chronic vomiting in cats - mississauga oakville...

Chronic Vomiting in Cats

Jinelle Webb DVM, DVSc, Dipl ACVIM

Is a vomiting cat normal? l  At my house – maybe? Or maybe I should

attend my own lecture. l  Cats do tend to vomit more readily than dogs

l  Hairballs l  I ate too fast l  I ate too slow l  I didn’t eat l  I ate too much

l  But is this really normal?

But it’s just a hairball!! l  Some longer haired cats may truly just

consume too much hair when grooming l  Or…..

l  Skin disease l  Food allergies l  Intestinal disease l  Motility disorders l  Behavioural abnormalities

JFMS 2013 M. Cannon

Categories of Causes Primary GI Causes l  Parasitic or Infectious Disease l  Neoplasia l  Inflammatory disease/Food allergy l  Intestinal dysbiosis l  Gastric ulceration/erosion l  Motility disturbances l  Gastric outflow obstruction

Categories of Causes Extra-GI Causes l  Pancreatic disease l  Hepatic disease l  Endocrine disease l  Systemic infectious disease l  Neoplasia l  Parasitic lung/vascular disease l  Acute/chronic renal disease l  CNS disease

Initial Diagnostic Steps

l  Detailed history and physical examination l  When does vomiting occur? l  What does it look like and does this vary? l  Is there ever blood present? l  Has there been any recent changes in diet, feeding

routine, household, new pets, new plants? l  Is there weight loss? Diarrhea? Straining to

defecate? l  Changes in energy levels? l  Changes in drinking/urination?

Initial Diagnostic Steps

l  CBC, biochemical profile and urinalysis l  Total T4

l  Fecal examination l  fPL or similar l  +/- TLI, cobalamin, folate l  +/- Heartworm test, FeLV/FIV testing l  FIP testing???

Imaging

l  Abdominal radiographs l  Suspicious of foreign body

l  Abdominal ultrasound l  Gastrointestinal disease l  Hepatic disease l  Pancreatic disease l  +/- Renal disease l  Abdominal neoplasia

How Useful is Ultrasound? l  Assessment of gastrointestinal tract

l  Stomach, intestine, ILEUM, cecum, colon l  Gastrointestinal masses l  Associated lymphadenopathy l  Thickness of gastrointestinal wall (stomach, areas of

small intestine including ileum, colon) l  Thickening of muscularis propria l  Irregularity, change in echotexture, change in layering l  Possibly assess motility – peristalsis, presence of

gastric food after prolonged fasting

How Useful is Ultrasound?

Normal SI Thickening of muscularis propria

How Useful is Ultrasound?

l  Assessment for abdominal neoplasia l  Discrete or multifocal masses l  Lymphadenopathy

l  Assessment of pancreas l  Enlargement, change in echotexture, irregularity l  Nodules, masses, cystic structures

l  Assessment of liver l  Size, echotexture, assessment of gall bladder

How Useful is Ultrasound? Normal Pancreas

Chronic Nodular Pancreatitis

Chronic Nodular Pancreatitis

Next steps l  Symptomatic treatment

l  Antiemetic l  Gastroprotectant l  Diet change l  Laxative/Hairball remedy

l  Endoscopy and biopsy l  Imperative to get duodenal samples, ideally get

ileal samples l  Exploratory laparotomy and biopsy

l  Sample the GI tract, pancreas, liver, LN

Next steps l  Make sure you have ruled out some

other causes: l  Hyperthyroidism l  Renal Disease l  Parasitism l  Foreign Body l  CNS disease

Endoscopy l  Assess the oral cavity, esophagus, stomach,

and duodenum l  Ideally perform a lower GI endoscopy to

evaluate the colon and obtain ileal biopsies l  If endoscopy is visually normal (which is often

is), obtain at least 12 samples from each site l  If endoscopy is not visually normal, obtain at

least 12 samples from each normal site, and also samples of abnormal area (submit in separate formalin jar)

