Mucoceole medical therapy

RE: Mucoceole medical therapy

Richard Carter — Fri, 28 Oct 2016 14:38:03 GMT

or could trial on 2 weeks preds at 2.5mg bid and see if can control inflammation without going to biopsy which would then prove the need to find the appropriate food?

RE: Mucoceole medical therapy

Andrew Kent — Wed, 26 Oct 2016 17:41:32 GMT

[quote user="Martin Atkinson"]But another big advantage is that it also gives me chance to take lymph node, pancreatic and liver biopsies at the same time which of course you can't do endoscopically and as GI disease is often multi-factorial you have a better chance of a definitive diagnosis.[/quote]

Absolutely - as I said above if there is any hint that we need to biopsy other organs then surgery wins every time and that is the case in a lot of cats. Much less of an issue in dogs where we rarely go for surgical bx.

[quote user="Martin Atkinson"]Maybe it comes down to whether you have the kit v how confident a surgeon you are.[/quote]

This is certainly true and that's why there is no right answer to this. Bad endoscopy will be inferior every time to good (or probably even average) surgery and the requirement for kit is much higher for good endoscopy.

RE: Mucoceole medical therapy

Martin Atkinson — Wed, 26 Oct 2016 17:08:28 GMT

[quote user="Andrew Kent"]There are some situations when I wouldn't advise endoscopic biopsies - particularly if ultrasound suggests the disease is primarily based on the muscularis, but actually even in those cases superficial biopsies usually give the diagnosis if surgical biopsies are declined.[/quote]I admit to being biased in my approach in that I don't have suitable endoscopic equipment and I'm anxious to keep the case in house as far as possible. I will normally take multiple full thickness punch biopsies from the length of the gut via laparotomy and never had a surgical complication. But another big advantage is that it also gives me chance to take lymph node, pancreatic and liver biopsies at the same time which of course you can't do endoscopically and as GI disease is often multi-factorial you have a better chance of a definitive diagnosis. Maybe it comes down to whether you have the kit v how confident a surgeon you are.

RE: Mucoceole medical therapy

Andrew Kent — Wed, 26 Oct 2016 16:13:56 GMT

[quote user="Martin Atkinson"]

[quote user="Andrew Kent"]in the right cases endoscopic biopsies actually allow more extensive biopsies than surgery [/quote]How do you work that one out? You may be able to get a greater number of samples but you can't get samples of the serosa, muscularis externa and lucky even if you are skilled if you can get reliable samples of the submucosa and in some cases like IBD and lymphoma that's where the lesions are.

[/quote]

Because the severity of the disease is often patchy along the length of the GI tract so you often find evidence of more severe disease by taking samples from more of the length - surgical biopsies rely on a bit of luck that you select an area that is representative of the entire length.

I accept that endoscopic biopsies are more superficial but its uncommon that that leads to a different clinical diagnosis, especially now we have clonality testing to give more information about the nature of cells seen (particularly lymphocytes).

There are some situations when I wouldn't advise endoscopic biopsies - particularly if ultrasound suggests the disease is primarily based on the muscularis, but actually even in those cases superficial biopsies usually give the diagnosis if surgical biopsies are declined.

So I tend to find taking more samples along the length helps me more than taking less deeper samples. But its still largely a matter of opinion and an area that good evidence is lacking as we don't have really good studies comparing the two approaches in the same patient.

I wouldn't suggest having a set approach for all cases and would be guided by pre-biopsy testing (particularly ultrasound, folate/cobalamin etc) but for the 'standard' cases that don't suggest to me I should be doing differently I find endoscopy the preferable option when balancing risk against reliability of results.

Andy

RE: Mucoceole medical therapy

Martin Atkinson — Wed, 26 Oct 2016 15:53:04 GMT

RE: Mucoceole medical therapy

Andrew Kent — Tue, 25 Oct 2016 19:45:57 GMT

[quote user="Martin Atkinson"]

[quote user="Thomas Johnson"]I spoke to Nick Bacon at Fitzpatrick's about endoscopic biopsies, and he said that he prefers to take GI biopsies in cats at ex-lap as he finds he often gets answers from the jejunum and ileum[/quote]I have always believed this. Much of the pathology is in the bits you can't get at with an endoscopic biopsy - I think they're often a waste of time. Only the risk of full thickness biopsies is off putting but I've not had a complication yet.

