almost complete liver failure after three short years of life.

Lily is a pet shop Maltese. Her true origins are as unknown as the exact cause of her liver disease. But we do know her liver doesn’t work. And we know it’s the result of a variety of circulatory abnormalities that allow her blood vessels to bypass her liver, thereby limiting the ability of her liver to clear the blood of its toxins.

The Liver 101

The liver is an organ that functions to 1) aid in the digestive process by helping to break down food into digestible nutrients, 2) help the immune system, 3) produce important blood chemicals and 4) filter toxins through enzymatic reactions that eliminate their poisonous effects (among other wonderful functions).

It’s a multi-purpose organ that we think of mostly as one that secretes bile for digestion and biochemically breaks down bad stuff so that animals can survive the effects of toxins they’re regularly exposed to in their environments.

When the liver doesn’t do its anti-toxic job or doesn’t get enough blood, it can’t do its other functions either. That’s when it curls up and dies.

Luckily, the liver is one of those organs that has a surprising ability to regenerate. We don’t know exactly why that is, but we suppose it has something to do with its adaptation to occasional or chronic exposure to toxins. If it wasn’t able to absorb insults related to ingestion of or exposure to bad stuff, animals would never survive bouts of food poisoning or common encounters with other environmental toxins.

Portosystemic Shunts 101

Some dogs, unfortunately, (and some humans too) have a congenital malformation that leads blood vessels to bypass the liver. It’s called a “portosystemic shunt” but is also often referred to as a “hepatic shunt” or “liver shunt.” Others have the "acquired" form of the disease, which is typically secondary to severe, diffuse liver ailments in [usually] older dogs.

Here’s what happens: The abnormal vessel(s) allow blood to go around or through the liver without stopping to clear the blood of its toxins or feed the liver its normal quantity of blood. The toxins then move along to the rest of the body. Animals with portosystemic shunts eventually die of common toxins and infections normal bodies don’t stress over. But first, they usually show some or all of the following symptoms:

Abnormal behavior after eating
Pacing and aimless wandering
Pressing the head against the wall
Episodes of apparent blindness
Seizures
Poor weight gain
Stunted growth
Excessive sleeping and lethargy

Normally, we see the first sign of a portosystemic shunt in dogs when they’re very young––six months is common––but some dogs won’t show signs until a year of age or later.

Some shunts are “simple.” A big vessel leading to the liver completely circumvents it. Instead of driving blood through the liver so that it can be “cleansed,” it gets “shunted” completely around it. The blood (in which all the bad stuff goes when it enters the body) just keeps circulating, taking the untreated toxic waste to all the organs and tissues. This is called an “extrahepatic shunt,” and it’s most common is small breed dogs.

Bad. But fixable––with surgery to clamp off or slowly constrict this “shunted” vessel. Here's a pic of an extrahepatic portosystemic shunt and its high-tech clamping job.

Back to Lily:

Lily’s problem was not so easy to handle. When she was an eight month-old pup, she came to me as a second-opinion case as a result of chronic vomiting. Sometimes she would stumble around as if she was drunk, stare at walls or press her head against them, but her owners thought this was a Lily-ism...not a sign of disease.

Lily was easily diagnosed with a portosystemic shunt after some simple bloodwork (CBC, chemistry, urinalysis and a bile acids test) and X-rays (revealing a small liver because of poor circulation). Sometimes a test called nuclear scintigraphy is done to confirm the diagnosis of a shunt, but in many cases, as in Lily’s, exploratory surgery is a more immediate approach.

In surgery, the veterinary surgeon specialist found numerous vessels being shunted around the liver instead of just one. He clamped as many of these as he could, but assumed the worst: Lily’s liver might well have shunts that travel through it, too. In these cases, called “intrahepatic shunts,” the bad blood vessel is located in the liver but does not actually exchange blood with its tissues.

Intrahepatic shunts are more common in large breed dogs and they’re especially tough to handle because they’re very difficult to find and in most cases can’t be clamped off the way easier to see extrahepatic shunts can be. This is especially problematic when multiple intrahepatic shunts are present.

Because Lily had numerous extrahepatic shunts, and because her liver was already in such bad shape, the surgeon assumed he had missed many small intrahepatic shunts as well. The only good news was that the slice of liver he biopsied in the process (a common practice for careful surgeons) showed a liver that was still capable of doing its job––for now, anyway.

