A Puppy’s Life

At risk of anthropomorphizing Moxie too much here, I’ve decided to write from Moxie’s point of view — as I imagine it to be. Why not? Disney does it all the time! If she were to tell her story, it would be in a child’s voice because most everything happened before she was a year old…..

(Some of this was written in real time and some of it later. Sorry about the present/past tense flip flops.)

I have 5 sisters, 4 live in different places now, but Ruby and I got to stick together. It is great! We are never scared, and I always have someone around to play with me. I love toys! I always have. When all my sisters lived together, I was always the first to get everyone to chase me with a toy and play with it. It was kinda my thing. It always made the people laugh. 

When we got to our forever home, my new mom gave us these really fun collars with a bell. I could always find Ruby when we played all around in the big yard. But we could never hide in the bushes because someone would always find us. We like to chew on all the sticks, but we have to be fast because they get taken away. Actually, come to think of it, someone always took away the fun stuff like leaves, rocks, and flowers. Mom moved really fast when we caught a dove! Doves aren’t very smart, and we are really fast. We caught several of them this year. The feathers are a gift that keeps on giving. We find them inside and outside for days after we catch one. All the little feathers stay in our beards for fun times later. 

I’m so lucky. I get to play, wrestle and run with my sister every day. Our pack isn’t just us though. We have Rhône and Saphira here too. They like to lay in the grass on sunny days and lay on the couch most of the time. All of us like to snuggle up on the couch or in the big bed. I’ve figured out that I can pretty much lay across anybody and sleep really well.

Ruby and I go with mom to work everyday. We go pee outside at home, but mom works in a tough neighborhood, so we have to use pee pads at work. Ruby has better aim than me. I go more times than Ruby, but I love to drink water, so that’s just what I do. 

Mostly we just sleep while mom works, but when we started to tell her we were bored, she got us enrichment games. We both learned to follow our noses to yummy food. We can sniff out food anywhere! We both love to eat. I’m doing such a good job eating that I’m growing bigger than Ruby. Mom is teaching us impulse control so she puts a bowl of food right in front of us and we have to wait until she says OK. Then I get to eat the whole thing! I love food. I’m a very enthusiastic eater, even if I’m kinda sloppy. After every meal, I lick clean Ruby’s beard and she does mine at the same time. Mom laughs at us a lot. 

We have a big basket that mom puts all our toys in over and over all day so we can shop for just the right ones to scatter all over the house. We play shake-the-toy and tug-a-war and over-under the bed in front of the TV. I’ve watched TV, but I make mom laugh more than the TV. 

Mom has lots of meetings on the computer at night, so dad takes us outside lots of times so we can get our ya-yas out…. And so we can pee. 

At night my whole pack rotates for prime sleeping positions. All of us like to be right next to our people whenever we can, day or night. At night, in the big bed, mom sleeps on her stomach and doesn’t move much, so we can all find a favorite place next to her. When Rhône snores, we all feel safe going into deep sleep too. 

All night my mom always knows where each one of us is just by feel.  I make it easy because my favorite spot is to curl up on her shoulder. I rest my little head across her neck and whisper sweet nothings in her ear.  It is my particular talent to relax into any body contour. This serves me well when things get rough later…

I love socks! It’s the way they wiggle when they go on my people. Irresistible!  I have to bite the wiggly sock, even if sometimes I get the toes too. Every morning I get this opportunity. It is so great! I crawl up on mom’s lap when she tries to put on her sock and I can find those socks even when she tries to hide them. Then she rolls me over, belly up. I get to wiggle my whole body with my feet in the air and she rubs my belly.  Even if I can’t reach her socks, it is still part of a fun morning routine. A win-win for me!  Joy joy joy!

All of us eat, then play inside and out all morning. I wrestle with my sister everywhere and sometimes even the big dogs get excited about it. Ambushing Ruby when she least suspects it is so great! She usually gets me back, but that’s my plan anyway, so again, win-win. 

Mom put stairs at the end of the big bed. We learned to go up and down in a minute. I have my own style when I go up and down. Mom always knows it’s me if I get up in the night. The stairs are awesome and I’m awesome on them! I can climb up and cuddle with anybody I want to ….especially when they are trying to sleep.

Loving me is so easy. I was born this way. 