[/quote]

I really think this depends on what equipment and skills you have - if you are limited to gastric and colonic biopsies then surgical biopsies win every time but in the right cases endoscopic biopsies actually allow more extensive biopsies than surgery - it's only the jejunum we can't sample but it's not been demonstrated in any of the studies that this is an issue.

But I do think in cats its a harder choice because of the benefit of sampling other organs.

RE: Mucoceole medical therapy

Thomas Johnson — Tue, 25 Oct 2016 16:14:41 GMT

[quote user="Kate Richardson"]

Agree will all others re likely gi disease but also check urine (my own cat was vomiting with increasing frequency and had a urinset tract infection- treated and resolved and no more vomiting) and also check teeth thoroughly- dental pain can lead to intermittent vomiting in my experience, poss due to rapid ingestion?

Just worth checking before slicing the intestines

[/quote]

Thanks for your thoughts, I haven't checked her urine so I will do that. Her teeth are very good, no sign of any dental disease, she's a good advert for Royal Canin Dental diet!

RE: Mucoceole medical therapy

Martin Atkinson — Tue, 25 Oct 2016 15:08:14 GMT

RE: Mucoceole medical therapy

Kate Richardson — Mon, 24 Oct 2016 23:50:17 GMT

Just worth checking before slicing the intestines

RE: Mucoceole medical therapy

Andrew Kent — Mon, 24 Oct 2016 16:56:27 GMT

Hi Thomas,

Thanks for the update - sorry to hear things are still ongoing.

[quote user="Thomas Johnson"]I just can't work out why she would have been fine on the d/d for 2 weeks, and then started vomiting.[/quote]

I guess its difficult to know if this is due to natural waxing and waning of disease or true diet response, but I guess some kind of indiscretion leading to deterioration is possible.

[quote user="Thomas Johnson"]but if she keeps vomiting I guess I'm going to have to take biopsies. [/quote]

Agreed that would be the next logical step.

I guess the answer to this is largely a matter of opinion but it doesn't surprise me that if you ask a surgeon who doesn't perform flexible endoscopy that they will say to cut :-) our surgeons would probably say the same - but then we only let them have the cases that we think are not good candidates for endoscopy so its a self-selecting population.

Its true that, in cats, evidence suggests there can be disagreement between a diagnosis obtained in the duodenum and ileum which is why most of us that perform endoscopic biopsies will biopsy the ileum as part of a lower GI scope (so I routinely bx stomach, duodenum, ileum and colon).

Having said that, many of the cases I see have concurrent hepatic/pancreatic/biliary disease and in those cases we often send them to surgery so we can get liver biopsies +/- pancreatic biopsies +/- bile aspirate at the same time.

[quote user="Thomas Johnson"]He also wondered if the mucoceole was a problem despite the normal liver values as there could be chronic pain from the stretching of the gall bladder, however I re-scanned her a couple of weeks ago and thankfully the mucoceole has gone.[/quote]

Agreed that gall bladder disease can be painful and that we may under-appreciate that in our patients - but obviously not an issue anymore here!

RE: Mucoceole medical therapy

Thomas Johnson — Mon, 24 Oct 2016 16:34:12 GMT

Time for another update on my cat. We didn't get on well with the Royal Canin Sensitivity Duck and Rice, she ate it okay at first after some mirtazapine, and there was no vomiting, but then after 2 weeks she wouldn't eat it, but appeared to be hungry. We gave her some of her previous food, Royal Canin Dental, which she was very keen to eat, but after 5 days she started vomiting again. I gave her Cerenia and switched to Hills d/d venison and pea, which she ate, but after nearly 2 weeks has started vomiting again. It's possible she could have eaten something outside, I've given her some Cerenia and we'll see how she gets on in the next couple of days, but if she keeps vomiting I guess I'm going to have to take biopsies. I just can't work out why she would have been fine on the d/d for 2 weeks, and then started vomiting.

