Chronic Vomiting in Cats. Jinelle Webb DVM, DVSc, Dipl ACVIM

Transcription

1 Chronic Vomiting in Cats Jinelle Webb DVM, DVSc, Dipl ACVIM

2 Is a vomiting cat normal? l At my house maybe? Or maybe I should attend my own lecture. l Cats do tend to vomit more readily than dogs l Hairballs l I ate too fast l I ate too slow l I didn t eat l I ate too much l But is this really normal?

3 But it s just a hairball!! l Some longer haired cats may truly just consume too much hair when grooming l Or.. l Skin disease l Food allergies l Intestinal disease l Motility disorders l Behavioural abnormalities JFMS 2013 M. Cannon

4 Categories of Causes Primary GI Causes l Parasitic or Infectious Disease l Neoplasia l Inflammatory disease/food allergy l Intestinal dysbiosis l Gastric ulceration/erosion l Motility disturbances l Gastric outflow obstruction

5 Categories of Causes Extra-GI Causes l Pancreatic disease l Hepatic disease l Endocrine disease l Systemic infectious disease l Neoplasia l Parasitic lung/vascular disease l Acute/chronic renal disease l CNS disease

6 Initial Diagnostic Steps l Detailed history and physical examination l When does vomiting occur? l What does it look like and does this vary? l Is there ever blood present? l Has there been any recent changes in diet, feeding routine, household, new pets, new plants? l Is there weight loss? Diarrhea? Straining to defecate? l Changes in energy levels? l Changes in drinking/urination?

7 Initial Diagnostic Steps l CBC, biochemical profile and urinalysis l Total T 4 l Fecal examination l fpl or similar l +/- TLI, cobalamin, folate l +/- Heartworm test, FeLV/FIV testing l FIP testing???

8 Imaging l Abdominal radiographs l Suspicious of foreign body l Abdominal ultrasound l Gastrointestinal disease l Hepatic disease l Pancreatic disease l +/- Renal disease l Abdominal neoplasia

9 How Useful is Ultrasound? l Assessment of gastrointestinal tract l Stomach, intestine, ILEUM, cecum, colon l Gastrointestinal masses l Associated lymphadenopathy l Thickness of gastrointestinal wall (stomach, areas of small intestine including ileum, colon) l Thickening of muscularis propria l Irregularity, change in echotexture, change in layering l Possibly assess motility peristalsis, presence of gastric food after prolonged fasting

10 How Useful is Ultrasound? Normal SI Thickening of muscularis propria

11 How Useful is Ultrasound? l Assessment for abdominal neoplasia l Discrete or multifocal masses l Lymphadenopathy l Assessment of pancreas l Enlargement, change in echotexture, irregularity l Nodules, masses, cystic structures l Assessment of liver l Size, echotexture, assessment of gall bladder

12 How Useful is Ultrasound? Normal Pancreas Chronic Nodular Pancreatitis

13 Next steps l Symptomatic treatment l Antiemetic l Gastroprotectant l Diet change l Laxative/Hairball remedy l Endoscopy and biopsy l Imperative to get duodenal samples, ideally get ileal samples l Exploratory laparotomy and biopsy l Sample the GI tract, pancreas, liver, LN

14 Next steps l Make sure you have ruled out some other causes: l Hyperthyroidism l Renal Disease l Parasitism l Foreign Body l CNS disease

15 Endoscopy l Assess the oral cavity, esophagus, stomach, and duodenum l Ideally perform a lower GI endoscopy to evaluate the colon and obtain ileal biopsies l If endoscopy is visually normal (which is often is), obtain at least 12 samples from each site l If endoscopy is not visually normal, obtain at least 12 samples from each normal site, and also samples of abnormal area (submit in separate formalin jar)

16 Surgery/Laparoscopy l Assess the entire gastrointestinal tract, liver, pancreas, lymph nodes l Biopsies of all of these areas, aerobic and anaerobic cultures of liver, gall bladder l Consider the status of the patient l Geriatric cats, consider preoperative IV fluid therapy l May take longer to recover than the average patient

17 Pros and Cons - Endoscopy l Minimally invasive, especially in geriatric vomiting cats with co-morbidities l Reduced cost to owners l Can start therapy right after procedure and biopsy results (steroid therapy, chemotherapy) l Do not obtain samples of jejunum l Do not obtain samples of LN, liver, pancreas (assess for triaditis)

18 Pros and Cons - Surgery l Can obtain samples of jejunum l Can obtain samples of LN, liver, pancreas l More invasive, especially in geriatric vomiting cats with co-morbidities l Increased cost to owners l Cannot start therapy right after procedure and biopsy results (steroid therapy, chemotherapy) l Laparoscopy can also be considered

19 What if I have normal biopsies? l Causes of chronic vomiting with normal biopsies l Intestinal dysbiosis l Dietary intolerance l Chronic idiopathic vomiting (but did we miss the cause?) l Patchy disease (IBD, neoplasia, etc) l Undiagnosed systemic disease

