chronic vomiting in cats - mississauga oakville...
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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?