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Discussion Starter #1
Hi,

We've got a 5 year old small black & white tabby named Pnut. She was a sickly kitten and somehow miraculously survived, but her growth was stunted and she is a mini-cat. She has been healthy all of her life except for 2 instances which I will describe later.

The current problem is that she is jaundiced and will not eat or drink on her own, and when fed and given water through a feeding tube, will vomit either immediately or a few hours later. We were able to curb this by getting an antacid shot and a painkiller on Monday (now Wednesday night), and she had not vomited since Monday until this evening, so we thought we were making progress. Now it seems to be backsliding. We will talk to the vet tomorrow but wanted some opinions here too. Blood work ruled out any obvious disease that would normally be diagnosed as such. X-ray ruled out obstructions or gall stone. Next option is ultrasound $250+ to look for deadly diseases, was hoping to avoid but not sure what to do now. When we were unable to consistently get food down her for almost a week, she got to "skin n bones" point, and vet hinted at euthanasia. I did not want to give up so easily, reasons given below.

The feeding regimen is that we are giving her 50 to 60 cc of A/D 4 times a day, followed by 10cc of water to flush the feeding tube. Beforehand, half of a 5mg Metaclopramide tablet dissolved in water is given 30 minutes before feeding. The pill is supposed to settle her stomach, but seems to have little effect. The greatest effect came from the painkiller and antacid shots, after which we were able to consistently feed her until tonight. She did not vomit for two entire days and passed two stools in the meantime. To me, that suggests that her system is working if we could just get her to keep down her food until whatever she is fighting goes away.

Her history is that she had jaundice before, a little over a year ago. We noticed she was not feeling well and took her to the vet, who saw the jaundice and could not find anything from the blood work. The vet thought that she just needed some help eating, so we installed a feeding tube and started feeding her that way. After a week or two of that, she started eating on her own again, and there was no further problem. We chalked it up to depression or something similar, caused by being a lone cat in the house after we had a previous cat die of anemia in oct 2002. We had no other way to explain it at that point.

Fast forward to Feb 2004. We bring in a maine coon from the local animal shelter. He is in great shape and has only been there a few days, coming from a nursing home patient's previous dwelling. He does, however, have a "cold" - sneezing and some drainage. Pnut seemed to pick this up from him unfortunately, and from mid Feb to mid Mar, was droopy and you could tell she wasn't feeling too well. The new inmate has recovered from whatever he had, but just under 2 weeks ago, we noticed Pnut was really looking rotten and seemed to be losing weight. She had a dripping face and sneezing typical of a cold, but her gums looked a bit yellow and nobody could remember the last time they saw her eating. We fed her turkey at first, which she was interested in and ate, but she began to vomit her meals. We took her to the vet on the 19th of March; vet diagnosed the obvious jaundice and did blood work with no obvious findings besides a slight elevation in pancreatic enzymes (which seems to be meaningless as a pointer to pancreatitis without further tests). We had a feeding tube installed, because she was getting obviously emaciated at this point so it was clear she would need some outside help.

For the next five days, we fed her A/D through the feeding tube at regular intervals while giving the anti-vomit pill at a given time before feeding. She was given antibiotics at this time and throughout the coming weekend. Vomiting of the feeding became more and more frequent throughout the week. Eventually, on Saturday, she was looking more rotten than ever before, she had not held food down for a day, and was meowing pitifully.

One of the family members decided to take her to an emergency vet at significant cost, and that visit bore no fruit; spending two days (sat and sun) in the emergency care, she did not hold down a single meal. She was returned to us in the most rotten, pitiful, lethargic state I could have imagined. I was being urged by a family member to euthanise her Monday. I insisted that we keep trying. I reasoned that since we have no confirmation of anything incurable, our only challenge at the moment is to get her to hold down food and water until we have more information. And after we had already spent so much in vet costs, what harm would a little more trying do.

I had her taken to the vet on Monday afternoon, given under-the-skin fluid to make up for lost time on the weekend, given an antacid shot and a painkiller shot, and we took her home (total cost, $87). She held down all food and water given until this evening. She seemed to be looking a bit better and in gradually slightly higher spirits over the past 2 days, but that might just be observational bias. Tonight, after her third feeding of 60cc A/D, she vomited a small amount approx. 2 hrs after feeding, and after the 4th feeding of 50cc A/D (I tried to back off a bit), she immediately vomited the majority of it. Frustrated, I had the idea that I might find some help on the Internet (as I'm getting a bit desperate for ideas here), and so I came to post here.

