High ALKP and bile acids.

Dr. Marie replied:

Hi Suzie. Thanks for sending me that report. That gives me a lot more insight about Oreo's case. And you know what? If he was my patient I would not be worried about him at all.

It's true that he has some elevation in his ALKP, but in my books these elevations are very minor. Almost every dog I see that is over the age of 5 has some mild increase in ALKP. I once spoke with a pathologist about this and her thought was that most dogs develop some mild Cushing's disease as they mature. She feels that the disease in most dogs never gets to the point where we are seeing clinical signs and we don't ever have to do anything about it.

With that being said, when I do see an elevation in ALKP I generally do recommend doing a liver workup or tests for cushing's. Even though many dogs have elevations that are nothing to worry about, there is the odd one that has an underlying problem. If those tests are normal then I simply keep an eye on the liver enzymes every 6 months or so. If I start seeing ALKP numbers of 800 or so or higher then I get more serious about looking for actual disease again. Or, if I have a dog that is losing weight, not eating and not feeling well then we revisit the situation. (If Oreo is 3 pounds overweight I can almost guarantee you that there is no active liver disease!)

I recently talked to a specialist recently about a dog who had a really high ALKP (like 1200 or so) and I couldn't find any disease present. He said in his experience dogs with high increases in ALKP and no other symptoms usually end up being diagnosed with Cushing's disease down the road. Now, Oreo's ALP is not even close to me wondering about Cushing's, but if the level keeps going up and gets to high levels then we could consider retesting for Cushing's. With that being said, we don't treat Cushing's unless we have clinical signs of increased thirst and urination.

It is true that ALKP can be elevated in a growing puppy because the bones are growing, but it is pretty rare that I would attribute an increase in ALKP in an adult dog to bone disease.

The only thing that seems a slight bit abnormal to me is the elevated bile acid. However, the specialist's comment that we treat the dog and not the lab results is so true. What I see here is a slight elevation and again, nowhere near the levels that I would worry about. I think it's a great idea to cover all bases and treat with the liver protectant and antibiotics just to be sure. But, likely there is really not much we can do. Remember that no test is 100% accurate...we use them as guidelines.

What I can see on Oreo is a slight elevation in liver enzymes (which is often normal) and a dog that is happy and healthy and overweight. If this was my patient I wouldn't be worried at all, but I would occasionally be doing some blood tests just to be sure that there is not something looming. You will likely see a mild increase in ALKP each time and possibly variation in bile acid results. If you start to see a really high increase then I would be more vigorous in looking for disease.


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Dr. Marie replied:

You're right that the bile acids may jump around a bit. I don't think a slight increase or decrease will mean much, but if suddenly we are seeing a level like 120 or something like that then this tells us that we need to start being concerned.

Lactulose would only be necessary if there were signs of hepatic encephalopathy. You need a really diseased sick liver for this and this is not the case with Oreo!

If a clotting panel is normal then I have very few concerns in doing a liver biopsy, but really, I don't think it is necessary at this point. The only reason to do one would be to satisfy your need to put a name on Oreo's condition. But, often if there are mild liver elevations we could do a biopsy and STILL not have an answer. At this point, doing a biopsy won't change Oreo's quality of life at all. I'd hold off on this. If the bile acids or liver enzymes have a dramatic increase or if he is not feeling well then the vet may be more keen to do it.

The gall bladder is just part of the whole liver enzyme thing. There are some conditions that we can diagnose by aspirating the gall bladder. But again, this seems extreme to me at this point. But, if/when it comes the point where you are going to do a biopsy of the liver you might as well be thorough and look at the gall bladder too.

Cipro is generally safe. There are some rare cases where dogs have gotten bladder crystals after a long course of these antibiotics. It's not enough risk to stop the meds though. If we can encourage him to drink this lessens the risk, but as the risk is tiny I wouldn't be too worried.

If Oreo was my dog I would do no further testing on him for at least 6 months. Perhaps I may do it sooner if he was losing weight or not feeling well. Then, in 6 months I would repeat liver enzymes and bile acids. It wouldn't surprise me if there was a slight increase. If there is a large increase then I would consider doing the biopsy. And, at any point if he develops symptoms of cushing's disease (drinking and urinating more) then I would re test for that.

Dr. Marie.

Dr. Marie replied:

Thanks for the bonus Suzie. It's greatly appreciated.

About the increases and decreases all I can say is that these numbers are not absolute. They are averages. You could do a test today and repeat it tomorrow and the numbers could be significantly different. What we look for are continuing trends upwards or dramatic increases. You will drive yourself crazy worrying about minor changes like this.

The best advice I can give you is to trust your vet. It sounds like they are doing an excellent job. They wouldn't put him on Cipro if it wasn't safe. And no, the coughing/sneezing is not a side effect of cipro. If that continues you may need to have him checked again, but it doesn't really fit with his liver elevations.

I can't comment on which drugs are best. Trust your vet. They have Oreo's best interests in mind.

It really sounds like he is fine and now we need to work on getting mommy not to worry so much. :)

Dr. Marie.