Triad Syndrome in Cats

"Triad syndrome" in cats

Question: I have been a subscriber for several months and am so glad! I would appreciate it if you could give me some information about the "triad syndrome" in cats. My cat, Gizmo, was suspected to have this condition in 1997 when he had a bad case of diarrhea with gas. He was on actigall, baytril and flagyl for several months. This past May he suddenly stopped eating and playing (for Gizmo, playing "Kitty tease" is the most important thing ever, followed closely by food). He was given an injection of depo medrol as well as a vitamin injection, neither of which seemed to help. All we could get him to eat was tuna fish. He was then put on cyproheptadine to stimulate his appitite, which I have to say worked wonders - he couldn't get enough to eat, but it made him very edgy. He was also given reglan. He is fine now, we give him laculose about twice a week and he is on Select Care HiFactor, both canned and dry, which is very high in fiber. He has a bad habit of eating carpet - he will dig and pull at it until little strings stick up which he then will chew on. We use tape wherever he's been working-until he finds a new place. This is something Gizmo has always done and nothing seems to be able to dissuade him. The triad syndrome was mentioned when he first got sick and pancreatitis as a possiblility the second eposide. An x-ray of his lungs showed signs of asthma, possibly as a result of heart worm years ago. He tested negative for heart worms and has been on HeartGuard for the past five years.

Gizmo is ten now and at his first senior wellness exam, his blood work was high in blood sugar, but two tests since then have been normal.

There's no rush for this information, as he's doing well now. I just have not been able to find out anything about this condition, other than in passing mention. I really appreciate the time, caring, and effort you make allowing people to email you questions and your thoughtful, indepth answers. I don't know how you find the time, but I'm glad you do! Also, your monthly newsletter is really great - I look forward to it each month, and am learning more every time I get one.

Thank's much! Joan

Answer: Joan-

There are a couple of things to think about with Gizmo's history. My wife and I attended a continuing education seminar this month on infectious diseases in cats and the speaker (Dr. Lappin from CSU) said that they were finding that roundworm migration was causing some of the cases of lung changes and clinical signs resembling asthma in cats. This would correlate some with our experience that some cats who we deworm with fenbendazole or ivermectin stop coughing even though we thought their problem was asthma. It might be worth trying this, especially since there are both asthma and gastrointestinal signs in Gizmo's history.

Triad syndrome is the name used to describe the occurrence of pancreatitis, inflammatory bowel disease and cholangiohepatitis at the same time, which seems to be a fairly common problem in older cats. It has only recently been recognized as a syndrome and there isn't a lot of information on why it might occur or on what the relationship is between the three conditions that causes them to occur concurrently.

Pancreatitis is hard to confirm in cats. Just about the only sure way is to have a biopsy of the pancreas. I don't know of anyone who really pushes hard for pancreatic biopsies, though. These are more likely to be done when exploratory surgery to obtain intestinal or liver biopsy samples seems like it might be helpful in making a diagnosis -- so there is an opportunity to also get pancreas samples.

Inflammatory bowel disease (IBD) is not always easy to confirm, either. It is best diagnosed with biopsy samples, as well. These can be obtained during an endoscopic examination or during exploratory surgery of the abdomen, if that seems necessary. Ultrasound examination sometimes indicates thickening of the intestinal walls compatible with IBD. The most consistent clinical sign of IBD in cats is persistent vomiting but weight loss, decreases in appetite and diarrhea can also occur. Dr. Lappin felt that some cases of suspected IBD actually were infections with Cryptosporidium bacteria which can sometimes be identified through microscopic examination of fecal smears when special staining (acid fast staining) is used. Most of the time IBD is pretty responsive to corticosteroids, including methylprednisolone acetate (DepoMedrol Rx) but not always.

Cholangiohepatitis can be acute (early infection) or chronic. If there is an increase in liver enzymes in lab work, or if a bile acid response test indicates a problem, cholangiohepatitis is more likely. Sometimes there are mild elevations in total bilirubin or in gamma-glutamyltransferase (GGT) levels when other liver values are normal. Confirmation of the diagnosis is only possible with liver biopsy specimens. These can sometimes be obtained with a needle guided biopsy without doing more invasive surgery but it may be necessary to allow a surgical exploration of the abdomen and sampling of the liver to obtain a diagnosis.