20 What about equivocal results? Lymphocytic IBD versus small cell lymphoma l Recent study JSAP l Findings suggest that if histologic diagnosis is lymphoma, no further testing needed l Many cases with histologic diagnosis of IBD actually have early small cell lymphoma l PARR (clonality) testing in all diagnosed IBD cases? l Even PARR can have false negatives

21 Main Disease Processes l Inflammatory Bowel Disease/Food Allergy l Small Cell Lymphoma l Chronic Pancreatitis/Cholangitis Age Dependent Disease Processes l Foreign Body l Infectious (Parasites, FIP, etc) l Neoplasia

22 Inflammatory Bowel Disease l Different types classified by main inflammatory cell present l Lymphocytic-plasmacytic l Eosinophilic l Pyogranulomatous l Main causes l Genetic susceptibility l Intestinal microbial dysbiosis l Food allergy

23 Inflammatory Bowel Disease l Therapy varies but usually includes one or all of: l Dietary modification l Anti-bacterial treatment l Immunosuppressive therapy l Vitamin B 12 supplementation or monitoring l Probiotic/fecal biotherapy l Minimal objective data on efficacy l Staged approach recommended

24 Lymphocytic-plasmacytic IBD l Most common type l Typically start with dietary modification l Some cases managed long term with diet +/- symptomatic therapy (Cerenia, famotidine etc) l Severe, non-responsive or hypoproteinemic cases will require immunosuppression l Prednisone/prednisolone (and vitamin B 12 ) l +/- Cyclosporine, Chlorambucil l Some difficult to differentiate from lymphoma

25 What to do with LP-IBD Dx l Recommend PARR clonality testing l Consider symptoms and signalment (is there weight loss, is the cat older) l Consider pre-biopsy use of steroids l Consider degree of inflammation and mucosal disruption l Use a pathologist that you trust l Consider prednisolone and chlorambucil in severe LP-IBD cases

26 Eosinophilic IBD l Second most common type l Rule out parasitism, hypoadrenocorticism l Most <5 years age l More common in dogs l Mucosal erosion and ulceration l More likely to present with hematemesis, melena and/or hematochezia

27 Eosinophilic IBD l More likely to require multimodal therapy l Prophylactic deworming in all cases l Mild cases can try dietary modification alone l Some cases managed long term with diet +/- (Cerenia, famotidine etc) l Most cases will require immunosuppression l Prednisone/prednisolone (and vitamin B 12 ) l +/- Cyclosporine, Chlorambucil

28 Pyogranulomatous enteritis l Feline infectious peritonitis l Would expect to find other evidence of FIP l Granuloma formation l Nodules in other organs l Ascites l Pleural effusion l Nodules along peritoneal and/or pleural cavity l Nervous system inflammation

29 Small Cell Lymphoma l Very common in older cats l May only see weight loss l Can have normal ultrasound findings l Occasional mesenteric lymphadenopathy l Commonly see thickened muscularis propria l Occasionally can have SCL in liver, etc l Diagnose with surgery or endoscopy (ileum!)

30 Small Cell Lymphoma l Much different prognosis than large cell LSA l 75% of cats with gastrointestinal lymphoma have lymphocytic (small cell) lymphoma l 70-90% response rate for SCL, <20% response rate for large cell lymphoma l Median survival time (MST) of 2 years for SCL, MST of 2.7 months for large cell LSA l Treat with prednisolone and chlorambucil l Rescue with cyclophosphamide

31 Pancreatitis/Cholangitis l Any age of cat, either gender l Underweight, normal weight, overweight l Lymphoplasmacytic is most common form l Lethargy, anorexia, and dehydration l Not linked to getting into garbage, high fat foods, etc l 66-75% with cholangitis also had pancreatitis l Possible link to bacterial cholangiohepatitis

32 Pancreatitis/Cholangitis l Pancreatitis/cholangitis difficult to diagnose l fpl l Ultrasound l Biopsy (especially cholangitis) l fpl sensitivity l 100% in severe pancreatitis l 80% in moderate pancreatitis l 65% in mild pancreatitis l 25% of normal cats had an elevated fpl

33 Pancreatitis/Cholangitis l Ultrasound l 80% sensitivity in moderate to severe pancreatitis l Less so in mild pancreatitis l Often normal in cholangitis l Typical changes l Hypoechoic pancreas or liver, nodules l Hyperechoic mesentery l Dilated common bile duct, thickened gall bladder wall l Normal appearance

34 Pancreatitis/Cholangitis l Cholangitis, and intestinal inflammation, commonly occur with pancreatitis (triaditis) l Typical blood work changes l Neutrophilia, mild thrombocytopenia l Increased ALT, ALP l Increased bilirubin l Mild hyperglycemia l +/- Hypoalbuminemia

35 Causes and Diagnosis l Bacterial (suppurative inflammation) less common for chronic cases l Immune-mediated (lymphocytic-plasmacytic inflammation) most common l Neoplastic often small cell lymphoma l Biopsy required l One study indicated only 48% agreement through Tru-cut biopsy and wedge biopsy l Higher risk to Tru-cut livers of cats l No ability to sample pancreas

