Digestive and bowel disorders of cats

Please note: The most recent medical information is at the top of the page to least current at the bottom.

Eosinophilic Enteritis or Lymphocytic/plasmacytic Enteritis

Question: Hello, I need to know what eosinophilic and plasmacytic gastritis are. There are several articles on the Web that discuss it, but from the layperson standpoint I`m really not sure what these problems are all about. Could you perhaps enlighten me as to what these diseases are? Or point me in the right direction? thanks, Anthony A.

Answer: Anthony- Eosinophils, lymphocytes and plasmacytes are different types of white blood cells. When a particular type (or types) of these cells invade the digestive tract in unexpectedly high numbers and this causes clinical signs, then the result is "eosinophilic enteritis" or "lymphocytic/plasmacytic" enteritis. Since some white blood cells are normal in the intestinal lining and since white blood cells are supposed to fend off bacteria, parasites and other invaders, it isn`t unusual to find these cells in the intestinal tract in high numbers in dogs or cats with chronic diarrhea or vomiting. However, it also seems clear that at least at times there are situations in which these white blood cells are there when they shouldn`t be and that they are the cause of the disease rather than part of a normal response to a disease process. When eosinophils are the predominant cell the most likely causes of the enteritis are parasitic infection, allergies or "idiopathic", which means that there is not an identifiable cause. When lymphocytes and plasma cells are the predominant cell types the most likely underlying causes are sensitivities to dietary components (wheat gluten is one example), parasites, bacterial toxins, cancers, heritable tendencies (occurs in Basenjis and wheaten terriers), and again a big group of dogs where a specific underlying cause isn`t identifiable, or the idiopathic cases. As you can see there is some overlap in these conditions and there are similar conditions associated with other types of white blood cells. When it is possible to identify an underlying cause and treat it, these conditions can sometimes be cured. When no underlying cause can be identified an effort is still usually made to eliminate as many of the common causes as possible, by using a wide spectrum dewormer (usually fenbendazole) to try to rule out parasites, dietary food trials to try to identify food sensitivities and allergies, biopsy of the intestines to try to rule out cancers and to aid in identifying other underlying causes and by the use of antibiotics to try to rule out the bacterial overgrowth/toxin issues. If none of these things help then it is usually necessary to use immunosuppressive drugs to try to reduce the immune system component of the disorder. Drugs such as prednisone and azathioprine (Imuran Rx) have been used for this in dogs and chlorambucil is sometimes helpful in cats. Cyclosporine may also help some dogs or cats with these problems. I hope that this is helpful. Mike Richards, DVM 10/12/2004