Back to the Present:

It’s two years later and Lily’s had been doing well all this time. She’d been eating a low protein food, taking liver supplements and drinking lactulose (a sugar syrup that helps draw toxins into the colon for immediate expulsion).

She’d had a few bouts of gastroenteritis, which were apparently always related to foods she’d managed to consume without her owners’ blessing, but otherwise had remained in great shape. Her liver enzymes had remained high on blood tests but they’d been stable, as had her bile acid levels (the blood test which often most specifically helps identify the degree to which the liver isn’t processing toxins).

When I saw her last week, however, she’d been vomiting again. While her liver enzymes and bile acids were unchanged from previous tests, an ultrasound at the specialists’ two days later confirmed this was no mere bout of gastroenteritis. Lily’s liver was shot. Within these two days, her bile acids had skyrocketed and her liver enzymes actually plummeted, (a sign that the liver’s most basic functions were shutting down).

Success?

Though 85% of dogs with portosystemic shunts do very well with surgery, Lily’s case was not among the typical success stories. Yes, two years of life beyond treatment is something of a success, especially given her numerous faulty vessels and the length of time her liver had lived with the disease before the surgical “fix,” but it’s nonetheless a heartbreaking story for her family.

Lily's now living with her family at home for what will most likely be the last few weeks of her life. She’s receiving a diuretic that helps relieve the fluid that build up in the abdomen due to backed up blood (portal hypertension), lactulose to help remove toxins like ammonia and antibiotics to kill the bacteria her liver isn’t currently handling.

So many of my cases do so perfectly well with liver shunts it’s a shame I’ve chosen Lily’s depressing case as an example. But Lily doesn’t so much seem to mind. Sure, she hates her meds and declines her prescription dog food (so would I) but for now she’s taking it as we all should...one day at a time.

March 7th, 2009

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What a sad story!

Would you recommend having every dog that shows potential liver disease on blood work and bile acids testing to get biopsied? My rescue dog has seen two vets about her problem and they both said different things. One said no biopsy needed b/c no clinical signs, the other said yes, biopsy should be done. Problems with the liver scare me.

Linda March 7th, 2009 12:28:26 PM

Linda: That really depends on the situation. Sure, liver biopsy sounds like the safest thing but surgery, even the minimally invasive variety, isn't always so safe.

Truly the safest? See an internal medicine specialist and get an ultrasound to start.

Dr. Patty Khuly March 7th, 2009 12:51:31 PM

This is another example of poor breeding such as you see in puppy mill dogs. What a tragedy for the family that loves Lily. I wish I knew how to get out the message to the rest of Amercia: DON'T BUY PUPPIES FROM PET STORES!!!! I wonder how many littermates Lily has, and howm any of them suffer from the same thing. Not to mention other puppies from the same dam and sire.

Sassy March 7th, 2009 01:28:16 PM

When you say her bile acids were stable, I assume they were still high? I screened a 2 yo Pom with elevated ALT (no clinical signs) by doing a bile acids test, which was normal, so I'm not pursuing it any further.

For liver dogs, I also put them on Denemarin or milk thistle or something of that sort.

Sorry to hear about poor Lily!

JCB March 7th, 2009 01:36:02 PM

Oh yeah, still high. In the 80 range. And yes, I use Silybin and SAM-e for all.

Dr. Patty Khuly March 7th, 2009 03:24:06 PM

What does SAM-e do? (Says the inquiring mind whose dog underwent chemo for 7 months.) I knew that Silymarin helps support liver function....

Deanna March 7th, 2009 03:45:05 PM

"Truly the safest? See an internal medicine specialist and get an ultrasound to start." Dr. K: I would respectfully disagree with you. ONLY a board-certified radiologist can correctly read and interpret US.

And yes, I totally agree with you--surgery even the minimally invasive variety is DANGEROUS, especially liver biopsies.

Fotini March 7th, 2009 04:34:22 PM

In all fairness, hereditary mode of liver shunts has not been determined. It is suspected to be polygenic and a liver shunt puppy can come from a respectable & informed breeder.

Lily's young age makes you think hereditary, (Not the fully informed in this dept.)Scotties have "liver issues" and a funded study is in progress. I'd like to know more about "acquired" small intra-hepatic shunts?

