Forums » Feline Medicine

"Martini" - Chronic diarrhea, vomits once a day

    • 26 posts
    January 27, 2014 9:49 AM EST
    Signalment:  "Martini" is a 1 year old, female, DSH
    Complaint:  Chronic diarrhea and vomits once a day
    History:  Found on a farm, is "skinny and sickly," lives 100% outdoors, no other cats in the household
    Diet:  Commercial dry adult cat food
     
    Physical Exam Findings:
    • BCS = 3/9  (Reference: BCS System)
    • Weight = 2.5 kg
    • Distended abdomen - thickened small intestines and gassy
    • URTD (upper respiratory tract disease)
     
    Fecal floatation and direct smear = Negative
     
    Question:  What is your initial treatment recommendation for "Martini?" - be specific - include drug(s) you would use (if any).
     
    a)  Change the diet
    b)  Deworm
    c)  Antibiotics
    • 26 posts
    January 28, 2014 3:52 PM EST

    There's no right or wrong answer, so let me know what you'd do with Martini. The owner isn't interested in testing at this point - "just give her some medication to fix her, doc!"

    • 3 posts
    January 28, 2014 4:16 PM EST

    I would deworm anyway with Milbemax - false negatives are common with faecal flotations and I have to assume that she is exposed to internal parasites by virtue of her lifestyle.  Once now & repeated in 2-3 wks.

     

    How much is the URI affecting her?  Is she appetent? Is she spayed?

     

    Metronidazole (10mg/kg) certainly be a useful antibiotic to tamp down the anaerobes that may be present and producing gas, as well as a treatment for possible giardia.

     

    The URI may be solely viral and, with better nutrition, deworming and a resolution of the diarrhea, may be self-limiting.  Depending on the severity, I may hold off on treating this specifically until the other issues had resolved. If it did affect her, I would consider Baytril (doxy is my first choice for URIs, but may cause too much GI upset).

     

    Diet - wet chicken/rice variety, like i/d or gastro, little & often feeding schedule. Need to feed those villi to get them to heal, without asking too much of them!  I would additionally add in a probiotic to help adjust the bacteria in the gut (Fortiflora or similar).

     

    How'd I do?

    • 26 posts
    January 29, 2014 10:25 AM EST

    Great thoughts!  The initial therapeutic approach taken for "Martini" was:

     

    • Broad spectrum dewormer:  Fenbendazole 50 mg/kg once daily (for 3-5 days as a rule)
    • Doxycycline for the URTD
    * Reference - findings of a study on the treatment of feline URTD reported in Cat Health News from the Winn WINN Feline Foundation (Aug 3, 2012):
    The most common bacterial isolates found in the study population of 48 affected cats were:
    Mycoplasma (n=22) and Bordatella (n=9).
     
    Amoxicillin-clavulanic acid and DOXYCYCLINE proved superior to a single Convenia injection;  Bordatella isolates were RESISTANT to Convenia.

    As for other drug options:Feline URTD - Comparing and Contrasting Antibiotics

    10 days later, "Martini" came in for a re-check:
    • URTD had resolved BUT she continued to have diarrhea with intermittent vomiting
    • BCS = 3/9
    • Weight:  2.45 kg (she lost an additional 0.05 kg)

    What else should we be asking the client regarding "Martini" - thoughts?  Next steps?
     
    • 26 posts
    January 31, 2014 8:42 AM EST

    At this point, I'd like to make mention of the Fecal Scoring System.  It is helpful for better characterizing the patient's stool (instead of words like, soft, loose or liquidy) and can help when making a determination about a patient's response to treatment / management of GI issues.  This helpful guide is courtesy of Nestle Purina:

     


    Back to "Martini" - in questioning the owner further and examining a stool sample provided: 

    • She was given a fecal score = 5
    • The owner reports she passes stool 2-3 times / day
    • No tenesmus
    • No blood or mucus evident in the stool



    At this point, the owner agreed to blood work and abdominal radiographs.  Findings were:

    • CBC - Normal
    • Serum chemistry panel:  Increased ALT - 157 IU/L  (normal = 5 - 110)
    • FeLV / FIV - Negative
    • Abdominal Radiographs - Normal 


    In summary here's what we know about "Martini" to this point:

    • Female, DSH, approx 1 year old
    • Chronic diarrhea
    • Chronic vomiting
    • Normal appetite
    • Weight loss
    • Mild increase in ALT

     

    Question 1:  Does she have small bowel or large bowel diarrhea?