Ruby is more mature than I am. I don’t care. I’m happy every day. She lost all her baby teeth, I still have my baby canine teeth on the bottom. Two rows.  Sing it, baby shark do do do to do…

Ruby went into heat at 7 months. I don’t think I ever did. Rhône would have told me. 

Ruby loves to bark. I don’t know why. I only bark when I really have to, like to tell my people that other people look sketchy. We both bark at everyone we see at work in the office parking lot. They all look suspicious. We also bark at people or animals that come close to our house. That is our job. My whole pack is really good at protecting our house. 

I had an idyllic puppy-hood…. then when I was 9 1/2 months old I couldn’t hold my pee. I peed in the foyer 3 times. Mom yelled at me once and we both felt bad. The next day, I started peeing blood. It was a Friday, so mom gave me antibiotics for a urinary tract infection. Mom thought I’d be able to hold my pee when the medicine started to work, but it never worked. She took me to the vet the next week to test me for diabetes and I got an X-ray to see if I had bladder stones. She brought in my pee too. She told the vet that my pee smelled like a shrimp stand in a third world country. She was sure there was an infection. There was bacteria and struvite crystals, so I got a different antibiotic. (Augmentin 125mg bid) 

After 21 days of that antibiotic, my pee finally didn’t have bacteria. But I still had to pee all the time. I didn’t pee if I was resting or sleeping, but if I was moving, I had to pee—— like the commercial. Gotta go, gotta go, gotta go right now! It was always mostly blood and my pack didn’t even want to smell it. They like to smell everything. Mom’s nose is almost as good as mine and she knew when I peed even when she was in the other room. 

Then I had to wear baby diapers. They were great. I could rip them off and play with them in just seconds. Then no one put them on me anymore. But I still peed blood everywhere, sometimes right after I just peed.

For 6 months mom planned our vacation. We all went together in the motorhome. There were pee pads all over for me, but we still had to stop every 1-2 hours so I could pee outside. I’m really good at peeing fast. My people carry me down the stairs, set me on the ground and I pee. I don’t even have to smell around to find the right spot like the rest of the pack. This, at least, seems to make my people happy. They don’t get mad at me. They know now that I can’t help it. Mom worries that something else is wrong with me. 

The day before we left on our trip, my urinalysis showed zero bacteria, but it was positive for ammonium urate crystals. This means I probably have the kind of stones in my bladder that don’t show on an X-ray.  But now my mom is really worried about me. The vet says a liver shunt can make me make these stones. 

Vacation was so much fun. All of us pee’d on all kinds of new stuff. Rhône is really good at peeing on stuff that smells. Saphira won’t be outdone by her brother, so she stands on her front paws to reach where Rhône likes to pee. 

We all like the autumn leaves, and we carry as many of them as we can into the RV in our beards. We saw all kinds of new plants and animals and people. 

One place only allowed 2 dogs, so dad just walked 2 of us at a time. One black and one grey. No one noticed, even though Rhone is a boy. I guess we all look alike to people who don’t know us. 

In Wyoming, dad got up early to go fishing. He took all of us out for a walk early, but right after that, I needed to pee again. Mom knew she better hurry because just 3 days before, I couldn’t get off the bed in time and I peed in the big bed. It took a lot of work to clean that one. Unfortunately, it wasn’t the only time that happened. This day, mom didn’t have time to get out of her PJs, but I promised her I’d be fast if she just set me outside for a second. I was really fast! It was cold and windy. The door closed and we got locked outside without a phone or keys. 

I’ve never seen mom embarrassed before. 

She carried me around that RV park in her PJs, holding me close to her chest, as we looked for someone who could call dad. A nice lady with 3 dogs in her car finally got dad. He was on his way! Yay! Then it started to rain. She kept me dry. I still looked cute. She said it was a humiliating experience. 

When we got home again, that’s when everything changed. First, I got new clothes. My people were really happy because I didn’t pee blood everywhere. None of the rest of the pack has ever worn clothes, but I got used to my jean skirt diapers really fast. First, I froze and didn’t walk, but then I could do everything in them. I looked awesome! I can rock a jean skirt. Mom always says I’m kinda groovy, in that Janis-the-Muppet-band-girl sort of way. 

I have a big personality. Everyone says so. I like people, especially my people. I can run, jump and play with my sister or anyone. In the middle of any of it, I’ll still run back to mom to give her a kiss and some love....  just because I can.  I’m big and strong and smart.  I'm happy. Life is good!

