One liver value is high, maybe cancer?

[carrielynn]

Hi all, a couple months ago I wanted to get my cat a much needed dental, but when the vet saw his blood results she didn't want to put him under anesthesia due to a high liver value. ALT was 200, then on his next blood draw 200 again, then today actually up to 215. None of the other values are elevated, and my vet says that is unusual for liver disease. She also said it is unusual that he has no symptoms and still eats and plays a lot. Because of his age (we think around 13, but unknown exactly because he was a stray), she is concerned about cancer. He will be having an ultrasound and maybe a biopsy, but the vet is not eager to put him under anesthesia with a high liver value. We have already tried antibiotics and Denamarin. I was only able to get 5 doses of Denamarin down him because he is extremely difficult to pill and the bitterness was causing him to drool everywhere. The vet is going to see about getting a more palatable version from the compounding pharmacy, but so far after those doses his liver value is higher, not lower. The vet seems stumped about why just the one value is high so I figured I would ask if anyone has dealt with something similar or had any thoughts. I'm really worried that it will turn out to be cancer.

 

[silent meowlook]

This is a good read:

Approach to Elevated Liver Enzymes in Cats - WSAVA 2019 Congress - VIN

 

[daftcat75]

Ugh! ALT!

Krista went through so much grief over that one enzyme. I call it the ghost of inflammation elsewhere. There are many reasons ALT can be elevated including muscle and tissue damage not related to the liver. Even inflammation in his mouth could very well be the reason for this value. 200 is a slight elevation. Krista's was 1400 when her vet refused her a dental. While they were trying to do an ultrasound on her, she was far too feisty and they ended up sedating her anyway. Since she was already under, my vet performed the dental. At least three teeth needed to be pulled and some painful root fragments from previous extractions. I'm fairly convinced that Krista's ALT values were not going to go down until those teeth were addressed.

I don't think it's cancer. You'd probably see other symptoms most notably butt or gut issues. And weight loss. I also don't think waiting on Denimarin is a good idea. Those liver supplements are notoriously difficult to give and take a long time to work. Also, one of the ingredients in Denimarin specifically makes it difficult to compound it into any other format. Meanwhile, if that ALT value is high because of inflammation, the Denimarin doesn't address that. It won't fix his teeth if he has teeth that need to go. One thing that might help bring those liver values is a weekend or longer on IV fluids. I guess the thought being you're going to flush the markers that ALT is responding to from the body. But this is expensive. It was something like $300/day to have Krista on IV fluids. And of course, the cat needs to stay at the vet's office for the duration. To get Krista from a 1400 reading to something under 200, she needed two dentals and ten days on IV fluids.

My recommendation: If you think there are dental issues in his mouth that need to be addressed sooner than later, ask your vet if you can give informed consent that she has informed you of the risks and concerns of anesthesia and you consent to it anyway. Because those dental issues are likely to get worse before those liver values get better.

An ultrasound is not a terrible idea just to rule out any other obvious reasons why that value might be elevated.

 

[carrielynn]

This is a good read:

Approach to Elevated Liver Enzymes in Cats - WSAVA 2019 Congress - VIN

Thanks, it's interesting to read about the different ways they may do a biopsy. But with so many causes of inflammation listed, I'm hopeful the ultrasound won't show anything concerning.

Ugh! ALT!

Krista went through so much grief over that one enzyme. I call it the ghost of inflammation elsewhere. There are many reasons ALT can be elevated including muscle and tissue damage not related to the liver. Even inflammation in his mouth could very well be the reason for this value. 200 is a slight elevation. Krista's was 1400 when her vet refused her a dental. While they were trying to do an ultrasound on her, she was far too feisty and they ended up sedating her anyway. Since she was already under, my vet performed the dental. At least three teeth needed to be pulled and some painful root fragments from previous extractions. I'm fairly convinced that Krista's ALT values were not going to go down until those teeth were addressed.