I spoke to Nick Bacon at Fitzpatrick's about endoscopic biopsies, and he said that he prefers to take GI biopsies in cats at ex-lap as he finds he often gets answers from the jejunum and ileum, not the stomach or duodenum. He also wondered if the mucoceole was a problem despite the normal liver values as there could be chronic pain from the stretching of the gall bladder, however I re-scanned her a couple of weeks ago and thankfully the mucoceole has gone.

RE: Mucoceole medical therapy

Anthony Dennison — Thu, 22 Sep 2016 17:34:21 GMT

[quote user="Andrew Kent"]

i don't use a lot of Z/D as its chicken based as well and, although hydrolysed, about 30% of people still react to a protein when hydrolysed which is why I pick novel protein hydrolysed diets like the Purian diet.

But can still work in many cases so hopefully yours will be one of them :-)

[/quote]

Just saw the client in question today, buying more z/d. After a week of transitioning, the cat's stools have solidified and been normal since!

RE: Mucoceole medical therapy

Thomas Johnson — Wed, 14 Sep 2016 18:57:19 GMT

[quote user="Andrew Kent"]

Hi Thomas,

I think that sounds a good plan and would also be looking at biopsies (either endoscopic or surgical) if the signs persist.

[/quote]

Great, I'll let you know how we get on. If she has biopsies it will probably be an ex-lap as we don't have endoscopy here, though I did wonder if a referral centre might do a GA and endoscopy for me as a sort of outpatient procedure rather than as a traditional referral.

RE: Mucoceole medical therapy

Andrew Kent — Wed, 14 Sep 2016 17:26:05 GMT

Hi Thomas,

I think that sounds a good plan and would also be looking at biopsies (either endoscopic or surgical) if the signs persist.

We do occasionally see hair causing problems but my feeling is that it is usually a secondary rather than primary issue.

Andy

RE: Mucoceole medical therapy

Thomas Johnson — Wed, 14 Sep 2016 14:43:14 GMT

[quote user="Aine Seavers"]

Is there visible hair in the faeces. I know a UK vet who used to shave any IBD/Triaditis cat (not that we are allowed use the term Triaditis anymore) of fur/hair as he believed it gave the intestinal tract a chance to recover from a major irritant either as a primary or secondary player. And he personally de-hairballed them orally daily in clinic in out-patient visits first part of the first week as he never trusted clients to do this or deworming properly.Many cats did so well on that and hills i/d or zd(despite the chicken component) or RC Siamese which helps with those constant regurgitators/vomiters /andor scattered the dry food so the cat had to forage not scoff food down. That and a short dexafort injection to settle the inflammation, the vit b injection for the IBD and it was extra-ordinary how many did so well. The slight difference in your cat is the advanced age it has become a vomiter-unless you have slackened off on some of the basic maintenance meds we should do with our cats- of which I am guilty of with my own 2 Siamese as they got older- the carpet bore the brunt of it- so back to better discipline and tiled floor . I do find ranitidine in cases such as yours do better on 1mg/kg ranitidine as an appetite supporter long term than mirtaz as the ranitidine makes it more comfortable to eat and digest food rather than just driven to eat as occurs with mirtaz.

[/quote]

Thanks for the reply, there is no visible hair in the faeces, and when she was sedated for the ultrasound I gave her a very thorough brush! I have to admit that I'm not very good at remembering to worm her so I'll give her a Drontal to see if that helps. With the ranitidine are you using it for its pro-kinetic activity rather than its antacid activity? She's on famotidine at the moment. I had been thinking about giving her a short acting steroid injection, but at the back of my mind I'm wondering about small cell lymphoma so I didn't want to mask that, though I guess if it is then the main part of the treatment would be prednisolone anyway.

RE: Mucoceole medical therapy

Aine Seavers — Wed, 14 Sep 2016 12:52:45 GMT

RE: Mucoceole medical therapy

Thomas Johnson — Wed, 14 Sep 2016 12:23:21 GMT

[quote user="Andrew Kent"]

Sounds a sensible diet choice, and agree on that basis hyperthyroidism sounding unlikely.