Then mom started taking me to different veterinarians to see who could help me. I was brave and happy with them. My mom was always there. I trust her. 

The week before my first birthday, I got a CT scan. I didn’t like it. This was the first day in my life I didn’t see my mom all day. But I made friends with the staff before my test. Then they gave me medicine that made my mind all fuzzy. When I got home, I was out of it. I almost ran straight into the pool. Mom caught me first. I trust her to protect me, like I protect her. She’s got my back!

Ruby and I had our first birthday November 1, 2024. I was still looking stylish in my jean skirt diapers and it was a good day. 

Well, crap. My mom said when she read my CT report. I think she cried a little too. She knows too much. 

I was born this way, but I’ve never had any of the neurological symptoms that a puppy with a congenital liver shunt usually has, so everyone, including the surgeon, thinks the best thing is to fix my shunt. 

(Moxie’s pending surgery would be somewhat extensive in that it included not only attenuating the shunt that was high and deep into her abdomen, but also a cystotomy to remove the 3 bladder stones- 10mm and 6mm x2. Since she should never breed, a hysterectomy and oophorectomy needed to happen as well. A long incision was required. She was given a very high probability for success and normal life for $10,000…maybe more.)

Julie, who bred my parents, has been breeding miniature schnauzers for over 40 years. I come from a long line of show dogs, agility dogs and great pets. She has never had a dog born like me. Julie still has my mom, Sparkle and sister, Sadie. They are both healthy and winning beauty contests. 

Ruby is beautiful and could give Sadie some competition. Mom says I would win Miss Congeniality!  I’m all personality, but I am a little different. She says that makes me quirky and endearing. 

By our birthday, Ruby is everything an adult dog should be. She has a solid musculature, and I’m still floopy like a puppy. I sleep in weird positions. I still have those extra teeth, my bark is still a puppy bark, and I haven’t gone into heat. Not that I care about any of it. I’m happy. 

(Julie stands by all her puppies. She has given me 3 choices going forward. First she asked if I had considered euthanizing Moxie. I couldn’t even stomach the thought given her loving personality and minimal symptoms. When would I do that??? Julie offered to take her back for a full refund. How could I let her live somewhere else after being with her 24/7 all year?  Or she would provide a new puppy when she had one available. Or she can refund the money to help with the surgery. Given her high chance for success, a refund should be helpful.)

I had surgery the week after my first birthday, on a Friday. Everyone said it was a success. The morning before my surgery I sat on my mom’s lap like normal as she talked to the surgeon. Then a lady carried me away. 

The surgeon was able to perform everything without incident. The in-house IM vet and all the ER vets watched me for 3 days. I got bells on me again so they know immediately if I have a seizure. But I’m not having fun in these bells. I’m shaved all over in different places that itch, I’m in pain all over, and my mind is all fuzzy again. The vet says I’m doing everything I’m supposed to be doing, which is basically nothing, but nothing is a good thing. On the third day I ate. I still love to eat. With a little help I even walked outside to pee. On my way back inside I wanted to greet all the people. The pain meds and the seizure prophylaxis still make me weird inside. I can’t be me yet. They’d all love me if I could just be me again. 

Now, for the sake of pursuing clarity,  instead of tormenting myself, this narrative will be in my first person. 

Anyone who has ever loved their dog, lives with them with the belief that they know what they are thinking. They show it in their eyes, their body, their actions. It breaks my heart to imagine her now having any thoughts at all. Even if she only has the developmental cognition of a young child, the thought of it is heartbreaking. Was she wondering why this happened? Why she got cut up and left in pain? Why I left her there and this happened?  She trusted me. She loved me. Now I question every decision I made. Yes, I can console myself with good intentions, but when I replay everything in my head, I have to hope that she really doesn’t possess all the cognitive abilities that we, pet parents, like to believe our pets possess. But how could I not wonder what was going on in her mind and body? How could it be anything but fear and pain?  It is a haunting thought. My anguish. When Moxie got to see us she was still drugged up and didn’t react with any excitement. It was odd and unexpected, but I was told the Gabapentin (pain medicine) would be sedating. 

It is only a 5 minute drive home from the hospital, and by the time I set her out in the yard, she did that weird run straight to the pool. I had her on a leash. She looked at me and walked to me, but the cone around her neck seemed to be a hinderance. Then she sat on the porch and gave a pitiful little howl. My assessment of her that night was that she was surprisingly mobile and simultaneously distant. I dismissed it as a side effect of her medication.

