Jaundice in a young cat

Re: Jaundice in a young cat

Miriam Lodewyks — Mon, 10 Feb 2014 19:56:17 GMT

Me too! Just dealing with an almost identical case: also young male, initially thought to have been scrapping, got persistently quieter, and today looks dreadful! Significant pyrexia and bloods unremarkable, apart from raised TBil, alongside mild anaemia (PCV = 25%) and thrombocytopenia... Will scan him tomorrow, and try not to feel shy to refer if I think it's getting out of hand.

Re: Jaundice in a young cat

mariette asselbergs — Mon, 10 Feb 2014 18:21:32 GMT

Interesting case, I just had a patient this afternoon who went through exactly the same last summer, also with good outcome. What do others think of adding samolyn (liver support stuff, methionine etc) to treatment for jaundiced cats?

Mariette

Re: Jaundice in a young cat

Christopher Saul — Mon, 10 Feb 2014 18:17:36 GMT

[quote user="Robin Grimmer"]O tubes are easy to place and well within the reach of anyone in general practice. [/quote]

I absolutely agree with this sentiment also, however the reason for referral in this case was that ultsound was not available at the practice and this was urgently indicated

Re: Jaundice in a young cat

Thomas Johnson — Mon, 10 Feb 2014 15:22:56 GMT

[quote user="Robin Grimmer"]

O tubes are easy to place and well within the reach of anyone in general practice.

[/quote]

I agree, and if you don't have overnight hospitalisation facilities you can get owners to tube feed them at home overnight and re-admit them the following morning.

Re: Jaundice in a young cat

Robin Grimmer — Mon, 10 Feb 2014 13:56:13 GMT

O tubes are easy to place and well within the reach of anyone in general practice.

Re: Jaundice in a young cat

Christopher Saul — Mon, 10 Feb 2014 13:09:30 GMT

Good stuff, I'm glad he's doing well. It's very frustrating for you not having access to ultrasound. You can, though, be happy in the knowledge that you did the best thing for the cat.

Re: Jaundice in a young cat

Kirsten Simpson — Mon, 10 Feb 2014 11:19:01 GMT

Update!

Diagnosed with Cholangiohepatitis (as I suspected), o-tube placed, on pain meds, antibs and the usual liver supplements, Picked up, eating on his own well, removed feeding tube and home with oral meds + a feeding plan. All good, yay! Just frustrating being in GP sometimes where we don't have o-tubes or the facilities to keep them in 24h but I think he did well as he went to the best place for him.

Re: Jaundice in a young cat

Christopher Saul — Tue, 04 Feb 2014 10:00:43 GMT

No worries. I wouldn't think too bad of the vet school.. I can tell you it really does take some time to do reports on medical cases as they're rarely straightforward. If you have a day rammed full of investigations it can be very tiring; I've been wiring reports at midnight before now when I'm in at 7 the next day.

Re: Jaundice in a young cat

Kirsten Simpson — Tue, 04 Feb 2014 09:01:01 GMT

Not yet! Its at the local Vet School. I know someone who works there and all she knew is that it was having an o-tube placed and being tube fed. They can be slooooow in getting reports back to us, not usually until it has been discharged :/ Might ring up and ask...

Re: Jaundice in a young cat

Christopher Saul — Mon, 03 Feb 2014 20:53:32 GMT

Just wondering... any news on this one??

Chris

Re: Jaundice in a young cat

Kirsten Simpson — Fri, 31 Jan 2014 17:18:49 GMT

I did think about Lepto but then didn't think it would be as the two cases I have seen with Lepto were a) both dogs and b) in kidney and liver failure at the time (both young dogs and unvaccinated). Still a possibility though I suppose but I would have though if it was commoner, it would be included in cat vaccines too rather than just dog ones?

Re: Jaundice in a young cat

Chris Barker — Fri, 31 Jan 2014 15:08:01 GMT

Simply highlighting how medicine moves on In Practice has had at least two articles over the years discussing the jaundiced cat Leptospirosis appears as a differential in the first article, but a few years later it didn't even rate an entry at the bottom of the list! So I was simply wondering, given the possibility of exposure to rodent urine, does no-one consider it as even a possibility in the jaundiced cat nowadays, or is leptospirosis infection in cats a non-disease?

Re: Jaundice in a young cat

Kate Richardson — Fri, 31 Jan 2014 14:56:14 GMT

[quote user="Chris Barker"]

Going to show my age here... But I find it fascinating that in all the above discussion no-one has even mentioned the possibility of Leptospirosis. I wonder if this is a hidden, unsuspected disease or simply very very rare

[/quote]

It's a cat? Did people not have them as pets in the old days?

