Flynn 11 y/o Foxie Cross - Right adrenalectomy- Good Bye Flynny We will miss you

Trish,
that would've scared me to death too!
The lengths they go through to get at our food!

One of the few times when vomiting makes us happy! I get it.
Thankfully everything worked out.

Report is in, IMS must take after me as it is quite long!!

Dear Mike and Team and also Trish,

Please accept my apologies for the delay in reporting on Flynn's visit here earlier this month. It has been crazily busy here and we actually have fewer staff than we had at this time last year so it has been a case of managing the sick patients as best as we can and getting reporting done when time permits. I know this is much less than desirable for you and the owner but I can't do much about it at the moment. I am advertising for a new specialist but unfortunately the American market is humming again and is soaking up all of newly qualified specialists with salaries that exceed those that we can pay here! As you know better than anybody Flynn is a very complex character and Trish has done a great job of documenting all of his biochemical abnormalities. I explained to Trish that the chances of me being able to manage every issue in one single visit were very small.

I think we should focus on the good news in that the imaging shows an abdomen that that looks pretty much identical to the previous ultrasound study done here. There is no sign of a new or redeveloping liver mass nor is there evidence of progressive gallbladder disease. The enlarged lymph node that was mistaken for an adrenal gland last year is gone. His remaining adrenal gland looks exactly the same.

Chest radiographs were taken because of Trish's concern about increased snoring but as you can see there is little of significance there.

I will discuss various problems below; please take into account that I can't possibly know Flynn's issues in the detail that you and Trish know them.

(1) His inflammatory bowel disease seems clinically quite quiet at the moment. As you know there is no commercial diet that is truly hypoallergenic and also designed to be optimal for his liver. It did not seem to me that his gastrointestinal tract was causing him enough trouble to justify additional treatments or dietary change at this time. I am always cautious with dogs that are on multiple treatments that the addition of another medication could cause unforeseen drug interaction issues and upset a stable situation. If his bowel seems to deteriorate then switching him to the new Royal Canin Anallergenic diet might be appropriate. However this is not a low-fat diet, not is it optimized for the liver. One could also consider the addition of azathioprine as a form of gentle immunomodulator aimed at the inflammation in his bowel. This could have the additional benefit of being anti-fibrotic for his liver.

(2) Trish was worried about his skin and the effect that the steroids are having on his liver enzymes. I explained that I am not a dermatologist and if this issue does not improve she should consider seeing one. She asked about Apoquel. I am just getting to know this drug because as you know the launch has been delayed by Zoetis due to supply issues. I don't know of any reason why it could not be tried in Flynn but Trish would have to be aware that we are stepping into the unknown a little bit. There is no group of dogs that are exactly the same as Flynn that have been tested with Apoquel to ensure safety. However if anything untoward was seen I would estimate that it would quickly resolve once the medication was discontinued. I think on balance the risk of trying the new product is less than the risk of using ongoing steroids which we know are bad for his liver.

(3) We discussed the possibility that he may have Cushing's of one form or another. He is displaying some degree of muscle weakness according to Trish. This I think is an under-appreciated clinical sign of Cushing's disease in dogs. As you know proving a diagnosis of Cushing's disease can be problematic and if he has so called atypical Cushing's disease then it is even harder with our limited laboratory backup in New Zealand. One option is to try a trial course of trilostane at a conservative dose and see what happens. Another is to go with a non--pharmaceutical approach to Cushing's as some people with a more alternative philosophy are trying.

This would include the use of lignans and melatonin as a more "gentle" approach to controlling adrenal hyperfunction.

One thing that we should say is that Cushing's is an insidious disease that creeps up slowly and in such a well supervised dog it's improbable that he would have an irreversible complication from Cushing's before it became more obvious that he was suffering from the syndrome. I am not a believer in a hands-off approach to Cushing's but I am cautious about subjecting a dog to too many tests in the early phases of such a syndrome.

