episodic anorexic kitten salivating/vomiting

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Tue, 26 Nov 2013 17:26:30 GMT

Another update from RVC on this case after finally received the full case report. The high ammonia is clearly the cause of the neurological symptoms and ptyalsism but what's causing that? Other possible causes of increased serum ammonia concentration are UTIs but urinary culture was negative and no symptoms of that and cobalamine deficiency but that was normal. Then we're onto the weird and wonderful. Congenital urea cycle enzyme (UCD) has been recorded in a cat or ornithine transcarbamylase (OTC) deficiency. The latter in humans is X chromosome linked and females are usually only carriers, affected males normally die withing 72 hrs of birth. Plasma quantitative amino acid analysis and urinary orotic acid measurement can distinguish between UCDs.

Well you learn something every day, the stuff italics is cut and pasted from the report and is double Dutch to me but there probably is a smarty on here who's seen several - isn't that the wonder of this profession?

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Fri, 22 Nov 2013 17:58:42 GMT

STOP PRESS..... Ammonia was high but apparently no anatomical shunt on ultrasound (but we are talking 1kg kitten here so it would take some skilled operator to spot that and or categorically eliminate it). Kitten is now home on antibiotic and lactulose but maintaining kitten food, doing well and not salivating as much. I could have saved them a lot of hassle/money if I'd gone with my first differential but its nice to know that even the best can't make the absolute diagnosis sometimes. That said it 'only' cost them £1.5K for a week at the RVC so not bad at all really. We will review in 2-3 weeks and think about stopping the antibiotics if all is OK, RVC suggested that the response to antibiotic may be due to bacterial action in the gut but I can't see it quite frankly, this is as nailed on a shunt as I've seen clinically its just the liver function tests didn't all add up.

Re: episodic anorexic kitten salivating/vomiting

Helen Wallace — Thu, 21 Nov 2013 21:20:48 GMT

Thanks for the update Martin.

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Tue, 19 Nov 2013 16:54:03 GMT

[quote user="Anthony Todd"]Make sure you tell us all what the referral results were and what was done won't you..[/quote] Well after 4 days at the RVC they are no closer to a diagnosis, the symptoms remain the same albeit apparently less marked. Everything from your differential list has been eliminated so far except porto-systemic shunt which they are revisiting with an ammonia test. If that still doesn't throw light then they are talking about an MRI. I'll keep you posted.

Re: episodic anorexic kitten salivating/vomiting

Anthony Todd — Sun, 17 Nov 2013 00:13:56 GMT

[quote user="John Flynn"]Of course if your ex lap is followed by a referral, then that's got to be most expensive of all.[/quote]

Touche, and I take your points.

What happened eventually?

Re: episodic anorexic kitten salivating/vomiting

John Flynn — Fri, 15 Nov 2013 17:55:13 GMT

[quote user="Anthony Todd"]

[quote user="John Flynn"]I think the only one that would have "definitely" been eliminated by a 30min ex lap from the list above would be the linear FB?[/quote]

Could you not add Hiatus hernia, chronic pancreatitis, pain from an inflam. process, portosystemic shunt and vascular ring anomaly?

and I forgot enlarged lymph nodes

to say nothing of the large bill, definitely eliminated surely.

How many would have been definitely eliminated by the non invasive techniques apart from a megaoesophagus and pancreatitis [with the bloods, I guess], if you were lucky?

[/quote]

Hiatal hernia - these are often dynamic and tricky to rule-out even when high on differential list IME; how many have you picked up by ex lap? Do you routinely assess for a sliding hiatal hernia on every ex lap? If so, how - by sight/feel etc?

Chronic pancreatitis - i guess you might have biopsied the pancreas [and to be pedantic even that might not be a "definite" rule-out], but this would really be a diagnosis of exclusion in my books [especially as i'm unaware of any specific treatment, so once ruled out conditions with specificc treatments, there's little advantage to further diagnostic refinement].

Pain from an inflam process - i guess you might have taken multiple biopsies

PSS - I guess an obvious extrahepatic shunt could be seen [whether i'd figure this in 30mins of general ex lap and then fix it would be another matter...]; small liver might be a clue and biopsy i guess might show microvascular dysplasia

Vascular ring anomaly - ?? on an ex lap?

I'm not sure your chances of eliminatring pancreatitis by non-invasive means are worth talking about, unless of course you find an alternative diagnosis which explains the clinical signs outright and therefore the search can be ended. [Megaesophagus can be tricky to rule out at times also...]

As per referral bill, i guess that depends on how much they charge and how much your ex lap cost.

Of course if your ex lap is followed by a referral, then that's got to be most expensive of all.