The main thing is that I have no idea what the underlying problem could be, which is affecting my ability to reasonably approach the matter. It seems that some cats get really sick from colds, but in most cases they should recover. Are the above symptoms consistent with a severe cold (or upper respiratory infection)? Anyone else had something like it happen when bringing a new cat into the house who had some slight illness of his own?

Apart from a cold, the only other maladies I can find (on the internet) that would come on so quickly are:

- Distemper. Deadly. Consistent with strange cat brought home from shelter, but strange cat has no symptoms. I conclude as very unlikely.
- FIP. Deadly. Consistent with symptoms. Strange cat displays no such symptoms. FIP seems to prevail in kittens and geriatrics. I conclude as very unlikely.
- worms or lung/liver flukes. Treatable but require identification. Likelihood? What about intestinal parasites? Should I have a stool checked out if I can get one out of her? Seems too remote of a possibility due to circumstances.
- Fatty liver disease. Very likely that it is happening, but is it the cause, or is it the effect of not eating due to some other problem? Liver values abnormal in blood work, and liver shown slightly enlarged on x-ray. Moderate to severe jaundice is obvious.

Or maybe this is an acute attack of something underlying:
- Inflammatory bowel syndrome. Consistent with random vomiting and/or previous jaundice. Tends to cause pancreatitis which would be consistent with the current situation. Need to give steroids to treat IBS, but can't give steroids if currently under pancreas attack. Testing for pancreatitis would require at least a few days to see results. Likelihood?
- Hepatitis. Liver slightly enlarged on X-ray. Seems unlikely but I can't find much consistent info.
- Hyperthyroidism? Doesn't seem consistent with symptoms. Not worth pursuing.

My hypothesis is that she had an underlying problem (hence the previous jaundice episode) that turned into a disaster when the new cat showed up with a nice virus for her. I have a feeling that she is fighting the underlying problem plus an attack of something nasty. I have never seen her in such general bad shape.

In addition to any stabs anyone can take at a diagnosis, I have the following major questions:

1) What is the likelihood that she is in pain? I can't see any obvious signs of pain, but cats are strange that way. Is vomiting usually more of an indicator of pain as in a terminal illness, or just plain feeling rotten as the result of an infection or something similar? I know when I'm puking sick I usually feel like death would be a blessing, but I would not go so far as to equate that with pain like what a cancer patient feels.

2) What is the likelihood, based on past experience, that she will recover from the current state, given the level of care I have mentioned? Is there anything we can do to improve our process? Should I keep up the antacid/pain shots to try to control the vomiting? What is the chances that they will continue to be effective? They will cost over $50 per visit, so it needs to be worth it in the long run. We have already spent so much that I hate to give it up at this point, but I also don't want fruitless suffering.

3) Would an ultrasound potentially lead to a cure (by diagnosing some disease that is treateable), or does it just serve as confirmation of diseases whose course is inevitable anyway? Has anyone had a cat who was cured of some malady due to an ultrasound diagnosis that bloodwork and x-rays couldn't cover? I am torn whether to spend another $250, but if there is potentially a significant benefit to be had from it in terms of identifying some problem that can be curable through appropriate treatment, I will do it.

Thanks so much for any insight! We are inexperienced at this, Pnut being only the second ill cat we have ever had to deal with. Any suggestions are appreciated, and obviously time is of the essence here. If I can get replies before the vet visit tomorrow, I will bring them along with me to serve as discussion material.
 

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Hi,

For a "small" cat 50-60 cc at a time seems like a lot of food. You might check with your vet and downsize that; just the sheer volume could be causing the vomiting.

Hepatic lipidosis (fatty liver disease) seems the most likely current "diagnosis" but you hit it right on the head, is it a cause or an effect? HL can occur simply from a cat not eating for a few days for any reason, including a cold (cats often won't eat if they can't smell the food, so nasal congestion could have triggered it).

Ultrasound is the best diagnostic you could choose at this point, and it will potentially affect the treatment. However, there is no guarantee that it will provide an answer.

Let me quickly run down the others:

Symptoms of distemper are bloody diarrhea and vomiting. Doesn't sound like that.

FIP is unlikely in a cat her age but possible. Dry FIP is rarely definitively diagnosed ante-mortem.

Worms or flukes are diagnosed on a stool sample, but consider having it sent to a lab where they will centrifuge it and get the best reading. Unlikely but not expensive to rule out.

Because of her poor response to treatment, feline "triaditis" is very likely. This could be diagnosed by ultrasound. Involves hepatitis (or HL), inflammatory bowel disease, and pancreatitis. This has a relatively poor prognosis.

