PIs something inside telling you that things with your dog are just not right?

Is your dog lethargic at times when he/she shouldn’t be?

Does your dog seem uninterested in food?

Karin and her dog Mr Darcy discovered what was really going on with him…

Printed with permission

By Karin Singleton

Experience with PPDH

(Peritoneal Pericardial Diaphragmatic Hernia)

and a complicated recovery process

On August 12, 2009 my dog Mr. Darcy underwent surgery at the Veterinary Specialty Hospital in Cary, NC. It was supposed to be a liver biopsy and turned into the repair of PPDH.

Mr. Darcy, 2 yrs

As often, I did some research after the event, and found that PPDH is a congenital birth defect that, while rare, seems to be more prevalent in Weimaraners. It happens when the fetus does not develop properly. There is a hole in the diaphragm (that is the large muscle that separates the chest from the abdominal cavity) that allows tissue from the internal organs, such as liver, pancreas, intestines, or stomach, to protrude into the chest cavity, potentially affecting the heart (the pericardium is a sac that surrounds the heart).

In Mr. Darcy’s case, this hole was almost 2 inches in diameter. However, until the day of the ‘liver biopsy’ nobody was expecting to find the condition PPDH. It is rare, and there does not seem to be a clear-cut set of symptoms. When I reported back to my regular vet, he told me that he knew of the condition but had never encountered it himself.

In hindsight, there were signs that pointed towards it, and I want to summarize them here so that others may be alerted and can possibly shorten the diagnostic process.

• A blood test detected highly elevated liver enzymes (in his case lymphocytes, ALT (SGPT) and alkaline phosphatase). The initial diagnosis was hepatitis, and it was treated with antibiotics. Initially, it seemed to improve, but after 2 re-tests, the levels were as high as they had been before, prompting the recommendation for a laparoscopic liver biopsy.
• Both ultrasounds of the liver showed a texture that was not right. The second one indicated potential problems with the gall bladder and bile duct.

In addition to that, I had also made some casual observations that only in hindsight make sense.

• Mr. Darcy is about 2 years old. I had often noticed that he was not as energetic as I expected a ‘normal’ Weimaraner at that age to be. I just thought he was very laid back.
• The whole process started when I rushed him to the hospital because I thought he was about to bloat; his stomach was distended and something just did not seem to be right.
• He began to act differently towards food and refused to eat dry dog food. I later learned that part of his pancreas, intestines and liver had herniated into the chest cavity. The dry food probably made him feel bad.
• He sometimes seemed to feel unwell after having eaten. That went away after a little while, and he acted completely normal again.
• He also once had an umbilical hernia. It was fixed when the club had him neutered (he is a rescue), and I never thought anything of it. I know now that it can go together with PPDH.

I had never even heard of PPDH until a few weeks ago. It is obviously a very serious condition, but it not the first thing that a vet would suspect. As our Weimaraners are more prone to it than other breeds, I wanted to share my experience with you.
The story continues …..

After the surgery, I expected that things would gradually return to normal within a week or two the way they do after abdominal surgeries. Unfortunately, they did not. I had completely underestimated the complicated recovery process following this kind of surgery, and I suppose that there is not much data to guide the patients and their caretakers. I put Mr. Darcy on the normal ‘EN’ diet which is normal after surgeries.

Subsequent blood test showed that his liver enzymes were still elevated. A bile acid test was done and also had elevated values.

The hunt was on for the cause, and the possibility for a ‘Portosystemic Shunt’ was mentioned.  An ultrasound was done, and the possibility of an external shunt was pretty much eliminated. An internal shunt was only a remote possibility because dogs with this condition usually have stunted growth (Mr. Darcy is large for his breed), and their livers are shrunken. The ultrasound showed evidence of pancreatitis.

In the meantime, Mr. Darcy had good days (few) and bad days (more), was often lethargic and really did not show any signs that he was returning to his normal self. His food intake became more and more picky. Ultimately, he only ate milkbones, and even those he refused after throwing up.

Mr. Darcy was getting worse, and ultimately had to be hospitalized one more time after a flare-up of pancreatitis, vomiting and just being worn out. It was now more than 5 weeks after the surgery, and, frankly, I was bracing myself for the worst because I saw no improvement and did not want to subject him to any more invasive tests.

I had a meeting with the surgeon, and he told me how bad the situation inside Mr. Darcy’s body actually had been. Parts of his liver, pancreas and intestine had been entrapped in the hole. He actually had to enlarge the hole first to pull them out! We agreed to hold off on any more tests and try a diet route.

I had read that a low protein and low fat diet sometimes helps, and that was the plan of action. However, putting theory into practice in such a difficult clinical case is easier said than done. I was blessed to have found Dr. Susan Lauten who specialized in pet nutrition. With her help, I put Mr. Darcy on a strict diet. Within 2 days, I began to see an improvement.

I am writing this at the end of October 2009. I have almost completed the process of moving Mr. Darcy to a more normal diet. At this time, I decided to cook for him according to a recipe that Dr. Lauten has provided for me.

Mr. Darcy is much improved, and I am no longer concerned for his life. The recovery process is still ongoing. It seems that his liver and pancreas are still trying to get used to the new situation after having been entrapped for about 2 years.

Having the benefit of hindsight both with the diagnostic process (see above) and with the recovery, the one essential component after his surgery was the nutrition. I believe that I could have spared Mr. Darcy a lot of pain and suffering and myself many sleepless nights if I had contacted Dr. Lauten immediately after the surgery.

Mr. Darcy was fortunate in having a surgeon who was able to ‘fix’ the mechanical part of the problem. But this was only half the battle. The nutrition part was just as important for his recovery, and I cannot recommend Dr. Susan Lauten more for her caring and expertise. She can be reached through www.petnutritionconsulting.com.