Congress on Demand 2021: Internal Medicine

There are always going to be ethical questions and concerns when introducing new treatment modalities, and rightly so. As veterinarians we must always have animal welfare at the forefront of our decision making. Heart disease is a very common disease in dogs and can have a huge impact on quality of life, a subject that until recent years has been largely unresearched in veterinary patients. When considering any treatment option we must always consider its likely effect on quality of life; expected detrimental effects weighed up against potential improvements, in addition to quantity of life expected to be gained. This is particularly challenging in veterinary patients when assessment of quality of life and decision making has to be made by proxy. Maintaining a good health related quality of life (HrQOL) is just as important as survival to most humans in chronic heart failure (Lewis et al. 2001) and is also more important than quantity of life in owners of cats and dogs with cardiac disease (Oyama et al 2008, Reynolds et al. 2010). It is imperative that with any intervention, be they medical or surgical that owners are fully informed of potential risks and consequences, and presented with the most up to date and accurate information candidly.

The results of blood and imaging tests are non-specific in liver disease, so a liver biopsy is usually indicated to give a diagnosis and allow most effective treatment. Certainly, steroids or copper chelators should never be used without justification from a liver biopsy. The clinician must decide the best way to perform this biopsy considering how stable the patient is, the financial resources of the owner and the relative reliability of the results obtained with different methods. There is also little point in taking a biopsy which is not representative of the underlying disease – if the sample is too small, or from the wrong place, or only from one of a number of organs affected with disease, it may lead to the wrong conclusions being drawn and the wrong, or incomplete, treatment protocols. Fine needle aspiration (FNA) cytology is not strictly a biopsy but a potential alternative to more invasive biopsies but beware becoming ‘liver FNA happy’ for fear of false diagnoses and wasting the client’s money. FNAs are only helpful in a small number of cases, predominantly for bile aspirates and to rule out feline hepatic lipidosis or lymphoma. Wedge biopsies taken at laparotomy or laparoscopy are the most reliable diagnostically.

Following on from their lecture ‘Update on Current ACVIM Consensus Statements MVD & HCM’ Kieran and Jose discuss and challenge over two case studies. Watch Kieran and Jose put each other to the test, discuss their thought process around the cases and compare notes on their experiences of managing heart disease.

What are the medical options for mucocoeles? First, one must identify those animals whose gall bladder mucocoeles are suitable for medical management because medical therapy of mature “kiwi fruit” mucocoeles may result in substantial morbidity and even mortality. After selecting the appropriate cases, one should next look for co-morbidities (especially endocrine) that are believed to increase the risk of mucocoele, and if found need to be treated. Finally, choleretics (especially high doses of ursodeoxycholic acid) are used to help liquify the gall bladder contents, must like a diet designed to dissolve uroliths.

When and how should we intervene surgically with mucocoeles? This talk compliments the medical perspective regarding treatment of this disease and tries to explore some of the challenges in decision making that surgeons can face when managing this interesting condition. This talk will be available in the BSAVA Library until May 2023.

Why should we do more? Many clinicians view the liver as a “black box” that is difficult to understand and which has diseases that are only treated with basic supportive therapy. Hence, they see no reason to do something invasive like a biopsy. Or, perhaps they have been “burned” in the past by doing a biopsy incorrectly or at the wrong time, resulting in therapeutic failure and an upset client (outcomes that they want to avoid ever experiencing again). In fact, a lot of chronic hepatic diseases can be cured or controlled if diagnosed in a timely fashion. However, the only way to definitively diagnose most chronic hepatic diseases is by histopathology. Furthermore, it is extremely rare that a properly performed hepatic biopsy results in morbidity or mortality.

How should we do more? Taking a liver biopsy is central to diagnosis and effective treatment in most canine and feline liver diseases. I explain to the owner that the results of the biopsy will help treat their animal more effectively and that treatments such as copper chelators or immunosuppressives cannot be used without histology. Owners usually want the least invasive option, but a poor, unrepresentative sample is worse than useless. It is important to explain to them the strengths and limitations of different techniques and the value of taking larger, representative wedge biopsies. Fine needle aspirates are only indicated for bile culture and cytology and to help diagnose lymphoma or hepatic lipidosis, but even then have to be viewed with caution. Ultrasound-guided trucut biopsies are often poorly representative of the disease as a whole and carry an increased risk of bleeding. I discuss the benefits of wedge biopsies in making a more reliable diagnosis, allowing more effective treatment. I am lucky to have access to laparoscopic biopsies which we made cost effective by matching the price of ultrasound-guided biopsies so that owners do not make a decision based on finances. Wedge biopsy at laparotomy is a good alternative but owners can be harder to persuade because it is more invasive.