Inflammatory Bowel Disease in Cats 2


IBD and long term use of prednisone in cats Question: Dr. Mike, I have been reading a variety of your responses to people on various topics. I am so happy to have found your site. I have a cat, Pinkie, who was diagnosed with IBD 15 months ago. She was only 2 years old at the time of diagnosis. I rescued her when she was about 10 months old (feral colony). She was not in very good shape: very thin, bad coat and serious URI. With care and good food, she responded quickly, put on weight, and seemed to become a healthy and happy cat. In late spring 1999, she had a bout of diarrhea which cleared up after a couple days of RD. During the summer of 1999, she became sick one weekend. The symptoms were vomiting and diarrhea. Another one of my cats had a milder bout of the same thing. Treatment was fluids and medication for vomiting. Xrays showed no blockage. Bloodtest showed elivated ALT which was deemed to be related to the vomiting. After Pinkie felt better, she continued to have diarrhea. After trying metronidazole, another antibiotic, and lomotil, my general vet sent me to an internal medicine specialist. An endosopy/biopsy indicated IBD. The treatment approach was: 2 weeks on an antibiotic for spiral bacterial in the intestinal track and 1/4 tablet of metronidazole (250 mg) twice per day. I tried switching her from Science Diet Lite to Lamb and Rice (which she didn't seem to like) so I kept her on her standard diet for these 2 weeks. Then: Diet - Duck and Rice Metronidazole 1/4 250 mg tablet twice per day. Prednizone 5 mg twice per day. 2 weeks no response. Increased prednizone to 7 1/2 mg twice per day. 2 weeks very minimal response -- stools were still loose (pudding rather than liquid however) Added 1/2 tablet 2 mg leukeran once every other day. 2 more weeks - still minimal response, possibly some improvement but too slow Changed diet to WD Stools became soft but formed. Over the period of the next year, I was able to reduce the prednizone to 1 5 mg tablet once per day. Stools were stable with intermittent vomiting of undigested food immediately after eating (perhaps 1 time per week or every two weeks). At one point, I tried to reduce the leukeran to once every 3 days, but stools seemed to become softer so I returned to the original dose immediately. Also, one time during the year, Pinkie had an instance of vomiting (not the undigested food -- more like bile) and wet diarrhea. I took her immediately to the vet for fluids and medication for vomiting which resolved the problem quickly. In September, we thought it reasonable to attempt to reduce the prednizone slowly since her stools had been stable for quite a while. I tried 5 mg every 36 hours instead of every 24 hours. This was one week after her annual checkup where she received her FVRCP. After about one week on the new medication frequency, she had an instance of wet diarrhea and vomiting. I immediately took her in for fluids and medication for vomiting. We put her back on 5 mg prednizone 2 times per day. The vomiting ceased, but the stools stayed borderline. At this point, I have her on: 1/4 250 mg tablet of metronidazole twice per day 1 1/2 5 mg tablets of prednizone twice per day 1/2 2 mg leukeran every other day Stools are not great, partly soft/formed with occasional 'muck'. Pinkie seems to feel well. She is slim compared to most housecats and has lost some weight over the past year 8 lbs 3 oz to 7 lbs 14 oz. My vet indicates that she looks good and is not concerned about this right now (it may be a seasonal variation). She poops about 3 times per day. I feel badly because my wish for her to be medication free may have caused me to be too aggressive in trying to reduce her medications. I would appreciate your perspective on the following: 1. I fear that the medications that I am giving Pinkie must be shortening her life. I understand that untreated IBD is worse. What is your perspective on the impact these drugs have on cats' longevity? 2. I recently heard of a new food by Science Diet called ZD (short iminoacid chains) that may be useful in IBD cats . Have you had any experience with this or thoughts? 3. Would you have any thoughts on additional things that I should discuss with my vet as possible courses of action to help Pinkie? I noticed that you mentioned omega fatty acid and tylosin in another response. I once administered tylosin to kittens that I was fostering -- is this the powder that is difficult to mix and tastes terrible? I would not want to stress Pinkie out over medications. She is very easy to pill at this point. Thank you in advance for your time and attention. Answer: Betts- I think that it is pretty hard to tell if the long term use of prednisone, Metronidazole or chlorambucil will actually shorten the life span of an individual patient but I think that these medications have that potential. Prednisone's major side effects in cats are weight gain, increased susceptibility to diabetes, decreases in immune system function making secondary illness more likely, muscular weakness with long term use and secondary effects on other conditions that develop during the cat's lifetime, such as cardiomyopathy or kidney failure (doesn't cause these problems but can make them worse). For cats that don't develop diabetes and aren't exposed to other contagious illnesses, there may be no effect on life span. From the standpoint of comfort prednisone is a toss-up. Many human patients don't like side effects such as a bloated feeling, mood changes, increased urination and thirst, etc. --- but often tolerate these effects to get the benefits, if their particular