Ongoing haemorrhagic diarrhoea...

Re: Ongoing haemorrhagic diarrhoea...

Thomas Johnson — Tue, 30 Sep 2014 18:55:09 GMT

[quote user="Hannah Wynne Richards"]

Don't be too depressed. You did everything the owner would allow you to do. Frustrating case - but definitely not one to feel guilty about.

My sympathies

[/quote]

I agree, I don't see what else you could have done. Any chance of a post-mortem being done?

Re: Ongoing haemorrhagic diarrhoea...

Hannah Wynne Richards — Tue, 30 Sep 2014 18:29:30 GMT

Don't be too depressed. You did everything the owner would allow you to do. Frustrating case - but definitely not one to feel guilty about.

My sympathies

Wynne

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Tue, 30 Sep 2014 18:15:32 GMT

**Update**

Sadly this cat was PTS ooh over the weekend :o(

He had quite a heavy bleed from his rectum, and when he was examined there he had pale mm and was passing fresh blood. The decision was made to PTS as it the ooh service thought it unlikely that a mass in his rectum or extensive inflammation, or whatever it was, would have been operable.

A massively frustrating case and not a good outcome. Felt pretty down when I heard about it on Monday.

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Thu, 25 Sep 2014 12:35:27 GMT

Here is what the local referral centre said -

'My thoughts are that a true exclusion diet does not appear to have been trialed according to the notes provided, but i think in light of the rectal thickening and current problems it may be best to refer ***** for colonoscopy/further assessment as this problem sounds to have acutely deteriorated and is causing **** considerable discomfort. There are no real topical treatments i would advise but if he is very painful then a trial course with buprenorphine may also be indicated in addition to your current therapy (palliative until further assessment performed). I suspect he may have had a dietary hypersensitivity originally that caused the clinical signs or possibly more severe IBD than the biopsies identified but at this stage the rectal thickening and possible colonic narrowing is more of a concern so i would strongly urge referral for further investigation if possible. We would be looking for any sign of strictures/mass/inflammation etc and would want to take further biopsies of the intestines (endoscopically) to ensure we have representative samples of the length of the colon. If we find a mass or stricture, depending on the site, surgical intervention may be required but we could give a better idea of what this may be once we have a clearer picture of the disease process.

You have otherwise done a very extensive work up and it can be incredibly frustrating in these cases when no treatment appears to help - we would be very happy to see **** to assess him further so please do not hesitate to contact us if you would like to arrange referral or discuss this further.'

I've rung the owner this morning, she thinks he's been doing much better the past couple of days. He's still on vetergesic in addition to his preds, but his faeces are looking more like lumps then long narrow bits and he hasn't had any bleeding recently. So she's going to hold off of referral for now, we'll see him back here in a couple of days to check him over and then decide what to do.

Re: Ongoing haemorrhagic diarrhoea...

Hannah Wynne Richards — Thu, 25 Sep 2014 09:41:50 GMT

Borrow a copy of BNF or MIMS from a friendly doctor.

Wynne

Re: Ongoing haemorrhagic diarrhoea...

Matt Hilary — Wed, 24 Sep 2014 12:41:03 GMT

[quote user="Rebecca Benge"]

She also didn't see any value in testing for fPLI as the cat isn't vomiting or showing any other pancreatitis type symptoms.

[/quote]

It may not be helpful from a clinical point of view but I have had a few cases with an elevated fPLI without typical pancreatitis symptoms. One had a fPLI of 10x normal range despite maintaining a good appetite, normal demeanour, no abdominal pain, no GI signs (presented for chronic weight loss).

Re: Ongoing haemorrhagic diarrhoea...

Anthony Todd — Tue, 23 Sep 2014 14:50:03 GMT

Didn't you see my post? I know it's the dreaded steroids but what else?

Is it around the anus or just the rectum?

Not just scalding from the D+ giving a nasty reaction?

Google anal steroids and there's plenty.

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Tue, 23 Sep 2014 10:02:33 GMT

Ah well this is my question!! What can I safely put up his bottom to help?