Re: Jaundice in a young cat

Chris Barker — Fri, 31 Jan 2014 14:22:58 GMT

Re: Jaundice in a young cat

Hannah Wynne Richards — Fri, 31 Jan 2014 12:37:05 GMT

I would definitely have referred - no reason not to since the cat is insured.

I think we (as a profession ) often over-stress ourselves by thinking we have to know everything about everything. The secret of being a good GP is to be moderately good at everything, and very good at recognising early on when greater (if narrower ) expertise is necessary.

Wynne

Re: Jaundice in a young cat

Christopher Saul — Fri, 31 Jan 2014 12:01:38 GMT

[quote user="Kate Richardson"]Not a cop out in the slightest-[/quote]

Couldn't agree more. This cat needs an ultrasound and if you haven't got the facility, that does not put it on your shoulders as a cop out. You have done the best for the cat, and that is what matters most. If you want to put an even more positive spin on the situation, think of the report you get back from the uni as a learning exercise.

Would be interested to hear what happens!

Cheers, Chris

Re: Jaundice in a young cat

Kate Richardson — Fri, 31 Jan 2014 11:24:13 GMT

Not a cop out in the slightest- cat needs an ultrasound to enable best treatment plan- options available to do so, so cat getting what it needs!(Regardless of what day of the week it is) Keep us posted!

Re: Jaundice in a young cat

Kirsten Simpson — Fri, 31 Jan 2014 10:58:03 GMT

I feel like a cop out but the cat was overtly much more jaundiced today, even more lethargic and still pyrexic. Deep palpation of his abdomen elicited to fluid thrill/pain/swellings etc. He IS insured so I rang the local Vet School, Spoke to Prof Ramsey and he is currently there being examined and admitted for further investigations. I felt it was the best option rather than admitting him for further investigations here when he really needed more expert hands/ultrasound., o-tubes etc which we have none of here. Fingers crossed all goes ok for him as he is lovely and I am quite worried. Much appreciated for all the help, if hadn't been a Friday I would have been more gung-ho I think but as insured and Friday, though best to refer!

Re: Jaundice in a young cat

Christopher Saul — Fri, 31 Jan 2014 10:28:52 GMT

[quote user="Kate Richardson"]Check electrolytes if you can and supplement potassium if low.[/quote]

[quote user="Kate Richardson"]anti emetic such as maropitant also useful as these cats are often nauseus even if not vomiting. B12 supplementation also, if you can get a B12 measurement great, but if not an option supplement anyway as will do no harm.[/quote]

+1. Forgot these with my sleepiness last night!

Hope all goes well today, keep us posted

Re: Jaundice in a young cat

Kirsten Simpson — Fri, 31 Jan 2014 09:52:07 GMT

Yes, I'm thinking the cat fight was either a red herring or wasn't actually a cat fight at all, maybe even booted by someone? No other overt signs of an RTA but still poss, fell from a tree? He's in next so will let peeps know whats happening.

Re: Jaundice in a young cat

Martin Atkinson — Fri, 31 Jan 2014 09:45:40 GMT

Paul has given a very comprehensive answer so I wouldn't attempt to add more but I suspect the cat fight is a red herring and in a cat of this age I would put cholangiohepatitis or triaditis at the top of my diff. list but I would certainly go for FIP and retrovirus testing. Any chance the cat was in an RTA and ruptured its gall bladder?

Re: Jaundice in a young cat

Kirsten Simpson — Fri, 31 Jan 2014 09:14:09 GMT

Cheers Chris and everyone else who answered. I've been dreaming about this cat (and another anorexic older cat) all night. Hate Fridays! I will see if the cat is insured and will admit him this morning for IVFT, antibiotics, FIV/FELV/fPLI on our in house snaps from serum I saved last night and may also blind tap his abdomen using the 4 quadrant technique to see if any FF evident. Cheers peeps, will keep you updated as/if/when I get some answers.

Re: Jaundice in a young cat

Kate Richardson — Fri, 31 Jan 2014 08:57:26 GMT

Ditto everything Chris said,and an ultrasound scan of abdomen would be the ideal next investigative step, pancreatitis or cholangiohepatitis would be top of my list. But if referral not an option, then iv fluids and antibiotics- I would use a combo of amoxyclav/marbofloxacin and metronidazole so all 4 quadrants covered. Buprenorphine for pain relief. Destolit not a bad idea either. Check electrolytes if you can and supplement potassium if low. Feeding tube a really good idea. An anti emetic such as maropitant also useful as these cats are often nauseus even if not vomiting. B12 supplementation also, if you can get a B12 measurement great, but if not an option supplement anyway as will do no harm.