disease condition warrants it. Metronidazole is pretty safe for long term use, with one exception --- it may lead to cancer in some patients with long term use. This has been noted in humans and rats (I think -- one of the lab animals, anyway) but has not been shown to occur in either dogs or cats, for sure. However, it is reasonable to presume that there is a small risk of inducing cancer with long term use of metronidazole. It seems to me that the comfort provided is often worth that risk, but it is something that has to be considered when using metronidazole long term. Chlorambucil has been used long term in many feline patients and if it doesn't cause specific side effects, such as bone marrow suppression, its use appears to be reasonably safe long term. I have not seen a list of problems other than bone marrow suppression in cats, but there can be liver damage, kidney damage or damage to the cilia lining airways with long term use of this medication in humans. Except for bone marrow suppression the side effects are reported to be rare occurrences. We have not used z/d (tm) diet in our practice, yet. That is not because we have no plans to do so, it is just that it is a new product and we have just gotten ordering information on it. We have used HA (tm) diet, which is a similar product made by Purina. These products contain hydrolyzed proteins (sort of like partially digested proteins) which are altered to make all proteins small enough that they do not stimulate the immune system. In theory, these diets should not be able to cause an immune system response and so they should work well to rule out the possibility of a food allergy. Using novel protein diets (lamb/rice, duck/potato, salmon/rice, etc) was the "old" way to rule out food allergies. These new hydrolyzed protein diets probably will be better for this. I do not know how palatable the z/d (tm) diet will be for cats, but we have had some resistance to HA (tm) diet in the dogs when we have tried to use it. If Pinkie will eat the diet it is worth a try. There have been some articles that suggest that the omega n-3 fatty acids (found in marine fish oils) may be beneficial for inflammatory bowel disorders. We have tried these in a few dogs and cats (around 5 to 10) over the last few months and two or three of the owners felt it helped a great deal. The rest either saw no improvement or an increase in diarrhea (one cat). These are also included in the hairball formula foods, I think, and we have had a bunch of cat owners tell us that the Hill's hairball diet has worked well for their cats. In fact, we usually advise trying this diet (or similar ones from other companies) first in inflammatory bowel disease cases, now. Remember when making any dietary changes to get your vet's advice and to make changes very gradually, though. Lower fat diets, like w/d (tm) diet, have also helped some of our patients in the past so I'm not sure I'd change an approach that was working, although it would be good to get off at least one of the immunosuppressive medications (prednisone or chlorambucil) if possible, so it might be worth thinking about. Tylosin (Tylan Rx) is hard to administer because it is a powder that tastes bad, and consequently we usually use it as a last resort. About once a year we have a patient we use it in and some of them do respond to the medication, though. So we continue to think about it as a possibility when other approaches don't work out. Hope this helps some. Mike Richards, DVM 11/19/2000 IBD and Diarrhea Question: My 11 year old cat (Otto) was diagnosed with IBD last february after two months of a lot of vomiting, diarrhea, and unanswered questions. He was having diarrhea approximately 2x per day for about two to three weeks and then started vomiting several times a day. Through it all we treated him with streoids, fluid packs, and metronidazole (?). The metrol. on several occasions worked for awhile but within a week or so, after the diarrhea was mostly under control, he began to experience spells of spastic vomiting (20-30) times in 2 or 3 hours. This happened on numerous occasions. The vet treated him with a medicine to calm the spasms and then he would be okay for 2-3 days or even a week. (FYI-He always started the spastic vomiting in the middle of the night between 3:00-4:00am) At this time the diarrhea would start up again! Eventually, we ran tests on his blood chemistry panel and his pancreatic function. His amylase count was elevated by multiples of 100 and his liver and kidneys also showed worrisome results. We could find nothing to treat exactly and the sickness was getting worse. The symptoms were worsening in both severity and frequency. He was vomiting blood, was listless, and the diarrhea was continuing. We decided to do exploratory surgery. The surgery and biopsy revealed that Otto was suffering from IBD with secondary liver, kidney, and pancreas diseases. There was necrotic tissue on the duodenum. My vet felt that the secondary conditions would resolve as the IBD was controlled. The cat was put on Metrol. 