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  Discussion on High bilirubins levels
Author Message
New Member:
Tiyoun

Posted on Friday, Sep 20, 2002 - 2:07 pm:

Dear Dr Oglesby

Since my last post to you in May, my vet has been soldiering on trying to get to the bottom of my horse's high bilirubins levels.

Since May he has has about 4/5 bloodtests , and his GGT, Bile Acids and Bilirubins have been going up and down , but theyve never managed to get back to within normal ranges. The horse has continued racing during this time,as the vet said it was ok but ,he seems to hit a brick wall, and stop as though shot every time .

Naturally I felt that enough was enough as it wasnt fair on the horse , and insisted on the horse being referred to a specialist in Newmarket ( Sydney Ricketts at Rossdale and Partners).

He was given a thorough examination,including full blood tests and a liver biopsy, and Mr Ricketts conclusion was that my horse has an infection in the biliary tract. (the liver was fine).

The medication suggested was two weeks of antibiotics and a month of steroids, and the horse was sent home .

With a week of treatment still to go , my local vet performed another blood test, and found that the bile acids and GGT levels were coming down nicely, but the bilirubins level has gone up to 172 . (when we started it was 126, has been 151, and was gradually coming down again (136 on 28.8.02).

Obviously I am wondering if my vet has been a little premature in taking his blood test,i.e would the level have been so high if they,d waiting for another week whilst the horse finished his steroids? and also, is it usual for levels to increase during treatment ?

The horse has been out of training since his biopsy ,and is turned out in a paddock during the day and stabled at night. He looks really well and is eating normally



Moderator:
DrO

Posted on Saturday, Sep 21, 2002 - 10:20 am:

Sharon can you copy the exact findings on the liver biopsy here? Why do we still not have a conjugated and uncongugated bilirubin level, this is the KEY to finding why these levels are high: the rule out list is different for them. What particular antibiotic and steroid are being used and what is the dosage?
DrO
Member:
Tiyoun

Posted on Saturday, Sep 21, 2002 - 11:39 am:

I am waiting for the full report to be sent from Newmarket with the results of the liver biopsy, but as soon as I get it I will forward them to you.

I have asked my vet to split down the bilirubins levels ,but I never get them. Next time , as I am losing patience ,I will insist on this .

With regard to the type of medication and dosage, yet again I,ll have to get back to you .

I received a copy of the biochemistry for the last set of blood tests, , which was an analysis of heparin plasma, and the comment was that the results should be rechecked on serum. (All the others have been on serum , so i have no idea why this type of analysis was performed).

Please bear with me and I,ll be back as quickly as I can.

Best regards
Sharon

Member:
Tiyoun

Posted on Sunday, Sep 22, 2002 - 4:47 am:

I rang the trainer this morning, and got his medication. Please excuse the spelling

Antibiotics - Batrick Max - 37.5 mg per day for 2 weeks

Steroids - Precortisyl prednisolene -
20 mg in 20 tablets for 2 weeks , reducing to 10 tablets the following week and then 5 tablets after that

Hope this helps.

Moderator:
DrO

Posted on Tuesday, Sep 24, 2002 - 12:06 pm:

The Batrick Max is a name brand I am unfamilliar with what is the generic name, I suspect it is enrofloxacin but cannot be sure. The dosage seems awfully small for a horse for any of the antibiotics I am familair with.
DrO
Member:
Tiyoun

Posted on Tuesday, Sep 24, 2002 - 4:13 pm:

Sorry Dr O

That should have read 37.5 g of antibiotics.
Apologies for any confusion
Best regards
Sharon
Member:
Tiyoun

Posted on Thursday, Sep 26, 2002 - 1:40 pm:

Dear Dr O

I have received the veterinary report from the specialists , and enclose a synopsis

The horse was admitted for further investigation of persistent elevations in serum bilirubin and bile acid levels associated with poor performance. On admission the horse was in moderate bodily condition, cardiovascular and respiratory parameters were within normal reference ranges. On analysis of haematological & blood biochemicals data,there were marked elevations in total bilirubin and indirect bilirubin , (T. Bilirubin 156.9, Direct Bilirubin 5.0,Indirect Bilirubin 151.9)
with a mild elevation in GGT and bile acids. All other parameters were within normal reference ranges. On a BSP clearance test there was an extended clearance test suggesting gross hepta-cellular dysfunction. .Transabdominal ultrasonography of the abdomen demonstrated no abnormalities with a relatively normal liver appearance. . On histological examination results were suggestive of primary bile duct abnormality rather than parenchymal damage or pathology.

