Group 1 HEPATIC PORTOSYSTEMIC SHUNT IN CANINE Portosystemic

Group 1 HEPATIC PORTOSYSTEMIC SHUNT IN CANINE

Portosystemic shunt (PSS) แบงได 2 ประเภท คอ - Congenital (primary) portosystemic shunt - Acquired (secondary) portosystemic shunt

- Congenital (primary) portosystemic shunt Intrahepatic portosystemic shunt Extrahepatic portosystemic shunt

Hepatic encephalopathy (HE)

การวนจฉย - Clinical sign - Serum chemistry - Urinalysis - Radiography Operative mesentery portography Ultrasound Scintigraphy

Ameroid constrictor

Hematology HCT Hb RBC MCV MCHc Retic RBC morphology Platelets WBC Seg *Band Lymph *Mono Eos Baso WBC morphology Case 39. 1 13. 7 6. 90 57 19. 9 35. 0 ND Codocyte 237 9. 8 7. 548 (77%) 0. 588 (5%) 1. 176 (12%) 0. 098 (1%) 0. 392 (4%) 0. 098 Normal % g/dl x/µl L fl pg % x/µl x/µl Normal (Dog) 37 -55 % 12 -18 g/dl 5. 5 -8. 5 x/µl 58 -79 L fl 16. 5 -25. 5 Pg 30 -38 % ND 170 -400 6 -18 3. 5 -11. 5 0. 0 -0. 3 1 -4. 8 0. 5 -1. 35 0. 01 -1. 25 0. 0 -0. 15 Normal x/µl x/µl

Serum Chemistry Case Normal (Dog) *BUN Creatinine *Total protein 2 0. 4 3. 7 mg/ml g/dl 6 -25 0. 5 -1. 6 5 -7. 4 mg/ml g/dl *Albumin *A/G ratio *ALP 1. 1 0. 43 181 g/dl U/L 2. 7 -4. 4 0. 8 -2 10 -150 *ALT 122 U/L 5 -107 U/L *Glucose Sodium Potassium Chloride Total CO 2 Anion gap 52 145 4. 1 118 21 5 mg/dl mmol/L mmol/L 70 -138 139 -154 3. 6 -5. 5 102 -120 17 -24 8 -25 mol/L mmol/L mmol/L *Calcium Phosphorus *Total bilirubin 8. 2 4. 1 0. 9 mg/dl 8. 9 -11. 4 2. 5 -6. 0 0. 0 -0. 4 mg/dl U/L

Serum Chemistry *Bile acid (fast) *Bile acid (post) *NH₃ (fast) *Cholesterol Urinalysis Case 18. 6 µmol/L 246. 1 µmol/L 438 µg/dl 45 mg/dl Normal (Dog) <15 µmol/L <25 µmol/L 15 -45 µg/dl 92 -324 mg/dl Case Normal (Dog) Urine source Cystocentesis *Color Turbidity *Sp Gr *p. H *Protein Glucose Ketone *Bilirubin Blood *Sediment Straw Clear 1. 006 8. 0 1+ None 3+ None Ammonium biurate crystals Clear yellow Clear 1. 008 -1. 045 5. 2 -6. 8 None None

อาการผดปกตทพบในสนขตวน Hepatic insufficiency � � � Hypoglycemia Hypoprotienemia Hypoalbuminemia Decrease A/G ratio Fasting hyperammonemia & Decrease BUN Increase bile acid concentration Hypocholesterolemia Hypocalcemia Hyposthenuria Ammonium biurate crystalluria Proteinuria Hyperbillirubiemia Billirubinuria Mildly increase ALP activity Increase ALT activity Microcytosis

1. Hepatic insufficiency a) Hypoglycemia (Glucose 52 mg/dl ปกต 70 -138 mg/dl)

b) Hypoproteinemia, Portosystemic shunt Hypoalbuminemia and decreased A/G ratio -Total Protien 3. 7 g/dl (ปกต 5 -7. 4 g/dl) -Albumin 1. 1 g/dl (ปกต 2. 7 -4. 4 g/dl) -A/G ratio 0. 43 (ปกต 0. 8 -2) Portal hypertension Reduce albumin Hydrostatic pressure oncotic pressure Transudation of fluid Ascite

c (Fasting Hyperammonemia and decreased BUN -NH 3 (fast) 438 μg/dl )ปกต 15 -45 μg/dl( -BUN 2 mg/ml (ปกต 6 -25 mg/ml)

d) Increase bile acid concentration -Bile acid (fast) 18. 6 μmol/L (ปกต < 15 μmol/L) -Bile acid (post) 246. 1 μmol/L (ปกต < 25 μmol/L)

e) Hypocholesterolemia (45 mg/dl คาปกต 92 -324 mg/dl)

2. Hypocalcemia (Calcium 8. 2 mg/dl ปกต เกดไดจากหลาย สาเหตแบงเปน 1)albumin เปน protein –bound calcium 2)Active vitamin D 8. 9 -11. 4 mg/dl)

4. Ammonium biurate crystalluria

5. Proteinuria (Protein +1 ปกต none)

6. Hyperbilirubinemia (Total Bilirubin 0. 9 mg/dl ปกต 0. 0 -0. 4 mg/dl)

7. Bilirubinuria (Bilirubin 3+ ปกต none)

8. Mildly increased ALP activity (181 U/L ปกต 10 -150 U/L) 9. Increased ALT activity (122 U/L ปกต 5 -107 U/L)