Gastrointestinal problems after dental procedure

Question: Hi Dr Richards Danny is a 10 year old male, neutered Havana Brown, very sweet and loving cat. He has never been sick until he had his teeth cleaned and one tooth extracted last year on 5.25.00. (isoflurane mask and monitor) His weight then was 11 lbs 10 oz. During and after he had this dental stuff, these are the medications the vet put him on: (I`m copying from Danny`s record): May 25, 2000: Amoxicillin Inj 250mg/ml Baytril Inj 22.7 mg/ml RX: Baytril 0.5cc under skin twice daily 7 days Torbugesic 1 mg/ml. Diarrhea and uncontrollable bowels followed immediately after this medication started. He has been sick or borderline sick ever since. July 23 `00: Vet did fecal smear/float , but found nothing. We put him on an exclusive white chicken breast diet. August 9 he went to vet again. Exam: no thyroid nodule palpated. RX: Metronidazol 100 mg/ml given orally (.75 cc twice daily for 7 days) Prednisolone 5 mg given 1 tab orally twice daily for 6 days then 1 tab orally twice daily for 4 days. August 15: RX: Inj. Depomedrol 20 mg/ml. Stable for a couple of weeks. But by now he weighed 11 lbs 2 oz. Oct. 23 : Severe diarrhea and vomiting bile and blood RX: Metronidazole 250 mg . Gave 1/4 tab orally twice a day for 5 days, then every other day for 10 days. Dec. 14. Vomiting blood and bile. RX : Metronidazole 250 mg - Gave 1/4 tab orally twice a day for 5 days then 1/4 tab daily continually for life to prevent flareups. Pepcid: 1/4 tab (2.5 mg) orally once daily Diet: Tried to introduce duck and FAVOR vitamins. Danny developed severe vomiting and diarrhea. Back to skinless white chicken meat. Feb 13.2001 Continues with Metronidazol 250 mg. 1/4 tab daily and Pepcid 2.5 mg orally daily. Every now and again Danny has a flareup of vomiting bile and blood as well as diarrhea, and we give him a few days of Metronidazole twice daily as well as the pepcid. Right now he is 9 lbs, very thin, tired and looks like a bag of bones. Three days ago, we started Danny on Jarrow formulas Pet Dophilus twice daily to see if it could be intestinal bacterial overgrowth. So far it`s ok but probably too early to tell if helpful. We wish to avoid instrusive, expensive diagnostic procedures if possible. Is there anything else we can do to get him well? If he has Inflamed Bowel Syndrome, which the vet seems possible, what is the long term/short term prognosis? Many thanks, Jane Answer: Jane- When problems start after a treatment, dental or surgical procedure, it is always tempting to blame the problem on the therapy. It is important to remember that it may not be the primary cause or that it may not even be a causal factor at all. However, it is also a good idea to consider the possible problems of medications and anesthetic/dental/surgical procedures and to think about what can be done to correct them. Enrofloxacin (Baytril Rx) is the most likely culprit, if a medication used is a causative factor in the problems, simply because it was used the longest and being an antibiotic it has the ability to disrupt the normal bacterial flora in the digestive tract. Vomiting and diarrhea are reported to occur, at a low incidence rate, as the result of administration of enrofloxacin. Sometimes these disorders seem to become self perpetuating once they start. Anesthetics sometimes cause gastrointestinal mobility problems that are usually short lived, but may lead to a longer term problem, such as small intestinal bacterial overgrowth (SIBO). Butorphanol (Torbutrol Rx) does not usually cause problems but has been reported to cause diarrhea in a few patients. If there were a primary problem that would be induced to show itself after a stressful episode, such as the dental cleansing and tooth removal, the most likely one in a cat would probably be intestinal lymphoma. This is a form of cancer that is a fairly frequent cause of inflammatory bowel disease in cats. It would be responsive to the cortisones used (prednisolone and methylprednisolone acetate (DepoMedrol Rx)) -- but so would most causes of inflammatory bowel disease. Another possible problem that could be exacerbated by anesthesia and stress at Danny`s age is "triaditis" which is cholangiohepatitis, pancreatitis and inflammatory bowel disease occurring at the same time. It seems odd that this would happen but it happens often enough for the syndrome to have a name now. Even though his thyroid glands are not palpable it would be a good idea to consider testing for hyperthyroidism with the weight loss that you are seeing. We often give three days of fenbendazole (Panacur Rx) to rule out giardia and worms, just to be cautious. I have to put at least one plug in for doing a diagnostic workup, even though I know that you would prefer not to. That is this -- it would really be useful to rule out the triaditis problem with lab work and/or ultrasound examination and to try to rule out lymphoma through intestinal biopsy, which would also help to rule out some other causes of inflammatory bowel disease. Doing these things would make it easier to figure out which direction to go in and to help limit the possibility for doing more harm when trying to treat the symptoms on a trial and error basis. At least a general chemistry panel to make sure that elevations in liver enzymes is not a problem would be best before some of the things that I am going to suggest in the next paragraph. I think that I might be tempted to try tetracycline for a couple of weeks in place of the metronidazole. Sometimes this antibiotic works to control small intestinal bacterial overgrowth when others won`t. It may also be worth trying either one of the hairball formula foods or a lower fat diet such as Hill`s w/d. Sometimes one or the other of these will work. After that, I`d be tempted to go back to the treatments that seemed to work as you went along. I have used methylprednisolone acetate at two to three week intervals for three or four injections in several patients in which this has been very helpful. In cats with intestinal lymphoma we will use this on an every three to four week basis indefinitely. It has lots of side effects when this is done, though. It is particularly important to rule out triaditis prior to using DepoMedrol in this manner, so a blood chemistry panel and perhaps liver function testing or a fine needle aspirate of the liver would be a good idea prior to taking this step. It is also a good idea to rule out diabetes but the blood chemistry panel will help with that. It would be pretty unusual for a food allergy to develop at ten years of age but it might be worth trying a hypoallergenic diet such as Hill`s z/d diet, just to be sure, if nothing else seems to be working. I wish I had a really good plan for getting to a diagnosis without doing the lab work, especially the intestinal biopsies, but I don`t. Many of my clients do not wish to do this type of work-up and so we do a lot of trial and error management of IBD in our practice -- but I try hard to explain to clients that there are risks in this approach, from just not successfully identifying the cause to causing harm, especially when we get to the point where we feel the use of long acting corticosteroid injections (DepoMedrol) is worth a try. Most of the time we can find some therapy that will work if the client will give us enough tries at it. Good luck with this. Mike Richards, DVM 2/24/2002

Colitis, Food Allergies, not eating, Hepatic lipidosis

Question: Dr Mike,

I have a cat who has been diagnosed with "INTRAMURAL NEUTROPHILIC COLITIS WITH LYMPHADENTITIS" - "SEVERE". We have been giving her antibiotics and feeding her with a syringe Hill`s a/d. We have tried to get her to eat Waltham`s Venison and Rice but she doesn`t like it and won`t eat it (neither will our other two cats). We need to get her to eat on her own and find something she likes. The "best guess" is that this was all caused by a food allergy.

My question is: what can we feed her and how do we get her to start eating on her own? In all other respects she has returned to "normal".

Linda

Answer: Linda;

I think that this reply might seem a little disjointed, so I`ll start with a couple of major points and then try to explain them.

1) It is really important to let your vet know that your cat is not eating this diet and it is even more important to let him or her know if she won`t eat any alternative foods that you offer. Cats who don`t eat for a few days can develop hepatic lipidosis, a liver problem associated with ingesting fewer calories than are needed to meet the body`s needs.

2) There are a number of possible choices in diets for cats who have food allergies and it is OK to switch between them to a limited extent, if necessary to keep a cat eating.

3) We recently attended a seminar by Dr. Lappin from CSU and he stressed that he felt it was important to control the inflammation associated with food allergies first and then to try to use dietary control after this was accomplished, because it limited the potential for developing new food allergies to the new diets.

4) Dr. Lappin also felt that some of the cats diagnosed with food allergies actually had chronic bacterial infections with organisms such as Cryptosporidium. It may be worth looking for this possibility or even to consider treating for this possibility for short period of time to see if it is beneficial to do that.

With these things in mind it may be hard to figure out the best order to address these possibilities. I try to stay vigilant for the possibility of hepatic lipidosis and might want to draw blood or even do a fine needle aspirate of the liver, to see if was the cause of the inappetance. While this is a secondary problem that is caused by the failure to eat it is still a very important consideration. It is possible to find the bacterial organisms on fecal smears or with fecal culture in some cases and this is a relatively easy thing to do while thinking about the liver problems.

