An ANGRY liver, and Plechner consult

04/19/11 - Today, we got Reo's CBC back.  It was not good.  :(

ALT was 1990 (normal is 12-118)
Alk Phos was 2642 (normal is 5-131)
Total Bilirubin was 4.6 (normal is 0.1 - 0.3)

It seemed that Reo's liver was failing.  Things happened quickly today.  First, I frantically emailed Caroline about what happened with the bloodwork.  Caroline patiently explained that excess estrogen is very hard on the liver.  The liver has to work hard to break down excess estrogen, and so this was not a surprise.  Caroline helped me to realize that the elevated liver enzymes were a symptom of Reo's elevated total estrogen.

Dr. N completely abandoned any support she had for our adrenal exhaustion theory, and asserted that the Medrol and L-thyroxine Reo has been taking caused her liver failure.  She was also concerned that there may be a bigger problem, like cancer, and so suggested an ultrasound.  We scheduled the ultrasound for that afternoon.  In the meantime, since Reo hadn't been eating, they gave her some sub-cutaneous fluids.

I felt desperate.  I went home and filled out the consult form on Dr. Plechner's website.  Thankfully, Dr. P called me back in a matter of minutes.  I thought that perhaps Dr. N would be more willing to listen to Dr. P as he was a "real" DVM and has the most experience with Plechner's Syndrome/adrenal exhaustion than anyone.  Dr. P confirmed everything about Reo that Caroline had, and confirmed that under no circumstances do we stop giving Reo her Medrol and L-thyroxine.

Meanwhile, Reo was getting her ultrasound.  The results revealed the liver was normal size (good) but mildly inflamed (not so good).  Her gall bladder wall was uniformly thickened, which suggests an infection like cholangiohepatitis, which comes from bacteria in the intestine.

Notably, Reo's adrenal glads were normal size and shape.  This finally led Dr. N to abandon the theory that Reo had Cushing's disease (yay!).  All of Reo's other organs were "unremarkable" - for some reason, this term in the report makes me smile.  Spleen, kidneys, lymph nodes, stomach, etc. - pretty boring!

After these results, Reo got some sub-cut Baytril (antibiotic), Pepcid, and an anti-nausea medication.  When a dog has extremely high bilirubin as Reo, this can make her feel truly awful, and so it was no surprise Reo was anorexic.  Dr. N wanted to hospitalize Reo so she could have continuous fluids, but I decided not to do this right away until I could consider all of the options.  I promised to bring Reo back the next day for more fluids and medications.

I abandoned the "cooked food only" from the Levin protocol, and decided to give Reo almost anything she wanted, just to get her eating again.  I abandoned her supplements for the time being.  As soon as she got home from the vet, she ate some Wellness canned food and a few treats.

So, now what?

After talking to Dr. P and Caroline, they both suggested intramuscular (IM) injections of hormone.  By doing IM injections, it would completely bypass any absorption issues that Reo was having with the oral Medrol.  It also meant that Reo's body could come into balance much quicker than using oral supplementation.  I was on board.

Now, this is where it started to get confusing.  Both Caroline and Dr. P suggest one long-acting and one short-acting corticosteroid.  Caroline suggests triamcinolone and dexamethasone.  Dr. P suggests triamcinolone and DepoMedrol (methylprednisolone - basically the injectable form of what Reo had been taking orally).

I suggested this to Dr. N and she flatly refused.  She was now completely not on board with the Plechner's syndrome/adrenal exhaustion theory, and would not advocate the use of any steroid for Reo.  We appeared to be at an impass.

This was the most frustrating feeling to want a treatment for my animal that I was paying for, but have a vet not willing to help.  I said I would sign waivers, no matter.  So, I decided to cut ties.  I told Dr. N that I didn't want to compromise her ethics, and I understood I was asking her to step outside her comfort zone, but, we've started down this path, and I was committed to doing what I thought was best for Reo.  We parted with no hard feelings, but I told her that I would be calling around to find a new vet.

The search begins...