Surgery/Laparoscopy

l  Assess the entire gastrointestinal tract, liver, pancreas, lymph nodes

l  Biopsies of all of these areas, aerobic and anaerobic cultures of liver, gall bladder

l  Consider the status of the patient l  Geriatric cats, consider preoperative IV fluid

therapy l  May take longer to recover than the average

patient

Pros and Cons - Endoscopy

l  Minimally invasive, especially in geriatric vomiting cats with co-morbidities

l  Reduced cost to owners l  Can start therapy right after procedure and

biopsy results (steroid therapy, chemotherapy) l  Do not obtain samples of jejunum l  Do not obtain samples of LN, liver,

pancreas (assess for triaditis)

Pros and Cons - Surgery

l  Can obtain samples of jejunum l  Can obtain samples of LN, liver, pancreas

l  More invasive, especially in geriatric vomiting cats with co-morbidities

l  Increased cost to owners l  Cannot start therapy right after procedure and

biopsy results (steroid therapy, chemotherapy) l  Laparoscopy can also be considered

What if I have normal biopsies?

l  Causes of chronic vomiting with normal biopsies l  Intestinal dysbiosis l  Dietary intolerance l  Chronic idiopathic vomiting (but did we miss the

cause?) l  Patchy disease (IBD, neoplasia, etc) l  Undiagnosed systemic disease

What about equivocal results? Lymphocytic IBD versus small cell lymphoma l  Recent study - 2016 JSAP l  Findings suggest that if histologic diagnosis is

lymphoma, no further testing needed l  Many cases with histologic diagnosis of IBD

actually have early small cell lymphoma l  PARR (clonality) testing in all diagnosed IBD

cases? l  Even PARR can have false negatives

Main Disease Processes l  Inflammatory Bowel Disease/Food Allergy l  Small Cell Lymphoma l  Chronic Pancreatitis/Cholangitis Age Dependent Disease Processes l  Foreign Body l  Infectious (Parasites, FIP, etc) l  Neoplasia

Inflammatory Bowel Disease l  Different types classified by main inflammatory

cell present l  Lymphocytic-plasmacytic l  Eosinophilic l  Pyogranulomatous

l  Main causes l  Genetic susceptibility l  Intestinal microbial dysbiosis l  Food allergy

Inflammatory Bowel Disease l  Therapy varies but usually includes one or

all of: l  Dietary modification l  Anti-bacterial treatment l  Immunosuppressive therapy l  Vitamin B12 supplementation or monitoring l  Probiotic/fecal biotherapy

l  Minimal objective data on efficacy l  Staged approach recommended

Lymphocytic-plasmacytic IBD l  Most common type l  Typically start with dietary modification l  Some cases managed long term with diet +/-

symptomatic therapy (Cerenia, famotidine etc) l  Severe, non-responsive or hypoproteinemic

cases will require immunosuppression l  Prednisone/prednisolone (and vitamin B12) l  +/- Cyclosporine, Chlorambucil

l  Some difficult to differentiate from lymphoma

What to do with LP-IBD Dx l  Recommend PARR clonality testing l  Consider symptoms and signalment (is there

weight loss, is the cat older) l  Consider pre-biopsy use of steroids l  Consider degree of inflammation and mucosal

disruption l  Use a pathologist that you trust l  Consider prednisolone and chlorambucil in

severe LP-IBD cases

Eosinophilic IBD l  Second most common type l  Rule out parasitism, hypoadrenocorticism l  Most <5 years age l  More common in dogs l  Mucosal erosion and ulceration l  More likely to present with hematemesis,

melena and/or hematochezia

Eosinophilic IBD

l  More likely to require multimodal therapy l  Prophylactic deworming in all cases l  Mild cases can try dietary modification alone l  Some cases managed long term with diet +/-

(Cerenia, famotidine etc) l  Most cases will require immunosuppression

l  Prednisone/prednisolone (and vitamin B12) l  +/- Cyclosporine, Chlorambucil

Pyogranulomatous enteritis

l  Feline infectious peritonitis l  Would expect to find other evidence of FIP

l  Granuloma formation l  Nodules in other organs l  Ascites l  Pleural effusion l  Nodules along peritoneal and/or pleural cavity l  Nervous system inflammation

Small Cell Lymphoma l  Very common in older cats l  May only see weight loss l  Can have normal ultrasound findings l  Occasional mesenteric lymphadenopathy l  Commonly see thickened muscularis propria l  Occasionally can have SCL in liver, etc l  Diagnose with surgery or endoscopy (ileum!)

