Timeline

Copper storage hepatopathy

Doing very well, with no pancreatitis signs since the triglycerides were controlled. Routine bloodwork looked good after a 15-hour fast. The triglyceride recheck was pending. The team noted the lower-fat diet reformulation had still not been done, and said it could become the main long-term treatment for the triglycerides.

Ultrasound: suspected bile duct blockage resolved

Focused ultrasound showed the suspected bile duct obstruction had resolved, with mild widening remaining where the ducts meet. The pancreas looked small with scarring. The team noted pancreatitis returning could cause another obstruction, and moved back to occasional monitoring with fasted bloodwork.

Single source. Summarized from the discharge report. The full radiology report is not in the records.

Ultrasound: liver structure much smaller

Focused ultrasound and recheck. The cystic liver structure first seen on 3/31 had shrunk dramatically without treatment, which made abscess or tumor very unlikely. The team's working explanation: bile duct widening caused by pancreatitis partly or fully blocking the common bile duct. Ursodiol was prescribed, to be stopped at once if pancreatitis signs returned.

Records disagree, needs confirmation. The discharge is dated 4/22 and the radiology report is dated 4/22, but the narrative says he was seen 4/7. Treated as 4/22.

CT: widened bile ducts, suspected cholangitis

Suspected cholangitis. Bile duct widening could come from inflammation or a past common bile duct obstruction. Abscess or tumor judged much less likely. Rounded liver margins suggest chronic hepatitis, consistent with copper storage disease. Suspected chronic pancreatitis in the right limb.

Ultrasound: fluid-filled liver structure and widened bile ducts

Concern raised for a focally dilated bile duct versus an abscess, cyst, or poorly formed tumor. Reported through the 4/22 discharge and the CT history.

Single source. Described in later reports. The original ultrasound report is not in the records.

Fenofibrate: 67 mg, once a day

Lowers triglycerides

Severe hypertriglyceridemia

Results of the fasted draw: pancreatic lipase still elevated at 1039 and triglycerides above 1000. The team felt the high fats could be driving the repeated pancreatitis, and recommended fenofibrate and a low-fat reformulation of the diet.

Copper storage hepatopathy, ALT normal

Two more flares since the emergency visit. ALKP was newly high while ALT stayed normal. The blood sample looked milky (lipemic), pointing to high blood fats. The team asked for a fasted triglyceride and pancreatic lipase draw and an abdominal ultrasound.

Presumptive pancreatitis flare

Playful in the morning, then tired and not eating in the evening. Perked up by the afternoon.

Single source. The report says 'early March', the weekend after the 2/21 flare. Start date approximated.

Presumptive pancreatitis flare

Refused dinner, Tired in the evening, Drank less, Tacky gums. Appetite returned the next day and he ate small bowls of his home-cooked diet. No vomiting or diarrhea at any point.

Presumptive acute pancreatitis

Emergency visit after 24 hours without appetite, nausea with one vomit, and dehydration. The pancreatic lipase test supported pancreatitis and X-rays showed gastrointestinal changes. He was treated with fluids and medication and recovered at home.

Single source. Described in the March 2026 report, not from the emergency visit's own paperwork.

Specialist recheck

A specialist recheck referred to by the March 2026 report, which says he was doing well at home afterward. No report from this visit is in the records.

Single source. Known only from the next report. The visit's own paperwork is missing.

Presumptive acute pancreatitis

Vomiting, Soft stools, No appetite, Loose stool with mucus, photographed 6/30/2025. About 48 hours, resolved with supportive care. Pancreatic lipase test reported abnormal (2000).

Single source. Approximate date. The report says only June 2025. Three stool photos taken the morning of 6/30/2025 fall inside the episode and were emailed to the specialist's team on 7/1/2025 for reference, so it is placed at about 6/30/2025. Exact start and end dates are still not in the records.

Copper storage hepatopathy, ALT normal

Liver values were still normal after another four months on Atopica (cyclosporine) and prednisone. No concerns at home, normal appetite and energy, stools around score 3. The team kept therapy unchanged.

Copper storage hepatopathy, ALT normal

Technician recheck four weeks after the December changes. ALT 80 and ALKP 146, both in range, and the blood count was normal. One loose stool the day before. Appetite, water intake and energy normal. Weight 9.3 kg.