(4) I know that his blood pressure bothers Trish, although the combination of amlodipine and benazepril is safe for ongoing use and benazepril will also be helpful for his kidneys. Some dogs never recover normal BP management after phaeochromocytoma surgery. Trish does worry that the remaining adrenal gland nodule is a phaeo, and this is certainly possible, although it does not seem to be growing. We regularly investigate the laboratory diagnosis of phaeochromocytoma and unfortunately living in New Zealand is a handicap here. The lab can do some urinary catecholamine metabolites but they cannot give reference ranges and we would need to supply a number of normal dogs for comparison. I don't think Flynn requires this level of input right now, but Trish may choose to go down this path way if it becomes more of a problem to control his blood pressure.

His high cholesterol is not a worry in and of itself but of course is a hint that there are underlying metabolic abnormalities. I assume that his thyroid hormone status has been checked regularly? He does not look like a hypothyroid dog. Yes the cholesterol could be a sign of Cushing's and I refer to the discussion above on that subject.

Trish mentions a high albumin reading. As you know there is only one reason for that and that is dehydration. That in turn can then cause the calcium to be slightly elevated. I think the best explanation then is that if he had high albumin and calcium at the same time on a blood test then he was dehydrated at that time for some reason.

I like the supplements he is on for arthritis. Trish mentions that he needs a lift up on to the couch sometimes. To me this is sometimes an indicator of underlying Cushing's disease but also it could just be arthritis and old age.

Overall it seemed to me that given his history and his age that Flynn was in quite good shape which is a tribute to his owner and to the various veterinary teams that look after him most of the time. I think the dominant question at the moment to my eye is; could he have some form of Cushing's? I think if Trish cogitates on all these factors she will either choose to sit tight and wait for the syndrome to become more obvious or try some speculative treatment as discussed above.

Please call with any comments or questions,

Regards,

Repeat Abdominal Ultrasound Report

The appearance of the liver is similar to the previous study with several small nodules throughout the

parenchyma. Most of these are less than 1 cm in diameter. Some of the nodules are hypoechoic in

appearance, some hyperechoic in appearance. The previously identified nodule with a target appearance was

not visible in the study today. The 2 cm diameter hyperechoic nodule in the right liver is unchanged compared

to the previous study. A very small amount of free floating echogenic debris within the gallbladder is identified.

The gallbladder wall appears normal.

The spleen appears normal in size and echogenicity.

Both kidneys are normal in size, shape and echogenicity. The urinary bladder appears normal.

The left adrenal gland still measures 11 mm in thickness. The hyperechoic area within the left adrenal gland is

also unchanged.

The mass effect in the region of the absent right adrenal was not visible today.

Portions of the stomach wall, small intestinal wall, colonic wall and pancreas imaged appear normal.

Thoracic Radiograph Report

A peribronchial–interstitial pulmonary pattern is identified. This is very similar to the previously reported

radiographs. There is no evidence of metastatic disease.

I'm pretty pleased with this, especially the stable liver!!

The cushings talk came from a discussion on the adrenal nodule he has and narrowing down what it could be. He still thinks it is benign. Adrenal hyperplasia with elevated hormones has been linked to liver adenomas so we also talked about that, testing in my country is tricky for this as you can see from his comments. Trilostane was only to be considered if cortisol was high on testing. He has not had ACTH/LDDS since before his adrenalectomy 18 months ago so we don't know where his cortisol is sitting, but I suspect not high with no typical symptoms of PD/PU so from my point of view I would not even think about trying trilostane. I might consider lignans and melatonin at some stage. But with no growth in that adrenal nodule in over 18 months again I don't think I would right now.

I want to look into that lung thing, but he does not seem too alarmed by that.

Mike just text, he is still on a little break but said he has received it and is going to digest over weekend then we can discuss.

Appreciate any thoughts and comments, really sounds somewhat similar to our Molly Muffin...

Flynn's tummy seems better and even the itching has settled somewhat! So all in all, pretty happy this Friday evening. Not going out, just ordered fish and chips and looking forward to a nice relaxing weekend!

