Case 2

After having a long conversation with the owner about your concerns regarding the ALT elevation, she approves an abdominal ultrasonographic examination. In the meantime, you decide to discontinue the NSAID and institute treatment with tramadol (a centrally acting opiate agonist) instead.

The abdominal ultrasonographic examination reveals a mildly enlarged liver with rounded edges. There are scattered hypoechoic nodules, all measuring less than 3 cm in diameter. The rest of the liver and abdomen are normal.

While biopsy of the nodules would be ideal to obtain a definitive diagnosis, the owner has declined because of cost and invasiveness (her dog feels fine!).

Some common differential diagnoses for the changes seen on the ultrasound would include

• Chronic hepatitis

• Neoplasia

• Benign nodular hyperplasia or vacuolar hepatopathy

• Abscess or granuloma

• Cirrhosis

With most of these differential diagnoses, we would expect more marked clinical signs (e.g. vomiting, weight loss, poor appetite) and likely more impressive lab test changes. So, while you can't know for sure without a biopsy, you strongly suspect that these nodules are benign hyperplasia and likely the cause of Spot's elevated ALP activity.

QUESTION 4

What is a reasonable long-term treatment plan for Spot at this time? (There is more than one correct answer.)

a) Have Spot return in two weeks to recheck his ALT after being off of the NSAID.

b) Since he continues to feel good, continue the tramadol treatment, and recommend a recheck panel again at his next yearly visit.

c) Recommend a recheck abdominal ultrasonographic examination in three to six months to look for any changes in the liver nodules.

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