Tuesday, March 31, 2015

Cookie's Elevated ALT: The Ultrasound and Cytology

Cookie's ALT remained elevated on two blood panels in a row. First thing we did was to test for pancreatitis since Cookie had that in the past. The test came out clean. That was some weight off my shoulder because I've been worried about it coming back or brewing under the surface ever since it happened.

While I thought the GI function test would be a great next step, it has turned out that doing that would be quite cumbersome.

Cookie's vet suggested doing the ultrasound if I really wanted to do something.


The problem with that was that it does require shaving of the belly and the Winter was REALLY cold. Of course, we could put a sweater on Cookie but that would last on her for about five minutes if that long.

As much as I didn't like it, we decided to wait for the weather to warm up a little bit. Of course, if any symptoms cropped up, we would have done it right away.

Couldn't wait too long either because I wanted Cookie's fur to grow back before the bugs come out.

The weather finally did warm up enough and we booked Cookie for the ultrasound.

She was an extremely good girl and didn't require any sedation whatsoever neither for the ultrasound nor for the biopsy they took. They didn't make any comments on what they saw or didn't see, just mentioned they also did the biopsy.

Frankly, I find it amazing that anybody can tell anything from these pictures.

So they clearly saw something, didn't they?

The hospital routinely sends the ultrasound images out for interpretation. We were told the report should come back in 24 to 48 hours.

I waited to hear back. One day passed, two days ... three ... I called to see whether they got the results. I was told there was nothing on file and the vet will call me when she can.

Four days passed ...

Wouldn't you get suspicious?

I started thinking there was something amiss and they were waiting for the biopsy results before talking to me. Which objectively made sense but subjectively only got me worried anyway. So they could just go ahead and tell me.

Few hours after I called for the third time, with nothing showing on the file still, I finally got a call.

The ultrasound did indeed show some minor abnormalities and they were, indeed, waiting for the biopsy results before talking to me.

Minor abnormalities, huh?


This is what the report said:
113 still abdominal ultrasound images were reviewed.

There is no evidence of free abdominal fluid. The liver may be minimally enlarged. The hepatic parenchyma is slightly mottled, with ill-defined regions of slightly increased and decreased echogenicity. There is no evidence of discrete nodules or masses however. The gallbladder is unremarkable. There are no splenic abnormalities identified.

The kidneys are symmetric and within normal limits, with normal overall renal architecture. The visible portion of the G.I. tract is unremarkable.

Assessment:
Probable minimal hepatomegaly.
The slightly mottled echotexture of the hepatic parenchyma is a mild and nonspecific finding. Hepatitis, a variety of drug or toxin induced hepatopathies, metabolic/endocrine disease or less likely neoplasia may all be considered. If clinically indicated, a fine needle aspirate or biopsy may be helpful.

Doesn't really tell much other that there are some things that are a bit off. Could mean all sorts of things.

Had to wait for the biopsy results to get a better idea of what's going on.

We were out walking the dogs when the vet called about it. From the tone of voice alone I could tell it was good news.  Though after reviewing the cytology report, I do have some questions.

Here is what the report said:
Smears contain numerous clusters of intact hepatocytes on a hemodiluted and mildly vacuolated (somewhat lipidic) background with few clusters of ruptured adipocytes. The hepatocytes show adequate nucleocytoplasmic ratio and contain basophilic staining, faintly granular cytoplasm. Nuclei are uniform with coarse chromatin and single distinct nucleolus. Binucleated hepatocytes are frequently identified. Leukocytes are subjectively estimated to be numerically in proportion to blood contamination. There is no evidence of atypical cells.

Microscopic findings: unremarkable liver aspirates


Comment: There are no significant cytological abnormalities to explain the biochemical changes in this patient. The hepatocytes are well-differentiated and show minimal atypia. Binucleated hepatocytes are commonly observed in liver aspirates but may be numerous in association with tissue regeneration or heperplasia. Correlate with clinical presentation and sonographic findings. The sample is noninflammatory and there are no elements to suggest underlying neoplasia.


In other words, things look generally normal, with no evidence of inflammation or cancer. There seems to be a little more liver cells about to divide than normal. Why? Is the liver healing from something or is there something else going on?

There seem to be a bit more fat present than normal. Why?

I still have to decide whether to dig deeper to figure out the reason behind these minor anomalies.

The vet who called me with the results said, "That's how Cookie chooses to be."

As I know myself, I won't rest until I know why. If it can be figured out.

Related articles:
Incontinence? Cookie's Mysterious Leaks
From The End Of A Lead Line To Casa Jasmine: Meet Cookie, Our New Adoptee
And So It Begins Again(?) Our First Health-Related Heart Attack With Cookie 
I Didn't Know I Could Fly: Why Cookie Wears A Harness Instead Of A Collar
C.E.T. Oral Hygiene Chews For Dogs CAN Be A Choking Hazzard 
Our First Health-Related Heart Attack With Cookie: The Knee Or The Foot? 
Creative Solutions And An Incidental Product Review
Too Young For Pot: Cookie's Snack With A Side Of Hydrogen Peroxide  
Taming Of The Wild Beast: Cookie's Transition To Civilization  
Staying On Top Of The Ears: Cookie Is Not Impressed  
Putting The Easy Back Into Walking
Cookie's Ears Are Still Not Happy 
The Threat Of The Bulge Is Always Lurking 
Today Is Cookie's Three-Months Adoptoversary  
Cookie Meets The Electric Horse Fence And Her First Chiropractic Adjustment  
Why Examine Your Dog's Vomit? 
Why Is That Leg Still Not Happy? Cookie's Leg Keeps Getting Sore 
Cookie Too Is Insured With Trupanion
Does Being Insured Mean Being Covered? Our First Claim With Trupanion
Is Cookie's Leg Finally Getting Better?
Is Cookie Going To Be Another Medical Challenge Or Are We Looking To Closely? 
The Project That Is Cookie: Pancreatitis Up Close And Personal  
Pancreatitis: Cookie’s Blood Work   
Another Belly Upset: Pancreatitis Again Or Not?  
Happy Birthday, Cookie 
Who's Training Whom? Stick And Treat 
Don't Just Stand There, Do Something? Cookie's Mysterious Bumps 
Cookie's Mysterious Bumps Update
One Vomit, No Vomit 
Happy One-Year Adoptoversary, Cookie!
Cookie's Leaks Are Back: Garden Variety Incontinence Or Not?
Cookie's Leaks Update 
Don't Panic, Don't Panic: Know What Your Job Is 
The Continuing Saga Of Cookie's Leeks: Trying Chiropractic Approach 
Cookie's Minor Eye Irritation
Regular Wellness Exam: Cookie's ALT Was Elevated 
Cookie's Plantar Paw Pad Injury 
How Far To Take It When The Dog Isn't Sick?
Cookie Has Tapeworm Infection 


Do you have a story to share?

Your story can help others, maybe even save a life!

What were the first signs you noticed? How did you dog get diagnosed? What treatment did/didn't work for you? What was your experience with your vet(s)? How did you cope with the challenges?

Email me, I'll be happy to hear from you!

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