The first thing that came to mind with my deceased "Pocket" was liver shunt. Stunted growth, seizures after her 2nd DHLPP. Neurology exam normal, bile acids normal, but on phenobarbital for 11 years. Was her LIVER shot at the end? Well, let's just say her liver enzyme levels never looked so good. Her dam had a "huge" liver tumor at the end.

Barbara A. Albright/NH

Pocket's Story from NH March 7th, 2009 05:08:00 PM

I disagree. Laparoscopic liver biopsies can be quite safe if done properly. The actual surgery to collect the biopsy is not dangerous, it's the anaesthetic that is the main risk (low blood pressure etc). If all patients are screened beforehand with full bloodwork, including liver enzymes, bile acid function tests and clotting times, you can minimise the risk if you also have a quick surgeon and good anaesthetist. A number of times I've seen dogs that have been just a little off, and the liver enzymes only 1.5-2x normal. Other vets would have said "just monitor the bloodwork". Some of the dogs were found to have early cirrhosis and chronic liver disease. So putting off finding out what was going on would have meant waiting until it was really clinical, and possibly too late - the liver is too scarred to recover with medication. It's a fine line. If a dog is clinical and has elevated liver values I always recommend an ultrasound. If not clinical, I recommend follow up liver enzyme testing in 4-6 weeks, if not resolved or going down then I recommend ultrasound. But I digress. Anaesthesia for a laparoscopic liver biopsy is probably the main risk, not the surgery itself.

AlexH March 7th, 2009 05:48:12 PM

Fotini: It is patently untrue that only board certified radiologists can read and interpret U/S. It is true that they are the people with advanced schooling in radiology/imaging, but that doesn't mean that other DVMs cannot! Saying that is akin to saying that only a clinical pathologist can interpret bloodwork, that only a radiologist can interpret xrays, that only a nephrologist can interpret a urinalysis, that only a cardiologist can interpret ECG and echo data, that only an oncologist can interpret a biopsy and select appropriate chemotherapy (and administer it).What's left for GPs to do? Nothing. You'd have to be a specialist by your reckoning to do anything more than vaccinate.

That's WHY we go to vet school. I've had many ultrasound courses in vet school, taken CE, and use it DAILY at the ER/referral practice where I work. Would I defer to a radiologist's opinion? Yes. Are they always right? No. Am I comfortable with basic abdominal U/S? Yes. If I was unsure, would I defer to a radiologist? Yes.

Being able to do a general abdominal ultrasound is part of veterinary training - just like learning to read xrays, bloodwork, urinalysis, and give chemotherapy.

Cat ERVet March 7th, 2009 06:29:44 PM

And liver biopsies are not DANGEROUS. They do carry risks - such as the risk of anesthesia and the risk of bleeding, but when done correcltly - they are quite safe.

Cat ERVet March 7th, 2009 06:31:30 PM

Here's some info on SAM-e in a post on cognitive dysfunction and another on my favorite supplements.

Agreed on the ultrasound and radiologists, though I'll add the caveat: Whenever we perform an ultrasound at my hospital we send our findings to a radiologist or internist (unless it's a very simple bladder check or pregnancy check). It's built into the price of the ultrasound. But that's because we're not so good at ultrasounds and because it's a safe backup that also helps us improve our skills. Similarly, we send all our questionable X-rays to a specialist (though not always a radiologist).

On liver biopsies: They're quick and relatively safe. Caveat is, I reserve the liver biopsy for cases that have been fully worked up. For me, that usually means an ultrasound and an internal medicine specialist are involved in addition to serial bloodwork.

Remember, I'm a big referrer. That's largely because my area has many specialists, including a large specialty hospital right across the street.

Dr. Patty Khuly March 8th, 2009 03:47:25 AM

BAB: On acquired portosystemic shunts: I should have included these as a category unto itself.

Acquired shunts occur (usually in older animals) when the liver is so sick that the pressure in her portal vein rises as a result of the blood's difficulty in passing through the organ. That's when the body tries to compensate by increasing blood flow through vessels that go around the liver. Over time, these "acquired" vessels manage to circumvent the liver entirely, thus producing the same effect as described by the congenital shunts.