If it seemed unlikely that hepatic lipidiosis was present and testing for bacteria was negative or unequivocal, then I would probably want to try either an anti-inflammatory medication like prednisone or antibiotic therapy anyway. Sometimes we do both, although this can confuse diagnostic process. I like metronidazole as a short term solution because it seems to have some anti-inflammatory properties even though it is an antibiotic. Tylosin is another good choice for antibiotic therapy but it is hard to get cats to take this medication because it tastes really awful. A compounding pharmacy may be able to help with a dosing formula that will work, though.

Once we get to a point where the cat is eating OK and we are ready to try a long term solution, we try the diets that might help. There are a number of these diets. Hills has a new diet z/d (tm) that is composed of low molecular weight proteins that should be hypoallergenic. Like most diets for cats, we have variable luck with acceptance of this diet. Some cats won`t consider it and others think it is great. The next alternative is a diet with protein choices that are not typical for cat diets, such as the venison in the current diet. These work because the cat isn`t allergic to a protein source it hasn`t been sensitized to because it hasn`t eaten it before. The problem with this approach is that cats are like many teenagers -- they aren`t going to eat something they aren`t familiar with. So it may be necessary to try several of these diets to find one that works. Lamb, rabbit, venison, duck, ostrich and several other protein sources can be found in these diets and often a cat will eat at least one of these.

Dr. Lappin`s suggestion to avoid these diets when the intestines are inflamed is based on the way that food allergies are thought to occur. The immune system doesn`t become sensitized to proteins unless they are absorbed intact, or nearly so. This usually happens in very young animals or in pets whose intestines are inflamed enough to allow larger proteins to be exposed to the immune system. Consequently, waiting until the intestinal inflammation is under control might make it possible to avoid having a cat get sensitized to the new diet, which could make your vet suspect food allergies as a primary problem when it is really a secondary one (inflammation first, allergy second, rather than allergy first, inflammation second).

It really is important that your cat begins to consume adequate calories on her own. It is important enough that you really need to contact your vet if she is not willing to eat food on her own. I would want you to feed her something you knew she liked to judge whether the choice of food was the problem or whether she just didn`t feel like eating, but your vet may want to take a different approach based on what he or she knows about your cat`s medical history.

I hope that this helps some. If it is too confusing, please feel free to ask for clarifications.

Mike Richards, DVM 11/7/2001

Chronic soft stools

Question: Dear Dr Mike:

I have some question regarding the stool of my five months old cat, Sardine. (I emailed to you previously regarding my another Scottish fold, Chocolate, who had high fever) I am not sure whether he has diarrhea. His stool is generally cylindrical. However, for the first half of the part which comes out from his body (forgive me that my description seems a bit funny here), it is quite firm. However, for the second half, it is quite soft. Is this to be counted as diarrhea or it is quite normal in cats? Sardine has not gone through any deworming process ever since he came home. Will this be related to this phenomenon? My pet shop recommends me a high quality deworm pill, Dontrol (something like this, I am not sure) for Cats, produced by Bayer. However, since I bought only one pill but not a pack, the pet shop did not give me the original instruction issued by Bayer. Are you familiar with this drug? If yes, can you give me more details regarding the feeding amount, time interval for 2nd treatment, and more importantly, is it safe to my cat? I jut want to know everything about it.

One final question, when I open the mouth of Sardine and smell it, it has a little bit bad smell, not very severe, but I cannot describe it as pleasant or smelless. Is this normal to a cat or there is anything going wrong with him?

Thank you very much!! I am so happy to have known and subscribed to this site since I always have someone to consult here. However, sorry that my tiny money may not justify the cost you have to incurred in answering the questions posed by this troublesome subscriber (I studied economics in University, haha). Anyway, keep on providing this great services to the pet owners over the world!!

Regards, Ernest P.S. For your information, Chocolate is fine now. Her fever has gone away and she is active and willing to eat now. I will take her back to the vet tomorrow to make sure she is ok. Just hope that the virus is not related to FIP or FeLV.

Answer: Ernest;

A number of cats in our practice have formed stools that become softer as they are excreted. I guess that I do not consider this to be normal but I also do not think that it requires treatment in most cases. It isn`t a bad idea to deworm Sardine, though. Drontal (Rx), is a combination of praziquantel (kills tapeworms) and pyrantel pomoate (kills roundworms and hookworms). Usually there is no need to repeat the praziquantel dosing but the usual recommendation is to repeat the pyrantel pomoate dosage at two to three week intervals for 2 or 3 doses, to try to ensure that roundworms are eliminated as well as possible. Both of these deworming agents are considered to be among the safer medications and it would be acceptable just to repeat the Drontal dosing but you might want to find a dewormer that only contains pyrantel pomoate for the follow-up doses, since that would be less expensive and is probably all that is necessary.

Video: How To Help Dog Gas, Inflammatory Bowel Disease (IBD) in Dogs And Cats

We have found that the commercial cat foods formulated for hairball prevention seem to help in many situations in which there are slight signs of digestive system irritation, such as soft stools on a chronic basis.

Mike Richards, DVM 3/28/2001

IBD, pancreatitis and cholangiohepatitis "triad syndrome" possible

Question: Dr. Mike,

I have a 14 year old female cat named Beauty. She has really never been sick before except for a couple of times years ago when she lost some hair on her back near the base of her tail (no other symptoms). At the time the vet said it was probably a nervous condition and they gave her what I think was a cortisone shot and the hair came back. I think these occurences were in the fall

Since the beginning of this year I have noticed that she slowly started to eat less and she started to look thin. Her coat which is long and silky started to look sort of ruffled, perhaps from losing weight. I took her to the vet in April for her yearly check up which included all kinds of blood work and the vet gave her an A+. All her tests came back normal. At that time she weighed 8 pounds and even though I didn`t think she looked as good as she use to I figured she was just getting old.