Because of her cone and the incision, I set her up in a stroller next to the bed. I slept with the light on so she could see me if needed. We only slept from midnight to 4 am and she seemed sedate but ok. She loved her breakfast, took her medicine, walked slowly in the yard and we went to work together. Ruby got to stay home like grown up dog—potty trained and non-destructive. Ruby did great. I’m so proud of her. 

I got Moxie settled in my office just like she has done every other weekday, but she was not having it. She howled her puppy howl as soon as I walked away. She didn’t seem like she was in pain because she was standing up to protest at the puppy gate. I really thought she was just upset because last time I left her bad things happened. I switched to Telehealth and sat her in the chair next to me. She settled right down to sleep. When I had to get up again, I put her in my office in her bed. Nope. She howled.  She peed twice in my office—mostly on the pee pads. The urine did not smell foul.  I left the office early and we got home by 1:30. She settled immediately in the car, as always.

At home she seemed unsteady on her feet at first, but then better, and peed several times. I gave her some water and we sat on the couch. She slept on me for 2 hours. She slept hard, and I could feel her heart beat as she slept like always. At 3, I got her up to got outside. Again a little unsteady. By the second or third pee, (that part is normal for her) I noticed something that really concerned me. I don’t know how to do a thorough neurological exam on a dog, but I remembered this test from a dog many years ago who had seizures from Valley Fever. I’ll mention here that I’ve had miniature schnauzers my whole life, as many as 7 at a time. I’m not a novice pet owner. As Moxie squatted, the toes on her left hind leg were curled under and she didn’t seem to be bothered by it. This is called knuckling. I called the Vet Hospital to see if I could talk to a vet to ask about the clinical significance in the context of a sedating medication. The hospital is also an ER, the receptionist said they were super busy with emergencies and she couldn’t pull a veterinarian to the phone. I then called my primary vet to ask the same question and I was told by the receptionist that if I was worried, I should take her to the ER. The same ER that is too busy to talk to me.

We came inside and she started to howl.  She did this after her first CT when I brought her home.  It was tiny then —and at this point I’m going to refer to it as "vocalizations", because it was a harbinger of things to come when it later escalated in volume and constancy.  We settled on the couch again and she slept soundly again…  I could move her and she didn’t startle or wince. Was she just calm or was she obtunded? Retrospectively, probably the latter. At 6 she was supposed to get her antibiotics and seizure prophylaxis, Keppra. I got up and scooped up all 15 pounds of her to go to the refrigerator for her medicine.  She urinated down my side and all over the floor. This is not good. (She had never been incontinent before, just the urgency.)  I gave her the medicine and she got excited at the smell of food. I had been told to look for hepatotoxic signs. Seizures being the most ominous, but also nausea, and aversion to food, vomiting, diarrhea. Nope. Still loving the food. She drank all her water that was in her soft food, but she did it in sloppy way, even for her. We took off that terrible cone of shame to see if it was contributing to her difficulty and making her disoriented. She was disoriented without the collar. She didn’t seem to be seeing.

I got her to the Vet ER before 6:30. It was dark.  She rested so hard in the car, 2 minutes down the road I stopped to make sure she was alive. I got her sleepy body out of the car and held her in my arms. As soon as I walked into the building she howled at the top of her lungs. It was jarring to hear her, but inside of 3 minutes they whisked her away from me. I was put in a room to wait to talk to the vet. That was the last time I saw Moxie. It was abrupt and unceremonious. I sat in that room listening to her “vocalize” in another room for 2 hours. She was screaming.  It was pure torture for me as I paced helplessly. The vet came in and confirmed she was blind. I feared the worst, as I had read about the post operative consequences of portosystemic shunt surgery. I checked the box not to perform CPR this time. The working diagnosis was hepatic encephalopathy. The thing she never had before surgery, but was clearly beginning now. The vet explained that she was optimistic that the blindness would subside in a few days with treatment. They anticipated 72 hours (more $$$) of treatment to prevent seizures. At 2:30 in the morning, a new ER vet called me to tell me she had had 2 Grand Mal seizures already with 3 different anticonvulsants working to try to prevent them…but to no avail. She wanted permission to fully anesthetize her in hopes of calming her brain. Before I had left the ER that night, while talking to 2 other veterinarians, I offered to go back and hold her to maybe calm her down. They had already given her high doses of pain medications, so the discussion was that she was not in pain, but rather disoriented, and probably wouldn’t know me. She was out of her mind screaming. Is that better than pain? I wonder. I told myself as I left….. her inconsolable scream echoing through the walls…. that my strong, loving, trusting, happy puppy was gone already. She had never really returned since she left my arms 3 days ago. Did she still know my smell, my touch? Was she solidly in the cascade of hepatotoxicity that was ultimately irreversible, or did the smell of the return trip to the hospital trigger pure terror? If I had brought her earlier, could the cascade been avoided? Or would they not have had time for her and it was better that we had 3 hours of peace together at home. 

