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  Discussion on Primary Diagnosis of Liver Failure
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Posted on Monday, Feb 28, 2000 - 2:28 pm:

I've moved my posting to this forum because my stallion, Anchor Hill Abbat, has now been diagnosed with liver failure. I noticed when I read back over Dr. O's initial response to my post in the autoimmune disease forum that he mentioned liver disease as a possibility for my horse.

I'm concerned because my vet's only option when he called me was euthanasia. The only tests have been blood work up.

The horse is standing, eating (only grass, hay, and carrots refuses feed concentrates of all kinds). He had very bright pink gums, but that has subsided, and I may be seeing the beginning of jaundice in the gums and eyes, though he had just eaten 2 lbs of carrots when I looked at his gums, so who knows... maybe carrot juice I was seeing. Horse urinates, defacates (stressed looking small dryish balls, but plenty of them).

I need questions to ask my vet. He went into euthanisia mode awfully fast. The horse is grey, so maybe he assumes it is a tumor causing the problem. Also, I told him I didn't want my horse to suffer needlessly, so maybe I made him think I wouldn't consent to more invasive testing.

I'm going to talk to him in a bit and try to get more information. I was shocked when he phoned with the bad news and didn't get the exact results of the blood panel. Now I've had a good cry and settled down to think better.

My concern is that while the blood test shows liver failure, it doesn't show WHY the liver is failing. My friend had a horse with liver failure which she transported to the University of Missouri and had treatment with very good results. He was also a grey Arabian.

Would I be out of bounds to request that my vet support my horse with fluids and make a referral to the University of Missouri for further diagnostic testing? I know this will be expensive, but this horse has meant the world to me. I don't want to kill him if he can recover.

I read all the article on liver failure and a lot of it sounds dismal... but not always.

Thanks for reading the ramblings of a distraught horse owner.
Nina

Posted on Monday, Feb 28, 2000 - 6:22 pm:

I'm back with what information I was able to get from my vet regarding the tests run on my 21 year old Arabian stallion now diagnosed with liver disease. Test run by Antech Diagnostics on 2/26/00, Equine Comprehensive Screen:

Glucose 51 (L)
Urea Nitrogen 14
Creatinine 1.4
Total Protien 9.2 (H)
Albumin 2.4
Bilirubin,total 3.8 (H)
Alkaline Phosphatase 1803 (H)<------very elevated
AST (SGOT) 396 (H)
Calcium 12.7
Phosphorus 3.0
Sodium 137
Potassium 3.7
Chloride 98
A/G 0.4 (L)
Globulin 6.8 (H)
CPK 110
GGTP 691 (H) <----------very elevated

Hemoglobin 20.3 (H)
Hematocrit 55.2 (H)
WBC 7.2
RBC 12.70 (H)
MCV 43
MCH 16.0
MCHC 36.8
Platelet Est Adequate

Absolute Polys 5616 78%
Absolute Bands 0 0%
Absolute lymphs 1512 21%
Absolute Monos 72 1%
Absolute EOS 0 0%
Absolute Basos 1.6 MCG/DL

Febrinogen 100 MG/DL
----------------------------------------------------------------------------------------------------

Needless to say, since I am not a vet, I don't know what any of these readings mean. To make matters worse, the phone line at my vet's office was cut by road construction crews, so I had to drive over there just to get this much info, and he was out on a farm call so I was not able to talk to him.

These results are what he based his recommendation upon that I should consider euthanizing my horse. I can't tell if these test results tell us that the horse has cancer, or what is the cause of the liver disease. I can tell that my horse is doing better today than he was over the weekend. His head is up. His eyes look bright. He ate 4 lbs of carrots (which was to be his last meal before the vet came to euthanize him) and he ate grass for two hours in the yard, after which he went over and challenged another horse over the fence...something he has not done since he got sick.

Since the phone line was cut to the vet's office, I was not able to call him to ask him to come out and perform the euthanasia, and the more time passed, the more this horse looked like he WANTS to live.

Should I INSIST on further tests? What support can I give my horse while waiting? Any and all help appreciated.

