Opinions on fatty liver/possible pancreatitis problem

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Underwood - 04 Apr 2004 07:58 GMT

We have a 6 yr old tabby who was recently introduced (February) to a new
member of the house, a maine coon mix from the local shelter. He
brought what appeared to be a cold home with him, which he transmitted
to Pnut. During most of February, she was dealing with the effects of
the cold or upper respiratory infection. The new cat completely
recovered and is fine now, and never had a problem to begin with.

In early March, we noticed Pnut was looking rather grim. We started
trying to take stock of when she was eating, and couldn't determine if
she was in fact eating sufficiently. After a week of moping around and
looking rotten, we took her to the vet on March 19. The vet diagnosed
jaundice and fatty liver, and sent us home with a feeding tube and a
bunch of Hill's A/D to feed her. It has been extremely difficult to
keep any food down her for the past two weeks. She will vomit at least
once per day on average, and went a few days when we were unable to get
her to keep anything down. I will elaborate on our feeding strategy
further down.

Apparently we had not paid enough attention to her when she was ill with
the cold to realize she had stopped eating to the point where she was
losing weight and developing hepatic lipidosis. The house is full of
busy people though, so when she is depressed and hiding due to an
illness, keeping tabs on her isn't exactly the first thing on our minds. :(

From the testing at the vet, the blood work looked normal except for
elevated liver values and slightly elevated pancreas values (though I am
told the latter is rather meaningless in general). An x-ray turned up
no gall stones or obstructions. The vet has been reluctant to give any
more information or suggestions besides to have an ultrasound done at a
cost of $250. I am reluctant to do this because I feel very strongly
that the cat is suffering a pancreatitis and/or I.B.S. inflammation
episode brought on by the previous month's cold and/or the stress of
being exposed to a new cat. It seems that the ultrasound will only
serve to rule out terminal illness, and not provide a conclusive
diagnosis in any case.

Before you dismiss the self-diagnosis I just tossed out there as a
logical leap, let me give you a bit of background. In late 2002, after
a previous cat died of unrelated problems (NRG anemia), Pnut underwent a
similar episode to what is happening now, though much less severe. She
simply stopped eating, developed jaundice, was diagnosed with fatty
liver, and a feeding tube was installed. We fed her A/D until she
started eating on her own again. She has always had periodic random
vomiting during her adult life, maybe once per few weeks on average.
Most of the time it is a clear liquid similar to bile. We could never
tell what would bring this on. She also loves to raid the trash despite
our best attempts to keep her out of it, which seems to be a risk factor
for chronic pancreatitis.

Right now, we are trying to keep her nourished with Hill's A/D and
recently I/D which I tried to see if it would have any effect.
Anti-vomit pills (Metaclopramine) and painkiller (Butorphanol) have
little to no effect on the vomiting. The only thing that seems to help
her keep food down is giving antacid, 1/4 of a 10mg pepcid pill 1 hr
before eating for the first time that day. If she misses that dose, she
will vomit all feedings until it is given. If she gets that dose, she
usually will not vomit until an evening feeding. I tried I/D as an
attempt to "go easier" on her digestive system than A/D. An initial
feeding was kept down OK, but an evening feeding (10 hrs after antacid
was administered) was vomited 2.5 hrs after feeding.

In a nutshell, we give antacid in the morning, then try to feed at least
20cc and at most 40cc of a mixture of one can A/D or I/D with 32cc warm
water, three times a day. If she vomits, we cease feeding for at least
six hours and try again later. We flush the feeding tube with 5cc warm
water. If she vomits, she will vomit anywhere from immediately to 3
hours after a feeding. She is passing vaguely normal-looking fecal
matter (occasionally diarrhea) and appears to be urinating regularly, so
at least something is working properly. She is very likely to vomit
when agitated or disturbed, so we leave her in a closed but ventilated
bathroom most of the day. Only the bathroom's visitors disturb her, and
she occasionally vomits when a visitor has just used the facility. (The
smell?)

The vet suspects triad syndrome, and so do I, though I more highly
suspect a simpler combination of pancreatitis and fatty liver that are
working in cahoots with each other (similar to how cholangiohepatitis
and pancreatitis provide a feedback loop for each other in a triad
syndrome situation).

It seems I am in a textbook catch-22 situation.

