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Nutrition Nuggets is the newest offshoot of petMD's Dog Nutrition Center. Each week Dr. Coates will use her expertise and wisdom to blog about the intricacies of dog nutrition.

Feeding Dogs with Hepatic Encephalopathy

May 17, 2013 / (10) comments

One of the complications commonly seen with advanced liver disease in dogs is hepatic encephalopathy. The liver acts as a giant filter for the gastrointestinal tract (among other roles). After a meal, the circulatory system absorbs all sorts of things from the gut. Many of these substances, especially ammonia, can adversely affect the brain after reaching excessively high levels in the blood.

When liver function decreases to approximately 70% of normal, the signs of hepatic encephalopathy begin to emerge, including:

  • mental dullness
  • staring
  • unsteadiness
  • circling
  • head pressing
  • blindness
  • drooling
  • coma

These symptoms are usually observed in combination with the typical sings of liver failure including loss of appetite and weight, increased thirst and urination, vomiting, diarrhea, a yellowing of the skin and mucous membranes, and accumulation of fluid in the abdomen.

The symptoms of hepatic encephalopathy typically wax and wane throughout the day, often worsening after meals. Therefore, it’s not too surprising that dietary manipulation plays a big role in the management of the condition.

Dogs with hepatic encephalopathy should eat a diet with a reduced amount of protein since the byproducts of protein digestion (e.g., ammonia) are responsible for many of the symptoms associated with the disease. Diets should contain just enough protein but no “extra” to ease the liver’s workload. Research also indicates that soy protein may be a better at ameliorating the signs of hepatic encephalopathy in comparison to meat-based sources of protein.1 Dogs with advanced liver disease still need calories, however, which are best supplied by increasing the percentages of high quality carbohydrates and fats in the diet.

Feeding several smaller meals throughout the day rather than just one or two larger meals is also beneficial. This feeding schedule reduces the spikes in deleterious metabolites circulating in the bloodstream thereby reducing clinical signs associated with hepatic encephalopathy.

Medications that reduce the numbers of bacteria within the GI tract also play an important role in the management of this disease. Antibiotics, often amoxicillin or metronidazole, are used because they kill off many of the bacteria in the gut that produce high levels of ammonia. Enemas can be given to physically remove feces and bacteria from the colon. Oral lactulose, a type of indigestible sugar, is also used for it cathartic properties. The goal is to encourage rapid transit of stool through the intestinal tract to reduce the amount of time bacteria have to act upon it. Lactulose also lowers the pH within the gut, which reduces the absorption of ammonia. The dose of lactulose should be titrated to the point where the dog produces two or three soft stools throughout the day.

Sometimes the liver disease responsible for causing hepatic encephalopathy is reversible, sometimes it is not. In either case, dietary management and other forms of treatment for hepatic encephalopathy buy dogs precious time.

Dr. Jennifer Coates


1. Proot S, Biourge V, Teske E, Rothuizen J. Soy protein isolate versus meat-based low-protein diet for dogs with congenital portosystemic shunts. J Vet Intern Med. 2009 Jul-Aug;23(4):794-800.

Image: Hannamariah / via Shutterstock

Comments  10

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  • Head Pressing
    05/17/2013 08:43pm

    It is my understanding that when a cat head presses, it might have brain damage. (I'm guessing that it's the critter's only way of rubbing its temples for a headache.)

    Is that true for dogs with hepatic encephalopathy? Do they have a headache on top of everything else?

  • 05/18/2013 02:20am

    I'm sure they do.

  • 08/18/2013 03:53pm

    Dr. Coates,

    I'm desperatelly seeking advice on how to effectively treat a possible case of hepatic encephalopathy that our beloved 11 year old Schanuzer named Shelly seems to have.
    Blood tests shows her kidneys are OK but her liver is doing pretty bad. Our veterinarian has already treated her with antiboitics for almost two weeks now for Shelly doesn't seem to be responding. She can hardly walk and sleeps all day long. It seems like she has lost her sphinter control as she pees and poos as she is laying down. She seems to be in a lot of pain and we as a famly have already discussed a sooner than later euthanasia.
    We are devastated and I think we have still a couple more days to try to do something for her. Now I'm thinking about her diet. Should we try soy products and fruits?
    Is this condition really reversible and manageable or once it is acquired the dog's quality life will be this bad? We'd like her to get better obviously but we cannot stand see her suffer any more.
    Thanks in advance for your time.

  • 08/19/2013 01:00pm

    The only definitive way to deal with hepatic encephalopathy is to treat the underlying liver disease. Diet and other treatments (e.g., lactulose) can help as well, but if the underlying condition is worsening, they will eventually stop being effective. Your veterinarian is in the best position to make specific recommendations regarding what is best in your pet's case.

  • Copper Liver Disease?
    01/29/2014 03:30am

    Dr. Coates,
    We took in a mini-pincher a few months ago. After many expensive tests, we discovered he had copper liver disease, with approximately 12% functioning (at that time, about three months ago now?). We realize there's no recovery from this disease, whatever its cause was.