I also wanted to say thank you all for the comments on our "incident" :p luckily there appears to be no real damage done. Barbara I do not know how he swallowed it, it must have scratched going down, we all looked in amazement when it came up with the chicken still skewered and we were sooo pleased to see it come up!! Addy, I did ask Mike if he had to go in would he try via endoscope first and he said he would have but thank goodness we did not have to go there. Good to know Koko was a bit off after being made to vomit, (well not good for Koko to be off) but you know what I mean! Flynn seems better but I have not actually seen a poop since those soft ones overnight yesterday, Dad said he did one on their walk today but he is hopeless at describing them :rolleyes: he said bit soft but OK, I asked if there was mucous and he said he does not look that closely at dog poop LOL just "it's fine" :cool: OMG Zoe ate a 6 pack of hamburgers AND the plastic, little witch :eek::eek: did that come out on its own??

He has been given one week of the Stomorgyl, he has had two doses. I think if I see some normal poops I might stop it. Just figure with his liver problems the less meds the better.

Sharlene, we got carrot cake with cream cheese icing! He said he had not baked a cake in 10 years so we all think he did very well!! We certainly do have our favourite bakers over the years, we hear the next girl we are getting is a brilliant baker and does it often, so we won't have to wait until her last day :D

Usually after we get these big reports Mike and I go over it, I will email him my questions this weekend, then he can get back to IMS then we go from there. So hopefully now he gets over the tummy thing, the results are good, we can relax!!! Phew, so relieved tonight! xxx

Trish, I just have a couple of minutes here as I have to go in way early to work today for a meeting and also in the hopes of not having to work late tonight going into my 3 day weekend!!

I think this report looks great! I am so pleased for you and Flynn. Aren't you so relieved? I will need to go back through and re-read when I have more time, but my initial take is that it all looks wonderful. As far as the Cushing's discussion, I don't think I would even consider treatment unless he was showing some symptoms. So great that he isn't.

As far as the lungs, I am not sure what a peribronchial interstitial pulmonary pattern is exactly, will need to look that up. But as you said, they don't seem too concerned. And the liver report sounds very good. I am so pleased to read all of this, and also happy to see that his tummy has settled after his latest "adventure". Once again, our boy amazes! :)

Well, it looks like you should have a nice relaxing weekend! I better run, I want to post a quick blurb on our thread since I still haven't been able to get an update posted on Jasper. It seems like my evenings go by in a matter of minutes, and then it is time for work again. Hope to do some catch up with you over the weekend. Give a pat to that boy for me.

Hugs,
Tina and Jasper

Hey Tina!! Yes generally pleased, I do have a few questions about his lungs, I googled it and scared myself lol... but I think his is just minor and as he said to me while I was there "old-dog lungs" :p Ohhh I forgot about your 3 day weekend, nice!!! We have one next week! YAY for long weekends :) I will be looking for Jasper's update too. Already 5am for you Tina, back to bed asap... you need to be up soon!! xxx

Trish, no back to bed for me, I am up now for the day since I have to go in to work so early. :eek: Still need to shower and get ready, and then there is the struggle to get Jasper to eat. :rolleyes:

I will need to do some googling as well after work. Hope to catch you later. Almost bedtime for you, Happy Weekend! I better run.

OH no, you poor thing, you will be in bed early tonight! Hope Jasper eats his brekky for you... have a good day, it always seems a bit easier on Friday and it is my favourite day of the working week, not just because I get the next day off because I genuinely love that day the best with the people I work with so hopefully it will be the same for you!!

I think the report is pretty darn good and as always, I am amazed at the awesome quality of your veterinary teams. You and Flynn are so lucky to be in such thorough hands and the teams are lucky to have such a knowledgeable, proactive Mom.
His IBD sounds under control, I think this doctor is spot on with that. Actually I think he is spot on with everything.

Now Flynny boy, no more helping yourself to dinner.

Trish, I think you and Flynn are just fine. Thank goodness for that!!!!