He's already on preds so don't want to give a systemic injection - but I am looking for suggestions as to what I could use topically! When you say steroid cream, do you mean fuciderm??

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Tue, 23 Sep 2014 10:02:28 GMT

Ah well this is my question!! What can I safely put up his bottom to help?

He's already on preds so don't want to give a systemic injection - but I am looking for suggestions as to what I could use topically! When you say steroid cream, do you mean fuciderm??

Re: Ongoing haemorrhagic diarrhoea...

Mark Hedberg — Mon, 22 Sep 2014 20:38:25 GMT

[quote user="Rebecca Benge"]

I fail to see how putting him on a hypoallergenic diet would sort his bottom out?

[/quote]

Depends on if a sensitivity is part of the issue or not. That said, I don't remember if you'd said you'd treated for hookworms - few months of advocate sorted out a hemorrhagic gut issue with a collie patient of mine many years ago...(I saw the hookworms on endoscope, they were there!)

Re: Ongoing haemorrhagic diarrhoea...

Anthony Todd — Mon, 22 Sep 2014 19:40:25 GMT

[quote user="Rebecca Benge"]But I no longer see the diarrhoea as an issue[/quote]

Sorry, I thought the D++ was the issue. DId the rectitis[?] come before the D+ of after?

Dare I suggest a steroid jab, suppository ,or just steroid cream up the rectum??

Still need diet control or the D++ will start again.....

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Mon, 22 Sep 2014 15:58:05 GMT

I know and I'm obviously doing a poor job of convincing this lady that we need to do a food trial :(

But I no longer see the diarrhoea as an issue, the faeces are formed. It's this inflammation and thickening in the rectum that's the issue! And I'm reluctant to put him on something that will soften the faeces up again, having only just got somewhere with the D+. We've tried a short course of katalax recently, just to see if this makes passing faeces easier for him and he's on vetergesic to keep him comfortable. I fail to see how putting him on a hypoallergenic diet would sort his bottom out?

Re: Ongoing haemorrhagic diarrhoea...

Anthony Todd — Sun, 21 Sep 2014 10:13:51 GMT

[quote user="Rebecca Benge"]a single source protein diet[/quote]

Sorry, I and most dinosaurs I know, would have done that one day one and kept the cat in so that it was a "single source".

There is a plant supplement for humans and animals which you can mix with tinned food for chronic constipation which turns the faeces into mousse; Isogel is the human product and there is a vet one, I think. but I can't remember the name. It's accepted well and works well too.

Re: Ongoing haemorrhagic diarrhoea...

Andrew Kent — Mon, 15 Sep 2014 15:57:15 GMT

I don't disagree with the comments regarding B12 and folate, folate rarely needs supplementing and your B12 is in the normal range.

However the clinical signs of cats with pancreatitis are often much more subtle than dogs, so excluding it on the basis of no vomiting would probably miss a lot of cases. Equally the problem with TLI is that there is a tendency to consider it a yes/no test for EPI. This may be true in GSD's with the immune-mediated disease but is certainly not true when considering EPI as an end stage to chronic pancreatitis. We know in chronic pancreatitis dogs (and in people with chronic pancreatitis) that the weight loss occurs well before the TLI falls to a low level and it is suspected this is due to the concurrent inflammation elevating TLI (remember TLI was originally developed as a test for pancreatitis!). So we tend to be very pro-active in supplementing pancreatic enzymes and would do so even in the face of a normal TLI if there is weight loss and clinical suspicion (clearly for us clinical suspicion is easier with access to specialist ultrasonographers).

Equally the faeces with EPI is not always classic, we have certainly seen colitis as a clinical signs of chronic pancreatitis quite frequently.

So it may be a long shot but you lose nothing by trialling some enzymes whilst the owner considers the next step.