2x/day, Urisodiol 1x/day, and Prednisone 2x/day for approx. one month. The gall bladder was also "expressed" while he was in surgery. The medications seemed to control the symptoms and we cautiously reduced the dosages to 1x/day after several weeks. These medications are still given to Otto daily. The cat has also been eating Purina NF for two years or so and this Rx diet was maintained and still continues. The problem is this: for approximately 6 weeks now the cat has had diarrhea 1-2 times per day and it has not responded to his medications despite increasing the dosages. The vet first tried a sulfa antibiotic 1x/day and when it was clear it was not effective, now an antibiotic called Tylan powder 2x/day. He has been on the Tylan for approximately one week and the diarrhea does not seem to be resolving. It is occurring sometimes once and sometimes twice per day. There has not been much concurrent vomitting. He seems healthy, to have maintained weight, is drinking/eating/sleeping/playing as usual. The only change was that just about the same time the diarrhea recurred is when my cats and I moved into a new and fairly stressful environment. By this I mean that there is a cat already living in the home who doesn't like my older cat (Nigel) and this requires some juggling of who gets to raom and when. Otto and the resident cat get along fine but I suspect Otto feels stressed by the whole environment. Unfortunately, I need to be here for an indefinite period of time. My vet and I are stumped. We are going to try a novel protein source which will be avail. in October (ZD?). If that doesn't work I think we are both at a loss. What do you recommend? Have we overlooked something? And is it harmful for the cat to have this type of chronic diarrhea or just a nuisance to me? He always makes it to the box so I am really just worried about the implications of bowel irritation and possible colon cancer, etc. Any help/advice you have to offer will be greatly appreciated! Sincerely, M Answer: M- The answer to your last question is that diarrhea that does not cause a change in attitude or weight loss, can often be tolerated with no detrimental effect on the cat. However, since there is often a progression over time to a condition in which weight loss, depression or other chronic illness occurs, it is a good idea to try to continue to make a diagnosis. Just in case, this is some additional information that might be helpful. There is a condition in older cats, sometimes referred to as "triad syndrome" or "triaditis", in which pancreatitis, cholangiohepatitis ( a liver disease) and inflammatory bowel disease occur at the same time. This seems to have some sort of immune mediated origin in many of the cats and it can be very difficult to treat. It sounds like you and your vet have done well to get Otto stabilized and to the point he is at now. Tylosin (Tylan Rx) is an antibiotic which can be helpful in some cases of inflammatory bowel disease and also is helpful when bacterial overgrowth occurs as a complication to the IBD. An antibiotic more specifically helpful in IBD is sulfasalazine, although it has to be used at lower dosages than in the dog (usually 10 to 20mg/kg every 12 hours in cats). Other antibiotics may have to be used, depending on the severity and location of infections that occur in conjunction with the IBD, pancreatitis or cholangiohepatitis. It is sometimes necessary to use supplemental medications along with prednisone to control IBD. Chlorambucil is usually used in cats because it seems to have less potential for adverse side effects, but another option is azathioprine, which does sometimes have bad effects, so the severity of the IBD has to be considered before deciding to use this medication. When prednisone stops working or won't control the problem on its own, these are additional options. The most commonly recommended diets are low residue diets (such as Eukanuba Low Residue (tm)) or limited antigen diets (one protein source). However, the new hydrolyzed diets, such as z/d (tm) offer an option that might even be better, although it is hard to be sure at this time. Once in a while, it seems to help to give cats with these problems ranitidine (Zantac tm), usually 3.5mg/kg of body weight. This medication is usually used for megacolon problems but will sometimes help with diarrhea for other reasons. This part of this note isn't logical, nor is it common advice from vets treating IBD -- it is just something we think helps sometimes. I think this is especially true when stress does seem to be part of the problem. Cancer is a possible problem but if it didn't show up in the biopsies and wasn't visible on the exploratory laparotomy, it is less likely to be a problem. Good luck with this. You and your vets and Otto really have done well, so far, considering the severity of the clinical signs at times during Otto's illness. Mike Richards, DVM 10/5/2000 IBD and problems getting Muffin to eat now Question: I am a new subscriber to your service. My 8 year old tabby Muffin has been diagnosed with IBD (inflamatory bowel disease) in February of this year. She is under the care of a vet and receives cortisone injections when she is bad and prednisone tablets (5 mg per day). She had a complete blood work up and x-rays and was healthly. The cortisone at that point completely solved the problem and she would stop vomiting and continue eating. However, as time went on and as a result of this condition, she has turned into an extremely finikey eater. The injection she last received was August 11th. (her last injection before that was May 27th) She did very well and was scheduled to resume her pills on August 25th. Starting around the 23-24 she became very finikey, to the point that I had to force feed her baby food lamb. The following week she was no better and on August 31st she had not urinated for over 24 hours. I rushed her to the vet, he expressed her bladder, there was no obstruction, no high levels of white or red blood cells but a higher level of protein which my vet said suggested a uniary tract infection. He gave her a shot of antiobotics and cortisone and prescibed an antibotic called "celptabriog" (don't quote me on