[/quote]

Another update on my cat, I took blood 5 days ago, T4 was 20.2 (10-60), Folate >24 (9.5-20.2) and Cobalamin 954 (270-1000). I started her on the sensitivity diet on the same day, she ate very well for the first meal, moderately well the next day, and then had further vomiting, the first for 2 weeks and just clear fluid, she had an injection of Cerenia and hasn't vomited since. She is eating the sensitivity diet, but as with the dental diet only about half as much as she should be. My plan at the moment is to give her some mirtazapine as an appetite stimulant for 2 weeks, then see how she gets on after that as she will have been on the new diet for 3 weeks. If this doesn't get us anywhere I'll probably then ex-lap her to take intestinal biopsies.

RE: Mucoceole medical therapy

Anthony Dennison — Thu, 01 Sep 2016 11:49:10 GMT

Thanks Andy, will know for next time!

RE: Mucoceole medical therapy

Andrew Kent — Thu, 01 Sep 2016 11:31:44 GMT

But can still work in many cases so hopefully yours will be one of them :-)

RE: Mucoceole medical therapy

Anthony Dennison — Thu, 01 Sep 2016 10:54:28 GMT

[quote user="Andrew Kent"]

Choice of diet is difficult in cats but yes we try to use ideally a novel single protein. RC GI and I/D are (I think) chicken based and I tend to avoid chicken as its not usually novel.

The RC sensitivity is more novel (at least the duck version) and I believe the other proteins in it are hydrolysed.

i still use novel hydrolysed diets as my first choice (usually Purina HA) but palatability can be an issue. Otherwise Hills D/D venison is useful as a wet option.

Andy

[/quote]

Thanks for this. Tried a cat with chronic diarrhoea on i/d and it made no difference, so I went for z/d this time. Seeing the cat later this month for a check up so we'll see what's happened.

RE: Mucoceole medical therapy

Andrew Kent — Thu, 01 Sep 2016 10:24:16 GMT

Choice of diet is difficult in cats but yes we try to use ideally a novel single protein. RC GI and I/D are (I think) chicken based and I tend to avoid chicken as its not usually novel.

The RC sensitivity is more novel (at least the duck version) and I believe the other proteins in it are hydrolysed.

i still use novel hydrolysed diets as my first choice (usually Purina HA) but palatability can be an issue. Otherwise Hills D/D venison is useful as a wet option.

Andy

RE: Mucoceole medical therapy

Thomas Johnson — Thu, 01 Sep 2016 10:03:26 GMT

[quote user="Anthony Dennison"]

Could there be a small hairball or bezoar in the stomach causing irritation? Might be a good one to scope.

[/quote]

She does occasionally bring up hairballs, and I couldn't see anything in her stomach on the ultrasound scan. We don't have an endoscope, but it is at the back of my mind that I might need to refer her for one at some point.

RE: Mucoceole medical therapy

Anthony Dennison — Thu, 01 Sep 2016 09:47:55 GMT

[quote user="Thomas Johnson"]She's just coming to the end of her last bag of RC Dental food so I was going to switch her to the Sensitivity Duck and Rice.[/quote]

Andrew Kent, with a GI case, if looking to do a diet trial would something like RC gastrointestinal or Hills i/d be a better choice? The GI CPD I've been to recently all suggest using a single source, or novel protein. I'm sure my clients would be happier with just sensitivity control, as it's cheaper!

Could there be a small hairball or bezoar in the stomach causing irritation? Might be a good one to scope.

RE: Mucoceole medical therapy

Andrew Kent — Wed, 31 Aug 2016 14:17:07 GMT

Sounds a sensible diet choice, and agree on that basis hyperthyroidism sounding unlikely.

Andy

RE: Mucoceole medical therapy

Thomas Johnson — Wed, 31 Aug 2016 13:13:07 GMT

[quote user="Andrew Kent"]

Thanks Thomas, I think I would focus more on GI now (presume thyroid normal?) and would likely start a diet trial pending results also.

[/quote]

I haven't checked T4, though she's not got the sort of weight loss I would expect with a hyperthyroid cat, and her heart rate was 160 last time I checked it. She's just coming to the end of her last bag of RC Dental food so I was going to switch her to the Sensitivity Duck and Rice.