Nina

Posted on Monday, Feb 28, 2000 - 11:18 pm:

I'm sorry about your horse and unfortunately I don't know a thing about liver failure in horses. However, I went thru a serious problem with one of my horses a few months ago. My regular vet said we should put him down. We got a second opinion and tried to save him, but failed. That is not my point. My point is that many vets don't realize what horses mean to their owners, and many owners are willing to spend the time and considerable $$ to save their horse. I would definately consult a vet at a major equine hospital or vet. school before making such a decision.

Posted on Tuesday, Feb 29, 2000 - 8:01 am:

Hello Nina,
Not only does the blood work not show why the liver is diseased but it does not show liver failure either. It does indicate a remarkably effected liver but it may not be in failure. Not only would it be approriate to ask but to insist on the referral, I am surprised he has not recommended it though there may be a reason we do not know. How old is this horse? Does the vet have an idea why the liver is effected? Has tetanus antitoxin (not the same as the vaccine) been given in the last 6 months?
DrO

Posted on Tuesday, Feb 29, 2000 - 11:12 am:

Thank you for your supportive comments, Dr. Oglesby. Sometimes things happen for a reason. Yesterday my vet called me from his cell phone with the diagnosis of liver failure and suggestion of euthanasia. A road crew had cut the phone lines to the vet's office and phone service was expected to be restored by noon. I was shocked at the only alterntive being euthanasia, and told my vet I'd call him in the afternoon, after I made arrangements for disposal of the horse's body. I was not able to reach my vet by phone, which gave me time to spend with my horse and to notice that he had improved remarkably over his condition of the weekend. He started eating, his red gums were pink, the edema in his legs was gone. That's when I started doing some more investigating about liver disease, and decided to drive over to the vet's office to talk to him further. He was on a farm call. I got a copy of the blood work up and left a message for him to call me. He has not returned my call. I don't know if he has information that I don't have because I can't get him to talk to me. I think that relationships with our vets are important, and I believe that events of the last few months may have led him to believe that we "have had enough" and that just letting this horse go would be easier on us. I need to talk to him and let him know that we can handle the expense and that even if we ultimately lose the horse, we will be better off knowing what happened than to just put him down. The other thing is that this horse is rallying everything he has to recover on his own. I can't help but think that with just a little support, vitamins and hydration, he could easily make the trip to MU.

Finally, the factors that may have made the results of the blood test "worse" are that the horse had been very ill for nearly a week prior to the blood test. He was dehydrated and had eaten VERY little during the illness. The horse was stalled for a prolonged period and got no sunshine, grazing, or excercise due to a hock injury. I had given him a product called "Bute-Less" for the hock, but no other medications were given. This horse is easily stressed when his routine changes. He has not received any tetanus shots of any kind in over a year. This is a 21 year old Arabian stallion. He has lived with us for about five and a half years. This is the first illness he has suffered that we know of. He does have an old hock injury that occassionally bothers him and lays him up for a while. Also, I was extremely ill with the flu (particularly virulent intestinal virus) for about a week during the time he got sick, and was unable to spend any time with him during that period. My symptoms were not too different from his (except that I was able to vomit and he wasn't ).

I am still unable to reach my vet by phone. I hate that this is happening to my relationship with my vet. I want to talk to him... and I also want to save my horse. I have placed a call to another vet to see if we can't get the horse referred to MU.

Maybe you could start a forum on client-vet relationships and how to ask the questions without tripping the triggers .
Nina

Posted on Tuesday, Feb 29, 2000 - 2:57 pm:

Still unable to communicate with my vet, I decided to just telephone the University of Missouri Equine Clinic. I was pleased to learn that no referral is required for me to bring my horse to them. My vets here have always given me to believe that they needed to refer the animals to MU. I was further pleased to be able to communicate directly with one of the well known vets at the university, and that he showed very genuine concern for our plight. I have just emailed him the blood work up results that I posted here and a history of this illness. Hopefully, I will have an answer about taking my horse up to the University before the end of the day. In the mean time, this horse is rallying in every way, and with no supportive medical care (unless you count carrots as therapy ). I am very grateful to everyone at Horseman's Advisor for their supportive comments. I'm a little mad at myself for not picking up the phone sooner to call the university...but I honestly didn't know I could do that myself. That bit of information itself might be helpful to someone else.
Thanks again!
Nina

PS-If you don't mind, I will continue to report on the outcome for this case.