A parenteral course of enrofloxacin and prednisolone were prescribed and further tests be performed in 6 weeks time

Histology report
Histological examinations revealed scattered foci, some around central veins, of mononuclear and polymorphonuclear leucoytes. Otherwise no significant histopathological features were seen.

These finding constitute some very low grade chronic/active non specific hepatitis consistent with only a marginal rise in serum GGT level but no other liver enzyme abnormalities. These finding, assuming that the biopsy features are representative of the liver as a whole, suggest that the raised bile acid and bilirubin levels may reflect bile duct rather than primary liver pathology.
…………………………………..
Sorry to be so long winded, and I hope I didn’t make too many spelling blunders.

The last blood tests done , (heparin plasma) showed the bilirubins levels to have gone up to 172.4 . Would this be indicative of the treatment he is on , or should they be going down ?

Hoping to hear from you soon.
Best regards
Sharon
Moderator:
DrO

Posted on Friday, Sep 27, 2002 - 9:23 am:

Hello Sharon,
I am still interested in the PCV (Hematocrit) and hemoglobin levels as requested in my first post. As breakdown of the RBC's is the source of the elevated uncongugated levels of bilirubin they are important in evaluating it.

What were the BSP clearance values and your labs normals? Also what were the latest bile acid levels? Is your horse jaundiced?

I disagree with your assesment above, if your bilirubin levels were elevated due to bile duct pathology I would expect the conjugated levels to be elevated (Has the urine been checked for bilirubin?) not just the unconjugated levels and I would also expect much more remarkable elevations in the GGT. Your bile acid levels in your first post would be normal at my lab.
DrO
Member:
Tiyoun

Posted on Friday, Sep 27, 2002 - 1:32 pm:

Dear Dr O

Thanks for your prompt reply.

The assessment wasn’t mine, but text from the letter received from the veterinary hospital, do you disagree with their analysis ?

I didn’t received any blood test analysis in the report, but will endeavour to get the PCV and hemoglobin levels etc for you as well as the BSP clearance values and the labs normals. I don’t think the results of the clearance test were promising , because we were advised he probably had degenerate liver disease, but we should wait for the results of the biopsy to come throug, after which they were much more positive

In response to your questions, on the 10.7.02 the bile acids (fasting) were 16.9 , but on the 19.9.02 they were 33.4 (Done on heparin plasma) . Similarly the Gamma GT levels were 74.4 and then 48.8 , with the GLDH going from 2.5 to 16.5 .

No one has said the horse has jaundice, and I don’t know if the urine has been checked for bilirubin. I will check and get back to you on this.

Best regards and thanks for being patient with me
Sharon
Moderator:
DrO

Posted on Sunday, Sep 29, 2002 - 11:24 am:

Yes from the information I have so far. It sounds like they are back peddling on the quite grave diagnosis they gave initally. I will review the new results early this week.
DrO
Moderator:
DrO

Posted on Wednesday, Oct 16, 2002 - 10:08 am:

Sharon,
Are you still out there? Did you get the test results we discussed? How is your horse doing?
DrO
Member:
Tiyoun

Posted on Wednesday, Oct 16, 2002 - 2:13 pm:

Hi Dr O

Sorry about the delay in getting back to you , but I,ve been on holiday.

When I got back, I found that I still hadnt received the results I asked for so I,ve had to chase them up again. Sorry about this.

Whilst I was away another bloodtest was taken, two weeks after the treatment finished and sent to the hospital at Newmarket for analysis. I havent seen the results, but have been told by my trainer that the vets are over the moon with the results and he can go back into training, with no more medication being prescibed.

Naturally i,ve asked for these test results too, as am sure you,d be interested in them.Im curious what the bilirubins levels are now ,having gone from 126 to 170+ .

The horse himself has put on a lot of weight, according to my trainer, and is bright and perky. In fact hes so well in himself, hes been fighting with all his paddock pals, vying to be 'top dog'!!

Be back to you as quickly as I can with those results
Best regards
Sharon






Member:
Tiyoun

Posted on Monday, Oct 21, 2002 - 2:36 pm:

Dear Dr O

At long last I,ve received the results of the last two tests. The first was taken when my horse was admitted to hospital, the second lot of results were taken 2 weeks after the end of his treatment.