And yes, Barbara, we do see well-bred dogs that are congenitally affected with shunts. But we would expect that a responsible breeder would take the parents and siblings of affected dogs out of the breeding pool and to flag the entire breeding line––perhaps even starting over with new genetic material. I seldom see any of this happen, much though I counsel my clients to urge their breeders to do so. As with cleft palates, breeders are more likely to view this condition as a fluke, not as a potentially inherited issue (multifactorial though it may be) with disastrous consequences.

On Lily: We believe she has acquired shunts at this point as a result of her diffuse liver pathology. We also suspect that some of the liver shunts we saw in surgery may have been acquired due to the amount of time it took for her to receive definitive treatment for her condition.

Dr. Patty Khuly March 8th, 2009 03:58:46 AM

Dr. Khuly: Yes, indeed, a sire/dam should be removed from the gene pool upon producing liver shunt.Unfortunately, because the mode of inheritence seems complicated (polygenic) it isn't always done, and can crop up totally unexpected. But yes, I immediately sought specialist workup on Pocket; not only for her sake but the implications of the breeding. Although, as it turned out, her bile acids weren't even questionable. Without writing a book, it was years later when placed on thyroid hormone, her seizures stopped!! But I could not eliminate pheno dependancy, but did taper it down significantly.

She did not ever have the other symptoms typical of shunts.

The liver disease in Scotties is under review, and thought to be the 3rd major cause of death (and this is in "healthy" dogs, without life-long complications, such as Pocket)

Other later in life diagnosis for Scots have been: chronic hepatitis, blocked biliary disease, gall bladder involvement, ? of copper storage, etc., atypical Cushing's, and definitely late acquired shunts, or sadly congenital/hereditary shunts at birth.

Another hugely interesting topic, and great pictures. Barb A./NH

Pocket's Story from NH March 8th, 2009 08:42:05 AM

Cat ERVet: My personal experience: Two GPs and an Internist (hematologist) misinterpreted barium series test and US performed on my dog. They diagnosed intestinal obstruction and URGED ME to have my dog operated on ASAP! The board-certified surgeon of the referral hospital diagnosed also a liver lesion. The surgery for the removal of the obstruction and the liver biopsy were a waste of LIFE and money. No obstruction and no lesion! My dog died 3 days after release from the surgeon. I desperately tried to initiate telephonic contact with the surgeon since he is 100 miles away from my home. Couldn't get the receptionist to fetch him to the phone and explain to me why my companion had died.

The pathologist diagnosed:

1. Ileocecocolic junction: Smooth muscle hypertrophy, mild, focal, chronic.

2. Liver: Glycogenosis, diffuse, moderate to marked, chronic, consistent with steroid-induced hepatopathy.

Comments: The diagnosis of thickeniing in this area is subjective, and may need to be interpreted in light of the animal's advanced age (13). No neoplastic cells or significant inflammatory infiltrates are seen within the intestinal tissue submitted.

After my companion died and desperate to find out why he had died, I sent the radiographic and US materials to a prominent professor of radiology at a major veterinary college for a second opinion. He diagnosed that there was NO OBSTRUCTION but liver abnormalities (not lesion). The surgeon's visual examination confirmed the radiologist's interpretation.

Based on my unfortunate personal experience with liver biopsies, X-rays and US, my two remaining canines would only be examined and tested by veterinary college specialists. I already have established a client-patient relationship with a top-notch veterinary college.

If you are interested in more details here there are:

Asproolee’s Story

Fotini March 8th, 2009 01:58:45 PM

Fotini: I've read Asproolee's story long before now. I'm not going to argue. I'm glad you have a good relationship with a vet hospital. Misinterpretation of U/S and xrays and bloodwork and every other testt happens EVERY day - by GPs and by specialists alike. In vet school, I had AMPLE time to see how often the radiologists were wrong. I get to see it as an ER vet when the radiologists review my xrays and recommend surgery for a foreign body and then there is no foreign body. It's happened more than once, and I've learned to temper the radiologist's report with my own clinical experience and judgment.

Medicine is an art and not a science. Radiology is DEFINITELY an art. I worked under 6 different radiologist in vet school...and you should see them argue amongst themselves. SOMETIMES WE DON'T KNOW. All of these tests are prone to false positives and false negatives. Sometimes, we are wrong. It sucks, but it happens. If you see an "abnormality" on a liver via U/S - it is not incorrect to refer to it as a lesion.