    Question 2:  What are the main rule outs for this patient?

    • 26 posts
    February 3, 2014 10:07 AM EST

    If you think that "Martini" has small bowel disease, you are correct.  For your reference, this table describes characteristics of small bowel and large bowel disease:

     

    As for rule outs, our list of differentials should include:

    • Infectious / Parasitic Disease:  Giardia; Tritrichomonas; Bacterial
    • Gastrointestinal Disease:  IBD
    • Pancreatic Disease: Pancreatitis; Exocrine Pancreatic Insufficiency
    • Hepatic Disease:  Cholangitis

    We submitted a diarrhea PCR panel screening for:
    Salmonella, Toxoplasma, Giardia, Parvovirus, Cryptosporidium, Coronavirus, and T. foetus.
    All were NEGATIVE.
     
    She was prescribed the following:
    - Metronidazole 10 mg/kg BID (for 7-10 day)
    - Probiotic
    - Hypoallergenic diet

    A week later she was back in the office ... she still had diarrhea and vomiting.  Her BCS was 3/9 and her weight was 2.40 kg (she lost another 0.10 kg)

    Question:  What now?  What would you recommend (treatment / additional work-up) for "Martini?
    • 3 posts
    February 3, 2014 10:24 AM EST

    A GI panel would rule in/out pancreatitis and EPI (fPL & TLI)

    If these were normal, I would then be discussing endoscopy or exploratory with the owners to confirm my suspicion of IBD and to characterize it so as to better treat it. Exploratory would be preferable because you would get a better biopsies of the intestines (full thickness) and would also be able to biopsy the liver and pancreas at the same time.  Endoscopy is less invasive, but more limited in its scope.

    If the owners were unable or unwilling to get biopsies, I would have to put the cat on prednisolone as an alternative. 

    • 26 posts
    February 5, 2014 9:01 AM EST

    Great thinking!  :)

     

    GI function testing was done - results are as follows:


    * fTLI = 5.9 ug/L (normal = 12-82 ug/L)

    * Cobalamin = < 110 pmol/L  (normal = 600-1800 pmol/L)

    * Folate = 75 nmol/L  (normal = 27-46 nmol/L)


    Based on history, physical and lab findings our primary diagnosis was made:  Exocrine pancreatic insufficiency (fTLI <8 ug/L).  Inflammatory bowel disease may still be a possibility (concurrently) - recall her ALT is increased.


    From the literature:  a paper on cats with EPI reported by Xenoulis et al in J Vet Intern Med (2012) - in that paper:

    • 150 affected cats, fTLI <8 ug/L
    • Mean age of affected cats:  8 yrs (range 4-12 yrs)
    • 41% female, 59% male
    • Median BCS 3/9
    • 77% had decreased cobalamin
    • 47% had increased folate




    Of note - there are species difference in presentation of EPI:





    Question:  On to treatment: What would you prescribe for "Martini?"





    • 3 posts
    February 5, 2014 9:42 AM EST

    pancreatic enzymes with every meal, 1/4 tsp from memory.  And start B12 injections, 0.5ml weekly 6w then monthly thereafter.  Continue with low residue/hypo diet for presumed IBD.  See what effect this has and then add in metronidazole or prednisolone for IBD if diarrhea not fully controlled with enzymes alone.

    • 26 posts
    February 6, 2014 9:51 AM EST

    Our treatment plan for "Martini" included:

    Pancreatic enzymes with each meal (90% of cats will have a total or partial response) and a 
    canned hypoallergenic diet.

     

    Regarding cobalamin (Vitamin B12) deficiency:
    • Cats are suspectible 
    • It's commonly seen with chronic GI disease
    • Deficiency impairs normal enterocyte function
    • Supplementation with Vitamin B12 injections - 250 mcg/cat SC - is started once a week for 6 weeks then every 1-2 months
    Benefits of B12 supplementation in cats:  weight gain, improved appetite, decreased clinical signs.

    Any other questions or thoughts about this case?