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Mon, 15 Sep 2014 15:42:45 GMT

Have just spoken to one of the internal medicine people at Idexx. She seemed to think that there was little value in supplementing him with cobalamin as he was WNLs for this. Also she said that most cat foods have enough folate in them that cats don't require supplementation for this either. It's more just an indicator that a disease process is occurring. She says that usually cats with an TLI of less than 8 are considered to have EPI, so at 12 she wouldn't be putting him in this category - especially as he had colitis type symptoms, rather than EPI symptoms (bloody faeces, straining and small amounts, rather than large volumes of fatty faeces). In other words it may be normal for him to be the low end of the ref range, and we could consider re-testing at a later point if we wanted to check what was happening. She also didn't see any value in testing for fPLI as the cat isn't vomiting or showing any other pancreatitis type symptoms.

Feel free to disagree though!

It sounded like she thought I should continue as is with steroids, and consider a single source protein diet. Following the constipation episode he is producing better faeces than he has ever been previously in the past several months, so actually my main concern is now focused on whether he gets 'constipated' again, and whether there is a stricture/severe inflammation in his rectum that will cause us ongoing problems... It was his owner that was wondering if there was a preparation he could have inserted up his bottom to act as a topical treatment, but I didn't know! The treatments people have mentioned previously - are they available from normal supplier?

Re: Ongoing haemorrhagic diarrhoea...

Kate Richardson — Mon, 15 Sep 2014 15:12:06 GMT

B12 is fine, and no problem topping him up, his levels are in the lower half of the normal range, any excess will be peed out. Low folate means very little in terms of diagnosis as far as I am aware, maybe Andrew knows if this should be supplemented as well?

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Mon, 15 Sep 2014 14:51:47 GMT

So you'd use a B12 supplement like vitbee (ie the one that's stocked in my practice at the mo), instead of swapping to something else (is there actually something else injectable that covers B9?). Is it less important to try and sort out folate levels specifically? I wasn't sure whether topping up cobalamin levels with vitbee would do any good if the lab is telling us he isn't deficient in this?

Re: Ongoing haemorrhagic diarrhoea...

Andrew Kent — Mon, 15 Sep 2014 13:15:27 GMT

I would supplement pancreatic enzymes in this cat. TLI will also be elevated by concurrent pancreatic inflammation and so may well be lower than this in reality. Is it too late to ask the lab to measure fPLI on your sample? And the malabsorption associated with enzyme deficiency can cause this picture. If that doesn't improve things I might also try a bile acid binder.

I would go for a 4-6 week trial of enzymes and see whether it improves the faeces and leads to weight gain, if it does then continue.

And B12 is fine for these cats.

Andy

Re: Ongoing haemorrhagic diarrhoea...

Kate Richardson — Mon, 15 Sep 2014 12:35:14 GMT

I think Wynne may be right in their being more then one factor in play contributing to the clinical problem. You will do not harm by supplementing pancreatic enzymes and B12, even though the B12 is normal, I would prob still go with 0.25mls weekly. If the cat is still on metronidazole I would continue and if still on prednisolone I would also continue, just add the pancreatic enzymes. Did you manage to get the owner to feed a suitable diet eg Purina HA or similar? Did address any stress in the cats life? If you get resolution of the problem addressing all these factors, then you start taking off one medication at a time and see if things recur. The owner will no doubt just be happy to have normal poo! (the cats poo not the owners!!)

Re: Ongoing haemorrhagic diarrhoea...

Hannah Wynne Richards — Mon, 15 Sep 2014 09:57:31 GMT

My contribution for what it's worth.

One possibility could be pancreatic insufficiency leading to slow digestion,leading to 2y bacterial overgrowth, leading to chronic inflammation leading to thickening, leading to malabsorption,and therefore a "2 wrongs making a right" situation of a normal b12.

Wynne

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Mon, 15 Sep 2014 09:46:24 GMT

TLI result back this AM and is low at 12ug/L (12.1-82.0). Idexx interpretation says 'TLI results at 8-12 are equivocal. Repeating the assay at 1-2 months later is indicated.' I'm not sure what this tells me? Do I need to administer a pancreatic supplement? I might have to ring Idexx for advice.

fPLI hasn't been measured actually :(

Folate is low at 6.7ug/L (9.5-20.2). Cobalamin is normal at 553ng/L (270.0-1000.0).