    My main question here is, from an original weight of 9 pounds, Radar, the min-pin, has lost about a pound and a half. He's skin and bones. He gets very bored with his prescription food, so I do tend to add extras to spice things up. Altho I am concerned about keeping his liver functioning as long as possible, I would like to see him gain some weight! He has managed to gain some muscle strength back after a liver infection (that was bad, we almost lost him there).

    He's currently taking Prednisone, Lactulose, Denarmarin and Colchicine.

    Please, do you have any food or supplement suggestions that will help him gain weight without contributing too much to the copper accumulation in his liver?
    Thank you so much.

  • 01/30/2014 01:53am

    I can't make any specific recommendations since I don't know all the details of your dog's case, but generally supplemental feeding (especially protein sources) is okay in dogs with copper associated liver disease so long as they are not suffering from hepatic encephalopathy. Zinc supplementation is also sometimes recommended. Talk to your veterinarian to determine if these are good options in your dog's case.

  • Mass on liver
    04/04/2014 03:47am

    The past couple months my 12 yr old female corgi has just not been usual very active self..signs of slowing down when she didn't want to go on walks, but runs like a 2 yr old after her ball. She had blood work done 2 weeks ago today which showed she was slightly anemic. She was given Baytril and a steroid shot to help with whatever infection and to stop her from bitting her back end and scratching. Her anal glads were extremely full and were expressed. We arranged for her teeth to be cleaned the next Monday so she could be further examined while sedated. X-rays showed the spacing in her lower discs is not normal which could be causing her some pain which might explain her slowing down. She was prescribed Prednisolone for 7 days and we were going to go back in 10 days to be rechecked. Instead of getting better, she seemed to be getting worse, lethargic, drinking a lot of water, sleeping a lot, no energy, but still aware of surroundings so we went back in for more tests this past Tuesday morning (1 wk after teeth cleaning). Blood work shows she is very anemic now, and more X-rays show she has a mass on her abdomen. Yesterday a sonogram and today we were told the mass and several nodules on her liver is most likely cancer. She is very weak and to even do a biopsy she would probably need a transfusion....she has moments where she has slight energy and want to chase her ball (yesterday and today), but now realize it is not good at all to allow her to spend any extra energy. We have always fed her the best food, fresh veggies, fruit canned chicken with her dry food at every meal, limited treats, exercised her and this diagnosis came completely out of left field. One thing that has not been addressed is she had a slight cough when we took her in for the first blood workup and now it's more severe mostly after she drinks water. She looked and acted like she was dehydrated, so this past Sunday, 3/31, I mixed up some electrolyte solution with filtered water and have been giving that to her. We don't want to put her through surgery, a surgery that will most likely not change the outcome...so caring for her until she tells us it's time is our plan. NOW for my question(s)...what could be causing the coughing? She seems to be breathing faster than normal even after she is calm and sleeping, so is there something going on with the cough and oxygen? Could some of the meds she has been on brought on this drastic change in her condition? She has been on Metacam for a few years for her arthritis (lower back), and I'm wondering if she can go back on that soon after the Baytril and Prednisolone is out of her system to help her joints feel better? My heart is breaking because 2 weeks ago today I would have never dreamed I would be researching liver disease and writing this comment...Thank you for your time and attention to this post. I guess you are my first 2nd opinion! Sincerely, Aprilnews

  • 04/08/2014 03:35pm

    Sorry for the delay in getting back to you. I've been experiencing technical difficulties. I'm afraid I can't comment directly on your dog's case since I haven't had the chance to examine her or perform a physical examination. One type of cancer that might be responsible for many of the symptoms you describe is hemangiosarcoma - the tumors tend to bleed, which would explain her anemia and resulting shortness of breath and lethargy. I'm not sure where the cough is coming from, unless the cancer has spread to her lungs. If your current veterinarian can't answer your questions, it never hurts to ask for a referral to a specialist who might be able to provide more information, even if you don't want to pursue surgery (a totally reasonable decision). Best of luck.

  • Good Dental Chew?
    07/19/2016 10:36pm

    Hello! I was wondering what you think is the best dental chew for a dog with liver shunt? My dog is doing well at this time with liver diet dog food. She has elevated ALT of 600. She drinks filtered water. I have looked at several different chews but unsure of what to purchase? She has stinky breath and tartar and it has been recommended not to put her to sleep to get her teeth clean at this time. I brush her teeth once a week but it only helps a little. Also, is there a good raw diet for my dog with extrahepatic liver shunt or is it best to stay on her hills l/d diet? My dog used to like whimzee dog treats and they are minimal ingredients but there is no literature on the topic.

  • 07/20/2016 08:21pm

    Your best bet would be to increase your tooth brushing to daily or at least every other day. Brushing is much more effective than any available chew.

    If you are interested in a home-prepared diet, please consult with a veterinary nutritionist (your vet can make a referral) who is familiar with all of the details of your dog's case. L/D is a good commercially available choice.