Posted on Tuesday, Feb 29, 2000 - 3:15 pm:

Well done for persevering, and may I wish you all the very best of luck for him - I'm sure you are doing the right thing. I shall be looking forward to hearing how it goes.
Alexa

Posted on Wednesday, Mar 1, 2000 - 11:23 am:

Definitely, please keep posting on your progress. I am fascinated by this.

Posted on Wednesday, Mar 1, 2000 - 7:03 pm:

Question for Dr O. Isn't the GGTP specific to the liver? And I'm sure there are many causes of an elevated Alk Phos, but what would some of the cause be?
Thanks

Posted on Thursday, Mar 2, 2000 - 9:26 am:

Hello Alice,
Yes GGT is specific for the liver. Any insult to the liver will cause an elevation of liver enzymes. A common mistake is to mistake liver disease and liver failure. For more information on liver disease, these enzymes, and for a list of possible causes go to the article associated with this forum. You can use the navigation bar at the top of this page to go there.
DrO

Posted on Sunday, Mar 5, 2000 - 7:56 pm:

DrO:
Can you tell me what will happen to my horse when he undergoes a liver biopsy? Is it an invasive surgery, or is it done with a scope?
He had a wonderful week, brightening and eating/drinking more like normal,even though a second test for blood amonia levels was not good, so it was decided he could withstand the trip to MU, but that it was not an emergency, so he would not go on the weekend when they accept only emergencies. We'll go Monday afternoon instead. I haven't had a chance to find out how they will do the liver biopsy yet.
Thanks ever so much for your excellent advice.
Nina

Posted on Monday, Mar 6, 2000 - 7:49 am:

What have the blood ammonia levels been? Unlike the earlier lab posts you posted, blood ammonia is a liver function test with elevated levels indicative of liver failure.

There is surgery involved but this is pretty minor stuff, using a very small biopsy needle. The procedure is done standing and frequently guided with a ultrasound. Usually the sample is taken high just infront of the flank and between two of the last ribs. Bleeding can be a problem so cloting progiles prior to the biopsy are sometimes done.
DrO

Posted on Monday, Mar 6, 2000 - 11:43 am:

I didn't get a copy of the blood amonia levels from my vet. He has faxed them to MU. Our appointment is in the morning at MU. Horse made remarkable progress over the week, but had a "relapse" overnight, refusing hay and grain and gums are back to bright pink, which vet says is due to ammonia levels being high again.

It's a tough roller coaster ride we are on, but hopefully tomorrow will bring the answers we have been desperately seeking all week.

In addition, if the decision is "the worst" we have had time to prepare ourselves a bit. I've watched this horse go through "pretty good days" and "awful" days in the span of one week. If his life would consist of mostly those "awful" days, that is no quality of life for him... But if we can get him stable and relatively pain free, that's going to be wonderful news.

We have been in contact with Dr. Nat Messer at the University of Missouri ourselves. There are some very fine and caring people at the Vet School. I'm also pleased that we have been able to work things out with our own vet and are communcating more effectively.

Sometimes, DrO, I sense "frustration" in some of your posts when people are unable to provide the results of tests, or don't have the necessary information so that you can provided a more educated opinion to assist them. I think sometimes people are trying their darndest to get information from their vets and it just isn't forthcoming, and other times they don't understand what the vet says to them during the farm call. Usually the horse owner is under a lot of stress because it is their "baby" that is suffering. We have tried to ask all the questions without being offensive to our vet... but in the end, it was a very frank discussion (sometimes called a "come to Jesus" meeting here in the Ozarks ) that resolved our communications issues with our vet. I still think it took too long to get to the University with this horse, but at least we are going now, and we managed to preserve our relationship with our vet, and maybe even improved our relationship.
Nina

Posted on Tuesday, Mar 7, 2000 - 3:43 pm:

Hello Nina,
It is not so much "frustration" as "hurried" to get everyones post covered. I find on those days that there are just a dozen posts to cover that I seem much friendlier as I write (today there are 49 but what the heck, I will take a break and digress).

