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.

University of Wisconsin hosts Oiled Wildlife Clean-up Lab for Veterinary Students and Community Professionals

SAVMA's Education and Professional Development Committee awards grants to student organizations or clubs to design either a lecture and/or wet lab for a topic to which students would not otherwise be exposed. Three $250 dollar grants are offered each year, and winners are hosen by the committee in November. For this and other SAVMA funding opportunites, visit our website.

On April 27th, 2013 the University of Wisconsin School of Veterinary Medicine sponsored an oiled wildlife cleanup wet lab for the first time in the school’s history. This wet lab experience was organized by students in the Wildlife, Exotic, and Zoo Animal Medicine (WEZAM) club at the University of Wisconsin School of Veterinary Medicine and directed by members of Tri-State Bird Rescue and Research and VMAT (Veterinary Medical Assistance Team) from the AVMA.

Both students and community veterinary professionals took part in a unique wet lab experience where they were exposed to the basics of oiled wildlife clean-up procedures.  Participants were educated in proper handling of oil-contaminated animals, physical examinations with an emphasis on triage, clean-up and bath protocol, and appropriate safety precautions.  Participants gained an understanding of the role they can play as veterinary professionals in responding to oil contamination events and learned that such events can take place outside coastal areas.

WEZAM’s mission is to supplement the traditional veterinary education with subjects in wildlife, exotics, and zoo animal medicine that are otherwise lacking in the curriculum.  In addition to other wet labs such as this, WEZAM sponsors various events, tours, and speakers throughout the year and hosts an annual conference in the field of wildlife, exotics, and zoo animal medicine.  This was the first event held on the topic of oiled wildlife, and the club hopes to hold similar events in the future due to the positive responses after the lab.  We would like to thank Tri-State and VMAT for their help in putting on this great event.  We would also like to thank the US Fish and Wildlife Service for donating the waterfowl carcasses used in this lab.  The lab was made possible by generous funding from the AVMA, the University of Wisconsin SCAVMA and the EPDC Extracurricular Grant awarded by SAVMA. 

The Rotten Egg

By: Kendra Bauer

University of Wisconsin, Class of 2013

During my summer working as a Merck-Merial summer scholar at the International Crane Foundation in Baraboo, Wisconsin, I had the opportunity to participate in a lot of clinical procedures in addition to working on my research project. The following is an excerpt from my daily log of my experiences that summer:

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So you want to be a zoo vet?

By: Kendra Bauer

University of Wisconsin, Class of 2013

So you want to be a zoo vet? So do I. I have a long way yet to go, but I made one important step last October when I attended the American Association of Zoological Veterinarians Conference in South Padre Island, Texas. Prior to deciding to go, I had been told over and over by classmates, mentors, and zoo veterinarians that this conference is a must-see for every zoo vet hopeful. Now, it is my turn to pass on the knowledge. Here is a brief run-down of how the conference works:

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Update from the Education and Licensure Committee

Within the Student AVMA House of Delegates there are many committees made up of your student delegates. These committees work hard to create scholarships, grants and other contests that are available to you as a SAVMA member or a club or group at your school. This is free money that they want to give away! To check out the opportunities available to you through these committees, head over to:http://www.avma.org/savma/committee.asp#license

Back in the fall the Education and Licensure Committee picked two recipients for their Extracurricular Funding Grant. The purpose of this grant is to provide veterinary student organizations funding for wet labs or lectures supplementing their college's curriculum. These grants typically are awarded to help fund programs that veterinary students would not normally be exposed to in their traditional courses. The winners for the 2009-2010 school year were an equine acupuncture wet lab held at University of Pennsylvania and the Marine Mammal Conference at University of Wisconsin. You can read more about the Marine Mammal Conference below.

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