Over the summer. I noticed that her stool started to give off an unbelievably bad odor. The stool was large, soft and sort of a light gray color. I took her back to the animal hospital in July and this time she was seen by a different vet who said it may be the type of food I was feeding her. She has always eaten Fancy Feast wet food and she is very particular in that she will only eat the fish flavors. I occasionally bought her the store brand version of Fancy Feast and the vet said that store brands are usually a poor source of nutrition and that feeding her these inferior brands may be causing the problem with her stool. I immediately stopped giving her the store brand and she did seem to respond. Her stool started to become firmer, darker and the horrible smell went away. I brought a stool sample to the vet after it had improved and they said it was ok. Her weight in July was still around 8 pounds even though she looked like she may have lost muscle. The vet said to keep an eye on her and bring her back if she started to lose weight.

The problem with her stool returned a month or so later. She also looked like she was getting thinner. She spent a lot of time just laying around and not getting any exercise which is unusual for her. She is an indoor/outdoor cat but spends most of her time indoor unless it is really nice outside. She has always been very good about grooming herself and is very spoiled.

In September I brought her back to the animal hospital and she was seen by the vet who gave her a check up in April - Dr. Marge. She did a lot of tests including blood work to check for a thyroid problem, liver problems, pancreatic problems, etc. but everything came back normal. I brought in her awful smelling stool which I believe they test for parasites and that came back ok too. When Dr. Marge did a physical exam she said she thought she felt something in her abdomen and so she took x rays which did not show anything abnormal. The cat is very difficult at the vet, she hisses and squirms, so they had to sedate her just to get blood as well as take the x- rays. Dr. Marge wanted her to have an ultrasound. I brought her back a few days later for the ultrasound at which time they sedated her and shaved her stomach, and a board certified vet who comes to the animal hospital once a week from New York did the ultrasound on my cat and found nothing unusual but a slightly enlarged gall bladder. Dr. Marge said she may have inflammatory bowel disease. She asked me if the cat was vomiting and I said only the occasional hairball. We decided at that point to just keep an eye on her and not do anything unless her symptoms got worse. She still weighed very close to eight pounds. The only other thing I noticed was that she seemed to be missing some hair in front of her ears and I thought she might have fleas. Dr. Marge checked her for fleas by didn`t find any and said that her cats have patches of hair missing in front of their ears and it probably isn`t hair loss.

Beauty actually seemed to be getting better. She was eating a little better and I took her for walks every day. She would even run up trees and race across the yard. I did notice that she was scratching as though she had fleas so I decided to put some Advantage on her especially since we were going outside so often. I also have a Pomeranian who goes out a lot and may have picked up some fleas. This was the first time I had ever given her a flea preparation in her life except for flea collars when she was young which she use to pull off right away.

Since the cat seemed to be doing so well, I decided to go away for the Columbus Day weekend. My Father came over every day to feed Beauty while I was away for two nights. When I came back, I noticed that Beauty wasn`t looking very good again. She seemed thin and she walked with her tail down. After a few days, I noticed that she was always licking herself frantically. I looked closer and saw that she was licking this large red bald patch on her stomach. It looked like it might be infected. When I felt the inflamed area, it felt hard. Her stomach area hangs and sort of swings back and forth when she runs, I`m guessing that this is what happens when cats get older. I wasn`t sure if the area she was licking was already bald from when she was shaved for the ultrasound. The first thing I thought of was that the area was somehow infected from when they shaved her. I took her to the emergency clinic because it was a Sunday. The technician at the Emergency clinic pulled Beauty out of her carrier by the scruff of her neck which no one has ever done before. She hated it so much that the vet could not exam her thoroughly because she was hissing and growling. They threw a towel over her head to try to examine her and this further upset the cat. While wrestling the cat down on the table, the vet caught a quick look at the red area on Beauty`s stomach and said she could not examine her thoroughly without sedating her but she thought it was either an allergy problem or more unlikely a skin cancer. I decided not to put the cat through any more trauma at the clinic, so the vet gave her a shot of amoxicillin and gave me amoxi drops to give her because she said the area looked infected. When I got the cat home she would just lay there. She wouldn`t eat and she looked like she was very uncomfortable

The next day I took the cat to the animal hospital I always go to, but Dr. M was on vacation, so I saw Dr Ct. Dr. C was much gentler with the cat and so Beauty repsonded much better. Dr. C said the cat may have eosinophilic granuloma and she gave her an injection of Methylprednisone, which she said should hopefully clear up the problem. She also gave the cat another injection of the amoxicillin and gave me IVD Limited Ingredient Diet food to feed her instead of the Fancy Feast. I told her that the cat hadn`t really eaten or drank much since Saturday (it was now Monday) so she gave her some fluids under the skin as well.

By Tuesday afternoon the cat hadn`t eaten anything, not even her Fancy Feast or tuna fish which is her favorite. She looked very sick and she wouldn`t move. I remember her acting like this when she got a shot of cortisone years ago and aIso when she gets her vaccinations but to a lesser degree. I brought the cat back into see Dr. C the next day (Tuesday) she took some blood to check her liver function which was still ok although she did say she was slightly anemic. She gave the cat an appetite stimulant in pill form. She told me not to give her the amoxi since she wasn`t eating. When I got her home, she ate some of her Fancy Feast and an hour later she ate some more. I also gave her almost an whole jar of chicken baby food. Because she started eating so soon after I got her home, I don`t think it was because of the appetite stimulant, although that did kick in and she ate more than usual for the first 24 hours. I think the initial effects of the Prednisone had worn off and she started to feel more like herself. She is still eating pretty good but I think it is because of the Prednisone shot. She still looks very thin and sickly. She weighed about 7lbs 5 oz the last time I took her to Dr.C last Tuesday. The other thing she is doing is scratching around her ears, eyes and under her chin. She has taken some of her fur off doing this and she has a lot of scabbing from making herself bleed. After her episode of not eating her stool became very hard and small. So I gave her some hairball medicine because I know it is a laxative. She seemed to feel bad after eating, so I think she has something else going on.