Mild non-regenerative anemia, chronic disease

Pathologist review: neutrophils were normal, with some early inflammation and a mild non-regenerative anemia attributed to his chronic liver disease. Urine had 1+ protein, likely from prednisone. The team stopped the antibiotic, restarted penicillamine at the maintenance schedule (90 mg Monday, Wednesday, Friday) and lowered prednisone to 10 mg daily.

Penicillamine: 90 mg, 3 times a week (Mon, Wed, Fri)

Binds copper so the body can clear it

Prednisone: 20 mg to 10 mg

Calms liver inflammation

Clavamox: short course

An antibiotic started 12/5/2024 as a precaution while the low neutrophil count was reviewed. Stopped 12/10/2024 once the pathologist found the neutrophils normal.

Copper storage hepatopathy, ALT normal

ALT 115, normal for the first time in this episode, on Atopica (cyclosporine), restarted 10/29 without trouble, plus prednisone. The blood count showed unexpectedly low neutrophils, repeatable on the machine. The team suspected a machine error, stopped penicillamine and started an antibiotic while a pathologist reviewed the sample. The plan was to taper prednisone first, then Atopica (cyclosporine), once the blood count was explained.

Penicillamine: 90 mg, twice a day (every 12 hours)

The specialist asked for a restart on 9/29/2023. The 12/8/2023 report says it restarted about six weeks earlier, so about 10/24. Stopped 12/5/2024 while a pathologist reviewed a low neutrophil count. The review found the neutrophils normal, and it was restarted 12/10/2024.

Clavamox: short course

Precaution while a low neutrophil count was checked

One source, not cross-checked

Atopica (cyclosporine): 25 mg, twice a day (every 12 hours)

Immune-modulating therapy for chronic hepatitis

Suspected Atopica (cyclosporine) reaction

After a few days on Atopica (cyclosporine) he woke lethargic, refusing food and water, with yellow mucousy diarrhea. The emergency exam was otherwise normal (temperature 102.0, body condition 5 of 9, weight 9.3 kg). A reaction to Atopica (cyclosporine) was suspected. It was stopped, and Entyce and Proviable were prescribed. That night one stool had blood, and he improved the next day.

Atopica (cyclosporine): 25 mg, twice a day (every 12 hours)

Started 10/11/2024 at a low dose because of his sensitive stomach. Stopped 10/16/2024 after a suspected reaction: lethargy, refusing food and water, and loose yellow stool. It restarted 10/29/2024 (second period below).

Entyce: oral liquid, as needed

Appetite stimulant

Proviable: 1 capsule, once a day

Gut support

One source, not cross-checked

Atopica (cyclosporine): 25 mg, twice a day (every 12 hours)

Immune-modulating therapy for chronic hepatitis

Copper storage hepatopathy

ALT 139, flat on the long steroid course. The team offered tapering prednisone, or adding Atopica (cyclosporine) so he could eventually come off prednisone. A repeat biopsy was the alternative, because scar tissue can leave ALT mildly raised for life. The family chose Atopica (cyclosporine), started at a low dose because of his sensitive stomach.

Copper storage hepatopathy

ALT 132, improved but still not normal. Weight 9.8 kg after the portion change, and the diet was listed with adjusted amounts (1 egg and 75 g chicken). The team planned to start tapering prednisone at the next visit if ALT held steady.

Copper storage hepatopathy

ALT dropped to 159. Steroid side effects appeared: thinning hair on the tail, longer urination, and weight gain (10.5 kg, body condition 7 of 9). The team kept the dose, advised cutting his food by 25 percent, and planned to start tapering once ALT was normal.

Copper storage hepatopathy

ALT improved a little to 322 on the higher steroid dose. He was hungrier but otherwise well. Options: more time on the current dose, add Atopica (cyclosporine), or raise prednisone further. The family chose more time.

Copper storage hepatopathy

ALT was flat at 425 on prednisone 1 mg per kg. His appetite was up from the steroid. The team doubled prednisone to 20 mg daily (2 mg per kg) and planned a recheck in 2 months, with a second immune-suppressing drug or a repeat biopsy as later options.

Prednisone: 10 mg to 20 mg

Calms liver inflammation

Copper storage hepatopathy

Technician bloodwork recheck about a month into prednisone. ALT fell from 2431 to 424. Weight 9.5 kg.

Single source. From the ALT trend listed in later reports and a technician note.

Copper storage hepatopathy

ALT 2431, the highest on record, despite zinc being out of the diet and penicillamine restarted about six weeks earlier. The team chose to start prednisone 10 mg daily, picking a steroid so the diet would not need to change, with a possible switch to a different immune-suppressing drug later.

