C10000540 / invoice 10000

Reason: 05.03 VN Pathology Attached - liver biopsy results Appointment Notes: Special payment terms exist, Overdue remindersMICROSCOPIC H&E, Massons Trichrome, Gomori's and rhodanine stained sections are evaluated. Lobular architecture is often obscured by broad bands of fibroplasia appearing to extend between portal areas and associated with collapse and consolidation of the reticulin network (score 3/4). These bands contain moderate to abundant lymphocytes, plasma cells, frequent neutrophils and pigment laden macrophages/Kupffer cells. There are frequently entrapped hepatocytes and scattered single cell death (score 2/5). Portal components are often difficult to delineate but there are areas of biliary hyperplasia, often associated with most numerous neutrophils. Copper accumulation is sparse, confined to individualised or small 3-4 cell clusters in the periportal areas (consistent with secondary accumulation). Residual hepatocytes display mild patchy microvesicular vacuolar change. DIAGNOSIS Hepatitis, chronic, lymphoplasmacytic to neutrophilic and histiocytic, marked (score 4/5), with marked bridging fibroplasia (score 3/4), mild cell death (score 2/5), areas of biliary hyperplasia and scant periportal copper accumulation (centrilobular score 0-1/5) COMMENT/S There is fairly profound disruption to the normal lobular architecture with bands of inflamed fibrous tissue and some associated reticulin network collapse. The degree of copper accumulation is mild and its distribution is most consistent with a secondary change. Correlate with other clinicopathologic findings.Interim biopsy culture - negative Assessment: Ares liver biopsies have not identified any evidence of neoplasia. There is evidence of a marked hepatitis (lymphoplasmacytic to neutrophilic and histiocytic), with marked bridging fibroplasia. Interestingly the inflammatory process within the liver is somewhat similar to the inflammatory process in the intestines previous demonstrated endoscopically last year. Additional culture and copper quantification results are pending. The option of special stains for infectious aetiology will also be reviewed with the pathology team.. Whilst unlikely, other infectious diseases that could be screened for that in some cases could result in granulomatous hepatitis include toxoplasmosis, neosporosis and leptospirosis. Serology could be considered for these less likely possibilities.On review of the histopathology in this case, and in the absence of a detectable infectious cause, we have recommended that Ares management be intensified with immunosuppressive therapy. Ongoing hepatoprotectant therapy will also be important. If Ares has a poor appetite, concurrent management with short term appetite stimulants +/- placement of an oesophageal feeding tube will need to be considered. Given that Ares gastrointestinal signs have historically responded to Royal Canin Anallergenic, this can continue to be fed in the absence of hepatic failure. Ares prognosis is guarded. In a previous retrospective study of 29 dogs with granulomatous hepatitis, 20/26 dogs survived more than 30 days post diagnosis. Of these dogs, the median survival time was 865 days (range of 200-2482 days).Following commencement of the new medications, Ares should have a weekly recheck and biochemistry panel performed. If Ares does well, repeat liver biopsies may need to be considered in 3-4 months time to trend changes. Treatment: - amoxyclav 125mg PO q12hr (use until finished, then stop)- enrofloxacin 75mg PO q24hr (use until finished, then stop)- ondansetron 4mg TMS q12hr (as needed for a reduced appetite and/or vomiting)- pimobendan 2.5mg PO q12hr- Denamarin 225mg PO q24hr on an empty stomach (new)- Urodeoxycholic acid 125mg (1/2 of a 250mg capsule) once daily with food (new)- vitamin K 12.5mg PO q24hr with food (reduced dose)- prednisolone 15mg PO q24hr (increased dose)- cycyclosporin 40mg PO q12hr with food- mirtazapine 3.75mg PO q24hr PRN for appetite stimulationClient Communication: --- 06/03/2026 15:22:23 NDD:Phone discussion relaying the information onto Harry. Have followed up with an email due to the new addition of medications and changes to dosing to avoid confusion. Email below: "Dear Harry, As discussed as per our phone call earlier, I am just following up with an email to summarise the discussion. Ares liver biopsies have not identified any evidence of neoplasia. There is evidence of a marked hepatitis (lymphoplasmacytic to neutrophilic and histiocytic), with marked bridging fibroplasia. Interestingly the inflammatory process within the liver is somewhat similar to the inflammatory process in the intestines previous demonstrated endoscopically last year. Additional culture and copper quantification results are pending. Whilst very unlikely, other infectious diseases that could be screened for that in some cases could result in granulomatous hepatitis include toxoplasmosis, neosporosis and leptospirosis. Serology could be considered for these less likely possibilities.On review of the biopsy results in this case, and in the absence of a detectable infectious cause, we have recommended that the management for Ares is to be intensified with immunosuppressive therapy (steroids). We have added in liver protectant medications as they will be important to support his liver function. If Ares has a poor appetite, concurrent management with short term appetite stimulants (mirtazapine) +/- placement of an oesophageal feeding tube will need to be considered. Given that Ares gastrointestinal signs have historically responded to Royal Canin Anallergenic, this can continue to be fed in the absence of hepatic failure. Ares prognosis is guarded. In a previous retrospective study of 29 dogs with granulomatous hepatitis, 20/26 dogs survived more than 30 days post diagnosis. Of these dogs, the median survival time was 865 days (range of 200-2482 days).Following commencement of the new medications, Ares should have a weekly recheck and biochemistry panel performed. If Ares does well, repeat liver biopsies may need to be considered in 3-4 months’ time to trend changes. Below are the current medications for Ares with the new medications added at the bottom. Treatment: - Amoxyclav (antibiotic): Give half a tablet ONCE DAILY ORALLY (use until finished, then stop)- Enrofloxacin (antibiotic): Give half a tablet ONCE DAILY ORALLY (use until finished, then stop)- Ondansetron (anti-nausea): Give one wafer TWICE DAILY (as needed) - Pimobendan (heart medication): Give one tablet TWICE DAILY (ongoing) - Mirtazapine (appetite stimulant): Please give ¼ of a tablet ONCE DAILY ORALLY - Vitamin: Give half a tablet ONCE DAILY with food (reduced dose)- Prednisolone (steroid): Please give 3 tablets ONCE DAILY ORALLY (increased dose)- Cyclosporin (immunosuppressant): Give 0.4ml TWICE DAILY ORALLY with food (new) - Denamarin (liver protectant): Give one tablet ONCE DAILY on an empty stomach (new)- Urodeoxycholic (liver protectant): Give half a tablet ONCE DAILY with food (new)If you have any further questions, please do not hesitate to call us. Kind regards,Dr. Nore De Ridder (medicine intern at ARH Homebush)    Vital Signs    