I don't think it's cancer. You'd probably see other symptoms most notably butt or gut issues. And weight loss. I also don't think waiting on Denimarin is a good idea. Those liver supplements are notoriously difficult to give and take a long time to work. Also, one of the ingredients in Denimarin specifically makes it difficult to compound it into any other format. Meanwhile, if that ALT value is high because of inflammation, the Denimarin doesn't address that. It won't fix his teeth if he has teeth that need to go. One thing that might help bring those liver values is a weekend or longer on IV fluids. I guess the thought being you're going to flush the markers that ALT is responding to from the body. But this is expensive. It was something like $300/day to have Krista on IV fluids. And of course, the cat needs to stay at the vet's office for the duration. To get Krista from a 1400 reading to something under 200, she needed two dentals and ten days on IV fluids.

My recommendation: If you think there are dental issues in his mouth that need to be addressed sooner than later, ask your vet if you can give informed consent that she has informed you of the risks and concerns of anesthesia and you consent to it anyway. Because those dental issues are likely to get worse before those liver values get better.

An ultrasound is not a terrible idea just to rule out any other obvious reasons why that value might be elevated.

Thank you, I feel better about the chances of it being cancer. I will talk to my vet again about how we can get that dental done after the ultrasound, which I think she wants him to have due to his age. I forgot she did give him some fluids yesterday to try to help his liver, maybe she can give enough before the procedure.

 

[daftcat75]

Thanks, it's interesting to read about the different ways they may do a biopsy. But with so many causes of inflammation listed, I'm hopeful the ultrasound won't show anything concerning.



Thank you, I feel better about the chances of it being cancer. I will talk to my vet again about how we can get that dental done after the ultrasound, which I think she wants him to have due to his age. I forgot she did give him some fluids yesterday to try to help his liver, maybe she can give enough before the procedure.

That’s subcutaneous fluids. They are helpful in general. But they won’t move the needle for the liver enzyme level. IV fluids are an inpatient treatment and anything less than three days is a waste of his time and your money. If it were my cat, I’d ask if the teeth could wait six months. If she doesn’t believe they can or if she doesn’t know (it’s been too long since the last dental), I would discuss proceeding with the dental giving informed consent. After the ultrasound is okay. You want to rule out anything else before you proceed with the assumption that ALT is inflammation elsewhere (eg not a liver problem.) And since none of his other values are off, that’s how I’m leaning here. But I’m not a vet. Just a cat dad who’s been down this path before.

 

[FeebysOwner]

I would suggest you also ask the vet about running a bile acid test - which can help with determining liver function. This test is above and beyond the standard blood work done. After reading a lot of material on all kinds of cat related issues, most vets aren't terribly concerned about ALT levels until they exceed 300. But it may be because of your cat's age, and a pending dental procedure, that your vet is a bit hesitant. Because he does have dental issues, it would seem logical that the ALT level might be due to that, give the comments in the post above.

As far as an ultrasound, anesthesia is not usually required, and a fine needle aspiration (FNA) cytology might be able to be done as a much less invasive way of collecting tissue (vs. a biopsy). Feeby (17+ yo) received a mild sedative - butorphanol - for her first ultrasound, mainly to calm her so they could shave her. On her second ultrasound, no sedation was needed, and that is when they performed the FNA. I went to a specialty group, and they said they always try to perform an ultrasound without a sedative, if at all possible, but will give it when the cat is showing enough resistance by moving around too much for the ultrasound results to be clear.

 

[daftcat75]

If it were my cat, I’d ask if the teeth could wait six months. If she doesn’t believe they can or if she doesn’t know (it’s been too long since the last dental), I would discuss proceeding with the dental giving informed consent.

Having re-read this, I thought I'd restate it. What I meant is not putting the teeth off for six months, but rather to get your vet to agree that the teeth will get worse before that one liver value will get better.

