Old cat with fresh blood in faeces

Re: Old cat with fresh blood in faeces

Anthony Todd — Tue, 26 May 2015 17:26:19 GMT

[quote user="Rory Bell"]Other than that, nothing wrong with anecdote, so long as it's limitations are recognised![/quote]

Especially if it's the only information available!

Re: Old cat with fresh blood in faeces

Rory Bell — Tue, 26 May 2015 16:38:43 GMT

Hi all

Apologies - I was away for the weekend, without e-mail access.

In my initial reply to Neil I simply gave the options for investigation (which was I understood he was asking for) but also said that if the cat was well in itself, there was probably little point in doing much at this point in time. My sense from his subsequent post is that he agrees (sorry if I misinterpreted that Neil)

Michael is correct; what i wrote is anecdote and anecdote, whether 'expert' or not, is the lowest form of clinical evidence and should never be interpreted as being anything else. I also agree with what Anthony wrote however; the main way these forums work in terms of knowledge dissemination is through conveying anecdotal experience.

This will probably not happen (!) but using this thread as an example, one way to try to convert anecdote to the beginnings of clinical evidence through these forums would be to set up a thread whereby all participants replying to the thread listed the signalment, diagnosis and outcome or the last three cases chronic haematochezia that they saw. It would be asking a lot of respondents time, but IF enough people responded, you might start to identify meaningful trends and patterns. Other than that, nothing wrong with anecdote, so long as it's limitations are recognised!

rory

Re: Old cat with fresh blood in faeces

Matt Hilary — Tue, 26 May 2015 16:33:58 GMT

Another one for folate/cobalamin testing if GIT thickened.

Re: Old cat with fresh blood in faeces

Anthony Dennison — Tue, 26 May 2015 09:25:46 GMT

Something else to consider is pancreatitis - can get all sorts of clinical signs and they can all be pretty vague in cats.

Re: Old cat with fresh blood in faeces

Rob Loxley — Mon, 25 May 2015 12:04:41 GMT

[quote user="Neil Wheadon"]

As in so many clinical cases where a question has been posed the argument has gone down this line, result that for the majority we have learnt nothing.

[/quote]

I think we learn that there is no 'right' answer? My criticism might be also that from your original question it isn't clear whether these are acute or chronic cases of passing blood?
In acute cases I'd probably do little but sit tight if the rest of the history/exam is fine; in chronic cases I'd consider more investigations/imaging/diet etc. Have to say rarely do we biopsy these as we havent an endoscope and lower GI full-thickness biopsies worry me. With all cases where you're left with IBD/diffuse neoplasia as the most likely diagnoses I always question whether getting biopsies will change my treatment plan for the pet/owner?

Re: Old cat with fresh blood in faeces

Anthony Todd — Sun, 24 May 2015 16:13:51 GMT

[quote user="Michael Woodhouse"]His opinion is worth more than most of ours, but it's still a weak form of evidence.[/quote]

Rory gave us the options and put them well. The value of the forum is , actually, the anecdotal perceptions of others.

How many cats with "a touch of blood in faeces. The bowels feel uniformally thickened, but it's pretty subjective" turn out to have something sinister?

Now if a lot of replies said "Yes, seen a few of these and they all/some/none turned out to be x, y or z, or turned out to get better, or whatever ,then these anecdotes are valuable.

That's all I'm trying to get across and the obvious [to me] course of action is to give your placebo injection [or clients think you've done nothing] and see in a few days if the blood is still occurring.

Then, and only then, do all the tests etc. or refer but don't jump in on day one.

On the other hand, say, "a touch of blood in the urine" might be worthy of further investigation earlier.

Re: Old cat with fresh blood in faeces

Michael Woodhouse — Sun, 24 May 2015 15:59:23 GMT

[quote user="Neil Wheadon"]The initial post was encouraging, Rory replied with an eloquent and well thought out answer but as in so many cases posted on here it has been swallowed by anecdotal perceptions and I and many others haven't learnt a lot.[/quote]

Rory wrote a comprehensive post, but it was all just his opinion. Remembering that if he is in referral practice he's likely to see less of these than the average practitioner doing a lot of first opinion cat work. No one has suggested referring the cat! His opinion is worth more than most of ours, but it's still a weak form of evidence.

What would you like to see - the specialist gives his opinion and we curtsey and say "thanks sir"?

I'm quite happy reading how different practitioners approach these cases in real life.

Re: Old cat with fresh blood in faeces

Neil Wheadon — Sun, 24 May 2015 15:07:03 GMT

As in so many clinical cases where a question has been posed the argument has gone down this line, result that for the majority we have learnt nothing.

It's a straightforward question and one that is as interesting for new graduates as older graduates like me.

There are options

1) Investigate

2) Leave alone and re-assure

3) treat with something

I've seen 3 of these in the past month, clinically well cats with a touch of fresh blood in the faeces. The owner is concerned which is after all why they have come to see a vet and I am interested in what people do.

