High liver enzymes.

Dr. Marie replied:

Sorry to hear that your dog is dealing with these frustrating issues. It don't doubt that you are going crazy trying to research what high liver enzymes can mean because there is rarely a straightforward and obvious reason for this type of thing.

Rimadyl gets a bad rap when it comes to the liver because there can be the odd dog that can get serious liver complications within a short time of starting Rimadyl. It is quite rare. In 14 years of practice I can recall seeing one dog who had a serious liver related reaction to Rimadyl. Chronic Rimadyl use is *probably* not the problem with the liver right now. However, because Rimadyl is processed through the liver, it is wise to stop it for now.

You mentioned that the vet tested him for adrenal issues. I'm assuming you are referring to testing for Cushing's disease which is the condition that happens when the adrenal glands produce too much cortisol. He really has a lot of the potential symptoms of Cushings including an increase in thirst and appetite. Dogs with Cushing's will usually have a significant increase in alkaline phosphatase (ALP) as well. As ALP is associated with the liver, I'm assuming this may be the case for your dog as well. However, Cushing's doesn't usually cause vomiting. But then again, it sounds like the vomiting could have been something unrelated to the current problem.

In a case like this where we have elevated liver enzymes and some mild non specific symptoms like lethargy and increased thirst and urination then I'd usually be giving my clients a few options. The first would be to keep on the Denamarin and recheck the liver enzymes in a few more weeks.

The more aggressive option would be to do more tests. The problem is though that we can often do more tests and still not have an answer. The test that probably is best to do next is a liver ultrasound, but often there is no obvious diagnosis just by looking at the ultrasound and a biopsy is needed. In most cases, I would feel comfortable with the sedation needed for a liver biopsy but I would want to be doing some tests to make sure that his blood clots properly. As such, doing the tests, the sedation, the ultrasound and the biopsy can be quite pricey and there is still no guarantee of a diagnosis. BUT...sometimes we do get a diagnosis so I think it still should be considered.

If your vet feels that metronidazole is warranted here then I would not hesitate to use it. Metronidazole can often be good to take care of infections in the liver or even some parasites that can affect the liver. If it was going to be used long term then I'd probably be prescribing a lower dose than normal. But, if your vet is saying it is a good idea to prescribe it then I wouldn't be afraid to do so.

One other thing to consider is the possibility that this is early Cushing's disease that is still not able to be diagnosed with bloodwork yet. I have had a few cases where everything in my gut said the dog had Cushing's and the test was normal. But, we tested again a few months later and the test showed that Cushing's was there. This could be the case here.

It really does sound like your vet is doing all of the same things I would. I know liver problems can be frustrating and often we don't have immediate answers.

I hope things look up soon!

Dr. Marie.


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Dr. Marie replied:

The low dose dex test is the most commonly used one to detect Cushings. However, I have had some dogs that have tested normal on it and then a few months later, have shown signs of Cushing's disease.

The liver enzymes that you gave me are not extremely high. Sure, they're higher than normal but I wouldn't be too concerned.

I think that if your vet is wanting to prescribe a course of metronidazole I would have no problems with that. Don't be worried about what you read about side effects. In my experience it is very safe especially if it is just used for a short course.

The reason why there is no definitive path on what to do next is that really there is no obvious path to take. It's not wrong to do an ultrasound and even a biopsy but you still might not have an answer.

It sounds to me like the best course of action is to try the metrodnidazole and keep an eye on things for now. It really does sound like your vet is doing the same things I would.

Hope things are more clear soon!

Dr. Marie