Hyperthyroidism in a 5-year old cat is highly unlikely.

1) What is the likelihood that she is in pain?

Discomfort, certainly. Pain, unknown. If pancreatitis, then yes, that is extremely painful.

2) What is the likelihood, based on past experience, that she will recover from the current state, given the level of care I have mentioned?

Can you have the vet make up the shots for you to give at home, and show you how? It isn't rocket science!

3) Would an ultrasound potentially lead to a cure (by diagnosing some disease that is treateable), or does it just serve as confirmation of diseases whose course is inevitable anyway?

See above; yes, it could make the difference between blindly treating symptoms versus knowing and treating the cause. I am a great fan of ultrasound in cats; but as I said, there's no guarantee you'll get a definitive answer. However, it's a non-invasive test with the best likelihood of providing valuable information.

Good luck!

Dr. Jean
 

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Discussion Starter #3
Thanks for the reply. We tried to feed her again this morning and she vomited again. I am being pressured to euthanize her, and I still don't like that option at this particular point. However, after Sunday, I will be unavailable for some time so the cat will be left in the care of the euthanization proponent. My feelings are that it will not be a good formula for success.

Given the symptoms and the likelihood of triad syndrome, would it be a safe bet to go ahead and treat for that? It looks like the first approach for IBD is to try a low fat/high fiber diet, then a hair ball diet, and then try a diet with a "new" type of protein in it (IVD?). Fiber could be added to existing food with Vetasyl. It also seems like administering steroid shots is accepted practice. My vet claimed that steroids would have an aggravating effect on the pancreatitis though; is that consistent with others' experience? I also see the use of antibiotics mentioned (methimazole, tylosin, sulfasalazine), and I'm not sure whether or not I should push for those. For liver problems, I see Hill's L/D recommended. Will that diet also address IBD? Right now, I'm uncertain how to address any one of the triad maladies without negatively affecting another. It also seems like a diet change isn't a very aggressive way of approaching the problem. I also have no idea how to address the potential pancreatitis, even if it were conclusively diagnosed.

I see a use of Cisapride to control vomiting, seems to be some sort of antacid. I will mention this to my vet, but is this usually a successful angle? I am not sure what was in the "Tummy shot" that she received on Monday. Is it likely that she has an ulcer, perhaps from having an upset stomach for so long?

I think I will get an ultrasound done, though the cost is prohibitive. I feel embarassed at the moment, because I get the feeling that people around me believe that I am pursuing a hopeless case. But I'm not sure why it is so hopeless. Aside from the nebulous symptoms, it seems like keeping food down is the only challenge at the moment. But I have only four days to set a plan of action into motion, and only two of those days are business days.

If I can get a stool out of her, I will also get a stool test done. Besides the stool test, how can I rule out other forms of parasites?

Thanks for the informative reply! Calling the vet now, here's hoping for the best.
 

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I can't give you specific veterinary advice, such as advising on what medications to give her, sorry. That is your vet's job.

If it is triaditis, that is a poor prognosis. The treatments for liver disease and pancreatitis are completely opposite which makes triaditis extremely difficult to treat successfully. If she has pancreatitis, she is in great pain and that must be a consideration in whether or not to keep going with treatment. If she has a reasonable hope for recovery, that is one thing. But if you are merely prolonging her suffering, and trying different things "in case" something "might" make a difference, then it may not be the best thing to keep her going. You need to know as far as possible what her actual prognosis is, and decide based on specific information, that's why I recommend ultrasound as a diagnostic tool.

If everyone around her and working with her feels that euthanasia is the best option, you might ask them, and yourself, why that is, and most importantly, why you are keeping her alive and for whom. I am not advocating euthanasia, I don't know enough about the case and I'm not in a position to do that anyway. I'm just putting out the questions you should be asking yourself about her quality of life, now and in the future.

I don't recommend most of Hill's foods because they are inferior quality. A specific diet is not going to make a difference at this stage. Diet is a consideration only for the recovery phase, and she's not there yet.

Cisapride has a lot of side effects and is usually a last-resort medication for severe constipation. It is an intestinal mobility modifier, not an antacid.

Good luck!
Dr. Jean
 

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Discussion Starter #5
thanks for the reply. Sorry if it sounded like I was soliciting specific advice, that's really not what I meant to do at all. My posts were meant in a general sense, i.e. "if this were your cat, what would you do"?