36 Therapy l Dietary modification l Anti-bacterial treatment l Immunosuppressive therapy l Probiotics/Fecal biotherapy/vitamin B 12 l Antiemetics/Gastroprotection l Analgesia/Fluids l Ursodiol l Antioxidants l Appetite stimulation

37 Dietary Therapy l Fewer carbohydrates l Highly digestible protein sources l Can try either Gastrointestinal Diets or Hypoallergenic Diets l Many choices Issue of palatability with cats l Rayne l MCRC l Balanced home cooked Purina Iams Hill s

38 Which Disease? l Inflammatory bowel disease l Hypoallergenic diet l Some cases respond to gastrointestinal diets l Cholangitis/cholangiohepatitis l Gastrointestinal diet? l Liver diet not indicated unless failure present l Chronic pancreatitis l????????????????????????? l Gastrointestinal diet? Lower fat?

39 Anti-bacterials l Broad spectrum for possible bacterial cholangiohepatitis l Antibacterials for IBD with concurrent diarrhea l Metronidazole l Antimicrobial and immunomodulatory l Tylosin l Antimicrobial, may be immunomodulatory

40 Immunosuppression l Glucocorticoids l Most frequently used type l Prednisone/prednisolone drug of choice l 2 mg/kg q 24 hours x 2-4 weeks, then taper slowly l Give with food, and gastroprotection at high dose l Main side effect is potential to transition into overt diabetes mellitus in pre-diabetic cats l Dexamethasone can also be used (0.25 mg/kg q 24 hours starting dose), and in some cases causes remission in refractory cases

41 Immunosuppression l Budesonide - Locally acting nonhalogenated corticosteroid l High hepatic clearance, resulting in high local and low systemic activity l Useful in cases that are very sensitive to prednisone, or contraindications such as diabetes mellitus l Highly effective in some cases, other cases have little to no response l mg PER CAT q hours, usually not tapered

42 Immunosuppression l Chlorambucil l Most commonly used in cats l Side effects l Vomiting, inappetence, diarrhea, bone marrow suppression l Several dosing protocols l 2 mg PO q 48 hours (large cats) l 2 mg PO Mon/Wed/Fri (small cats) l 2 mg PO q72 hours (very small cats) l 20 mg/m 2 every 14 days l Monitor CBC

43 Immunosuppression l Cyclosporine l Induces rapid immunosuppression l Side effects in up to 50% l Vomiting, inappetence, diarrhea, alopecia, gingival hyperplasia, idiosyncratic hepatopathy, opportunistic infectious disease l 5 mg/kg PO q hours l Expensive l Should avoid certain formulations

44 Vitamin B 12 (cobalamin) l Vit B 12 deficiency causes ill-thrift, poor appetite l Suggestion that having high normal to mildly elevated levels may be beneficial to GI health l Many dosing protocols l We use ~20 ug/kg weekly for 4 weeks, then monthly l Can otherwise monitor levels l Less common to have folate deficiency, not usually supplemented

45 Probiotics l Live microorganisms that can confer a health benefit when given in sufficient quantity l Use supported in human/mice studies l Newborns in developing countries l Antibiotic associated human diarrhea l Positive response in human IBD l Improved immune response to Giardia in mice l Minimal information on effectiveness for cats l Can also perform fecal biotherapy

46 General antiemetics l Maropitant l Antiemetic, reduces visceral pain l 1-2 mg/kg q24h PO or SQ, usually 3-5 days but can be given longer if needed l Ondansetron l mg/kg q12-24h PO or IV l Metoclopramide l Likely less effective in cats l mg/kg q8h PO, SQ or IV (CRI)

47 General GI protection l Famotidine or ranitidine l 0.5 mg/kg q12h PO, IV or SQ, q24h in renal failure l Omeprazole l 1 mg/kg q24h PO l Sucralfate l 2-3 ml total PO q8h

48 Analgesia/Fluid therapy l Buprenorphine mg/kg IM, IV, or buccal q6-8h l Fluid therapy l IV if dehydrated, substantial vomiting, preanesthesia for endoscopy or surgery l SQ if hospitalization not needed l Caution in geriatric cats in case of subclinical heart disease

49 Ursodiol/Antioxidant l Cholangitis cases l Ursodiol mg/kg once daily PO with food. Likely will need to have compounded, may need to gradually increase dose to full amount l Cholangitis and/or pancreatitis cases l Antioxidant therapy l Zentonil Advanced/Denosyl l Hepatosupport l Vitamin E

50 Mirtazapine l Cats with a reduced appetite l Mirtazapine 2 mg per CAT PO every other day (once daily if normal kidneys?) l Caution if heart disease and hypotension l Caution in renal/hepatic cases recommendations are to monitor parameters while using

51 Prognosis l Dependent on cause l Dependent on response to treatment l Dependent on owner compliance l Difficult to monitor improvement in most cases other than through clinical response, unless there were lab work changes present

52 Questions?