We only have vitbee in practice which is B12 (cobalamin), so I'm guessing there's no value in administering this. Other multivitamin injections include B9, so would you start injections for this?

The rectal treatments people are talking about.... do you get those through your normal supplier or do they have to be obtained from a human pharmacy?

I think this is one of those cases where I can't see the wood for the trees at the moment :(

Re: Ongoing haemorrhagic diarrhoea...

Andrew Kent — Thu, 11 Sep 2014 16:25:27 GMT

We have used Colifoam (hydrocortisone rectal foam) in a few dogs with marked large intestinal inflammation. I am not sure how easy it would be to administer in a cat.

I wonder whether you might have a rectal stricture secondary to the chronic inflammation or whether there is just a marked fibrosis due to the same thing. We also had a case similar to this which had an invasive E. Coli on biopsies. There are various ways that you could investigate these possibilities - contrast radiography, proctoscopy, biopsy etc but I guess these may have to wait for the future.

Do let us know the TLI result when you get it. Did you measure fPLI as well?

Andy

Re: Ongoing haemorrhagic diarrhoea...

Evelyn Barbour-Hill — Thu, 11 Sep 2014 15:46:24 GMT

[quote user="Rebecca Benge"]So.... this may seem like a silly question, but is there anything that I could use topically inside the rectum to help (in addition to the systemic steroids he's already on)?[/quote]

There used to be a Betsolan gel for haemorrhoids - Betsolan and some antibiotic and some lignocaine, as I recall. Maybe you can still get it, or something similar. It came with an applicator tube that looked rather like the Micralax one. It would be a nice lubricant as well as a medication.

Re: Ongoing haemorrhagic diarrhoea...

Rebecca MacMillan — Thu, 11 Sep 2014 15:25:24 GMT

*Update!*

So we decided to start the cat on steroids, after the antibiotics were making no discernible improvement, at a dose of 1.4mg/kg BID on 18th August. A colleague also put him back on metronidazole on the 29th Aug after no initial response to preds. On 4th Sept he came back in as he was off his food, colleague palpated his abdo - constipated!!

The next day we took xrays, descending colon dilated full of faecal material, but not the small hard knobbley bits you normally see in constipated cats, just diffuse faecal material. No obvious pelvic injuries seen. Rectal exam revealed very irregular feeling rectum, thickened areas, friable wall - not very nice. Enema performed, unable to get much faecal material out as unable to get finger very far in and it generally felt tighter/more constricted than other cats I've enema-ed. Flushed lots of water and lube in and massaged abdo. After GA he passed one of his best looking faeces for quite some time! But it was quite narrowed in appearance (elongated and small diameter), which is something his o has previously seen recently.

Whilst he was asleep we did take bloods for TLI/folate/cobalamin. Still awaiting TLI but folate is low at 6.7 (9.5-20.2) and cobalamin is normal at 553 (270-1000).

Since going home again, his owner reports that his appetite is better and things he is passing faeces ok (but goes outside a lot...) but last night there were drops of blood on the floor, possibly from straining.

Urck. :(

So.... this may seem like a silly question, but is there anything that I could use topically inside the rectum to help (in addition to the systemic steroids he's already on)? It must be sore for him and is probably contributing towards straining. I'm also worried in case he gets a rectal prolapse.

Also has anyone ever seen megacolon follow on from chronic diarrhoea? The colon looked subjectively dilated to me. I'm worrying that although we seem to be improving the diarrhoea, there seem to be other structural issues going on... Owner will probably consider referral if/when he gets constipated again.

Re: Ongoing haemorrhagic diarrhoea...

Anthony Todd — Mon, 18 Aug 2014 08:42:26 GMT

[quote user="Eamon McAllister"] LOL[/quote]

Don't LOL, even my arch nemesis has intimated the same....

And I know you would have tried it very early in the piece.