Dr. C had asked me if I thought the red area showed up after the hair was shaved off her stomach and I said I wasn`t sure when it first appeared. She said that it is possible that she may have picked up a fungus from the clippers. I asked her for an anti-fungal cream to try and she gave me Conofite and a collar to put around her neck to keep her from licking off the medicine. The cat kept stepping on the collar and had trouble walking especially around corners. I was afraid she might fall of fthe furniture with the collar on and I knew she wouldn`t be able to eat or get into her covered litter box so I took the collar off her. She licked off some of the medicine and threw up. Dr. C had suggested doing a skin biopsy so that we know what we are dealing with. I think we were both hoping that she would show some improvement after three or four days on the prednidone but she hasn`t. So I want to go ahead with the biopsy. Do you think I should find a dermatologist to do the biopsy?

So far I don`t think the area on her stomach looks any better. She is still licking it all the time and scratching herself around the head. She still won`t eat the special diet food so I have continued to give her the Fancy Feast. All she wants to do is go outside and sit under the bushes next to my deck. I live in Connecticut and the temperature is now in the 40`s and 50`s. Normally this would be too cold for her but I think it somehow makes her feel better, maybe less itchy. She will sit outside all day and I have to pick her up to bring her in. I worry that she is allergic to something outside but she goes nuts if she is trapped in the house all day.

In addition to her skin problem, I still think that Beauty has something wrong with her digestive tract. Dr. C said she may have IBD or another possiblity may be lymphoma, but the only way to verify that is through exploratory surgery. I am very worried that the longer I wait to do something the more far gone she will get. I have Breast cancer and I know how important it is to catch things early. On the other hand is the cat too old to have such surgery? In any case I think Dr. C was hoping to clear up her skin condition before discussing surgery. Yesterday the cat started to have the horrible smelling soft stools she was having before. I will be taking the cat back today to see Dr. Cto try to figure out what to do next. Any input you can give me would be greatly appreciated. I don`t want to lose Beauty she is my best friend.

I apologize for the long message but I didn`t want to leave out anything important.

Thank you A;

Video: Cat Care & Health : Cat Parasite Symptoms

Answer: Increased odor in the stool sometimes occurs with inflammatory bowel disease (IBD), is noticed by many cat owners whose cats have hyperthyroidism and can occur with cholangiohepatitis and pancreatitis. There is a condition in cats that is sometimes referred to as "triad syndrome" or "triaditis", in which IBD, pancreatitis and cholangiohepatitis occur at the same time. Lymphoma, a form of cancer, can also cause symptoms similar to IBD.

Hyperthyroidism can be hard to diagnose in some cats because it is possible for an older cat to have this condition despite having total thyroxine (TT4) values in the normal range. A free T4 (FT4) measured by equilibrium dialysis can be helpful in determining if hyperthyroidism is present in this case. It would be worth considering running this test.

We have some older cats who have very non-specific signs of illness that are associated with cardiomyopathy (heart muscle weakness). Giving a cat with cardiomyopathy a long acting corticosteroid injection, such as methylprednisolone (DepoMedrol Rx) can make them worse for a few days, apparently due to salt retention induced by the corticosteroid. This isn`t all that likely but it is something to keep in mind.

Inflammatory bowel disease, with or without "triad syndrome" is very likely to be the cause of the problems you are seeing. A limited antigen diet like the IVD will sometimes help with this problem. Corticosteroids usually help but sometimes it is necessary to use other medications or additional medications to gain control of a case of IBD. Lymphoma can be thought of as a severe form of IBD when it affects the intestines and a poor response to treatment is one sign that lymphoma might be present. Differentiating between these conditions requires intestinal biopsy, which can sometimes be obtained through endoscopic exam, but which often requires abdominal surgery. If surgery is done, it is best to obtain samples from the pancreas and liver, as well. Lymphoma can affect the skin and that is another reason to consider skin biopsies. I do not know how often this occurs in cats but it is reasonable to pursue a skin biopsy, anyway.

It doesn`t matter too much who takes the skin biopsy. What matters is who reads it. It is best if your vet uses a pathologist with a special interest in skin (a dermatopathologist). There are several pathologists around the nation with this interest and there is a good chance your vet does this, but not all vets do. It isn`t a bad idea to ask if a pathologist with an interest in skin disease is going to read the biopsy samples.

Cholangiohepatitis (liver disease) and "triad syndrome" can occur in cats even though the liver enzyme levels are normal on lab work. This makes it frustrating to rule in or rule out this condition when trying to make a diagnosis in a cat that is just not doing well. I have done liver biopsies and found this when I couldn`t find any other reason for a weight loss on physical exam and tests for things like hyperthyroidism are normal.

We do surgery on older feline patients very frequently. We have done surgery on feline patients as old as twenty-two years of age --- so fourteen doesn`t seem too old to me. Cats usually recover very well from abdominal surgery and we are comfortable doing surgery to obtain biopsy samples of abdominal organs. I think I might want to take chest X-rays to check for heart disease and to do a free T4 test prior to going for abdominal exploratory surgery, but I wouldn`t hesitate to do it if it seemed like a good idea after doing those tests. We can almost always do skin biopsies, if you decide to do that first, with sedation and a pain reliever and then local anesthesia but since your cat is very nervous at the vets it might not be possible to do that.

Hope this helps some.

Mike Richards, DVM 10/31/2000

Vomiting and diarrhea that start at a very young age - with anemia

Question: Hello Dr. Mike, I apologize for the long letter, but I wanted to give you enough details to make a educated diagnosis. To get to the bottom of what we are asking see the very bottom. Both my wife and I really enjoy your website and all the information that is in it. We have learned more on your site than any of our vets could ever provide.