Re: Jaundice in a young cat

Michael Woodhouse — Fri, 31 Jan 2014 02:09:09 GMT

[quote user="Christopher Saul"]This cat could just possibly be a surgical emergency so my advice, if you do not have a scanner in-house, is to offer referral if this is an option. It could be a surgical emergency such as bile duct obstruction or worse rupture.[/quote]

Or ex lap, have a look and biopsy liver if required.

Re: Jaundice in a young cat

Christopher Saul — Fri, 31 Jan 2014 01:17:51 GMT

Hi. I'm sorry if this post isn't one of my finest but I'm on my phone and it's also v late ( can't sleep)

Firstly, I think you're on the right track with your logic, and you seem to be doing a good job so far. Your job hasn't been made any easier by the cat fight either, which may have confounded the clinical picture.

This level of icterus (TBil 85) is definitely significant. As you know, icterus can be grouped into 3:-

*Pre-hepatic

*Hepatic

*Posthepatic

With a PCV of 34% you have essentially eliminated pre-hepatic already. (I suppose the cat could theoretically be extremely haemoconcentrated and haemolysing at the same time but I believe this is highly unlikely; cats almost never get this jaundiced through haemolysis)

So, this leaves us with the other two. Yes, as you hint at, with either of these you would normally expect derangements in the liver enzymes (with post-hepatic disease you might normally expect more severe elevations in the cholestatic enzymes - ALP and GGT- whereas with hepatic failure you might expect the hepatocellular enzymes to be elevated) but I don't think normal liver enzymes rules anything in or out at this stage.

You are quite right to want to ultrasound this cat, and this test would provide the most useful information. With post hepatic jaundice you would see distension of the common bile duct - diagnostic for biliary obstruction You would also get information about the presence or otherwise of free abdo fluid and also potentially useful information about the appearance of the liver parenchyma.

This cat could just possibly be a surgical emergency so my advice, if you do not have a scanner in-house, is to offer referral if this is an option. It could be a surgical emergency such as bile duct obstruction or worse rupture.

If referral is not an option then what then? Well off the top of my sleepy head here are a few thoughts:

-Lymphocytic cholangitis classically affects younger, often pedigree, cats. It typically presents with jaundice and non specific dullness, so could fit in this case. It does not normally cause a fever, but maybe the fever is simply due to the cat bites??

-Pancreatitis can cause sufficient obstruction to biliary flow to cause jaundice; do you have any SNAP PLI? if not you could send off for fPLi. When accompanied by IBD and cholangitis some people term this 'triaditis'

-Neutrophilic cholangitis/cholangiohepatitis is more common in older cats but I guess it's not impossible

-FIP is on the list; it's the elephant in the room. normal serum proteins do not eliminate this possibility. To be honest it can be a nightmare to prove.

-Liver failure perhaps less likely but not eliminated at this stage - toxic, neoplastic (unlucky at this age but not impossible), infectious, lipidosis etc - but as you say you might expect liver enzyme elevations

[quote user="Kirsten Simpson"]If it was fatty liver would they not have changed?[/quote]

The classical enzyme picture for hepatic lipidosis is very high ALP but normal or only slightly elevated GGT, and mild to moderate ALT elevations. But this is just a pattern, you can neither make the diagnosis nor eliminate it from the enzymes alone

So, if you can't refer, what can you do?

-Supportive care. IV fluids. Analgesia? Antibiotics? Appetite stimulants e.g. mirtazipine? How about an oesophagostomy tube if the cat won't eat - they're cheap and easy to place and make nutritional support a whole lot easier in anorexic patients

-fPLI.

-X rays may provide some info, for instance if there is free abdo fluid then you might expect a lack of serial detail. If there is evidence of fluid then abdominocentesis perhaps. If you have indication from the x ray and abdominocentesis, then ex lap might become indicated. If you do ex lap place an oesophagostomy tube ( Did I mention I like oesophagostomy tubes?)

-Repeat the biochemistry to monitor what's going on

-Poss FCoV titre and AGP, esp if you get some fluid

Sorry if this doesn't make a lot of sense, I'm going to try again at getting some sleep now

Hope this helps

Chris