Tuesday morning a different vet called me to say that anesthetizing her had not helped, but since she was unconscious, could they run her through the CT scanner to make sure she didn’t have something that needed more surgery. CT was negative. She didn’t need another surgery. Just like before surgery, all of her lab work was normal. Normal liver function, negative ammonia, normal kidney function, negative urine, negative bile acids. The attenuating clips were in place and still partially patent as they should be. By design, the cellophane clips are hydrophilic to slowly close the shunt. The surgery was a success, but the big personality that my little puppy proudly displayed was already ghosting us. With every seizure the prognosis became more grave. At 10:00 the vet called to say as much. I asked if I could please have until 2 to make the final decision. 

At 1:30 I called with resolve that if my one year old puppy was destined to be blind and suffer with uncontrollable seizures, that was no way to live. The vet said that the whole team had been working on Moxie’s behalf and they consulted a neurologist in town who suggested Potassium Bromide, (kind of an old school drug, but ok) as they tried to wake her up from her Propofol induced state. She was responding! What a rollercoaster, but ok, they want to keep trying. She would call me in a few hours. At 5p on November 12, 2024 after a discussion with a bleak outlook, I gave her permission to euthanize my puppy. Rest in peace, Moxie.

I’ve had a week to process my grief. I’ve discovered that grief for a puppy is different than any number of the elderly dogs that I’ve had the privilege of loving for so many years. Their passing has always been sad for my selfish reasons of missing them, but I have taken comfort in knowing that “I was putting them out of their misery.” Mercy. Euthanasia.  As a pet parent, the comfort comes from knowing you gave them comfort.

I have none of that right now. There is the logic of knowing that I tried. My intentions were good. I wanted to fix her to give her a normal life expectancy with a high quality of life. I could have tried to manage her condition medically. A low protein diet, maybe some medication. But was it only a mater of time before she would exhibit hepatotoxicity anyway? Then the same surgery, the same outcome? Or poor prognosis for surgery because I waiting too long and her brain would be pickled.  What really was the chance that she could continue to be the Moxie we knew and loved? Who knows? Would one of these stones obstruct her bladder leading to extreme pain. “No stone is a good stone”.  Was she actually in pain from the chronic bladder inflammation and just hid it like animals do? Did I rush into surgery because of the inconvenience of changing doggy diapers? Did the money cloud my judgement? It was a lot of money. If money were no object, would she have ever pulled through and been normal, or even mostly normal? 

I would happily have kept her in diapers for years, if I knew she would continue to be as she was. 

She had less than a 5% chance of developing PANS (Post Attenuation Neurological Signs), if one can really predict such a thing.  Birth control pills are 99.9% effective, but if you are the 0.1%,  you are 100% pregnant. 

PANS,... what a crap diagnosis. It is just a label for Idiopathic, another empty name. No one knows why it happens. The leading theory is altered blood flow, but reaction to anesthesia is in the literature too. Did I ignore that early warning after she had her first CT? That night after the CT, I was told that liver shunts make it hard for dogs to come out of anesthesia, so when she put her little head next to my ear that night and made the faintest little “vocalization” all night. It sounded like she was dreaming. It was sweet really, like a tea kettle whistling far away…. If anesthesia predisposes to PANS, there’s no way to get around that, but maybe agreeing to more anesthesia exacerbated her decline. The vet also said that they can’t monitor if she’s having seizures while unconscious.  So, was it “resting her brain” or just paralyzing her body so as not to show the seizures? It doesn’t really matter now.