From reading your web site, we learned you like a challenge. We think we have such a challenge.

Let me start with some case history: CAT: 2 year male american shorthair Tabby. Name: Pumpkin Other cats: we have an 8 yr old female and a 1 year old female. Pumpkin is the middle child.

Problem: Pumpkin has vomitted off and on since 4 mths old and after a recent blood test, the Vet proposed a possible indication of cancer.

History When pumpkin was 4 mths old, he was very sick. He would throw up and have diarrhea. When we took him to the VET, he was given Metamucil (which did no good) and was later put on Metronidazole after it was determind he had Giardia. While on Metronidazole (for about 5 days), his vommitting stopped. He was finally given some Giardia medicine and After about 3 months, he was cured of Giardia.

However, his vomitting continued to occur off and on and we took him to the vet to determine if we could find out what was wrong. The Vet proposed Hyperthyroidism at the age of 9 months. So we had lab tests performed and about $500 and 2 months later, it was determined that his blood levels and thyroid were normal. This left us and the vet with question marks circling our heads. At this time, when he was about 1 year old, we decided to take matters into our own hands. The advice we had gotten from our vets was useless. We began examining what kind of foods was he eating when he threw up. We came across an ingredient in almost every food- CORN and CORN products. Almost all the Commercial brands had some kind of corn in it. Even Iams and some of the others had corn or corn starch.

To make a long story short, we finally came across NUTRO for dry food and Walthem`s for wet food that had no corn in it. Immediately upon eating this his vommiting stopped from several times a week to 1-2 times every other week. But we wanted to try and get to te botom of this problem.

At the age of 1 year and 3 months We had a allergy test performed which was $150 waste of our money. The allergy test we felt was inaccurate. The things the test said he could eat, we knew he would throw up if we gave it to him. The said he was not allergic to certain name brands, but during our trial and error, he had thrown up those name brands. So we were very upset and frustrated with our vet and all the tests we had done. So we abandon the search for a "cure" for about 8 months. Living with Pumpkins occasional "accidents".

But last month, we decided to try again. We went to a different clinic this time. We asked the doctor to do x-rays and a blood test to determine if anything obvious could be found. The doctor`s exam showed everything normal other than a observation that his kidneys were small. The x-rays showed no obvious problem. THE CBC however is what I am writing about today.

CBC: FCV IFA Negative Heartworm Negative

everything was normal except these items: Bloodcount Normal Range WBC 11.6 3.5-16 RBC 5.2 5.92-9.93 HGB 7.3 9.3-15.9 PCV 23 29-48

Magnesium 2.7 1.5-2.5 Albumin 2.0 2.5-3.9 CACIUM 11.2 8.2-10.8

BOTTOM LINE:

The Vet we talked to was not too concerned except for the ELEVATED Calcium levels. She stated that high calcium was associated with Cancer. perhaps Lymphosarcoma. We would like a 2nd opinion. To do a endoscope costs $1200.

Our cat is in generally good health. His spirits are high, he likes to play with his sisters and is still affectionate. We are monitoring when and why he would throw up But we don`t have enough data to report at this time. In the last 3 weeks he has thrown up 4 times. all 4 times due to either grass or corn in the wet food. (at least that is our hypothesis) When we keep him away from grass and corn, he does vomit less..

Please answer this question and advise your thoughts from an educated vet. Our Vets in Texas have been less than reliable.

HOW CONCERNED SHOULD WE BE ABOUT AN ELEVATED CALCIUM LEVEL? IS IT CANCER? WHAT OTHER THINGS COULD CAUSE ELEVATED CALCIUM LEVELS?

Before we spend $1200 we want your opinion and more information. At this time we are inclined to monitor his vomitiing and to do a new blood count in about 2 months to see if the calcium and blood count levels go up or down.

Any info you can provide, would be of a great help.

Sincerely, Douglas

Answer: Doug;

This is an interesting case history.

Vomiting and diarrhea that start at a very young age can be perplexing. Even though we always hope for a fairly easy to treat cause, like worms or giardia there are lot of kittens who do not respond to treatment for these organisms. This was still a good way to start the search for an answer, though.

Food allergies are a problem in some cats with vomiting and/or diarrhea. As you have discovered, allergies are usually to a specific ingredient, or a few limited ingredients, rather than a whole food. The only test for food allergies that I have much faith in is feeding a limited antigen diet, using a protein source the kitten has never been exposed to before, and seeing what happens. This is why there are exotic diets on the market featuring things like duck, ostrich and venison for cats. It is hard to find a meat source that doesn`t show up in some commercial cat food. This diet needs to be fed for at least six weeks to judge its effect. If the problem resolves during this time, then a food allergy is likely. To confirm the allergy, or allergies, specific foods may be added back into the diet to assess the response to them. If you add corn back and the problem returns, then corn is a good suspect. Most people actually skip this step and just stick with the limited antigen diet that works well, but it is a way of confirming the problem. Blood tests for food allergies are pretty much a waste of time and money, as you have discovered.

I am not sure why your vet would suspect hyperthyroidism in a kitten, since that would be very unusual, but I have convinced myself that stranger possibilities than that existed, so I don`t want to be too critical. In any case, it isn`t surprising that your kitten has normal thyroid function at this age.

Calcium levels in cats can be a little frustrating to evaluate. Usually, when the albumin level is low, the calcium level will also be low, because calcium moves through the blood stream attached to albumin (bound), except for a small portion that is freely available (unbound). This free calcium can be checked using an ionized calcium test. This test is a good idea but it can be hard to arrange for. Blood shipped to a lab may not have the same ionized calcium level when it gets there that it had when it left the clinic. For this reason, ionized calcium testing is best done using an in-clinic instrument, like an iSTAT, that most veterinary clinics don`t have. If there is an emergency clinic in your area they might have one, though. Getting a second calcium sample, preferably a fasting sample, would be a good idea if you can`t have an ionized calcium sample checked. Rechecking the calcium level and protein levels (total protein and albumin) would also be a good idea. It is best to be sure the calcium level increase is a real finding.