Cat ERVet March 8th, 2009 06:48:37 PM

Cat ERVet: I really don't think the average pet owner thinks a GP Vet should know "everything". The problem arises when a vet is so ego-ridden that they are INSISTENT that they know everything and can't possibly be WRONG.

What would you say to me? That an uncorrected extreme phos/calcium ratio is still grounds for treatment in an old elderly dog? Would you withhold the seriousness of that information? Would you tell a client that the huge decline in hematocrit is "no big deal"?

And if you did review Aprosolees site, would you have recommended surgery with a blood panel with those results in an elderly 13 yr. old dog, with a known cardiac condition?

And finally, would you ever 'euthanize' a pet in their owner's arms via an AVMA condemned method?

These are the types of things that have no ethical reasoning, these are not little booboos to file away as " it sucks, but happens". And if it happens often and every day, the public should not be placing "too much trust" and/or paying too much money.

Barbara A. Albright/NH

Pocket's Story from NH March 9th, 2009 02:07:09 PM

OK, OK. We all know that no veterinarian, specialist or not, is 100% on the mark with every diagnosis. And we also know that no human is perfect. The truth is, however, that veterinarians are trained to offer all options. It's your choice, whether you're offered door #1, #2 or #3. Sometimes we misjudge you and our skills, but it's not out of malice or ego, it's out of consideration for you, our clients, based on our clinical experience. Might we be wrong? Sure. But we do try. And remember, we do care. Misunderstandings and common mistakes are far more common than malpractice.

Dr. Patty Khuly March 9th, 2009 03:22:23 PM

Cat ERVet:

"Misinterpretation of U/S and xrays and bloodwork and every other testt happens EVERY day"

Then let the guardians know that veterinarians do make mistakes, don't lead them to believe otherwise. . .

In any event, I call your mistakes "malpractice."

Fotini March 9th, 2009 05:21:26 PM

After rethinking my above comment in response to a professional; my interpretation of the response to Fontini seemed a bit too casual, slightly callous, and a shrugging off. If I am wrong, I apologize.

My Dad often said to me a phrase and I shared it with a friend who's grandchild (recently) died from a vaccine-associated reaction: "Statistics suddenly mean something, when you or someone you care about, becomes one".

Barb A./NH

Pocket's Story from NH March 10th, 2009 02:12:12 PM

Liver shunts can definitely be congental in origin. I have had three people referred to me over the past year because they ended up with yorkshire terriers with liver shunts from the same (irreputable) breeder.

The funny thing is they paid the same or more for a puppy from a disreputable breeder, and they could have purchased a pup with a guarantee that *did not* require the return of the dog (which is a loophole to get out of replacing a sick pup- as the people are attached).

I've seen other conditions run in yorkshire lines and am currently watching one dog of mine very carefully. I've never had a dog come down with pancreatitus, but I had a young bitch I wanted to show come down at five months. She's ok now, but it is a condition that can tend to run in yorkshire lines so I am watching her carefully. I was supplementing her at the time with a flax/salmon oil combo, which might have triggered the episode, so I am not writing her off yet. Meanwhile she has to grow back all the beautiful hair that had to be shaved for IV access during her hospitalization.

What a heartbreaking experience for those poor owners to endure. They can rest easy in knowing that they attempted to fix the shunts and gave her a great quality of life for the time she was granted. Poor dears. Hope they have peace in the coming weeks.

jen March 11th, 2009 09:20:26 PM

http://www.acvr.org/pet_owners/acvr_ultrasound_statement.html

American College of Veterinary Radiology Position Statement on Veterinary Ultrasound

Diagnostic ultrasound is considered the imaging modality of choice for many conditions in veterinary medicine. However, the ability to accurately identify and interpret abnormalities is highly dependent on the training and skill of the individual performing the study.

Veterinarians who perform and interpret diagnostic ultrasound examinations should be licensed veterinary practitioners having a thorough understanding of the indications and guidelines for ultrasound examinations, as well as familiarity with the basic physical principles and limitations of ultrasound imaging technology. They should be familiar with alternative and complementary imaging and diagnostic procedures, and should be capable of correlating the results of these other procedures with the ultrasound examination findings. Veterinarians who perform ultrasound examinations should understand the anatomy, physiology and pathophysiology of the organs or anatomic areas that are being examined. They should be able to acquire ultrasound images that correctly depict anatomy, have a thorough understanding of normal ultrasound anatomy, and must be able to identify abnormal ultrasound anatomy. These veterinarians should be able to accurately document ultrasound studies and generate a written report on their findings.