the spelling, I am trying to read his writing). Following this she urinated on her own Thursday afternoon, urinated and deficated Friday (9/1) morning and urinated Friday night. On Saturday morning she ate almost a whole can of Fancy Feast Turkey, however she vomited about 5 hours later, brown liquid. After that she became even more finikey, which given the fact that she had received the shot, this should not have been. I force fed her baby food lamb in a syringe, she would eat only small servings of cat food and some chicken (table food). She did not urinate again until Sunday at 4 am and Sunday again refused all food except about 1/4 of a 3 oz can of Iams Lamb and Rice. At the suggestion of an vet emergency person, I gave her Baby Food Chicken which she said was blander than the lamb. It is now approximately 3:45 am on Monday, she ate some table chicken which I cooked for her. She again has not urinated. One vet, and many of my friends think this is just being finikey. She is not lethergetic. She will not drink water, because as a wet food cat she has basically always ingnored it. What are your thoughts? I am concerned that she might be hypersensative to the Fancy Feast (which I would have never started her on, had I known that it was so rich). I am getting a little desparate. Until she started with this problem six months ago, she was a cat that loved to eat and except for some allergy problems only went to the vet for her yearly check up. I would greatly appreciate your help. Answer: L- In an eight year old patient who requires prednisone daily and is not even responding well to that, at this time, I really think pursuing a diagnosis is a good idea. It isn't unusual for veterinarians to treat for suspected inflammatory bowel disease (IBD) without definitively confirming the diagnosis. Continuing to treat intermittently, or through dietary control that works, seems reasonable to me. However when medication must be given continuously, it is better to back up a step and try to figure out for sure what is going on. There are other approaches to figuring out what is going on, such as trying an elimination diet for food allergies, tapering off the prednisone and trying other medications, such as metronidazole, to see if it helps and checking for systemic illness such as liver disease, kidney problems, feline leukemia, feline immundeficiency virus and other possible contributors to reluctance to eat. If these things don't provide a strong clue to the origin of the eating problems, the process gets a little more complicated. I tend to refer my patients needing a work-up for inflammatory bowel disease to an internal medicine specialist, because it is usually necessary to do an ultrasound or endoscopic exam, or both, to diagnose this condition and then identify the cause. Biopsies can be taken during examination with an endoscope and it is possible to make a definite diagnosis of the problem from these biopsies much of the time, but not always. It is important to try to differentiate intestinal lymphoma (a form of cancer) from other causes of IBD in patients with signs similar to Muffin, if possible. So it is worth the effort to get biopsies, even though there is a chance they won't be diagnostic, since you also get the internal medicine specialist's (or endoscopist's) opinion about what was seen. I think that the signs you are seeing are serious enough to warrant this sort of work up. Your vet can assess the overall situation better than I can, though. When you and your vet disagree about the seriousness of a problem it is a good idea to consider a second opinion, at least, though. Mike Richards, DVM 9/10/2000 Inflammatory bowel disease Question: Dear Dr. Mike - Following a colonscopy and intestinal biopsy, my six-year-old cat was recently diagnosed with inflammatory bowel disease. The vet reported that her colon was so irritated that it was "cherry red." Her symptoms included blood in her stool, some lethargy, and significantly increased volume of stool. The stool was also a bit softer than usual. My cat has been through tremendous changes in the past year including the sudden loss of her litter mate, the adoption of a fairly aggressive kitten, and the surrender of her former dominant position to the kitten. She did, however, experience some digestive problems prior to all the changes -- including one bout with acute Pancreatitis. She is a sweet, sweet cat but fairly skittish. As for diet, I feed her Iam's less active dry food and 1/2 ounce of wet food (Fancy Feast Tuna or Iam's ocean fish). I would prefer to avoid a lifetime of medication for her. Is there a treatment you would recommend? I thank you in advance for your help. Mimi Answer: Mimi- There are some things that you can do that might make it possible for you to avoid long term use of medications to help your cat. One thing you need to do early in this process is to see if you can get a more specific diagnosis. Inflammatory bowel disease is a name that is applied to a group of conditions that affect cats and sometimes, but not always, it is possible to plan treatment alternatives or at least better understand the prognosis of the condition, by getting a more exact idea of what the particular cause is. If the pathologist who examined the biopsies was able to give a more specific diagnosis it may be in the report. The best hope for avoiding at least long term therapy is if this problem is a food allergy. We always hope for these, since it is possible to control the problem by avoiding the offending food ingredients that lead to the allergy. To test for food allergies it is necessary to feed a completely