Re: episodic anorexic kitten salivating/vomiting

Anthony Todd — Fri, 15 Nov 2013 17:32:14 GMT

[quote user="Martin Atkinson"]I think that there is too much else as a possibility at this stage to justify an ex lap otherwise I would be the first to dive in. The client is insured and was given the option of a referral which she took[/quote]

Make sure you tell us all what the referral results were and what was done won't you......

Re: episodic anorexic kitten salivating/vomiting

Anthony Todd — Fri, 15 Nov 2013 17:27:40 GMT

[quote user="John Flynn"]I think the only one that would have "definitely" been eliminated by a 30min ex lap from the list above would be the linear FB?[/quote]

Could you not add Hiatus hernia, chronic pancreatitis, pain from an inflam. process, portosystemic shunt and vascular ring anomaly?

and I forgot enlarged lymph nodes

to say nothing of the large bill, definitely eliminated surely.

How many would have been definitely eliminated by the non invasive techniques apart from a megaoesophagus and pancreatitis [with the bloods, I guess], if you were lucky?

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Fri, 15 Nov 2013 13:33:27 GMT

I think that there is too much else as a possibility at this stage to justify an ex lap otherwise I would be the first to dive in. The client is insured and was given the option of a referral which she took. Linear FBs can be a nightmare to deal with abyway: finding the best place to make your enterotomy incision or making multiple incisions if it won't pull out easily especially in a 1kg kitten - if someone else cocks it up then its not my fault! I get less and less adventurous as I get older.

Re: episodic anorexic kitten salivating/vomiting

John Flynn — Fri, 15 Nov 2013 10:47:27 GMT

[quote user="Anthony Todd"]

Surely just another one that would benefit from a quick ex-lap [see "Help exlap etc thread]

[/quote]

Smarting from yet another red star so, in a forlorn attempt to change it to gold, what we've had suggested but not, of course, confirmed so far is:

Linear FB

chronic pancreatitis

pain from an inflammatory process

Limbic epilepsy

simple belly ache

portosystemic shunt

megaoesophagus

vascular ring anomaly

Hiatus hernia

And an enormous bill with the referral fee as well.....

How many of these would have been definitely eliminated with a 30 minute ex-lap, with total emphasis on "definitely"?

Of course, ironically, you may have fixed it at the same time too, so a diagnosis and a cure in one!

[/quote]

I think the only one that would have "definitely" been eliminated by a 30min ex lap from the list above would be the linear FB?

Re: episodic anorexic kitten salivating/vomiting

Anthony Todd — Fri, 15 Nov 2013 08:45:32 GMT

[quote user="Anthony Todd"]

Surely just another one that would benefit from a quick ex-lap [see "Help exlap etc thread]

[/quote]

Smarting from yet another red star so, in a forlorn attempt to change it to gold, what we've had suggested but not, of course, confirmed so far is:

Linear FB

chronic pancreatitis

pain from an inflammatory process

Limbic epilepsy

simple belly ache

portosystemic shunt

megaoesophagus

vascular ring anomaly

Hiatus hernia

And an enormous bill with the referral fee as well.....

How many of these would have been definitely eliminated with a 30 minute ex-lap, with total emphasis on "definitely"?

Of course, ironically, you may have fixed it at the same time too, so a diagnosis and a cure in one!

Re: episodic anorexic kitten salivating/vomiting

Helen Wallace — Thu, 14 Nov 2013 21:29:48 GMT

Does sound like potential for megaoesophagus or hiatus hernia here. Hopefully referral will give an answer... will be intersting to know.

Re: episodic anorexic kitten salivating/vomiting

Anthony Todd — Thu, 14 Nov 2013 20:27:10 GMT

Surely just another one that would benefit from a quick ex-lap [see "Help exlap etc thread]

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Thu, 14 Nov 2013 19:03:33 GMT

[quote user="David Mills"]

[quote user="Robin Grimmer"]

Megaoesphagus? Is it definitely vomiting and not regurgitation?

[/quote]

Oooo yes or a vascular ring anomaly like a PRAA - in fact I've seen more of them than limbic epilespy. One of my all-time favourite ops.

[/quote] I don't think its even vomiting, its never vomited food, the owner just finds pools of froth I think it is just spitting out/ retching up xs saliva. It was eating well to start then this started after a week. When it eats it swallows and does not regurgitate or vomit and despite its limited appetite it has maintained its weight.

Re: episodic anorexic kitten salivating/vomiting

David Mills — Thu, 14 Nov 2013 18:26:14 GMT

[quote user="Robin Grimmer"]

Megaoesphagus? Is it definitely vomiting and not regurgitation?

[/quote]

Oooo yes or a vascular ring anomaly like a PRAA - in fact I've seen more of them than limbic epilespy. One of my all-time favourite ops.