The ultrasound training requirements in American College of Veterinary Radiology (ACVR) approved radiology residencies exceed those of any other specialty organization in veterinary medicine. Radiology residents undertake didactic courses in the physics and technology of ultrasound and learn to correlate ultrasound findings with gross anatomy and surgical pathology. During a 3 to 4 year radiology residency program, residents devote a minimum 6 months of intensive clinical training to diagnostic ultrasound, and must conduct a minimum of 1000 ultrasound examinations. Most programs far surpass these minimum requirements. Residents are also required to become proficient at safely performing ultrasound guided fine needle aspirates and biopsies.

The ACVR recognizes that technologists working with and mentored by ACVR Diplomates can effectively perform ultrasonography, and expand the clinical imaging services provided by ACVR Diplomates. The ACVR recommends that a minimum level of training for these technicians include doing at least 500 examinations supervised by an ACVR Diplomate, as well as didactic education in ultrasound anatomy and physics. Continued mentorship of these technicians by an ACVR Diplomate is strongly recommended. In the event an ultrasound examination is performed by a technologist without the direct supervision of an ACVR Diplomate, a written report should be generated and signed by an ACVR Diplomate based on a review of captured diagnostic ultrasound images.

w March 14th, 2009 10:35:33 AM

w: THANK YOU, although it is too late for my poor companion. I have taken one of my remaining dogs to an outstanding veterinary teaching hospital for radiographic and U/S examinations. The radiologist provided a copy of all diagnostic images on a cd as well as his written report. I was very impressed with their professionalism and accurate diagnosis.

Fotini March 14th, 2009 09:56:29 PM

w: I thank you too. And I have a question. Would a vet proficient in ultrasound carry the ACVR initials? And would a DACVIM , necessarily be proficient in ultrasounds for the entire body cavity?

If you are an ACVR Diplomate, I would think perhaps the wide-use and perhaps abuse of the numerous clinics employing (and charging significant fees) would be alarming to the profession.

As with Fontini (above), it is too late for my companion also, but not too late for the rest of the companion pet world.

Barbara A. Albright/NH

Pocket's Story from New Hampshire

Pocket's Story from NH March 15th, 2009 11:54:40 AM

To Pocket's Story from New Hamphsire -

No, a Vet proficient in ultrasound should NOT carry the ACVR iniitial. To become Diplomate of the ACVR you have to have completed a 3-4 years residency program (in a program approved by the ACVR and there are not many of them - so far all programs are at universities) AND pass the qualifying written examination at the end of the residendy AND then pass the certifying oral (practical) examination if you have passed the qualifying. More info on what it takes to become a Diplomate at http://www.acvr.org/pet_owners/whats_an_acvr_diplomate/index.html

Dipl ACVIM Vets have completed a residency training in internal medicine with sometimes some sub-specializations such as cardiology, neurology, etc. There is no requirement set forth in the internal medicine programs to have an extensive training in ultrasound aside from echocardiography for cardiologists. ACVIM vets have a 'general' knowledge of abdominal ultrasound but have not acquired skills close to the ACVR Dipl when it comes to regular and expert practice of abdominal and thoracic non cardiac ultrasound. Some of them have acquired a lot of experience by simply scanning a lot of patients but they have not received a formal training sanctioned by a standardized test with quality insurance. Therefore the average experise in interpreting ultrasounds by Dipl ACVIM vets is far less in my opinion than that of Dipl ACVRs though as in any field there certainly are out there some Dipl ACVIM who are as good as some Dipl ACVRs in reading ultrasound. But I think the discussion was about the majority or your 'average Vet Radiologist' and 'your average internal medicine Dipl'.... We are talking about quality insurance here. Some above said that a vet GP should be doing it all... .well I disagree. I would not, as a patient, want my abdominal ultrasound read by my internal medicine doctor. I would not want my echocardiography read by a MSK radiologist and I would certainly not want to have abdominal surgery performed by an orthopedic surgeon. As specialties are developed in a serious manner, the expectations of our clients are increasing and with the development of telemedicine, access to experts is becoming super easy. Everyone can perform the best job within their own limits and learn while learning from others with more expertise in some areas. I do believe that a GP ought to be able to read basic radiographs (ie heart failure or pneumonia) and basic ultrasounds (eg pyometra, bladder stones etc). But I disagree that students should expect get out of school having the same skills as their radiology teachers in radiology, ultrasound, CT and MRI or their surgery teacher in all areas of orthopedic surgery. That is simply unrealistic, dishonest to the owners and unfair to our patients.