The initial post was encouraging, Rory replied with an eloquent and well thought out answer but as in so many cases posted on here it has been swallowed by anecdotal perceptions and I and many others haven't learnt a lot.

I give up

Neil

Re: Old cat with fresh blood in faeces

Anthony Todd — Sun, 24 May 2015 13:38:00 GMT

[quote user="Martin Atkinson"]Can't understand why the steroid king is the one arguing against preds unless he's just playing Devils Advocate[/quote]

What, every cat with "a touch of [fresh ]blood" on the stool is put straight on steroids at the initial presentation?

Wow, I am having an influence at last.....

Re: Old cat with fresh blood in faeces

Anthony Todd — Sun, 24 May 2015 13:33:24 GMT

[quote user="robloxley"]here we go again, your quoted source in fact states: [/quote] etc

Yet the presenting signs were:

Old cat presents with a touch of blood in faeces. The bowels feel uniformally thickened, but it's pretty subjective.

And my reply was "wait and see" rather than leaping into loads of investigations and treating with steroids, although, back in the day, the B12 and Bets placebo satisfied the client that "he gave it an injection" which justified the fee for the consult and exam.

Still think it's a sensible approach, usually they stop bleeding in a day or two or even the next motion.

I wasn't suggesting that it was "nothing" nor to ignore it, if it continued, but to rush into, what, several hundred quids worth of tests and procedures if that is the only presenting sign is excessive IMHO.

It seems to be the modern way with even the most minor of initial presentations.

Re: Old cat with fresh blood in faeces

Michael Woodhouse — Sun, 24 May 2015 01:21:13 GMT

[quote user="Martin Atkinson"]Given hyperthyroidism is a common cause of diarrhoea in old cats[/quote]

"common"? I've dealt with quite a few hyperthyroid cats and never had diarrhoea as a feature.

I'd probably reach for the Depomedrone/B12 but would like some basic bloods first (We'd do a T4 in older cats routinely).

Re: Old cat with fresh blood in faeces

Martin Atkinson — Sat, 23 May 2015 19:02:48 GMT

[quote user="Neil Wheadon"]Interestingly of the 3 cases I've seen 2 had an enlarged palpable thyroid However in one case the T4 was normal [/quote]Given hyperthyroidism is a common cause of diarrhoea in old cats then this might be something worth addressing first (you haven't said if the bloody faeces are diarrhoeic or not). One can't of course rule out co-morbidities and the normal one may be euthyroid sick syndrome.

Can't understand why the steroid king is the one arguing against preds unless he's just playing Devils Advocate. Rob said that hypereosinophilic syndrome may be associated with forms of intestinal lymphoma and although of course you're not going to reach for the preds on day one, if the owners don't want further investigation, would be a against chemo anyway and the cat(s) are deteriorating then you are IMO justified in invoking the rule of 'never let anything die without the benefit of the 'roids'!

Re: Old cat with fresh blood in faeces

Rob Loxley — Sat, 23 May 2015 18:37:21 GMT

[quote user="Anthony Todd"]According to http://www.vet.cornell.edu/FHC/health_resources/brochure_ibd.cfm you'd need vomiting, weight loss, diarrhea, and lethargy as well as the blood, none of which were mentioned in your original post.[/quote]

here we go again, your quoted source in fact states: Some common signs of feline IBD include vomiting, weight loss, diarrhea, and lethargy. Appetite can be variable, ranging from ravenous to anorexic. While some cats will show obvious symptoms of disease, such as vomiting after every meal, other cats may exhibit symptoms much less frequently, such as vomiting or producing hairballs once or twice a month. The symptoms of IBD can also vary depending on the area of the digestive tract affected by the disease. For example, if the inflammatory cells are affecting the stomach or higher areas of the small intestine, then the cat may exhibit symptoms of chronic vomiting. If the inflammatory cells are in the colon, then the cat may have diarrhea or blood in the stool. The symptoms may not always correspond to the area affected, especially if the entire digestive tract is involved.

Re: Old cat with fresh blood in faeces

Anthony Todd — Sat, 23 May 2015 13:37:12 GMT

[quote user="Neil Wheadon"]inflammatory bowel disease seems to be the commonest/one of the commonest disease processes in cats,[/quote]

Surely a bit of a leap, based on some fresh blood in the faeces and possibly swollen bowel particularly when steroids are regarded as the invention of the devil and more dangerous than cyanide...??

Still,on the other hand, it sounds as if B12 and Bets might be coming back into fashion.

According to http://www.vet.cornell.edu/FHC/health_resources/brochure_ibd.cfm you'd need vomiting, weight loss, diarrhea, and lethargy as well as the blood, none of which were mentioned in your original post.

Re: Old cat with fresh blood in faeces

Neil Wheadon — Sat, 23 May 2015 12:13:56 GMT

[quote user="Anthony Todd"]Why on earth would pred be indicated at this stage? [/quote]

Because according to the references inflammatory bowel disease seems to be the commonest/one of the commonest disease processes in cats, therefore a short course are indicated? Rory who is a certificate holder has indicated this, so looks like I'm barking up the right tree.

