Forums » Feline Medicine

Chronic Feline Pancreatitis

    • 44 posts
    May 1, 2014 1:27 PM EDT

    I have an ~11 year old, male neutered DLH that has had chronic vomiting (several times per month) for a year or so. I recently notice some weight loss. CBC/Chem/T4 in late January were normal (except for an ever-so-slightly elevated lipase - 214 (0-205)). Ultrasound in February revealed MILD wall thickening in the intestines (normal architecture), with no other abnormalities. Primary differential: inflammatory bowel disease (obviously cannot rule out GI neoplasia).
    Switching cat to i/d significantly improved vomiting (~once a month now).

     

    Going forward to now, cat has lost an additional ~0.5 pounds. As of 4/25/13, chemistry and CBC normal again (mildly increased cholesterol - 286 (75-220)). Cobalamine WNL - 713 (290-1500) and folate WNL - 11.8 (9.7-21.6).
    TLI WNL - 50.1 (12-82)
    PLI SIGNIFICANTLY ELEVATED - >51 (0.1-3.5)
    Ultrasound findings on April 23: Pancreas appears thickened along side, with an enlarged pancreatic duct; bowel loops have prominent wall layering; 2 mildly prominent mesenteric lymph nodes.

     

    Major differential at this point is of course pancreatitis, but I know that pancreatitis can be secondary to (or concurrent with) other GI disease, so my plan is to (hopefully) try to get biopsies at some point.

     

    HOWEVER ... 2 days after the ultrasound, patient began acting depressed with decreased appetite. I was able to localize pain to the left maxillary canine, and there's quite a bit of gingivitis over there. No pain or discomfort on abdominal palpation. I'm going to have a dental performed on this coming Thursday, May 8 (with dental rads). P responded well to buprenorphine (only had to use it once). I was using clindamycin liquid (until we can get the dental performed) at ~16 mg/kg q24h for the past 3 days, but ever since starting the clindamycin liquid I've been seeing coughing (usually after administering meds, but a few times during the day as well). Lung sounds are perhaps SLIGHTLY harsh, but the lung sounds are homogenous throughout, so I think it may just be in my head. I'm going to discontinue the clindamycin and see if switching to clavamox changes anything.

     

    I know that the depression/pain can be due to pancreatitis as well, but the cat had never acted painful before (except when he had a tooth fracture about 5 years ago), and this maxillary canine tooth looks pretty painful right now. Pending biopsies, what should I do for long term management of the pancreatitis? Is Hill's i/d sufficient? Use buprenorphine for painful flare-ups? Is there anything else I should be doing?


    Thanks for reading through all of this,
    Steven

     

    EDIT: UA on 4/28/14 was unremarkable except for 1+ protein. It was a cysto sample with no abnormal sediment, but USG was 1.059 so I'm not too concerned about 1+ protein.


    This post was edited by Steven Edwards at May 2, 2014 2:08 PM EDT
  • May 2, 2014 9:39 AM EDT

    Because of the weight loss and spotty appetite, Dr. Edwards, I think an esophagostomy tube is going to be key to your boy's recovery. Place it when you remove the tooth. Antibiotics rarely are necessary for dental cases as removal of the source of infection is usually curative. My patients think Clindamycin is an attempt on their lives and despise me for it! Once you can make sure adequate protein and calories are in play, you have some time to get to the bottom of things. Cerenia is a great tool for nausea and pain. It may be very helpful as well. I can't say I have caused a cough with Clindamycin to my knowledge so thoracic films are due. If an E-tube is off the table, mirtazipine may be helpful but the agitation side effects can be troublesome for some patients.

    • 170 posts
    May 2, 2014 2:13 PM EDT

    This may be helpful:  Dr. Susan Little contributed this video on Esophagostomy Tube Placement in a Cat.  

     

     

     

     

     

     

    • 44 posts
    May 3, 2014 12:56 AM EDT

    I discontinued the clindamycin and the coughing has stopped. If I hear it at all again, i will get a chest rad before Thursday's dental. The only thing I can think of is that the alcohol in the clindamyinc solution irritated the oropharynx.

     

    His appetite returned after a single dose of buprenorphine. He still eats a lot slower than the other cats, but he finishes his food. His appetite was only truly "decreased" that first day. I don't think an esophagostomy tube will be necessary at this point because he's eating so well.

     

    And the lack of pain on abdominal palpation (and positive pain response on palpation of the inflamed gingiva above tooth #204) makes me hopeful that the painful episode was only due to oral pain.

     

    Assuming that's the case, what should my plan be as far as long-term management of the chronic pancreatitis? Is i/d an appropriate food for him? Any chronic meds you'd recommend, or just analgesia like buprenoprphine and cerenia if a "flare-up" occurs?


    This post was edited by Steven Edwards at May 3, 2014 12:57 AM EDT
  • May 3, 2014 10:18 AM EDT
    Because you describe ongoing weight loss, I think you need to leave an E-tube on the table. Monitor his weight and evaluate lean body condition. FPLI can be useful to monitor recovery. Since pancreatitis is often found in concert with enteritis, Prednisolone may be indicated to assist reducing inflammation. That puts diabetes as a risk so that needs to be a consideration for ongoing monitoring. I think a high protein low carb, preferably canned diet would be more helpful in pancreatitis. Some advocate pancreatic enzymes though I have rarely had a feline patient who would eat them in food, so I don't use them. Cerenia can be used over time with some confidence. Flares that you observe are more likely just visible manifestations of ongoing discomfort so chronic analgesia is indicated. Some say that Cerenia cannot be given long term because of the theoretical risk of serotonin syndrome. I have done so on many occasions without these side effects. Those who worry about that will adopt a regimen of 5 days on, 2 days off. Buprenorphine long term can be used but the risks of ileus and constipation are real, though uncommon.
    In summary, nutrition, analgesia and potentially anti inflammatory therapy. Monitor fPLI, B12, BG and liver enzymes, weight and lean body condition. If weight loss continues, put in an E-tube, super easy, well-tolerated insurance that you will have a good outcome.
    • 44 posts
    May 4, 2014 9:53 AM EDT

    How useful do you think fPLI is for monitoring therapy? How often would you test, and what would you do based on the values?

    Would you just consider anti-inflammatories (NSAIDs or steroids) if the PLI is consistently high?

  • May 4, 2014 12:22 PM EDT
    Yes, if you aren't seeing recovery with digestible diet and analgesia and time, fPLI will help you decide upon steroids. The coincidence of enteritis with pancreatitis is so common that you may find it useful. I often will check after a month or 6 weeks to see where I am with recovery.