w March 15th, 2009 01:54:39 PM

w: "That is simply unrealistic, dishonest to the owners and unfair to our patients." Once more, THANK YOU! You are a real professional!

Fotini March 15th, 2009 07:11:47 PM

w: Please read the radiologist's comments. . .

Asproolee’s Story

Fotini March 15th, 2009 07:13:17 PM

w: I thank you very much for responding to my question. And this is precisely the problem that the average and not-so-average pet-owner faces obtaining care day-to-day.

It seems that u/s equipment is increasingly purchased and offered by the GP clinics without the benefit of expertise, which in fact is misleading. Sure, as you stated, a grossly obvious issue is/can be picked up, just as on radiographs, and that would be ok, as long as it is disclosed to the client, the reader/interpreter's limitations and priced accordingly.

Actually, now that I rethink the above statement, it is really "not ok", because it may also provide "false assurances" too.

This problem can not be solved from outside the profession. The expertise of ACVR Diplomates must be brought to the pet-owner and referred accordingly.It was only "after the fact", that I learned of ACVR concerning u/s , and $3700 would have gone a long way to diagnosis, not to mention the avoidance of a horrendous personal tragedy that occurred.

This would be a terrific guest post/topic, Dr. K., about ACVR in general!

ps. w: A wonderful like-qualified professional took lots of personal time to explain the u/s process and how records/snapshots pictures can be equally misleading;I noted the statement from the ACVR includes "able to accurately document ultrasound studies and generate a written report on their findings".

Thank you again, we can only hope through public awareness that expertise such as yours will become the norm, as it should. Barbara A. Albright/NH

Pocket's Story from NH March 16th, 2009 11:40:16 AM

w: I thank you very much for responding to my question. And this is precisely the problem that the average and not-so-average pet-owner faces obtaining care day-to-day.

Actually, now that I rethink the above statement, it is really "not ok", because it may also provide "false assurances" too.

This would be a terrific guest post/topic, Dr. K., about ACVR in general!

Thank you again, we can only hope through public awareness that expertise such as yours will become the norm, as it should. Barbara A. Albright/NH

Pocket's Story from NH March 16th, 2009 11:46:56 AM

My three month old yorkie, Brooklyn, has just been diagnosed with a liver shunt, however we cannot afford the surgery. The vet said she may or may not live a normal life, and to try a low protein diet, along with lactulose. Does any one know the chances of survival without the surgery? It breaks my heart to know my puppy is so ill.

Jen March 17th, 2009 04:38:36 PM

I have been breeding and showing for over 12 years and have never had a puppy to my knowledge with a liver shunt before until my litter last year.One little female had a liver shunt the new owners did have her operated on and she is doing fine. all the other puppies in the litter are doing fine. This was the 3rd time I had bred my female and she was the only puppy. I have since had another litter from the same female and used the same male. Just wondering what the odds are that the previous little girls liver shunt was a one off.What testing should I do on my female before she is bred again maybe and also I kept a female from last years little to continue on with my breeding program> who is to say that this may not have come from my lines but from the males lines.any help would be appreciated

Sandy April 14th, 2009 12:16:19 PM

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amal_ May 22nd, 2009 05:09:31 AM

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hussain May 29th, 2009 08:50:57 PM

I took my puppy to my vet to get tested for bile acids, and he told me that fasting was normal, but the fatty meal test two hours later was 27. I ask if this was high, and he said not really. I got on line and took a look at the normal numbers for this test and found that 15 to 20 was normal. What should I do about 27????

My pup is happy and healthy other than the test numbers. Should I get them repeated and at what date?

Cindy McDaniel June 14th, 2009 08:27:48 PM

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