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ORIGINAL MESSAGE:
by Jeanne

I would like to know the symptoms and at what age liver shunts are most likely to occur. Also, are there tests that can be done on a Maltese puppy for this?

DISCUSSION:

Signs of liver shunts could include poor weight gain, sensitivity to sedatives (especially diazepam), depression, head pressing (pushing the head against a solid object), seizures, weakness, salivation, vomiting, poor appetite, increased drinking and urinating, balance problems and frequent urinary tract disease or early onset of bladder stones. If the signs of problems increase dramatically after eating this is a strong supportive sign of a portosystemic shunt. These are all pretty nonspecific signs. This is frustrating since there is not a really easy test for this condition. As far as tests, there is almost one - special dyes injected into the liver circulation that show up on X-rays can outline the problem pretty clearly....most of the time. But this is a pretty invasive test making it a poor choice for "screening" purposes.

Most shunts cause recognizable clinical signs by the time your Maltese is a young adult but once in a while one is diagnosed at a later time in life. The oldest dog I have heard of a diagnosis of this condition that was previously undetected was 8 years old. Since the severity of the condition can vary widely depending on how much blood flow is diverted past the liver it is possible for a lot of variation in clinical signs and time of onset of signs to occur. Often, this condition is recognized after a puppy fails to grow, making an early diagnosis pretty common, too.
-Jay

There is an excellent screening test that runs approx. 50-60 that most veterinarians can perform when a puppy is at least 14 weeks old. It is a bioacid screen. It actually screens for more than than just shunts- it can be indicative of other liver disorders as well. They will take a small blood sample from the puppy, have him drink a solution and take another blood sample approximately two hours later. It will not harm the puppy in the slightest. I would highly recommend having that test performed on any puppy I purchased unless I knew the breeder had had the Great grandparents of the puppy I purchased- parents are after all only 50 % of a puppy's genetics. Also some of the liver disorders(maltese have many more liver disorders than just shunts) are recessives so the breeder even with the best of intentions may not have had a problem for several generations, so it is never a bad idea to have the test performed on a new puppy.
-Jenny

Jenny, I have never heard of a "bioacid screen". Are you sure its not "bile acid screen"? Could you please clarify for me, I would like to know more about that test you're speaking of. I found some of the recommendations for interpeting "bile acid" measurements to be contradictory and almost all of them to be at least slightly confusing.
-Jay

I am sorry for the keyboard error, it is bile acid screen. The results are really quite clear interpreted and it has the advantage of screening for almost all liver disorders as well. There was an excellent article on liver shunts in the last Maltese RX(newsletter for AMA) and I am sure if they wrote the AMA they would be happy to furnish reprints. Dr. Benny Woody DVM has informed me that there are several other tests as well. The bile acid would be mine as well as most vets first screening choice, however there is also an ammonium screen where a maltese would have would have prebloodwork to get a baseline, drink ammonium chrloride, and have post bloodwork. That is measuring a different aspect of the liver than the bile acids but also gets quite good results. There is another very definitive test that is not invasive however it generally can only be done a veterinary schools and that is a nuclear medicine test, where a radioactive dye can be given to a maltese BY MOUTH and followed under a gamma camera. Some vets choose to do it by injection. I am curious to note exactly who would like to go on record as saying the bile acids test is not a good screen or that in a puppy above the age of 14 weeks it is not a good liver screen- I have been on tghe phone with cornell and several other vets and they are most interested.
-Jenny

At the specialty in July, a vet who has been studying shunts for the past few years discussed shunts. She reversed many of her earlier opinions about non-invasive testing for shunts in Maltese. For some unknown reasons, test values for other dogs, according to her, do not hold true for Maltese.

Jay--I think your original list of observable symptoms in this post are still the best diagnostic tool. I know a person who just lost a 1-year-old Maltese to shunt (she had been diagnosed for about 8 months) and she exhibited many of the symptoms you described. She was never thrifty (always under 3 pounds) and was dull-eyed, listless, pot-bellied, etc. She never looked robust and healthy.
-Linda (Snow Angel Maltese)

I would like to quote from Dr. Cynthia Smith's acticle from the American Maltese's Association's RX newsletter. In fact the quote is from the last issue where she had a featured article. Dr. Smith DVM who has spent a great deal of time going over Dr.s' Center(Cornell) and Dr. Snyder(Michigan) work(the two preeminent liver shunts researchers). The quote is as follows"First of all the Bile Acids test should not be abandoned as a diagnosis tool" Perhaps, Linda and Jay, you know much more than Drs' Smith, Center and Snyder and perhaps you should have written the article for the Maltese RX as you seems to know that these tests are so "confusing and unreliable". While it is true that maltese do have slightly higher values on these tests,most vets have not had trouble distinguishing the difference. The bile acids is a wonderful inexpensive screening test and that is exactly what it is a screen. It is a very good screen and one that I would unhesitating recommend to any new puppy owner-even if their breeder had no history of liver shunts in their line because there is some new research that indicates all maltese are at risk for shunts and that fact was again pointed out by Dr. Smith in her acticle in the AMA Maltese RX. Shunts are believed to be a multifactorial recessive and that is one of the reasons that they can seem to "come out of nowehere" in a line that had not seen a case for several generations.If a maltese scored high on a bile acids screen, then you do go to one of the more expensive tests. I would be interested in knowing the name of the Veterinarian who spoke at the symposium Linda attended. I cannot believe that he would say that there was any problem interpreting the radioisotope test with a gamma camera(nuclear medicine, maltese drinks isotope). That is a NONINVASIVE test and it is DEFINITIVE by every one's standards. Dr. Smith goes on to state that all responsible breeders should do everything they can to help alleviate this problem,I would certainly think encouraging rather than discouraging people to have shunt screens is a good first step, I know her office uses and believes in the bile acids screen as I was in touch with them today. I guess they do not find those results to be confusing and unreliable as you and Linda do, perhaps that is because they are DVM's and you are not. I believe Dr. Smith also goes on to state in her Maltese RX article that good breeders should guarantee against shunts for the life of the maltese, I agree with that and have always given a lifetime guarantee against liver shunts.I hope you are doing the same.
-Jenny

Jen-- Thanks for enlightening us on Cynthia Smiths article in the Rx. I had no idea either what she was talking about. I guess I'm a dummy like all the rest. It was helpful for you to put it into laymen terms for all of us. I went ahead and re-read it and I thought it peculiar when Dr. Smith said "Have I scrambled your brains with all of the ifs yet? If so, welcome to the club; there's just so much we don't know...." Did you find that strange also? I did. You made it so simple for me to understand now. Thanks again.
-Janet