She vomited a small feeding this morning. Determined to do something, I got some Butorphal tablets from the vet and some Pepcid AC 10mg tablets from Walmart. I dissolved one dose of pepcid (1/4 tablet) and one dose of the painkiller in water and gave it to her 1 hr before feeding. Then I fed 25cc A/D and washed with 5cc water. So far she has held it down (since 3:00). I will try to keep this thread active with the latest. She is looking bad compared to normal, but not as bad as a couple days ago. She actually has gotten up and walked around a bit. She is urinating somewhat regularly so hopefully that means that I am getting enough fluid into her. Perhaps with this regimen we won't see any more "crashes" so we can at least eventually get her eating on her own again, and down the road a bit we might have sufficient luxury money to get some real diagnostics done.

I need to be careful not to deceive myself into accepting wishful thinking as a real plan of action though. Our last cat succumbed to wishful thinking on our part. He had some form of NRG anemia; ultrasounds, x-rays, blood work, stool all turned up nothing except high calcium and low red (including reticulocyte) count. We had a transfusion done which improved his condition immensely, and then sort of ignored the problem for about 6 weeks because he seemed to be "better". Needless to say, by the time we tried to start him on Epogen to address the underlying problem, it was game over; he had crashed hard. He died in agony early on a Friday morning, slowly suffocating due to low red count. :( I am loathe to let an underlying problem go undiagnosed and unaddressed due to that previous experience, but budget-wise it's hard to justify at at the moment, while nursing the cat and hoping most definitely is within our means. I just have to ensure that she is not miserable and that there is a road ahead, otherwise I am really not doing her any favors by prolonging it.
 

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Discussion Starter #6
I feel like the best shot is to approach it from the triad disease angle, for reasons given below. It appears to treat this we need a hypoallergenic, low-fat diet, and ideally antibiotics to prevent short term complications, but I don't think I could get my vet to prescribe them without a diagnosis. What makes this frustrating is that even with an ultrasound, she tells me that a pancreatitis diagnosis is not conclusive, only a best guess due to symptoms, process of elimination, and if the pancreas looks bothered on the ultrasound. To diagnose triad disease, tissue samples would be necessary. All at a significant cost, and with few options for treatment anyway. Changing food and seeing what happens is an attractive option, due to the low cost involved in doing so, and the lack of any other realistic options anyway when pancreatitis is occurring.

Does anyone know what a food that fits the bill for triad syndrome would be? We are feeding her Hill's A/D which, as noted in a previous reply, could probably be improved on. I am reading that it should be hypoallergenic in general, low fat, bland (easily digestible), high in fiber, and ideally provide protein of a type that her body has not previously encountered, though the last criterion is optional.

She rarely vomits when she has been given antacid. I have been giving her 1/4 of a 10mg pepcid pill per day as recommended by my vet. The other "caretaker" gave her the wrong pill today, which may have led to a vomiting episode today. The anti-vomit pills (Metaclopramide) and painkillers (Butorphanol) seem to have very little observable effect on the vomiting compared to the antacid.

The reason I lean more and more towards triad disease and especially pancreatitis is thinking about her history. She had a previous episode similar to the current one. For the last few years, she has had intermittent sour stomach where she would vomit food and/or bile, maybe once every two months. She frequently raided the trash can even though we tried to keep her out of it and discourage the behavior. She was given whipped cream and cream cheese regularly throughout her life which she loves, but are extremely high in fat. She eats table scraps when they are made available to her (either through a human hand or through the trash can). Over the past year and a half, she had gained some weight (which we chalked up to the loss of her playmate).

The above seems to be a laundry list of the risk factors for chronic pancreatitis - high fat foods that are of low quality and make the digestive system work harder. I wish I had known it was such a bad idea to feed those things before, but oh well... hindsight and all that.
 

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Actually, high fat diets are not considered to be a factor in cats, although they are in dogs. In fact I typically use Hill's a/d for liver disease precisely because it is very high fat and low carb--lots of calories in a small volume. It is the only Hill's diet I use or recommend. Cats have entirely different liver metabolism than dogs, and what applies to one most likely does not apply to the other. IMHO carbohydrates are the most damaging to cats.

Keep on your vet for exact recommendations. Treatment for triad disease is a changing arena because it is a relatively recent disease (first described by Colorado's very own Dr. David Twedt!). Since I'm not in clinical practice I am not up on the latest recommendations, but your vet should be. The trick is to figure out which disease will kill her first--pancreatitis, or hepatitis. Pick one, then treat that primarily and the other will have to follow.

Just keeping her going while her *body* heals (which it will do in many cases, with or without interference from us vets!) may be the key here.

The only general recommendation I can make here is to go for the antioxidants, because they are gentle yet powerful anti-inflammatories without the side effects of steroids.

Good luck!
Dr. Jean
 
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