The surprising thing about this triad of pancreatitis, IBD and cholangiohepatitis is that a lot of cats with this syndrome have very little change in lab values and may not have severe enough clinical signs to make their owners worried, despite the risk to their health and even their life if the disease continues unchecked. Usually there will be a point in the disease when it causes enough changes in the lab values to be detectable. Slight increases in liver enzymes and mild anemia seem to be the most common lab findings and it may take several samples over the course of a few months to a year or so for these changes to show up. We think that if you find an indication of any combination of two of these disorders it is probably best to assume that all three are present and to treat accordingly.

I am not sure what the overall experience with this condition is but we seem to see improvement with low levels of corticosteroids, administration of ursodiol (Actigal Rx) and antibiotic therapy when it seems appropriate.

Due to the ease of administration and the safety, it seems reasonable to consider giving fenbendazole (Pancur Rx) orally for three to five days to try to rule out roundworm irritation as a contributing cause to the problems seen. It may also be reasonable to think about using an antibiotic such as metronidazole (Flagyl Rx), tylosin (Tylan Rx) or doxycyline to try to rule out a bacterial infection of the digestive tract. Your vet can help you decide if these things are worth a try.

Mike Richards,DVM 10/29/2001

"triad syndrome" liver disease, pancreatitis and inflammatory bowel disease occurring at the same time possible in older Siamese

Question: Dear Dr. Richards,

Thanks so much for providing this service. I can see that it must be a terrible drain on your time, and so am doubly appreciative that you are willing to help people like me.

I have been reading about the risks of long-term steroid use, particularly the effect on the immune system, and intend to discuss the pros and cons of continuing my cat's prednisone treatment with the vet. But before I do, I was hoping that you might give me an opinion. I am sorry to write you such a long and complicated e-mail, but I want to include everything which might be relevant. The details are as follows.

For the past 4 months Spider, my 15-year old, neutered male, Siamese, indoor cat, has been on Prednisolon, which I presume is the same as prednisone. Presently I give him 1.25 mg twice a day, orally. He is 3.11 kilos (approx. 6.84 pounds). The vet prescribed Prednisolon to help Spider gain weight and stop vomiting.

Prior to beginning the treatment Spider appeared in relatively good health. He was active and grooming, etc., but I was concerned about his thinness and the fact that he eats so little. Blood tests, including for thyroid, done about 6 months ago were normal. Over the past 4 years Spider's weight has dropped from 4.5 to 3.11 kilos. Unfortunately I don't know exactly how much he eats because there is another cat in the house and I am not always home to see who has eaten what. But when I'm around he eats very little compared to what he used to eat 10 years ago, and compared to what the other, overweight cat, 13.5-year old female cat eats. Over the past few years he has become a very fussy eater...or perhaps I have made him into one with my anxiety and efforts to find something...anything... he'll eat. Since he occasionally crunches dry food, I presume he does not have a tooth problem. I can't tell if he is eating more since he started prednisolon. Unfortunately I do not have an accurate reading of his weight prior to starting this treatment. But my guess is that his weight is stable since beginning the prednisolon. I have just now bought a suitable scale and will take weekly readings.

I should mention that he gets very excited about meal times, so I presume he is hungry (or is this habit?), but often he just licks his food or has a bite. Sometimes he nips me, which I believe indicates hunger.

Vomiting of undigested food has gradually increased in frequency over the past 4 years to about 3 times a week. After vomiting, he often heads to the food bowl. To my surprise, after beginning the prednisone treatment, the vomiting which had gone on for years stopped. It seemed a miracle. However, he suffered restlessness, sleeplessness, increased activity, and became a complainer/yowler. Dose was decreased from 5 mg to 2.5 mg per day and these side effects decreased but did not disappear. But at least he sleeps the night now. If I try to decrease the dose anymore, e.g., by reducing it by 1.25 mg every second day, the vomiting returns.

Other info: Spider wants to eat grass which causes him to vomit (although this is not the cause of the vomiting I am referring to). He has had a hard stool for the past few years...likely due to the fact that he eats so little and hence there is nothing to push it out. I give him lactulose and psyillium when I can. I have read your website and thought that he might be suffering from inflammatory bowel disease, however he has no diarrhoea, which I believe is one of the symptoms of this condition. I sometimes think he sounds congested in his sinuses, but there is no discharge.