The veterinary team that cared for Moxie were all very nice and all 5 of the vets have called me to express their condolences and let me ask my questions.  I believe they are sad too. No one works that hard to care for animals who wouldn’t be affected by losing this one. I’ve done my research, liver shunt puppies can have a very rough road, before and after any procedures. I don’t know if I was in denial or just overly optimistic, but I believed she would be able to continue her fun-loving life. If one is inclined to research liver shunt puppies, I think anyone could conclude that Moxie’s symptoms were very mild going into this. But ultimately, did it matter?

Hindsight is not 20/20 for me today. I keep saying to myself, I am not a veterinarian, I don’t need to learn something from this. I need to turn off my brain. Just be sad for a while until I’m not sad. Go through the stages of grief and be done. Writing this is part of that, so I don’t keep turning it over in my brain forever. Write it, then leave it.

But then there are the snippets of songs that permeate my dreams or my nights while not sleeping. Songs that haven’t played for decades….

The Partridge Family….are you kidding me? Where the heck does that come from? Not like they are getting any radio circulation right now! “I can feel your heartbeat and you didn’t even say a word, I can feel your heart beat and you didn’t even say a word, oh, I know pretty woman (puppy) that your love can be heard……”

And I don’t even like Celine Dion, but no truer words have been sung:

“Every night in my dreams, I see you, I feel you, That is how I know you go on…..” Ugh! Stop!

Zeppelin, ok that makes sense., and it is a classic:

“ ooh, and it makes me wonder…

Your head is humming and it won’t go, in case you don’t know,

The piper is calling you to join him.

Dear Lady, can you hear the wind blow? 

And did you know,

Your stairway lies on the whispering wind?

Moxie has a green collar in the above video.

The above story is a tribute to Moxie, to help my healing heart.

The following is written to rest my brain and provide information for those who have a scientific curiosity. No need to read further if you do not. Scroll to the end to click on a few more videos.

Since I originally published this blog, I’ve had inquiries as to how Moxie was considered “mild” as her symptoms presented before surgery. So, I have put together this addendum to address some, but not all, of the pathophysiology. 

What is the spectrum of symptoms in a dog with Porto-systemic shunt (Liver Shunt)?

I am not a veterinarian, but a quick google search of liver shunts in dogs can give you most of this list:

• Being much smaller than litter mates
• Not ever catching up to size of litter mates
• Poor appetite 
• Vomiting and/or diarrhea 
• Dull intellect, slow learner
• Polydipsia- drinks a lot of water
• Polyuria- urinates frequently
• Urinary tract infections
• Ammonium Urate crystals in urine
• Bladder Stones
• Neurological signs of hepatotoxicity

Hepatic Encephalopathy is what happens to the brain when it is exposed to toxins as a result of the liver not being able to fully detoxify the blood. 

If the above symptoms raise suspicion that a dog might have a liver shunt, the first thing most vets want to perform is a pre- and post-prandial bile acids test: 

Blood is drawn fasting, then the dog is given a high fat meal. You wait 2 hours, then draw the blood again. Cost at my vet was quoted at $210.

In a normal dog, bile acids are produced in the gall bladder and released into the digestive tract to help break down food and nutrients. The intestines reabsorb the bile acids and transport them back to the liver via their respective veins to be released again. Bile acids should never show up in the systemic blood that circulates throughout the body. 

In Moxie’s case, her gastro-duodenal vein did not lead back to the vein (portal vein) that goes back to the liver. Instead it bypassed her liver and dumped any number of byproducts/toxins directly into her vena cava (vein) that transported all that extra stuff to her whole body. When it went to her kidneys, some of those toxins and byproducts were likely ammonia and uric acid, because that combination makes ammonium urate crystals which then forms stones because the kidneys can’t break those down. The bladder is not designed to handle stones, only liquid urine. Stones rough up the whole system and when they land in the bladder they irritate the lining of the bladder causing chronic inflammation, infections, and blood. Her white blood cell count was always 17 (normal 4-15). At first, we thought it was because of the infection, but it stayed 17 up until the day she died. Likely just chronic bladder inflammation. 

Typically, because ammonia bypasses the liver via the shunt, it ends up in the blood stream at such high levels it causes seizures. Moxie’s ammonia levels were always zero, even when she began her seizures. At first, they gave her lactulose, in hopes of binding ammonia but it didn’t help. There are many toxins that could have been causing the seizures. But nothing that is routinely measured was high for Moxie. 