If the calcium is elevated, what does it mean? Unfortunately (only from a lab test standpoint), there are some cats with elevated calcium levels all their lives who are not affected by it and who don`t have an identifiable problem causing it. Other cats with high calcium levels do have one of the problems that leads to it. In cats, ingestion of plants or rodenticides that increase calcium levels is possible but not too likely. Cancers can lead to increases in calcium levels. The most likely cancers to cause this effect are lymphomas, which often are an intestinal cancer, and anal sac adenocarcinomas. High calcium due to these cancers is more common in dogs than in cats but it has been documented to occur in cats.

The low protein levels and mild anemia are suggestive of an inflammatory bowel disease, although they can occur with kidney problems and liver problems, as well. They can also occur with intestinal parasites, so rechecking stool samples could be justified.

You didn`t mention whether Pumpkin has been tested for feline leukemia virus. This would be a really good idea prior to doing endoscopy, since FeLV often leads to lymphoma. In many cases the lymphoma occurs in other places (like the thymus) rather than the intestines, but this would still be something to consider. A positive FeLV test might make it unnecessary to do the intestinal biopsy.

I would want to look for other causes of anemia, too. It would be a good idea to determine whether this is a regenerative anemia (one the body is trying to respond to) or a non-regenerative anemia (one the body isn`t responding to). The major cause of regenerative anemias in cats is probably hemobartonellosis, caused by a blood parasite. Non-regenerative anemias occur with chronic disease, kidney failure, liver failure, FeLV and several other conditions.

To sum up this note, I think that I would be more worried, or as worried, about the anemia as I would be about the calcium level. I would want to find out if the anemia is non-regenerative, or regenerative. If it was regenerative I`d want to rule out hemobartonellosis because that would be life threatening. If it was non-regenerative it would be supportive of a chronic disease. I`d want to be sure feline leukemia virus was not the problem. Then I`d really want to know what was going on in the intestines. If the cost of endoscopy was a concern, I would be willing to take intestinal biopsy samples surgically, as this would be less costly (at least it would cost less than $1200 in my clinic) and is more accurate when looking for intestinal lymphoma, anyway. I am sometimes more aggressive in this regard than many vets. It is probably a little safer for the patient to do endoscopy, though. So that is something you have to figure in to the equation. If lymphoma is still suspected, but not confirmed, after endoscopy, you may still be facing surgery to get full thickness biopsy samples, though.

If I felt comfortable that the anemia was due to chronic illness and not due to hemobartonellosis or something else I could treat, if I was pretty sure FeLV was not a problem and if I couldn`t find any evidence of lymphoma or other cancers after checking anal sacs, palpating the chest and abdomen and taking chest X-rays and I had used up a client`s financial resources to get to that point, it would be easy for me to make the decision just to treat for inflammatory bowel disease and see what happened. I would even be willing to wait and see what happened without treatment, comfortably, for a cat that was vomiting less than once a week. But that is because I practice in a rural area and am faced with this exact decision fairly often.

If treatment does seem necessary, I like to use prednisone for a couple of weeks and see if there is a big improvement. If there is, then I try to stay with this for a couple of months and then slowly withdraw it. If the problem stays away, that`s great. If it doesn`t, then I am willing to use corticosteroids long term. If there is no response, then it really does seem more necessary to go with endoscopy or other biopsy methods. It is probably better, from a strictly medical standpoint, to do the biopsies first. But a lot of my patients wouldn`t get any treatment if I insisted on that order.

Hope this helps with your thinking. I didn`t mean to compete with the length of your question!

Mike Richards, DVM 3/30/2000

Vomiting and diarrhea that start at a very young age - with anemia - continued

Question: Thank you Dr. Richards for your response. Your thorough knowledge of the subject is wonderful. Have you thought of making a book?

The FELV turned up negative. Blood parasites and heartworm also negative. If you would like I could fax you the blood test report and dr notes. Our Vet this time, said the cat was "slightly anemic probably due to anemia of chronic disease". But the course of action was not to investigate this, but rather go after the more expensive Cancer possibility. Their note on the Hypoalbuminemia was "may be due to decreased production or increased loss - spec. protein-losing enteropathy" Does this mean anything?

We have investigated introducing corn back into the diet, and he did vomit. You and i think alike in our scientific methods.

Our vets have not been, saying politely, not the best educated. (unfortunately) This is why we were happy to find your web site. It was a miracle!

At this point, we are inclined to monitor his vomiting, determining if it was related to something he ate or because of a possible disease. And to recheck his blood again in about 2 months.

One thing we would like to do is to determine if the anemia is regenerative anemia or non regenerative anemia. 1.How is this discovered? 2.A different blood test? please advise course of action.

As you suggested, I also would like to determine if the anemia is life threatening, related to a disease or not, or these levels improve in next 2 months.

3. How does one determine if the anemia is due to inflammatory bowel disease versus a kidney or liver problem? (by the way, the VET seemed to think these organs were operating normally, but the VET has been wrong before)

My gut feeling is our cat is fine, allergic to corn, and he just occasionally vomits and is something we will have to get used to. (but this could be wishful thinking)

We thank you for your advice. You have been a tremendous help. Please advise how to investigate anemia further so we can take necessary steps. We want to rule out any other possibilities before we subject Pumpkin to surgery or endoscopy.