novel protein source, and only this one protein source, for six to eight weeks. An example would be to feed duck or rabbit as a protein source IF your cat hasn't had these in its diet previously. Your vet can help you design an appropriate testing diet and explain all the details. The single hardest part of food trials is that you must control what your cat eats completely and there can't be any cheating on the diet. This makes it impossible for some people to even do the testing, so it isn't an option for all cats. But when a food allergy is identified, it does make it possible to avoid long term control through medication. A few cats also respond to higher fiber, or lower fiber, diets. Higher fiber seems to work more often, so that is the usual starting recommendation. This helps food and other stuff, like hair, move through the digestive tract more easily and cuts down some on irritation. If you are lucky, it cuts down enough to resolve the problem. That doesn't happen all that often, though. It is OK to add fiber to the diet your cat prefers by adding Vetasyl (tm) or some other fiber source like Metamucil (tm). Other cats respond to omega (n3, n6, more towards n3) fatty acid supplementation. These are available as food supplements, such as DermCaps (tm) and OmegaDerm (tm). They don't help all cats and it is best to get the symptoms under control (especially diarrhea) before starting these medications. We have an occasional cat who will respond completely to two to three weeks of metronidazole therapy and not require further therapy. We also have a fair number of cats who respond sufficiently well to metronidazole that we can use it on an "as needed" basis and not use other medications. We have used tylosin (Tylan Rx) in a small number of cases, on a regular basis, as well. It is an antibiotic and if it doesn't cause vomiting the side effects seem minimal. When it is clear that only immunosuppressive therapy is going to work, it is usually best to bite the bullet and give this for at least three months before trying to cut back on the dosage. Then it is OK to try to cut the dosage back gradually. Sometimes, a relatively short course, like this, of corticosteroids, will suppress the IBD symptoms for a long time. Other cats do require protracted, or even lifelong, administration of corticosteroids, though. If this happens, the goal is to use the least possible dose and the longest possible dosing interval -- so try for every other day, every third day, etc. I really do think that the stresses of life can induce some of these problems and that the cases where this has happened might be the most likely to respond to therapy. One other consideration is that inflammatory bowel disorders do become self-perpetuating and also sometimes seem to spread to other areas of the digestive tract (occurring in conjunction with pancreatitis and cholangiohepatitis) so effective treatment, even though it is difficult, may help to slow or prevent the escalation of clinical signs or spread to other related organ systems. Hope this helps some. Mike Richards, DVM 2/20/2000 Inflammatory bowel disease (IBD) likely Question: Hi Dr Mike! My cat Bosco, age 6, has his share of health problems. First, he has a history of FUS (1997 & 1998). Second, Bosco has had a regular habit of vomiting (1x-2x a month). However, my vet attributed this type of vomiting to eating food too fast. It really similar to a regurgitation because the food was not digested and it would happen within a few minutes of eating his food. Third, during a routine checkup in 1998, my vet detected a heart murmur. A heart specialist performed an ultrasound and his study showed a mild sub-aortic stenosis due to hypertrophic cardiomyopathy (congenital). Since then, Bosco has been on 1/4 of a 2.5 mg. tablet of atenolol and Hill's senior diet. The good news is that last month, his yearly follow up ultrasound showed no signs of a heart murmur and all parameters improved. Now for the current problem. Bosco started vomiting 6 days ago. This time the vomit was digested food in a yellow-greenish bile. He lost his appetite, although he shows interest in food. His behavior is normal. His coat looked slightly dry and ratty. I tried to feed him baby food (turkey) but he only lapped up less than 1/2 teaspoon. Vomiting continued each day so I took him to the vet (2 days ago) and they took a blood test, a urine test, administered fluids (he was slightly dehydrated), and gave him a vitamin B-complex and Vitamin C injection and his temperature was normal. The blood test came out normal with no indication of kidney or liver problems. Since his visit to the vet, he has twice vomited small amounts of yellow-green bile and still not eating his regular food. My vet now wants to perform X-rays and some sort of test where they watch the digestive system in process to see if there is any blockage. My question to you is how far does one go with all these expensive testing procedures (over $300) when my intuition tells me that Bosco just has an upset stomach (gastritis). This morning he started to eat a little. I was able to feed him approx. 