To address the fatty liver/jaundice, I need to feed her enough to
prevent body mass from being re-appropriated as an energy source. But
if I feed her, it would aggravate any pancreatitis that is present. The
possibility of a I.B.S. episode instead of pancreatitis also exists, but
the vet will not prescribe corticosteroids without ruling out a
pancreatitis episode (since they may make an already difficult
pancreatitis situation even worse). Ruling out the pancreatitis is done
through the ultrasound, and I am told that even if the pancreas is not
visible on the ultrasound, that is not a conclusive diagnosis one way or
the other, just a best guess. Also, to avoid aggravating pancreatitis,
I should be feeding high-carb foods. But it is questionable as to
whether they will provide sustainable nutrition to a critter whose body
is designed to run primarily on proteins and fat.

I (and Pnut) am up a creek. I can't afford the ultrasound or any more
conclusive diagnosis involving tissue biopsies. I can't afford
inpatient treatment. I _can_ afford the diet/Rx foods and the time to
spend with her concocting her food mix, feeding through the tube and
cleaning up messes (as I have throughout the last week). However, I
will not be the primary caretaker in the coming weeks, so I need to come
up with some kind of protocol that "covers all the bases" so to speak.

I have 3 scenarios I wish the group to consider:
1) Triad syndrome. I.B.S. causes pancreatitis and cholangiohepatitis,
followed by hepatic lipidosis.
2) Hepatic lipidosis caused by not eating due to acute pancreatitis or a
chronic flare-up.
3) Hepatic lipidosis caused by not eating due to I.B.S. flare-up. Liver
disturbance triggers pancreatic reaction. Sort of an "acute" triad
syndrome.

I have looked at other possibilities, such as parasites, FIP, distemper,
etc. None seem to fit the circumstances and none were even suggested by
the vet. The vet has generally agreed that we are probably looking at
triad syndrome or something approximating it. But she has offered very
few suggestions for treatment. She suggested cancer at one point, but I
can't help but think cancer would be an _extreme_ coincidence
considering the circumstances (new cat in the house, new cat brought a
cold, and anorexia was undetected for a period of time). Why would a
cancer wait until exactly now to start generating symptoms? How do I
explain the previous episode and chronic random vomiting?

It seems (from reading) that the only avenue of success with
pancreatitis is to withhold food and water for at least 24 hours,
preferably 48; but more than 24 hours requires hospitalization with IV
fluids. I am curious how successful these approaches typically are. I
have a feeling I would be laughed out of the state if I suggested an
approach that included withholding food to my vet, with the cat already
suffering from fatty liver. Is 24 hrs typically safe, assuming the cat
is given under-the-skin fluids to support her that day? Is this to be
considered a reasonable tradeoff between trying to solve the highly
suspected pancreatitis, and not aggravating the fatty liver/wasting
problem too much in the meantime?

What I need is options. I would like any of the following:
- Suggestions for treatment _in the case of_ one of the aforementioned
disease scenarios, to give me an idea of the scope of the problem I'm
likely to be dealing with. This will help me decide whether or not
euthanization is the best option for us in the long run, as much as it
would pain me to make that choice.

- Suggestions to pass along to the vet. She may not have all the bases
covered in diagnosis, nor have relayed all the options to me. If I can
"jog her memory" or get her to do some research on possible angles, it
may help us all out.

- Suggestions to stabilize the current scenario or how to improve on my
current methods of feeding/nursing, to pass on to the primary caretaker
for the next week. Anecdotal suggestions are ok, i.e. "This worked for
Fizban when he showed the symptoms you have described". I am looking
for dietary suggestions (_what_ is good to feed her) as well as
procedural suggestions (_when_ and _how much_ is good to feed her).

Remember that I have been nursing her for two weeks. She is stable and
not in a state of shock, but her stable state is not exactly that great,
and may be invisibly deteriorating. I would like to try to target the
most likely underlying problems, since I don't have the resources for a
proper diagnosis (and such diagnosis seems to be nebulous at best).

As of today, she was given antacid in the morning, given 20cc I/D
mixture at 2:00pm, which she kept down, given 20cc I/D at 7:00pm, which
was vomited at 9:30pm (perhaps due to a disturbance), and I gave 10cc
water at 11pm. Tomorrow is Sunday, so I won't be able to see a vet for
about 36 hours at this point.

Help me formulate a plan of action! I'd like to go in to her office
Monday armed with information instead of frustration.

Thanks for any insight your experiences can provide.