Prednisone: 10 mg, once a day

Calms liver inflammation

Penicillamine: 90 mg, twice a day (every 12 hours)

Binds copper so the body can clear it

Single source. Restart date approximate.

Copper storage hepatopathy

ALT was still high (1407). Penicillamine had been paused while the nutrition service built a diet, and he had been on the new diet for six weeks, with some evening pickiness and not tolerating the eggs. The team laid out options: stop the zinc in the diet, switch to zinc alone, add an immune-suppressing drug, or re-biopsy. The family chose to stop the zinc, restart penicillamine, and ask the nutrition service to reformulate the diet to avoid eggs.

Copper storage hepatopathy

Weight was recovering, but liver values were still high. The team listed possible reasons: ongoing inflammation, dietary copper, a supplement interfering with the chelation drug, or an effect of penicillamine itself. Penicillamine was stopped while the diet plan was pending, with zinc therapy mentioned as a later option.

Penicillamine: 90 mg, once a day, then twice a day (every 12 hours)

Started once daily, moved to twice daily on 2023-04-30. Caused vomiting after morning doses. Stopped 6/30/2023.

Copper storage hepatopathy

Copper storage disease had been confirmed by biopsy. Penicillamine was causing vomiting after the morning dose, and he had lost about 1 kg. ALT was still high. The team pushed for the nutrition consult and moved the main anti-nausea medication to Cerenia.

Zofran: 4 mg, once a day

Replaced by Cerenia, which worked better.

Zofran: 4 mg, once a day

Nausea from penicillamine

One source, not cross-checked

Cerenia: 16 mg, 3 times a week (Mon, Wed, Fri), plus as needed

Prevents nausea and vomiting

Records disagree, needs confirmation. The August 25, 2026 medication list says 16 mg on Monday, Wednesday and Friday. The written instruction in the same report says every 24 hours as needed for nausea or poor appetite.

Penicillamine: 90 mg, once a day, then twice a day (every 12 hours)

Binds copper so the body can clear it

Tramadol: 25 mg (half of a 50 mg tablet), every 8 to 12 hours as needed

Short course after the biopsy. End date approximate.

Copper storage hepatopathy, confirmed on biopsy

Laparoscopic liver biopsy under anesthesia, with samples sent for tissue examination, culture and copper measurement. A short course of tramadol was sent home for pain. The results, reported later in March, showed mild chronic lymphocytic hepatitis with copper accumulating inside liver cells (959 micrograms per gram, dry weight): copper storage disease.

Single source. The biopsy result itself comes from the nutrition consult letter and later reports.

Tramadol: 25 mg (half of a 50 mg tablet), every 8 to 12 hours as needed

Pain after the liver biopsy

One source, not cross-checked

Elevated ALT, cause not yet known

Liver enzymes had risen again despite no outward signs. The team planned a liver biopsy if the pancreatic lipase recheck was not explanatory, and continued the liver supplement and weekly vitamin B12 injections.

Elevated ALT, cause not yet known

First internal medicine consult for rising liver enzymes (ALT 366 in November, 863 in December, above 1000 on 1/13). Bile acids were mildly raised and a quick ultrasound at the family vet had shown a small but normal-looking liver. He had no symptoms. The team started a work-up: advanced abdominal imaging, infectious disease tests, and liver aspirates. Possible causes listed: chronic hepatitis, copper storage disease, infectious hepatitis, or pancreatitis. A biopsy was the next step if nothing explained it.

CT and liver aspirates normal

Nothing on the CT or the aspirates explained the raised liver enzymes. Pancreatitis was strongly suspected at that point. A repeat check in 3 to 4 weeks was planned, with a liver biopsy if enzymes stayed high. A biopsy followed on 3/10/2023.

Single source. From the team's 2/1/2023 phone note and the 2/17/2023 report. The original radiology report is an attachment that is not in the records.

Vitamin B12 (cobalamin): Weekly injection, then 250 mcg by mouth, weekly, then once a day

Low B12

One source, not cross-checked

Quick ultrasound: liver looked normal but small

No explanation yet for the raised liver enzymes.

Single source. Described in the history of the first consult. Date approximate.

Elevated ALT

Bloodwork before a planned dental cleaning found a high ALT (366). The family skipped the dental and started liver support with Denamarin. A recheck a month later showed ALT 863, and then above 1000 in January.

Single source. Dates and values come from the history in the first specialist consult.

Denamarin: 225 mg, once a day

Liver support

One source, not cross-checked