1 tablespoon of the baby food. Shouldn't we be treating for gastritis first, then if it fails, consider testing? What procedure vs. price justification should a vet consider for treating a stomach/intestinal problem? Do you have any thoughts as to what Bosco may be suffering from? Thank you in advance. Jackie Answer: Jackie- It is important in cats to get them back to eating as quickly as possible when they have a problem that makes them stop eating. Cats can induce liver disease (hepatic lipidosis) simply by not eating. So I understand your vet's desire to try to find a cause for the problem and correct it. I am not sure that X-rays using a contrast material or BIPS (barium impregnated capsules) is the thing I would do first, but that would depend on what I found during the physical exam. There may be a reason that your vet thinks an intestinal blockage is likely. He or she should be willing to explain why this is the first test that seems necessary, though. With the history of occasional vomiting, I would be worried about Bosco having an inflammatory bowel disease (IBD) problem that has worsened over time and led to the current situation. The best way to diagnose IBD and to differentiate between the various causes of it, is to endoscopic exam of the digestive tract. However, I do think that it is reasonable, when there is no contraindication based on lab work or physical exam, to try a short course of metronidazole to see if there is an improvement in the cat's condition. I do not know of any interaction between metronidazole and atenolol. Sometimes, probably when the cause of inflammation is bacterial overgrowth, this treatment will resolve the problem for a long time. Most of the time it is just helpful in giving an indication of whether to look for IBD or for other problems. It is often necessary to use cortisones or other immunosuppressive agents for long term control of inflammatory bowel disease. This would be a major concern with a previous diagnosis of hypertrophic cardiomyopathy, though. Our experience has been that corticosteroids can make cardiomyopathy symptoms much worse. If over time this does appear to be IBD and medication does seem necessary, it would be a really good idea to discuss proposed medications with the cardiologist prior to using them. Whatever else goes on, it is very important to get Bosco back to the point where he is eating satisfactorily. You will need to work with your vet to get to that point, but it is OK to ask why procedures have been proposed and to ask about alternatives. Your vet should be willing to discuss these things with you. Sometimes I have to tell a client that I just have a "gut feeling" that one approach is better than another. If that is the situation, you will just have to decide to go with your vet's plan or go with your own gut feelings. It can be a tough situation but you have to live with the consequences so it has to be your choice. Good luck with this. Hopefully he is eating now and this is resolving on its own. Mike Richards, DVM 4/15/2000 Inflammatory bowel disease symptoms, Thyroid testing Question: Hi Dr. Mike, I have a 17 yr old female cat named Topaz. She had an increased appetite for the last 6 months (approx.) and when I took her to the vet, suspecting feline hyperthyroidism, all her blood work was more or less normal, except for some elevated white blood cells. Her heart rate was also normal. The vet said she probably had inflammatory bowel disease, since her intestines felt hard and thickened. The increased appetite is due to her not being able to absorb enough nutrients. She prescribed metronidazole and prednisone. They seemed to help a little, but now they're finished and she seems to be doing poorly again. She eats OK, but doesn't beg for food like before. When she's not eating, she sits or lies in one chair most of the day and night. Her fur is getting a bit matted, and she's very bony. After she eats I can hear her stomach (intestines?) gurgling and squeaking. Her stools seem normal, except I have seen blood in them sometimes. Also, she refuses to use the little box for her bowel movements, and goes near instead of in it. I am worried that she is in pain. How can I tell? The vet said she may have cancer, but it's an expensive process to diagnose and treat it, and we just don't have that kind of money right now. Lately her pupils have looked dilated, and as I said she only gets out of her chair when it's time to eat (3 times a day). If she's not sleeping she just kind of stares into space a lot and purrs. It doesn't seem like a happy purr, though. When she's hungry, she will come upstairs if necessary (slowly) to tell me it's time to eat. I don't want her to suffer. Should I be considering euthanasia? How will I know when it's time? Dr. Mike, this is causing me a lot of heartache, please answer soon. Thank you very much, A. S. Answer: A.S.- It may be worthwhile to run a free T4 test, just to see if it is too high. This test can sometimes help distinguish a thyroid level that is too high for a particular cat but which still falls within the normal range. We have seen several cats in our practice whose total T4 levels (the usual value tested for) were well within the normal range, who had hyperthyroidism based on T3 suppression testing (most accurate but probably more expensive) or on free T4 testing using the equilibrium dialysis method of testing. There is some concern about free T4 levels rising in kidney failure and possibly some other conditions so it has to be thought of in conjunction with other clinical signs. Your vet is right that there are other possibilities and it is sometimes pretty easy to tell that inflammatory bowel disease is present based on intestinal palpation (or at least to get a pretty good indication of it by that). Intestinal lymphoma, a cancer, is fairly common in cats and is considered to be one cause of inflammatory bowel disease symptoms. The best way to diagnose this is intestinal biopsy and it is somewhat expensive to get biopsy samples of the intestine, no matter now it is done. I don't think of any of these conditions as painful but all are probably