Shunt Case Report

Kristin Reichert, University of Wisconsin 

1. Signalment: Xxxx (not revealing name for patient confidentiality), 4-month-old intact female Golden Retriever

2. Presenting complaint: Intrahepatic Portosystemic Shunt 

3. History: Back in July, Xxxx reportedly presented to the emergency service with unspecified neurological signs. She underwent investigations that revealed elevated total bilirubin and ammonia, and she was transferred to the internal medicine service with a suspicion for a congenital hepatic portosystemic shunt. Upon abdominal ultrasound, internal medicine suspected that Xxxx had an intrahepatic shunt and recommended a soft tissue surgical consult. This would likely be for computed tomography with contrast to confirm the location of the shunt, followed by surgical management. To help mitigate her neurological signs from the accumulation of ammonia within her system and ultimate crossing of the blood brain barrier, Xxxx was prescribed levetiracetam, lactulose, and metronidazole. She was reported to have improved significantly with regards to her clinical signs as a consequence of these medications.

4. Physical examination findings: Xxxx presented BAR. Eyes and ears were noted to be unremarkable. Oral examination identified multiple fractured deciduous teeth. Mucous membranes were moist and pink with a capillary refill time of under 2 seconds. Heart rate and rhythm were normal with no murmur auscultated. Lung fields in all four quadrant were normal. Abdominal palpation was soft and comfortable. Peripheral lymph nodes palpated within normal limits. Integument had no abnormalities. Temperature remained within normal limits throughout hospitalization. Her presenting weight was 11.3kg.

5. Differential diagnoses: Upon presenting to the soft tissue service, the top differential was intrahepatic portosystemic shunt, due to the previous diagnostics that had been performed. However, upon initial presentation, differential list included ingestion of toxins, an episode of hypoglycemia causing seizures (potentially secondary to other disease processes), intracranial congenital defects causing seizures, idiopathic seizure activity, peripheral vestibular disease (including secondary to otitis media or otitis interna), neoplasia of the central or peripheral nervous system, infectious disease processes (including bacterial, viral, fungal) and a vascular event in the central nervous system.

6. Diagnostic tests/procedures and associated results: Whilst with the soft tissue service; a pre-operative complete blood count and serum biochemistry were performed in conjunction with an abdominal computed tomography scan with contrast, to confirm the location of the shunt and to appropriately prepare for our intraoperative approach.

7. Working diagnosis: Total bilirubin had returned to the normal range, which was slightly anomalous, however her ammonia had increased since her previous bloodwork, which remained consistent with the shunt persisting. The CT scan confirmed the presence of an intrahepatic shunt and provided visualization for surgical approach. This was determined most appropriate between the left medial and quadrate lobes of the liver.

8. Treatments administered/procedures performed: A 9mm Amyloid ring and key was placed around the shunt once surgically accessed and freed from surrounding connective tissue to the liver. A concurrent liver biopsy was performed and is pending histopathology. Intraoperatively, a temporary total ligation was performed to determine the necessity of the amyloid ring. It was determined that the portal pressures were too high with total ligation. This was determined by assessing the increase in motility of the intestines and force of vessel pulsation with the ligation in place.

9. Outcome/progress (if applicable): The amyloid ring is slow-closing and will progressively close over the next month or so. Xxxx will be monitored closely during this time, as there are concerns over portal hypertension or formation of acquired shunts. While generally positive in the long-term, if these complications do not occur over the next few months, there is always a concern that acquired shunts may form over time. In the meantime, Xxxx will remain on levetiracetam for two weeks, and lactulose and metronidazole for two months following the procedure, in hopes of helping her transition back to life as a puppy and decrease the accumulation of ammonia within her system.

Waiting on the Weekend

It is almost Friday! Check out these funny memes creates by Taylor Williams from Ohio State University that will help you make it through the end of the week. 