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Thu, 14 Nov 2013 17:35:09 GMT

[quote user="Nicola Lawlor"]

Was the bile acid results a one off result or did you run dynamic bile acids? Much of the history you give makes me suspicious of a portosystemic shunt.

[/quote] Agreed primary differential was a shunt. The bile acids was a one off, if by dynamic you mean post-prandial then it was not possible to time this with eating as this has been so sporadic and it wouldn't allow syringe feeding. But it was still showing reduced mentation and salivating when sampled so I would have expected some result but bile acids was <1umol/l. Still its out of my hands for now, see what the RVC come up with.

Re: episodic anorexic kitten salivating/vomiting

Robin Grimmer — Thu, 14 Nov 2013 17:03:28 GMT

Megaoesphagus? Is it definitely vomiting and not regurgitation?

Re: episodic anorexic kitten salivating/vomiting

Nicola Lawlor — Thu, 14 Nov 2013 17:00:12 GMT

Was the bile acid results a one off result or did you run dynamic bile acids? Much of the history you give makes me suspicious of a portosystemic shunt.

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Thu, 14 Nov 2013 16:51:01 GMT

[quote user="David Mills"]

So...a non-vomiting, vomiting kitten?

Hypersalivation AFAIK in cats has a few limited causes - nausea is probably an unlikely cause given that it is occurring on cerenia. Could be intermittent intestinal pain/spasm from an inflammatory focus. Would have FB on the radar but low on the list.

My thought would be limbic epilepsy type events. I've seen a few (5-6) in dogs, where hypersalivation and gagging/'vomiting' saliva froth is the only sign; others have odd behavioural patterns as well such as tail chasing. I've seen it presumptively once in a young (<6m) cat. They tend to respond well to phenobarb - trial of levetiracetam 20mg/kg TID would be a cheap and cheerful way of assessing response (within 2-3d cf 2-3w with pheno) - can get a syrup formation which is easier to dose for smallies.

I find metoclopramide pretty useless in cats (they lack the dopaminergic brain receptor which it acts on in humans and dogs - not that its much good in the latter two) and I'm honestly amazed its got a licence as an anti-emetic.

[/quote] Thanks David an interesting thought or two. After discussion with the owners I have decided to refer to the RVC. I'll keep you posted on the outcome.

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Thu, 14 Nov 2013 16:48:26 GMT

[quote user="Kate Richardson"]get yourself an ultrasound- you won't regret it you will use it more than you realise[/quote] I do have an old NHS ultrasound machine but it is a bit temperamental and would not be much use on a 1 kg kitten. I'm 2 years away from retiring or selling to a corporate so not inclined to pay upwards of £15 for something worth having it is better to swallow my pride and refer the very few cases where it is beneficial.

Re: episodic anorexic kitten salivating/vomiting

Gillian Mostyn — Thu, 14 Nov 2013 15:58:39 GMT

[quote user="Martin Atkinson"]don't fancy NSAIDs in 1kg kitten thats not eating/drinking normally[/quote]

you should be fine using NSAIDS as long as you are maintaining good hydration status - easy enough to ensure with s/c fluids in this case. Even a simple belly ache is improved with decent analgesia!

Re: episodic anorexic kitten salivating/vomiting

David Mills — Thu, 14 Nov 2013 14:36:20 GMT

So...a non-vomiting, vomiting kitten?

Re: episodic anorexic kitten salivating/vomiting

Anthony Dennison — Thu, 14 Nov 2013 14:20:25 GMT

[quote user="Martin Atkinson"]If its a linear FB why is it episodic and why doesn't it vomit food, why did the large BIPS go through and not the small ones?[/quote]

Small ones get caught up/tangled in the linear FB, large ones big enough to be pushed past?

Re: episodic anorexic kitten salivating/vomiting

Kate Richardson — Thu, 14 Nov 2013 14:04:04 GMT

Was just throwing it out there. FBs can often cause intermittent signs. If you are happy no obstruction then metoclopramide will help with nausea and motility. get yourself an ultrasound- you won't regret it you will use it more than you realise

Re: episodic anorexic kitten salivating/vomiting

Martin Atkinson — Thu, 14 Nov 2013 14:01:48 GMT

[quote user="Kate Richardson"]

Linear FB? Ultrasound scan, metoclopramide, pain relief, not necessarily in that order.

[/quote] If its a linear FB why is it episodic and why doesn't it vomit food, why did the large BIPS go through and not the small ones? Metoclopramide probably not so wise if suspect FB. Doesn't seem in pain but has had butorphanol with sedatives, don't fancy NSAIDs in 1kg kitten thats not eating/drinking normally, Don't have ultrasound or it would have been done, I've managed to live without it all these years but there are the odd occasions when it would be handy - probably will be a referral.