Even after 5 years of doing this it still amazes me that some folks think they can give you a few details and you can diagnose, treat, and prognosticate their troubles. Neither is it my aim, because anyone who thinks that they can get a accurate picture of what's going on from a owners description has never practised medicine.

Just this weekend we had an emergency called in by people with decades of equine experience who thought they had a colic that turns out to be a horse developing heaves and overheating in our unusually warm winter days. But what they described was colic because that was what they knew. Most diagostic problems arrise from taking a subjective evaluation for granted, and not questionaing it. By making people critically evaluate the objective details and separate them out from the subjective evaluations they, working with their vet, can solve their problems.

I have two main objectives:
1) To create a logical framework that can be used to help solve problems.
2) Provide factual information on horse health.
Having been a scientist before a veterinarian I was appalled when I started practising at the amount of wrong and unsupported information that floated as fact in equine medicine. I could only get so much done from my truck in my practice so I started writing...and eventually ended up here.

Well I will climb off my soap box and Good Luck at the hospital, keep us posted.
DrO

Posted on Friday, Mar 10, 2000 - 10:08 pm:

I'm afraid the news is the worst. Anchor Hill Abbat was euthanised at the University of Missouri Veterinary Teaching Hospital. The staff and students were wonderful with us all, equine and human, and I have to say that Dr. Kellom was absolutely the best. She gave me all the facts and gently guided my decision to end the pain of my beloved horse. She also told me that she was not sure how he had withstood for so long without losing his will to live. I can only say that this horse was a good and honest horse who loved to be in the company of people, and who trusted in us. He continued to eat his hay and carrots up to the end, even though his blood amonia levels were shooting through the ceiling. I cannot express the guilt that I have felt over this illness and loss. Dr. Kellom told me that this was a very long standing chronic problem, and yet this horse greeted me every morning with a twinkle in his eye and a soft nicker. I did not see the illness until three weeks ago.

I should have autopsy results soon, but verbally, I was told his liver was very necrotic with very dilated bile ducts indicating a chronic problem with bile stones and infection. Everything that was found on autopsy indicated that euthanasia was the kindest choice.

These vets at the teaching hospitals have a crappy job in a lot of ways. They get the animals when local vets lack the equipment to deal with devastating problems, or when other remedies have not worked. A large number of the animals end up being euthanized or arriving too late to do a lot of good. I cannot say enough about the wonderful demeanor of the vets and students at MU. Dr. Kellom touched my life at a moment when my heart was broken, and I will never forget her kindness and sensitivity toward me, but clearly with all her loyalty lying with doing what was best for my horse. My own vet also understood my need to know if there were any options left, and ultimately, his original pronouncement was correct.

Many thanks, DrO, for your support during this episode. Liver disease is a tough one to battle, but I have learned a great deal, and Abbat's autopsy helped several MU vet students to learn even more. Now I will be very vigilant for the least signs of these problems in my other horses.

Nina Sala
---------------------------------------------
Fragile Circle
"We who choose to surround ourselves with lives even more temporary than our own, live within a fragile circle, easily and often breached.
Unable to accept its awful gaps, we still would live no other way.
We cherish memory as the only certain immortality,
never fully understanding the necessary plan."


Irving Townsend.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Posted on Friday, Mar 10, 2000 - 11:01 pm:

Dear Nina,
I'm so sorry to read your post. And I can't belive you were so eloquent at a time like this. My cousin and I lost our Tory two months ago and it still hurts a lot. I'm crying as I write this. Our thoughts are with you.
Pam Griffin

Posted on Friday, Mar 10, 2000 - 11:46 pm:

Nina,
My heart goes out to you. It is never an easy decision to make, letting go of our dear friends. Take comfort in the fact that you had the strength and courage to make that decision.
Paula

Posted on Saturday, Mar 11, 2000 - 9:14 am:

My deepest sympathies, Nina.
Robert Oglesby

Posted on Saturday, Mar 11, 2000 - 2:16 pm:

Dear Nina,
I'm so sorry, but you know you did try everything for Abbat. He sounded so special that I'm sure you will meet his spirit again. Don't feel guilt, you tried for him, and he tried to stay to be with you.
My tears for both of you, and thoughts also,
Alexa
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