Bile acids test is another good suggestion. Anything that rules out liver, gallbladder, or other organ involvement will help strengthen your case to proceed with the dental despite that one slightly elevated value.

 

[FlorasDad]

Hi, wondering if there was any update on this? Going through something similar with my cat Flora (7 year old girl).

Took her for her annual checkup in April and her vet recommended dental work as some of her teeth need to be extracted. Her bloodwork came back with high ALT (245), ref range is 10-100. Everything else was normal. He prioritized stabilizing the liver first and prescribed Denamarin and antibiotics for a month, then recheck. One month later, her liver enzymes went down to 224, still high but better, so he recommended an abdominal ultrasound from internal med (he doesn't have ultrasounds at his practice).

Went to another vet that required an examination before an ultrasound and they had the opposite view. They weren't overly concerned about the ALT, considered the dental to be a priority over the liver. She said it could be possible that the dental issues are causing the elevated ALT. Also said that ultrasound was a good recommendation by the vet and certainly can be done, but that in her experience with mildly elevated ALT that at times it isn't very conclusive, or if it is something it's so minute that it isn't really worth chasing the root cause when there was a pretty obvious dental issue at hand. This vet doesn't think it would be much of an issue doing dental with the high ALT, her normal vet most likely would not agree (or would want ultrasound first before proceeding to next step). Feels kind of like a Catch-22 situation.

BTW she has been her normal self - her appetite is good, bathroom and behavior is normal.

 

[daftcat75]

Hi, wondering if there was any update on this? Going through something similar with my cat Flora (7 year old girl).

Took her for her annual checkup in April and her vet recommended dental work as some of her teeth need to be extracted. Her bloodwork came back with high ALT (245), ref range is 10-100. Everything else was normal. He prioritized stabilizing the liver first and prescribed Denamarin and antibiotics for a month, then recheck. One month later, her liver enzymes went down to 224, still high but better, so he recommended an abdominal ultrasound from internal med (he doesn't have ultrasounds at his practice).

Went to another vet that required an examination before an ultrasound and they had the opposite view. They weren't overly concerned about the ALT, considered the dental to be a priority over the liver. She said it could be possible that the dental issues are causing the elevated ALT. Also said that ultrasound was a good recommendation by the vet and certainly can be done, but that in her experience with mildly elevated ALT that at times it isn't very conclusive, or if it is something it's so minute that it isn't really worth chasing the root cause when there was a pretty obvious dental issue at hand. This vet doesn't think it would be much of an issue doing dental with the high ALT, her normal vet most likely would not agree (or would want ultrasound first before proceeding to next step). Feels kind of like a Catch-22 situation.

BTW she has been her normal self - her appetite is good, bathroom and behavior is normal.

I agree with your second opinion. 200ish is a mild elevation, it’s most likely caused by the dental issue, and Denimarin takes a long time to work. It’s also a huge pill that cannot be broken. I would go with the second vet and prioritize the dental issue. Give that time to heal after extractions and then re-test the liver. Save the ultrasound for if the ALT is still elevated after the dental extractions.

Having had a cat who had resorptive lesions (a chronic degenerative dental disease), I was frequently upset with my vets who were willing to chase the ALT value yet ignore the obvious elephant in the room. Dental disease can elevate ALT and it can also become a serious systemic infection (among other potential serious complications), if left untreated too long.

 

[FlorasDad]

Thank you for your reply, appreciate it! I think that the second opinion made sense to me and I am leaning toward that as well. If I go with them, their earliest dental appointment is in July. Her normal vet seems to err on the side of caution, which I don’t blame either..the concern being if she was put under that she might not wake up.

Luckily Flora is not too fussy with denamarin when we hide it in her freeze dry chicken treats. I know it’s better to take on an empty stomach for absorption, but I don’t think she would take it by itself.

 

[daftcat75]

Thank you for your reply, appreciate it! I think that the second opinion made sense to me and I am leaning toward that as well. If I go with them, their earliest dental appointment is in July. Her normal vet seems to err on the side of caution, which I don’t blame either..the concern being if she was put under that she might not wake up.