Smithcors Veterinary History Essay Contest

Are YOU interested in veterinary history? If so, check out the link to the Smithcors Veterinary History Essay Contest! This contest is sponsored by the American Veterinary Medical History Society, and it gives students the opportunity to thoroughly research a topic related to veterinary history, write an essay about it, and possibly win scholarships and publication. There are scholarships available for those essayists placing 1st through 4th.  Students wishing to enter can find everything they need (guidelines, entry forms, etc) on the website listed below. Submissions are due April 15th, 2020. 

 https://www.avmhs.org/essay-contest 

Beautiful Pet Portraits

Check out these incredible pet portraits created by Alena Naimark from Tufts University!

  

Alena enjoys creating these as stress relief from school. If you want one of your very own, contact us here at The Vet Gazette, and we can get you in contact with Alena! 

2019 SAVMA Symposium Experience

Victoria Villafane, Ross University 

Amidst the hectic life of a veterinarian student, I hesitated before making the decision to travel mid- semester back to the states for SAVMA symposium. Most schools were on spring break but for Ross students, travel consisted of lugging our laptops, notebooks, and all study materials with us and studying throughout the day any break we got. The question came up more than once, of why we would put ourselves through that just for a convention. Since I have never been before, I did not know the answer until I took the chance and packed my bags, heading off to Athens, Georgia. I felt a mix of nerves, excitement, and stress as I settled in on the plane hoping it was all going to be worth it.

Stepping into symposium, I knew I made the right choice. I looked around at the many vet students from all across the country, glanced at the lengthy list of veterinarian names there to give us lectures and guide us through wet labs and I smiled. This wasn’t something I would ever be able to experience during any other part of vet school. I knew I had the opportunity to network with others in my field, listen to lectures expanding my knowledge on what we learn in school, and to strengthen skills during wet labs.

I took a turn into the big exhibit hall full of vendors, promotors, recruiters and was pleasantly overwhelmed with an influx of information. I stopped at the Hills table and was fascinated as they discussed the release of liquid diets for sick animals. My mind flashed back to countless hours of mashing up food and blending it with water into a soupy consistency and hand feeding sick patients and thought of how helpful and amazing this would be to have in hospitals. They also allowed us to practice placing a nasogastric tube on a model which was really neat as I had never done it before. I continued walking around learning about joint supplements, working with exotics opportunities, veterinarians in the army and about AVMA PLIT. As we stopped at the Zoetis booth, I stood in awe as they had a huge board announcing scholarship recipients and there under the RUSVM column was my name. I had no idea they announced the winners at symposium, so it was incredible and special to have been there when I won the scholarship.

I was also able to attend lectures given by veterinarians and it was an inspiring experience as for the first time in my vet journey, I was able to follow along with cases and examples and actually understand the information coming across. It was very encouraging to see the progress I am making as well as expanding my current knowledge base. One example was an oncology lecture given where the presenter discussed cases on osteosarcoma and hemangiosarcoma. Being able to follow along the cases from presenting complaint to treatments to consequences, it gave me the motivation and encouragement to keep working hard being able to experience how it is paying off. I was able to pull my clinical pathology knowledge out and answer questions about what we would expect to see in patients with these conditions and it was satisfying to feel like I can begin to think and communicate like a veterinarian.

Another day, I attended a dental wet lab. I was interested to learn more about topics that we do not go very in depth in at school, so I chose dentistry, not knowing what I was getting into it. At first, it was extremely intimidating and scary to watch the doctors show us what we have to do. I felt like we were on a construction site instead of in a lab with all of the drilling and hammering. I could never have imagined how hard it actually is pulling teeth, but although it was a challenge and I have never felt my arms so sore, I was still ecstatic that I chose this lab and got to practice extracting a whole set of teeth. It is not something I would have gotten to do at school. Not only did I walk out of that lab with a new appreciation for dentistry, but I definitely increased my muscle mass.

Aside from the wealth of veterinary knowledge I left with, I also learned a very valuable lesson; our education is not limited to the classroom and it’s our responsibility to take advantage of opportunities presented to us. Experiences are just as important as our studies. I am so happy I decided to take the trip to SAVMA symposium and I am grateful for the immense impact it has had on my journey as a DVM candidate.