Neil

Re: Old cat with fresh blood in faeces

Anthony Todd — Sat, 23 May 2015 12:08:00 GMT

[quote user="Neil Wheadon"]1) Moniter and re-assure.[/quote]

+1, as it's fresh blood it's low down in the bowel and is probably just a minor laceration, obviously if it continues then think again.

If the cat is on dried food then the husks or whatever could easily cause a minor rectal bleed I'd think.

Why on earth would pred be indicated at this stage? If anything it delays healing.

Should make 'im feel better and increase appetite, or at least B12 and Bets always did, so the problem went away concurrently and everyone was happy.

Re: Old cat with fresh blood in faeces

Neil Wheadon — Sat, 23 May 2015 11:31:18 GMT

Thankyou

The cat is a generic cat. I've seen 3 in the past few weeks

Basically, old cat aged 14 or 15, owners are concerned that cat is clinically well but has passed fresh blood in faeces. In all the intestines have felt thickened and I was curious as to what others would do.

The differentials noted are very helpful and thought provoking.

In these cases, the owners are looking for a realistic and pragmatic approach given the age and the clinical wellness of the cat and I was looking for any ideas as to what to give and how to proceed. I've trawled a few articles (In Practice and International Cat Journal) and they talk about differentiating large from small bowel, but then say nothing about large bowel disease. I'd be loathed to jump straight into biopsy, given that it's invasive and could make a well cat poorly, faecal samples seem useless, however your comments on eosinophilia are interesting, though this gives guidance rather than a definitive reason.

Interestingly of the 3 cases I've seen 2 had an enlarged palpable thyroid However in one case the T4 was normal (so resampling in 6 weeks) the other is in for bloods next week.

Ultimately it's a case of

1) Moniter and re-assure.

2) Preds for a few weeks/days

3) Anything else I should be doing/thinking which was the reason for the post

Neil

Re: Old cat with fresh blood in faeces

Rory Bell — Fri, 22 May 2015 21:28:55 GMT

Hi Neil

How's the cat? I don't know the answer to this question and it's important in terms of what you do next. Equally important is what the owners want to do. I think you have three options:

1) Wait and see: if it's an otherwise healthy cat then what are you trying to fix?

2) Take Martin's approach. the only thing I have to offer in addition to what he's said is that 1) IMHO cats develop an eosinophilia much more readily than dogs as part of a non-specific inflammatory response and 2) hypereosinophilia has been reported as a paraneoplastic syndrome in response to gastrointestinal T cell lymphoma (T cell immunophenotype not having the same negative prognostic significance in cats as it does in dogs)

3) Do option (2) plus a high quality ultrasound +/- endoscopic/surgical biopsies

I've taken each of these three approaches including option 1 +/- 2 + steroids (pred at 2-3mg/kg q24hrs) if NAD on my initial investigation. It all comes down to what the owners informed consent is. Bear in mind that low grade GI LSA is indistinguishable from IBD in signalment, clinical signs, occasionally endoscopic biopsy histology and (with nuances) treatment (pred + chlorambucil vs pred alone and no-one has ever compared the performance of cats with low grade GI LSA between those two treatment protocols). Mean survival of cats with low grade GI LSA on red/chlorambucil is approx 23mths, so its (often) not a rapidly fatal disease.

Obviously, diet is an important facet of workup with options 2 and 3, but if I want owners to fork out on an expensive diet, I'll usually try to exclude non diet response (non alimentary) disease first while acknowledging that many cats with diseases other than food allergy / intolerance will have an element of diet responsiveness.

So, how ill is the cat and how informed to the cat's owners (in the event that it is ill) want their treatment options to be?

strongly suspect I have just told you a lot of what you already know, but that's my approach.

comments welcome!

Re: Old cat with fresh blood in faeces

Robin Grimmer — Fri, 22 May 2015 19:04:01 GMT

I find these quite common. If it's a small amount of fresh blood then I think neoplasia is less likely and as you say are more likely to be ibd or colitis and usually get better with symptomatic treatment. Also occasionally can be caused by straining due to constipation.

Re: Old cat with fresh blood in faeces

Martin Atkinson — Fri, 22 May 2015 19:01:58 GMT

[quote user="Neil Wheadon"]

I consider neoplasia is on the list, but can't ultrasound these, biopsy seems over the top and am inclined to treat for colitis/IBD and see what happens

[/quote]Are these the thoughts of the client or you thinking out loud for them?

Ultrasound is not going to tell you any more than you already know - its bowels are uniformly thickened. Looking at other organs especially pancreas might help but if you're not going to biopsy then presumably your not going to give chemo if its lymphoma anyway. Its unlikely to be IBD in an old cat if its not had it before but I would do a blood profile and maybe include TLI/B12/Folate and fPLi plus haematology, IME true iBD cases will have an eosinophilia. Dietary control may help but one spot of blood, just as one swallow doesn't make a summer, doesn't mean a lot. without chronic diarrhoea, weight loss and changes in appetite.