uncomfortable. The dilated pupils concern me, because this can occur with hypertension (high blood pressure) as a secondary problem when hyperthyroidism or kidney failure are present. Kidney failure should have shown up in the lab work and therefore is less of a concern. Hypertension leads to retinal hemorrhages which are visible on an ophthalmic exam so this is something else to think about asking your vet about. I honestly think that most cats and dogs can communicate to their owners the point at which they are miserable or in pain. I really think you will be able to tell when your cat is at this point. But just in case, stopping eating is a good sign of depression or severe illness and is often the first sign that a situation is becoming grave. Topaz will probably give you stronger hints than that since you seem to be in tune with how she feels. I would not euthanize a cat of mine if I could not treat hyperthyroidism. It is a serious illness, it will eventually cause death but most cats just don't seem to feel bad enough, to me, to make me think about euthanasia until late in the illness. It is hard to be certain of what might be going on. A good physical exam, including a look at her retinas and feeling for thyroid gland enlargement would be a good recheck step -- and then you just have to decide whether to pursue further testing, or not. Doing further thyroid testing might be worthwhile since it is less expensive and less hard on Topaz than trying to get intestinal biopsy specimens. Hope this helps some. Mike Richards, DVM 10/22/99 Inflammatory bowel disease Q: I have a male cat about 12 years old. For the past couple of years he has suffered with IBD severely. He was first diagnosed in Raleigh at the vet. hospital / school. He was put on a diet of IAMS Lamb & rice (canned) and takes antibiotics, sometimes predniosone(sp.) and 1/4 pepcid ac. Right now he is taking the antibiotics and pepcid. He vomits alot sometimes reddish like blood. At one time he had diarrhea passing blood as well. He weighs approx. 13 lbs now. At one time he weighed nearly 20 lbs as he is a tall cat, large bones. He eats several times a day (like 10 maybe) not alot at one time just a bite or 2. Does this aggravate this disease? Is there any advice you can give me to help with it? Any help at this time will be eternally grateful. He is a inside house cat and I love him very much. It really tears me up to hear and see him sick. Thank you. Barbara A: Barbara- Eating small meals frequently probably does not cause problems with inflammatory bowel disease. There are several possible causes of this condition and they respond to different treatment approaches. It would also be good to consider checking, or rechecking, for hyperthyroidism given the weight loss that your cat is experiencing. Inflammatory bowel disease that is due to food hypersensitivities often will respond to feeding a "single antigen" diet. This is a diet that has only one protein source, preferably one that the cat has not eaten previously. Meats such as duck, venison and even ostrich are used to try make sure that the cat has not been exposed to the diet previously. Your vet can help find a suitable diet if you want to try this approach. Increasing or decreasing the fiber in the diet helps some cats with inflammatory bowel disorders. When intestinal lymphoma is present cortisones are often helpful. It would be good to try to determine what the underlying cause is, if that has not been done. The vets at NC State may already have an idea of that so it may be best to contact them for advice. Good luck with this problem. Mike Richards, DVM Inflammatory bowel disease Q: Dear Dr. Mike, I really enjoy your website. Thank you for bringing such a great resource to us pet owners who want to be better educated about the health of their faithful companions! My 12 year old cat has been blessed with good health thus far. In the last year, she has developed one symptom which concerns me. She intermittently leaves a spot of blood and mucus on the floor. It originally occurred maybe once every week to two weeks. It was literally just one drop, and it was a varying mixture of blood (sort of clot-like, or varicose-vein looking), mucus, and occasionally some really smelly, runny stool. She left it in all sorts of places, and I think she didn't realize when it was happening to her, because she once did it on my arm as I was holding her and she was just purring away. I first took her to my regular vet. He felt her abdomen and took X-rays, but didn't find anything. He examined her rectum with his finger and said there was nothing unusual there. He said her anal glands were normal and everything else as far up as he could feel. He listed my options as being 1) to do nothing and wait and see if it worsens or disappears, or 2) to get an endoscopic exam from an internal medicine vet. He gave me a couple of references in my area. I decided to wait a little bit. Over the next few months, the condition persisted. It didn't get worse or better. I called my vet sometimes to update him and brought her there another time or two. Still there was nothing that he could find. The strange thing is that she is entirely normal - happy and apparently healthy - in every other way. Nothing unusual about her eating habits, exercise, or stool. I took her to another vet who had the same results. He recommended one other option before going for the endoscopy. He gave me some antibiotics as a more conservative treatment first, in case it was some sort of bacterial thing. This was not easy to do with my cat (getting her to swallow pills). Actually, it was