Test results 28.8.02

Total bilirubin 156.9
Direct 5.0
Indirect 151.9

Haematology
RBC x10^12/l 8.81
PCV/I 0.36
Hb g/dl 13.7
McV fl 40.9
McHc g/dl 38.1
McH pg 15.6
WBC x 10^9/l 7.56
Segs % 68 x 10^9/l 5.16
Lymphs % 28 x10^9/l 2.13
Monos% 4 x 10^9/l 0.30
Platelets x 10^ 9/l 183
Plasma viscocity mPas 1.42

Proteins
Total protein g/l 54
Albumin g/l 36
Globulin g/l 18
Plasma Fibrinogen g/l 2.0
Serum Amyloid mg/l 3.2

Biochemistry
AST iu/l 269
CK iu/l 115
LD iu/l 338
GGT iu/l 65
GLDH iu/l 4.4
SAP iu/l 108
IAP iu/l (23%) 25
Urea mmol/l 5.3
Creatinine pmol/l 127
Calcium mmol/l 3.0
Phosphate mmol/l 1.0
Magnesium mmol/l 1.5
Sodium mmol/l 135
Potasium mmol/l 3.5
Chloride mmol/l 101
Bile acids pmol /l 17.3

The BSP clearance T1/2 secs was 210

Test results 8.10.02

Total bilirubin pmol/l 138.0
Direct 7.1
Indirect 130.9


No haematology test results

Proteins
Total protein g/l 55
Albumin g/l 36
Globulin g/l 19
Serum amyloid A mg/l 0.0

Biochemistry
AST iu/l 280
LD iu/l 525
GGT iu/l 39
GLDH iu/l 7.6
SAP iu/l 148
Bile Acids pmol/l 8.4

(These were the only figures on the report)

Sorry to take so long to provide these figures. I hope they make sense to you. Do you thing I still have something to worry about, or have we turned a corner ?

Looking forward to hearing from you

Best regards
Sharon
Moderator:
DrO

Posted on Tuesday, Oct 22, 2002 - 8:11 am:

Is this run by the same lab as the first posting so that I can use those normal values? Also what is the normal BSP T1/2 for your lab?

I am not sure your horse was ever in the woods Sharon. From the beginning your horse as been healthy (The horse himself looks a million dollars and is working exceptionally well and is not off colour in anyway) but with some rather odd and inconsistent laboratory results. No disease process has been found and I think the biopsy is equivacol as to whether it is of any practical significance. Really the only thing that makes any sense to me is a possible mild hemolytic episode. I guess a very early chronic active hepatitis might look like this but if this is the diagnosis they are making, treatment should continue till all parameters are normal.
DrO
Member:
Tiyoun

Posted on Tuesday, Oct 22, 2002 - 3:19 pm:

Hi Dr O

Yes the same lab did the last two tests. When I spoke to the consultant thre he said that the clearance rate should be 120 or less.

As you say , my horse has always looked very well, and apart from the early episode of his weeping eye, has never been off colour.

Its just when hes been put under pressure in a race that he seems to hit a brick wall, and literally falls in a heap . He races over 12f (2400 m) and has won several times at this distance, but this season as soon as he gets to 10f his tank empties and he stops as though shot. If he if blood is all wrong ,would be the major contributor to way hes been running? He is fit and clean winded, has never made a noise in his life and absolutely adores racing
Moderator:
DrO

Posted on Wednesday, Oct 23, 2002 - 7:21 am:

Hello Sharon,
In general lab values do not answer the question, why does my horse run slow, though chasing lab values is certainly a favorite past time of trainers and track vets. A single transient weeping eye has nothing to do with any of this. Lab values help diagnose and monitor disease states.

Reviewing the values I see there still is a problem with bilirubin levels. The ratio of the 2 numbers, PCV to Hb, is slightly suggestive of a increase in breakdown of the RBC's though maintaining a normal PCV indicates the breakdown must be very mild. Has anyone suggested looking for a hemolytic disease to explain the rise in bilirubin levels, if not why have they ruled this out?
DrO
Member:
Tiyoun

Posted on Wednesday, Oct 23, 2002 - 1:49 pm:

Hi Dr O,

No, no one has ever suggested looking for a hemolytic disease, but i will have a word with the vet and see what he says

Best regards
Sharon
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