Liver value elevations can be about more than the liver

A senior female spayed poodle mix presented to her primary veterinarian for removal of some lumps and bumps. Presurgical labwork revealed moderate liver value elevations. Her referring veterinarian recommended an ultrasound to ensure that no neoplastic disease was missed prior to the surgery.

Liver values are the “boy who cried wolf” of the canine veterinary blood panel. We commonly see them elevated, and we recommend investigation via expensive tests like bile acids and ultrasound only to find…nothing. It’s hard to justify the workup to owners, and so, after a while, we stop recommending it. Sometimes these liver values go down with time and liver support medications; sometimes they don’t. Frequently, they are not associated with any sign of illness in the dog. We diligently note the high ALP in the record, mention its increase or decrease over the last 12 months, script out another box of Denamarin, and hope we aren’t missing something.

My mission, when I am wearing my veterinary sonographer hat, is to promote the idea that ALP elevations are meaningful and worthy of workup. For every 5 patients I scan with high ALP, at minimum, I find one with pathology worth treating. Whether it is a gall bladder mucocoele, a liver tumor, or not infrequently, like in this case, an adrenal mass, those slightly elevated liver values shouldn’t be ignored.

This particular poodle mix had an ALP of 936 (5-131), an ALT of 186 (12-118), and a slightly high PSL. Her veterinarian recommended a scan. The first video below shows an enlarged and irregular right adrenal gland, with pinpoint hyperechoic areas of mineralization and hypoechoic areas of necrosis throughout the gland. There is phrenicoabdominal invasion (a neoplastic characteristic) and a clot or mass in the lumen of the vena cava. In the third image below, color Doppler picks up blood flow around this clot/mass.

Right adrenal mass with phrenicoabdominal and vena caval invasion.

Right adrenal mass with phrenicoabdominal and vena caval invasion.

Blood flowing through the vena cava and around the mass/clot in the lumen.

Blood flowing through the vena cava and around the mass/clot in the lumen.

As all you vets know, there’s a good probability that this little adrenal mass is a functional adenocarcinoma, over-producing adrenal hormones like cortisol that result in swelling of the liver (steroid hepatopathy). It could also be a pheochromocytoma, adrenal hypertrophy (less likely with vena caval invasion through the phrenicoabdominal vein) or a metastasis of a cancer elsewhere. The next ideal step, if the owner wishes to proceed, is a CT scan to determine whether this pup is a candidate for surgery. If the dog goes to surgery, biopsy of the liver would be a wise idea to make sure we aren’t getting tunnel vision on the adrenal mass.

Another lesson to this story is: image the adrenals on every scan you do. Trouble finding the right one? Call me. I can help teach you to find it reliably. You’ll be amazed how much pathology lives here; investigating an elevated ALP can make the difference between finding these tumors when they are surgically resectable and finding them when only palliative care can be offered.

Liz GrayComment