Small Cell Lymphoma

l  Much different prognosis than large cell LSA l  75% of cats with gastrointestinal lymphoma

have lymphocytic (small cell) lymphoma l  70-90% response rate for SCL, <20% response

rate for large cell lymphoma l  Median survival time (MST) of 2 years for SCL,

MST of 2.7 months for large cell LSA l  Treat with prednisolone and chlorambucil l  Rescue with cyclophosphamide

Pancreatitis/Cholangitis l  Any age of cat, either gender l  Underweight, normal weight, overweight l  Lymphoplasmacytic is most common form l  Lethargy, anorexia, and dehydration l  Not linked to getting into garbage, high fat

foods, etc l  66-75% with cholangitis also had pancreatitis l  Possible link to bacterial cholangiohepatitis

Pancreatitis/Cholangitis l  Pancreatitis/cholangitis difficult to diagnose

l  fPL l  Ultrasound l  Biopsy (especially cholangitis)

l  fPL sensitivity l  100% in severe pancreatitis l  80% in moderate pancreatitis l  65% in mild pancreatitis l  25% of normal cats had an elevated fPL

Pancreatitis/Cholangitis l  Ultrasound

l  80% sensitivity in moderate to severe pancreatitis l  Less so in mild pancreatitis l  Often normal in cholangitis

l  Typical changes l  Hypoechoic pancreas or liver, nodules l  Hyperechoic mesentery l  Dilated common bile duct, thickened gall bladder

wall l  Normal appearance

Pancreatitis/Cholangitis l  Cholangitis, and intestinal inflammation,

commonly occur with pancreatitis (triaditis) l  Typical blood work changes

l  Neutrophilia, mild thrombocytopenia l  Increased ALT, ALP l  Increased bilirubin l  Mild hyperglycemia l  +/- Hypoalbuminemia

Causes and Diagnosis l  Bacterial (suppurative inflammation) – less

common for chronic cases l  Immune-mediated (lymphocytic-plasmacytic

inflammation) – most common l  Neoplastic – often small cell lymphoma l  Biopsy required

l  One study indicated only 48% agreement through Tru-cut biopsy and wedge biopsy

l  Higher risk to Tru-cut livers of cats l  No ability to sample pancreas

Therapy l  Dietary modification l  Anti-bacterial treatment l  Immunosuppressive therapy l  Probiotics/Fecal biotherapy/Vitamin B12 l  Antiemetics/Gastroprotection l  Analgesia/Fluids l  Ursodiol l  Antioxidants l  Appetite stimulation

Dietary Therapy l  Fewer carbohydrates l  Highly digestible protein sources l  Can try either Gastrointestinal Diets or

Hypoallergenic Diets l  Many choices – Issue of palatability with cats

l  Rayne l  MCRC l  Balanced home cooked

• Purina •  Iams • Hill’s

Which Disease? l  Inflammatory bowel disease

l  Hypoallergenic diet l  Some cases respond to gastrointestinal diets

l  Cholangitis/cholangiohepatitis l  Gastrointestinal diet? l  Liver diet not indicated unless failure present

l  Chronic pancreatitis l  ????????????????????????? l  Gastrointestinal diet? Lower fat?