Hepatic Encephalopathy:

Hepatic encephalopathy (HE) in dogs progresses through four stages of increasing severity: 

• Stage 1
  Mild symptoms include loss of sleep, decreased mental alertness, and confusion 
• Stage 2
  Moderate symptoms include increasing lethargy, drowsiness, personality change, and disorientation 
• Stage 3
  Severe symptoms include worsening incoordination, mental confusion, increased salivation, head pressing, aimless wandering, circling, and seizures 
• Stage 4
  Coma and unresponsive recumbency, and is associated with a risk for impending death 
  
   

The chances of a cure for HE are not good, but depending on the cause, treatment before stage III can lead to good recovery. Treatment may include hospitalization, IV fluids, antibiotics, and anti-seizure medications.

As for Moxie, her liver shunt was suspected, not because of the bile acids or any clinical outward signs, but because of the urate crystals, the next step for diagnosis is either an ultrasound or CT scan. I chose to go directly to the CT because if she did have stones, she would need a CT for surgery. 

CT with consult and anesthesia was $2300. Ultrasound is cheaper and no need for anesthesia, but can be dependent on operator skill. CT is the gold standard for diagnosing a porto-systemic shunt, and providing the best look at the whole vasculature. Screen capture above is Moxie’s CT summary. 

If Moxie did not have a shunt, she likely would have had cellular liver disease (hepatic micro dysplasia), HMD. The only way to make that diagnosis is by biopsy and you can’t fix that with surgery. It can only be managed medically. They biopsied her liver during surgery, but I don’t have those results. 

Since Moxie, at a minimum, needed her stones removed.  She would have had to undergo anesthesia. Even if I had elected not to repair her shunt, a biopsy of her liver would have been warranted, but not mandatory. 

But liver dysfunction would lead to Moxie making more stones. Low protein diets supposedly help though. The diet is highly recommended when the dog shows hepatotoxic symptoms. Moxie would have had a high likelihood of forming more stones. As I said above, I don’t know if or when it was her destiny to show signs of hepatotoxicity without surgery. Obviously, she did after surgery. 

She was prescribed Keppra for 3 days before her surgery and to be continued until after the surgery. I don’t know if she would have been prescribed seizure prophylaxis, if I hadn’t elected to do surgery. Or if they would have waited until she possibly showed symptoms. 

The blindness happens in dogs as a result of “brain swelling”. The edema pushes on their optic nerves. This is why the vets were hoping to control the seizures and the edema. If they had, most dogs regain their vision. 

Moxie must have had brain edema, since she went blind. She didn’t have any edema (swelling) anywhere else. After her surgery and when she was re-admitted, they did multiple ultrasounds on her abdomen to check for ascites (fluid that leaks out of the liver and ends up free in the abdominal cavity). 

Her blood pressure dropped very low before they anesthetized her the second time, but her blood sugar maintained normal ranges the whole time. Her liver function tests, kidney function tests were normal before and after surgery. She did not have a urinary tract infection or sepsis. Never had any vomiting or diarrhea. 

Everything I read about dogs with a one vessel extra-hepatic shunt said she would have a shorter life expectancy without surgery than with surgery….. if it had been successful and she had avoided PANS. 

Post-attenuation neurological syndrome (PANS) is a potentially serious complication that can occur in dogs after surgery to attenuate a congenital porto-systemic shunt (PSS). PANS can include a range of neurological signs, such as: 

seizures, depression, behavioral changes, tremors, twitching, and ataxia. 

PANS, if it is to occur, usually occurs within seven days of surgery, but the exact cause is unknown. Some possible causes include: Central nervous system disease, Perioperative hypoglycemia, Perioperative electrolyte disturbances, Perioperative portal hypertension (PHT), and Infectious cause. 

I did find something in the literature that refers to a paradoxical excitatory switch of the GABA receptors as an etiology for post-op seizures. Propofol uses GABA receptors. 

Treatment for PANS focuses on controlling neurological signs with antiepileptic drugs and providing intensive care. In the worst cases, euthanasia may be recommended. 

Risk factors for PANS include: preoperative hepatic encephalopathy, increasing age, certain breeds, and extrahepatic shunt morphology. Moxie didn’t have any of these risk factors, and her morphology was straight forward. 

Surgery is the only definitive cure for a PSS. It's typically performed by gradually closing the vessel using a cellophane band or ameroid constrictor.

I’ve written this by memory and a few quick google searches. I’ve requested her records from her  operative and post-op admission, but I haven’t yet received them.... as of 2 weeks later.