Luckily Flora is not too fussy with denamarin when we hide it in her freeze dry chicken treats. I know it’s better to take on an empty stomach for absorption, but I don’t think she would take it by itself.

It’s been my experience and understanding that ALT is often a ghost of inflammation elsewhere. You can have her on Denimarin for months and not see a meaningful reduction in ALT. It may simmer there at a mild elevation until the dental issue is taken care of. In the meantime, dental disease left untreated can turn into a bone or blood infection. It can become a lot worse. Meanwhile, ALT in the 200’s is really not that alarming. My Krista was hospitalized and put on IV fluids and antibiotics while the vet tried to treat a more severe elevation of 1400. Krista had IBD and mild pancreatitis at the time so it made sense that her liver could also be involved. She was also a feisty one and they ended up having to sedate her anyway just to proceed with the ultrasound. At this point, my vet relented and also performed a dental and the necessary extractions. She went under at least two more times that week as she needed a feeding tube and two more dentals because the extractions were complicated and incomplete. She was allowed to come home after 14 days on IV fluids and antibiotics (plus the dentals and the feeding tube.) I believe her ALT was still over 300. I couldn’t get her to take the Denimarin. But I believe it was many months before her ALT came back into range. After a couple of months of checkups, my vet relented and said just bring her in if she turns yellow or lethargic.

Every cat and every case is different. But I would go with the second vet and do the dental without hesitation or worry. Sooner if you can find a sooner appointment.

 

[carrielynn]

Hi, wondering if there was any update on this? Going through something similar with my cat Flora (7 year old girl).

Took her for her annual checkup in April and her vet recommended dental work as some of her teeth need to be extracted. Her bloodwork came back with high ALT (245), ref range is 10-100. Everything else was normal. He prioritized stabilizing the liver first and prescribed Denamarin and antibiotics for a month, then recheck. One month later, her liver enzymes went down to 224, still high but better, so he recommended an abdominal ultrasound from internal med (he doesn't have ultrasounds at his practice).

Went to another vet that required an examination before an ultrasound and they had the opposite view. They weren't overly concerned about the ALT, considered the dental to be a priority over the liver. She said it could be possible that the dental issues are causing the elevated ALT. Also said that ultrasound was a good recommendation by the vet and certainly can be done, but that in her experience with mildly elevated ALT that at times it isn't very conclusive, or if it is something it's so minute that it isn't really worth chasing the root cause when there was a pretty obvious dental issue at hand. This vet doesn't think it would be much of an issue doing dental with the high ALT, her normal vet most likely would not agree (or would want ultrasound first before proceeding to next step). Feels kind of like a Catch-22 situation.

BTW she has been her normal self - her appetite is good, bathroom and behavior is normal.

Sure I can update. Unfortunately my Gray Boy hasn't had his ultrasound (or dental) yet because he suffered a urinary obstruction and it has taken him about a month to recover. He had to get catheterized twice, so he was under anesthesia twice. He got IV fluids and his ALT went down quite a bit to 115. I am not wanting to put him through the stress of an ultrasound right now, as his also has to be done at a different vet and for now it is nice to see him more like himself and not still traumatized from so many vet visits. I'm thinking of having another conversation with his vet and seeing if she might be comfortable proceeding with the dental as his elevation is mild.

 

[FlorasDad]

Hope all is well. Wanted to thank you all for the advice, and give an update- Flora had her dental earlier this week. They had to yank out a majority of her teeth, poor girl. She stopped taking the denamarin after a month, but was glad to see that her ALT values went down again when we checked prior to the surgery, to 190. Hopefully the trend continues now that the dental was done.

She is doing well, appetite is good (she always wants to eat!), playing, and her usual sweet self. We have a post-op follow up next week but so far I am happy with the results and hope that her quality of life will improve from this. Thank you all again!