impossible. I would have tried harder, but the vet said that this was just something to try, that there was no hard evidence that this would help, and so not to traumatize her. I finally decided to take her to the vet. of internal medicine. By this time, her stool seemed to be a little softer and smellier than normal, but not extremely so. This doctor was recommended by both vets. She listened to my story and discouraged me from getting an endoscopy. She thought it to be a rather extreme procedure given the symptom. Although she thought it might be inflammatory bowel syndrome, she indicated that it is a slow-developing disease, and that it would surely be in the early stages. She suggested trying to get more fiber in her diet. So, since March or so, I have been giving her 1/4 to 1/3 a teaspoon of metamucil every day. I have had to start giving her wet food in order to get her to eat it. It seems to be less frequent, but I still see it perhaps once a month or so. Her stool is still pretty soft and smelly. I don't know if the wet food would counteract the extra fiber or not. Do you have any other ideas of what these symptoms may be caused by or any better of an idea of where to look? Should I be taking more aggressive action in treatment options? Are there any other treatment options? Please advise! I can't bear to think of her getting irreversibly ill because I didn't follow up on the signs she was giving me. Thank you for your time, Erika A: Erika- I do not have any better ideas as to what might be going on. Your vets all sound like they have done pretty well in ruling out possible problems and then giving reasonable advice. Giving the Metamucil with wet food doesn't harm its effect and may enhance it since the fiber works best after absorbing water. I have had patients with very similar symptoms and can not recall ever really knowing what the cause was except for one cat that had a lump or polyp that eventually protruded a little from her rectum. It was easy to identify and to remove after it made itself apparent. I can't remember the other cats really getting into trouble due to this problem, either. It sounds like you are doing pretty well with the decrease in frequency. If the symptoms become more frequent again the best course of action would probably be to call the specialist and see if the changes make her more inclined to do the endoscopic exam. I wish I could help more than this. Mike Richards, DVM Inflammatory bowel disease Q: My cat has problems with his stomach so I have to keep switching his diet but one major hurdle at a time I guess. Some foods he throws up right away, others he does okay on for a week or two before vomiting. My old vet mentioned it might have something to do with an irritated stomach. Have you ever heard of that? Thanks for your thoughts! Joyce A: Your vet may have been referring to inflammatory bowel disease in your cat. This is a condition that is pretty common in cats and causes vomiting on an intermittent basis. Sometimes it will worsen and the vomiting occurs on a nearly continuous basis. In general, I think it is a good idea to consider making a sure diagnosis and treating this condition if the vomiting is happening more than once or twice a week. Mike Richards, DVM Inflammatory bowel disease and urinary tract problem Q: My cat's a (beautiful!) 7 yr old domestic longhair. Fed Iams dry for 6 yrs, then started doing 1/2 Iams and 1/2 canned. Developed a urinary infection 6 months ago, on antibiotics for a month. Was on W/D, now on 1/2 Iams & 1/2 Science Diet Feline Maintenance. Gave her Petromalt, threw up a hairball, now 4 days later is still throwing up. Eats little, throws it up later with dry heaves too. After second day, she drank a lot of water and threw it up in about 1 minute. Spent $250 at vet, no answer yet. Detailed blood work all normal. No crystals in urine, some white cells, am waiting for results of culture. On Baytril now. The day before I gave her Petromalt she had just finished a 2 week course of Cefa from another vet I took her to for a check since she had dribbled urine once but wasn't straining or showing any other signs of any problem. I feel like I KNOW something's still wrong, but I don't know how to find an answer. How can I get her to stop throwing up and keep some food down? She's been using the litter, so she must be keeping some water down somewhere. Can you help? Thank you! A: You may have two problems going on at the same time with what you describe. The urinary tract problem may be cystitis, bladder stones, bladder cancer, incontinence or may relate to problem encouraging urine production (although most of those, like diabetes and kidney failure) would show up on normal labwork. This problem may be under control at this time based on the history you gave. Vomiting is sometimes associated with urinary tract disease in cats but that isn't the most common cause. Inflammatory bowel disease is the most common cause of chronic vomiting in older cats and hyperthyroidism is the second most common cause, probably. Neither of these diseases show up well in labwork because the values all tend to be normal. Some blood panels do include T4 levels, which can indicate hyperthyroidism if they are elevated. Not eating can lead to hepatic lipidosis. Cats with this condition often have nearly normal lab values on routine test panels, too. It may take a couple of visits to your vet to sort through these possible causes of the symptoms you are seeing. Please continue to work with your vet to resolve this problem. Mike Richards, DVM Last edited 03/12/04


Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...