We will keep you apprised of our progress, as our cat is a mystery...... Best regards, Douglas

Answer: Douglas,

To determine if an anemia is regenerative it is necessary to look for younger than normal red blood cells, which are known as reticulocytes. Getting a reticulocyte count is the first step. Cats form two types of reticulocytes, punctate (older reticulocytes) and aggregate (younger reticulocytes). Normally there are many more punctate reticulocytes than there are aggregate reticulocytes. Looking at the ratio between them can help to determine how severe the need for immature red blood cells is, though. If there are a lot of aggregate reticulocytes the need is probably greater. It is a little harder to be sure of the significance of a cat reticulocyte count than a dog`s, because cat reticulocytes do not become mature red blood cells quickly and so they do not give as good an indication of the current state of the anemia. However, a good reticulocyte response indicates a regenerative anemia. In a cat, if the percentage of reticulocytes among the red blood cells is above 3 to 4 percent it is considered to be strongly indicative of a regenerative anemia. Blood loss anemias are regenerative in most cases, including loss to parasites. Anemia of chronic illness would not be expected to be regenerative.

Unfortunately, I don`t know of a way to determine what chronic illness is present based on the blood smear. You have to keep looking for an illness based on the clinical signs if anemia that appears to be due to chronic illness is present.

I tend to think that something is wrong due to the anemia but it is possible that chronic inflammatory bowel disease, for any reason, including food allergy, could lead to anemia and protein loss.

Protein losing enteropathy is a disorder associated with many inflammatory conditions affecting the bowels. Lymphangectasia is particularly likely to cause hypoproteinemia but I am not sure how commonly this occurs in cats. What happens, basically, is that the intestine becomes inflamed enough that proteins that are normally retained in the lining, blood vessels or lymphatic vessels of the intestinal mucosa are able to leak out into the intestine where they are lost. Usually the albumin and the globulin levels are low but in some cases there is enough antibody formation despite the low total protein to keep globulin levels in the normal ranges. The other likely causes of low protein levels are loss of protein from the kidneys and lack of production of proteins by the liver.

Intestinal biopsy is the best approach to diagnosing the cause of a protein losing enteropathy. Endoscopy is safer for this because low protein levels inhibit healing and that is not as critical with endoscopic biopsies compared to full-thickness intestinal biopsies obtained surgically. However, surgical exploration and full thickness biopsies are more likely to actually provide a diagnosis if the surgeon is experienced in looking for lesions.

Given the relative infrequency of the vomiting, I do not see a big problem with waiting on further biopsies by any method. I would try to figure out the anemia more quickly, if possible, though.

Good luck with this.

Mike Richards, DVM 3/31/2000

Bloody stools

Q: Dear Dr. Mike,

My four year old DLH, Jetty, for several years now, has periodically had bloody stools. The blood is very dark and appears as a small, mucous-like glob at the tail end of her stools. I`d say this appears about once a week, or so. Her stools tend to be a bit on the soft side as a rule. She eats only Iams regular kibble for adult cats ... virtually every time I have tried her on other brands of kibble (introduced gradually), either premium or market variety, she develops totally loose, runny stools.

Jetty is completely healthy in every way. I took her to the vet a few years ago, and they prescribed some antibiotics, which were a waste. I sort of just take this condition for granted, but I want to make sure there`s something I shouldn`t be doing. Thanks!

DONN

A: Donn;

A lot of cats have stools similar to the ones you are seeing. In a cat that isn`t losing weight, doesn`t have periodic bouts of diarrhea and isn`t vomiting more than once or twice a week my inclination is to do nothing for these, once I am pretty sure they don`t have intestinal parasites. Checking a couple of stool samples should be sufficient to rule that out.

It sometimes helps to add a small amount of fiber to the diet if you want to try something, though. About 1/4th tsp. of Metamucil once or twice a day or 2 TBS of canned pumpkin per day is enough fiber to help with conditions that are fiber responsive. Most cats tolerate both of these fiber sources pretty well. If you can find canned pumpkin with cinnamon in it a lot of cats seem to like that. I would only do this if it is easy to do -- if your cat likes the fiber or at least tolerates it well. If the fiber causes any of the problems that switching foods have caused then obviously it isn`t a good idea.

One of my cats does this. She is a picky eater, so I don`t do anything. She is 13 years old and I can`t remember any really long stretch where her stools have been completely normal but she is otherwise doing well and it doesn`t seem to affect her health or lifestyle.

Mike Richards, DVM

Gas and smelly stool

Q:We just adopted an 8 week old kitten. He did not take to the litter box at first but we are making progress and he is using the box. At first his stools were very loose. We switched from canned to dry food and watch his water intake. he has no problems with the kitten dry and drinks adequate water. He gets no milk. He does have lots of gas and his stools are very strong smelling. We thought at first this was due to the canned food as we experienced simular with another cat and when we switched her to dry problem was solved. Is there a common reason for gas and strong smelling stools in a kitten of this age? Should we be on the lookout for health problems? We really like your web pages and have them bookmarked for future reference. Thank you Lin and Clay and BurnOut (its a long story)

A: Lin- The short answer to your question is that I do not know of a specific frequent cause of excessive flatulence in kittens. It was a good idea to restrict milk intake since lactose intolerance is common in kittens and might contribute to any digestive problem.

Things that might help even if a specific cause can not be found:

Treatment for coccidia (not always found on fecal exams). Most vets use a sulfa antiseptic medication for this.

Treatment for giardia even though it isn`t found on a fecal exam. Most vets use metronidazole (Flagyl Rx) or fenbendazole (Panacur Rx) for this.

Restriction to one protein source in the diet (a "hypoallergenic" diet). There are several commercial diets and it is usually OK to feed a kitten a diet made at home with your vet`s advice if necessary, too.

Adding a small quantity of yogurt to the diet. I think th

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