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Hello.

Hope you are well. There is not a definite multiple of normal that would make me withdraw treatment. It depends on a number of factors. I would definitely be taking more notice when the ALT and ALP are getting greater than 3x the reference.

Hepatotoxicosis from phenobarbital appears to be dependent on cumulative dose, with possible individual modulating factors. Signs typically develop after a year or more of phenobarbital treatment, and the duration of administration is associated with the degree of histologic injury in epileptic dogs. Presentation can range from subclinical increases in serum bile acids to fulminant liver failure. Typical histologic findings in dogs with clinical signs are bridging portal fibrosis, bile duct hyperplasia, and nodular regeneration. Higher phenobarbital dosages or serum drug concentrations have not been correlated with the development of abnormal serum bile acids across epileptic dogs; however, individual dogs with phenobarbital hepatotoxicosis can improve clinically following phenobarbital dosage reduction. For dogs with hepatotoxicosis during chronic phenobarbital treatment, phenobarbital should be discontinued, or the dosage minimized, by adding another anticonvulsant. For example, potassium bromide (KBr) can be substituted at a maintenance dosage of 40-60 mg/kg PO q 24 h, and phenobarbital can then be discontinued with a rapid taper over 1-3 weeks.

b) It may actually be helpful to include the phenobarbitone levels in your monitoring. Clinically significant hepatotoxicosis can be preempted in most dogs by serial monitoring of serum bile acids, phenobarbital concentrations, and a liver panel, ideally every 6 months. Serum phenobarbital concentrations >40 mcg/mL should be avoided, as this can be a risk factor for hepatotoxicosis. In addition, the presence of hyperbilirubinemia, new hypoalbuminemia, or discordant increases in serum ALT > ALP is clinically significant. This would definitely be a trigger to consider dose reduction/withdrawal. Newly noted sedation on a stable dosage of phenobarbital might also indicate impaired hepatic clearance of the drug, and is an indication for bile acids testing.

This little table is also useful:

Let me know if you have any other questions.

Scott 🙂

Hello.

Thank you so much for your question.

Fine-needle aspiration of the liver should be performed with ultrasound guidance and typically using a 22G to 25G needle. Often less blood contamination is obtained with rapid agitation of the needle without a syringe (“sewing machine technique”) compared with aspiration using a syringe. Several aspirates from different sites should be collected in patients with diffuse disease. The collected sample should be sprayed onto glass slides and thin smears should be made.

I typically use a 1 1/4″ 23g. I would use the same size for dogs and cats.

Hope that helps.

Scott 🙂

Was there a peritonitis associated. I presume the penetrating woud was small so not significant leakage?

Scott x

It is amazing how these sharp objects can migrate through the GI tract wall. I have seen one penetrate the spleen too before.

The dog had surgery and actually did really well.

Scott 🙂

Indeed. I think it is good to have the option.

Especially in cases that are hospitalised and need more than maropitant. I think it highlights the really good point regarding stopping vomiting and tacking nausea. They are different and need to be tackled differently.

Scott 🙂

Intracellular bacteria and neutrophils indeed! Thanks for the comments about the glucose and lactate too!

The dog has a BBQ skewer through its stomach wall!

Scott x