Anti-bacterials

l  Broad spectrum for possible bacterial cholangiohepatitis

l  Antibacterials for IBD with concurrent diarrhea l  Metronidazole

l  Antimicrobial and immunomodulatory

l  Tylosin l  Antimicrobial, may be immunomodulatory

Immunosuppression l  Glucocorticoids

l  Most frequently used type l  Prednisone/prednisolone drug of choice

l  2 mg/kg q 24 hours x 2-4 weeks, then taper slowly l  Give with food, and gastroprotection at high dose

l  Main side effect is potential to transition into overt diabetes mellitus in pre-diabetic cats

l  Dexamethasone can also be used (0.25 mg/kg q 24 hours starting dose), and in some cases causes remission in refractory cases

Immunosuppression l  Budesonide - Locally acting nonhalogenated

corticosteroid l  High hepatic clearance, resulting in high local and

low systemic activity l  Useful in cases that are very sensitive to prednisone,

or contraindications such as diabetes mellitus l  Highly effective in some cases, other cases have

little to no response l  0.5 – 1 mg PER CAT q 24-48 hours, usually not

tapered

Immunosuppression l  Chlorambucil

l  Most commonly used in cats l  Side effects

l  Vomiting, inappetence, diarrhea, bone marrow suppression

l  Several dosing protocols l  2 mg PO q 48 hours (large cats) l  2 mg PO Mon/Wed/Fri (small cats) l  2 mg PO q72 hours (very small cats) l  20 mg/m2 every 14 days

l  Monitor CBC

Immunosuppression l  Cyclosporine

l  Induces rapid immunosuppression l  Side effects in up to 50%

l  Vomiting, inappetence, diarrhea, alopecia, gingival hyperplasia, idiosyncratic hepatopathy, opportunistic infectious disease

l  5 mg/kg PO q 12-24 hours l  Expensive l  Should avoid certain formulations

Vitamin B12 (cobalamin) l  Vit B12 deficiency causes ill-thrift, poor appetite l  Suggestion that having high normal to mildly

elevated levels may be beneficial to GI health l  Many dosing protocols

l  We use ~20 ug/kg weekly for 4 weeks, then monthly

l  Can otherwise monitor levels l  Less common to have folate deficiency, not

usually supplemented

Probiotics l  Live microorganisms that can confer a health

benefit when given in sufficient quantity l  Use supported in human/mice studies

l  Newborns in developing countries l  Antibiotic associated human diarrhea l  Positive response in human IBD l  Improved immune response to Giardia in mice

l  Minimal information on effectiveness for cats l  Can also perform fecal biotherapy

General antiemetics l  Maropitant

l  Antiemetic, reduces visceral pain l  1-2 mg/kg q24h PO or SQ, usually 3-5 days but can

be given longer if needed l  Ondansetron

l  0.5-1 mg/kg q12-24h PO or IV

l  Metoclopramide l  Likely less effective in cats l  0.2-0.5 mg/kg q8h PO, SQ or IV (CRI)

General GI protection l  Famotidine or ranitidine

l  0.5 mg/kg q12h PO, IV or SQ, q24h in renal failure

l  Omeprazole l  1 mg/kg q24h PO

l  Sucralfate l  2-3 ml total PO q8h

Analgesia/Fluid therapy l  Buprenorphine 0.01-0.03 mg/kg IM, IV, or

buccal q6-8h l  Fluid therapy

l  IV if dehydrated, substantial vomiting, pre-anesthesia for endoscopy or surgery

l  SQ if hospitalization not needed l  Caution in geriatric cats in case of subclinical

heart disease

Ursodiol/Antioxidant l  Cholangitis cases

l  Ursodiol 10-15 mg/kg once daily PO with food. Likely will need to have compounded, may need to gradually increase dose to full amount

l  Cholangitis and/or pancreatitis cases l  Antioxidant therapy

l  Zentonil Advanced/Denosyl l  Hepatosupport l  Vitamin E

Mirtazapine l  Cats with a reduced appetite

l  Mirtazapine 2 mg per CAT PO every other day (once daily if normal kidneys?)

l  Caution if heart disease and hypotension

l  Caution in renal/hepatic cases – recommendations are to monitor parameters while using

Prognosis l  Dependent on cause l  Dependent on response to treatment l  Dependent on owner compliance l  Difficult to monitor improvement in most cases

other than through clinical response, unless there were lab work changes present

Questions?