More history which may be relevant: About 2.5 years ago x-rays showed 5 nodes on his lungs, near the heart. Ultrasound, biopsy, etc. did not reveal the cause, so the vet in Canada, where I was at the time, recommended exploratory surgery in Aug. 99. After administration of 2 pre-op drugs (Torbugesic? and Glycopyrolite?), and while he struggled in fear as they tried to insert a catheter, he stopped breathing. He then had cardiac arrest and was resuscitated. While in intensive care on oxygen, IV, etc., he then suffered respiratory failure a few days later. By a miracle he pulled through. During his recovery I had to force feed him with a syringe for several weeks. He finally started eating again, but his appetite since then, has always been poor. Re. the scheduled surgery, he never received anaesthetic and was never operated on for lung nodes. To this day I don't know what they are. The vet had no satisfactory explanation for his expiry on the pre-operation table, but I am sick when I think of what this poor animal went through. And since I wonder if fear had something to do with what happened, I wish to keep stressful vet visits to a minimum. An X-ray of approx. 1 year ago revealed that the nodes remain the same and have not grown. However, they make me nervous and I am aware of his fragility. Since then, I am told that he has a heart murmur.

Despite this, Spider is active and interested in things. He grooms himself, interacts, etc. He certainly does not look or act like he has any serious problems.

MY QUESTIONS: * Given his medical history, and his unknown lung problem, is the predenisone dose he is on a risk for the long term? Particularly re. the immune system. * Which is more dangerous for him? Vomiting and being painfully thin and probably undernourished with regards to essential vitamins and minerals, or the side-effects of prednisone? * Based on what I've said, do you know why he might vomit? * Do you think I could rule out IBD given that he does not have diarrhoea?

This cat means everything to me and I am so worried that I am not doing the right thing for him...and perhaps am even making his situation worse. I would appreciate any comments you might have, based on your experience.

Many thanks, Monique

Answer: Monique-

Inflammatory bowel disease in cats will often cause vomiting but no diarrhea. In Spider's case, with the history you have given, I would worry some about a condition sometimes referred to as "triad syndrome", in which liver disease, pancreatitis and inflammatory bowel disease occur at the same time. The reason that this came to mind was that many cats with this condition seem hungry when they approach food but then won't eat it consistently. Liver disease sufficient to cause cats to have a variable appetite sometimes occurs without rises in the liver values that are commonly tested for (ALT and alkaline phosphatase). Pancreatitis is very hard to diagnose in cats without making a special effort. It can be diagnosed in some cats by ultrasound examination, in some cats by elevations in trypsin-like immunoreactivity (TLI testing) but in many instances it can only be conclusively diagnosed with biopsy of the pancreas, which is a surgical procedure. To be honest, we often treat for this condition without making a diagnosis, because it seems more reasonable than doing surgery.

Older Siamese cats are pretty prone to kidney failure and it can be a good idea to give potassium as a supplement, as it seems to help with appetite and may even help prevent the progression of kidney disease to some degree. If there is normal lab work for kidney values such as blood urea nitrogen (BUN), creatinine and phosphorous levels, it may be unnecessary to worry about this possibility, though.

When we suspect chronic pancreatitis we try to use a low fat diet. There are several commercially available low fat diets for cats in the U.S. but I have no idea what diets are available in Germany. Waltham makes a similar diet, though. This can be very helpful.

When we think that inflammatory bowel disease is more likely, we try three different dietary approaches. We start with the low fat diet approach because when it helps, it usually helps quickly, causing a noticeable difference within a few days. If it hasn't helped by about ten days of use we try one of the new diets used to control hair ball formation in cats. These have added essential fatty acids and are really made to treat IBD, since it is the most common cause of "hairball" formation. Usually we try these diets for several weeks to guage their effect. Finally, if these things don't work, we try limited antigen diets. These are diets that have a protein source that the cat has not been exposed to in the past. There are diets that contain proteins like rabbit, venison, duck, alligator, ostrich or other meats that aren't commonly in cat foods and there are diets that contain hydrolyzed proteins (broken down) that are not capable of causing allergic responses. Either approach is OK. We try these diets for 12 weeks before giving up on them. If dietary approaches aren't helpful, then we use medications long term and prednisone or prednisolone (these are essentially identical because prednisone is converted to prednisolone in the body) often work best. Other things that might help are methimazole (Flagyl Rx), tylosin (Tylan Rx) or sulfasalazine (Azulfidine Rx). These are antibiotics that seem to help in some cases of IBD.

If liver problems seem likely, the addition of ursodiol (Actigal Rx) is often helpful. If only liver disease is present a moderate to low protein, but very high quality protein, diet may be helpful. In the U.S. the only diet that I know of marketed for liver disease is Hill's l/d diet.

It seems like you work well with your vet, which is a good thing because it may take a while to sort through the possible problems and it will take some teamwork to get to the best possible solution. If you keep working at this you should be able to keep helping Spider, though.

Mike Richards, DVM 7/7/2001

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 immediatly 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 occassional 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 accross 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 thay shaved her. I took her to the emergency clinic beacuse 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-

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