Reason: O called - Ares not eating Appointment Notes: Special payment terms exist, Overdue reminders--- 05/03/2026 13:08:29 NDD:O called to say that Ares is refusing all food. He is not eating his anallergenic food and also refusing his usual favourites - egg whites and other treats. O is very worried about him as he is really struggling getting the medications into him when he is not eating. Discussed with TIH and gave O two options: 1) Mirtazepine trial - can send script to pharmacy 2) Feeding tube placement - discussed the procedure and logistics O wants to trial option 1 first - he will let us know if Ares is still not eating by tomorrow - otherwise will ideally need to place feeding tube Script written & on file: Mirtazepine 3.75mg SID PO (1/4 of 15mg tablet)    Vital Signs    

Reason: Drop Off For Procedure With TIH Tmr - Do  Consent Appointment Notes: Special payment terms exist, Overdue remindersReferral Vet Communication: Update sentHistory: Owner reports on the first day Ares was eating well. On the second day Ares was not keen to eat. Owner was feeding egg whites, sweet potato and Royal Canin Anallergenic. Would be keen to eat not suitable food, such as cooked chicken. Faeces - had been a little soft and sticky that he was having trouble passing. Hospital day 2Overnight, Ares was doing QAR, RR panting/36 with increased effort. HR 160-124 with moderate pulses, MM jaundice and CRT <1. Urination: +++Defecation: noneCoughing/vomit: noneEating: NPODrinking: yesCurrent Medications: Not on fluidsCurrent medications as per smartflow Examination Findings: QAR BCS 3/9 MCS 2/3RR 36 with normal effort. Ausc HR 88 with strong, synchronous, symmetrical pulses. Ausc heart murmur grade 5/6 left systolic T: 38.8 Skin & coat: thin coat, skin jaundice. EarsMM jaundice, moist, CRT <1. Sclerae jaundice, conjunctivae jaundice. Teeth: gingivitis /4, calculus /4. Lnn: Laboratory: 01/03/2026PT 7.4 APTT 17.9 Fibrinogen 1.2 (decreased) Assessment: Ares is being managed for a protein losing enteropathy, hepatopathy and hyperbilirubinaemia. His coagulation parameters have normalised since commencing vitamin K and receiving a whole blood transfusion. Ares will be admitted for liver biopsies today.Laboratory: PCV/TP 51/58Alb 23ALT 299ALP 1856GGT 55TBIL 360Procedure: Ares was sedated with methadone and medetomidine. He was induced with low dose ketamine and maintained on isoflurane. Ultrasound guided core cut liver biopsies. Multiple biopsies were obtained from the left medial and left lateral liver lobes. These were collected for histopathology, tissue culture and copper quantification. There was a scant amount of free abdominal fluid following the procedure. The biopsy sites were closed with tissue glue. The gall bladder was small. The wall was 1.5mm thick. The common bile duct was 1.8mm wide proximally and 2.8mm wide distally.Plan: Ares is being managed for hyperbilirubinaemia, a cholangiohepatopathy and a protein losing enteropathy (with previous biopsy results consistent with inflammatory bowel disease with associated crypt lesions). Area's has similar liver enzyme changes and evidence of a worsening hyperbilirubinaemia. External liver histopathology, culture and copper quantification are pending. Ares will be discharged this afternoon and continue management with additional treatment with oral prednisolone. His owners will phone for pending results at the end of the week. - trend PCV/TP 2 hours post procedure and monitor abdominal effusion- home this evening if stable- owners to phone later this week for resultsProcedure: The abdomen was assessed via ultrasound at 3pm. There was no evidence of any worsening of free abdominal fluid. PCV/TP - 52/56Treatment: - discharged at 4:20pm- amoxyclav 125mg PO q12hr- enrofloxacin 75mg PO q24hr - ondansetron 4mg TMS q12hr- pimobendan 2.5mg PO q12hr- vitamin K 25mg PO q24hr with food- prednisolone 10mg PO q24hr (new)Client Communication:--- 02/03/2026 10:57:04 SVV:O: Ares stable, going ahead with procedure today. If no abnormalities occur, tgh today. Estimate today 3.5k. Organise pickup and discharge with Harry (Husband).TH tried to call owner at 12:50pm. No answer. Was only able to leave a brief message. Harry phoned back. TH discussed in detail results of today's procedure and plan. Owner will be able to collect Ares 6/7pm today. We will update owner around 3pm to advise if suitable to go home.--- 02/03/2026 15:23:08 SVV:Harry: suitable to go home. Will receive additional painmedications (bup TMS once).    Vital Signs