Unexplained liver problems.

Dr. Marie, I have a now 14 year old yorkie with some complex medical issues and I’m hoping you can shed some light on his most recent test results.
We first noticed Scooby had elevated liver enzymes six months ago when he had a blood test for another reason. At that point his ALT was around 250 and the ALP at around 1500. In spite of our – and our vets – best efforts to figure this out and bring the enzymes down, they continued to rise at an alarming rate. In the past six months, we’ve had numerous blood tests, two ultrasounds, tested him for Cushings (negative), and ran a bile acid test. Bile acids were slightly elevated (pre level was 15.6 and post level was 35). The ultrasound in September showed a slightly enlarged liver, no shunts or anything that would suspect cancer, and all the other organs looked normal including his gall bladder and pancreas. We have changed his diet to Royal Canin Hepatic (with some homecooking – Dodd’s diet), he has been on Denamarin and fish oil for now six months. We have tried two different types of antibiotics (Amoxycillin and then Clamavox – both very long courses), and he has been on Flagyl. In November, his ALT had risen to around 500 and the ALP to 4500. The rest of his blood work has been and continues to be in the normal range. Clinically, he looks great. Eats well, is active and playful and has not lost any weight.
By the end of January, his ALT had risen to 600 and the ALP at a whopping 7000. That is when we did the second ultrasound, which when compared to the one in September did not really show any change. The second ultrasound in February was read by a board certified radiologist and the report said that his liver was slightly enlarged and had some areas which could be significant for inflammation, changes due to Cushings disease or even cellular regeneration. The same areas were noted on the first ultrasound in September but not defined. Then we did the Cushings test (negative) and the bile acids. Throughout all these tests and trying one thing and another, no definitive reason has been found for the issue with his liver.
At the end of January, he was put on Actigall, not because a problem was noted with his gall bladder but because there was not much else to try and he is not a very good biopsy candidate because of the very high liver enzymes. We also discontinued all the antibiotics and Flagyl. Thirty days later I was shocked that his liver values had drastically dropped. His ALT is now back in the high normal range at 104 and his ALP has dropped to 3900. The rest of the liver panel still looks good. Our little guy has been a puzzle trying to figure out because he does not have any typical symptoms of the liver problem except the two elevated enzymes.
My question is, could Actigall have made that much difference and that quickly? And have you ever seen a dog with ALT and ALP that high make a good recovery? I haven’t had a chance to speak to my vet and the blood test results were emailed to me over the weekend, so at first I thought it was awesome news. Then I jumped on the Internet and scared myself silly when I read that a drastic and unexplained drop like that can also signify even worse news…such as liver failure?? What are your thoughts on that?

Have you ever had a dog in your practice, with elevations that high over a period of time, actually make a decent recovery?

I realize that he is likely to need the meds and supplements for the rest of his life, which doesn't bother me. I mean he's 14 and I know that is old for a dog, but I'm curious about a prognosis. Since my vet can't give me a diagnosis, I don't know what to expect.

And is Actigall known to work that quickly? It seems like a drastic drop in just 30 days, especially since they've been climbing at an astonishing rate for six months now.

Thanks for giving me a little peace of mind.

Diana

Thanks. I guess we're in a wait and see mode then. Our vet wants to retest in 30 more days.

One more question, if the elevations do continue to drop significantly and making him a better surgical candidate, would you think a biopsy would still be beneficial?

Diana