Difficult Decisions Re Probable Hepatic Lipidosis

[jazee]

Need some support/input as like all pet owners in this situation I'm a complete wreck and exhausted.

Before I go into details, to sum it up, I'm struggling with the decision regarding my 13-yo cat to put in a feeding tube versus forcing feeding for another few days to help resolve Hepatic Lipidosis considering there's a high likelihood there's a serious underlying cause that I would elect to have my pet put down if it requires further and/or ongoing costly treatments. Diabetes and Hyperthyroidism have been confidently ruled out via tests.

Theo started eating noticeably less about 3 weeks ago (about half) until about 10 days ago he was eating little to nothing and I knew something was wrong. Took him to the vet 8 days ago. He had a pretty high fever, peaked at 105, was of course dehydrated. All the viruses you can easily test for came back neg. Kidney's good. Two 17-panel bloodwork tests one week apart didn't look bad. Had Glucose in his urine when we did a later urinalysis but second bloodwork confirmed no diabetes but he was borderline anemic since last blood test. He's a 13-yo male single indoor cat but we do use Rover for someone to come in while on vacation which coincidentally the cat sitter last visited about 11 days before he wasn't eating well. (Could they have brought something in all the tests missed?) No upper respiratory symptoms like sneeze, running eyes, etc.

The course of treatment to this point is Mirataz for appetite (made no difference so far), Gabapentin in case he has pancreatitis and is in pain, and we just added Cerenia which I should have protested and demanded Odansetron as he's not had any issue with vomiting this whole time (except once after a force feed) but could be nauseated. (The vet is young, in her 30's but I think she's competent.)

The fever broke 2 days ago and for the first he drank a little water on his own and just a couple of dry food chunks. Got him SQ fluids yesterday. I've been force feeding him with a 2 teaspoon syringe. Shooting for 180 calories (he's 9.5 pounds) but if I can hit at least 100 calories at least I'll know I'll be slowing the degree of wasting. Sometimes I try to also give him a teaspoon or two of unsalted bone broth for additional hydration and few calories. He tolerates the force feeding but after one 10cc syringe (2 teaspoons) he's pretty much done with me. So trying to see if he can tolerate it once every 2 hours 16-18 hours a day.

I've read a lot about what possibly could be going on. All along I was pretty convinced it had to be Acute Pancreatitis but after digging deeper, low temp is like 5 times more common than a fever for Pancreatitis. This is the key stat: In 90% of cases Hepatic Lipidosis is a secondary condition to a primary illness. The most common being diabetes, hyperthyroidism, pancreatitis and unfortunately cancer. I am confident based on test results we have ruled out the first two. It it's pancreatitis, the initial treatment was the same you would do for pancreatitis. If it's cancer I'd just have him euthanized right away. In addition about $1,000 is what I consider to be the reasonable max to spend on a later-middle aged cat for diagnosis and initial treatment (fluids, antibiotics, bloodwork, appetite/nausea/pain meds) and I've just about hit that point. If it was my human child, money would be no object. I did spend close to $2,000 on him 3 years ago to diagnose and have a bladder stone removed but in that case he was younger and more importantly we knew exactly what we were dealing with and what the prognosis would be. There was absolutely no guesswork involved.

So we are essentially on about day 10 since he was eating or drinking very little if nothing and had a fever. And although he has shown signs of progress two days ago, today he has not shown any signs of improvement. Once again drank a tiny bit of water on his own. Got off the bed when you shook the treat bag but didn't eat the treats and was able to jump back on the bed, barely. His energy is understandably very low not meeting his calorie requirements and he's also probably a little sedated from the 0.5ml of Gabapentin and daily Mirataz I'm guessing.

The key to resolving Hepatic Lipidosis is getting enough calories in them which is why a feeding tube is recommended. If it's caused by Pancreatitis, he may have a chance of full recovery if we can reverse the Lipidosis. And I could live with the chance he'd have another bout of Pancreatitis but I'd probably just put him down at that point. I don't really see the point in proceeding with an Ultrasound, as that is really a tool that if it uncovers anything the other diagnostics were not able to, it's very likely it will be something serious like cancer, requiring further expensive treatments.

The literature states force-feeding can be "contradictory" for Hepatic Lipidosis as it can create an aversion to eating. I would think if any cat recovered they aren't going to be so scared from being force fed for a couple weeks that they won't go back to eating their normal food?!? Feeding him Hills A/D in this case) which is far different than his normal Solstice Tuna+Skipjack in gravy. So really what I'm struggling with right now on this Saturday is if come Monday, he's basically not improved do I opt for the feeding tube? My gut is telling me, since I'm adverse to further expensive treatments, if he's not getting better at all with the force feeding for 5-7 days, then all roads would probably lead to Euthansia anyway and the feeding tube isn't going to be a difference as far as the ultimate outcome. On the other hand, would an esphogeal feeding tube not be a ton more money (a ton be > $500 in my case) and provide a significant higher chance he can recover and it ended up being acute pancreatitis and not cancer. My gut is telling me if I can't see even very small inremental signs of improvement with the force feeding the tube and and ultrasound is not worth it.

In general you would think if the fever went away and he started to touch his water bowl, things HAVE to keep gradually getting better as long as I keep force feeding him? If not, then it's the end of the road or would end up being the end of the road pretty soon anyway. Not knowing for sure what you are dealing with is just brutal emotionally and on the pocketbook!

 

[FeebysOwner]

Acute pancreatitis usually takes more treatment and time to resolve than chronic pancreatitis. So, you just started sub-Q fluids, which is almost a guarantee that they are needed with the acute version. Ask the vet how much longer you can stretch out the force feedings before it becomes a necessity to move to a feeding tube, but I think the feeding tube could be your answer to resolving this. At this juncture, I would go that route and put off an ultrasound for now. You might also ask for ondansetron as well - as far as I can recall, it can be given along with Cerenia if need be.

There is a test for trying to confirm pancreatitis, but I don't know the cost. One form of this test (SNAP fPL) is available as a rapid test and can give a same-day result in many vet's offices, while another form (Spec fPL) requires blood to be sent to an outside laboratory. Either is most reliable in acute and/or severe cases. I would guess that both are cheaper than an ultrasound.

13 yo's old isn't too old to try this approach, unless you absolutely cannot afford the feeding tube. Btw, in most situations, future flare ups would be considered chronic pancreatitis, and typically can be treated a little less intensely than the acute version.

 

[silent meowlook]

Hi. The most important test to do is the ultrasound with a board certified internal medicine veterinarian. The ultrasound can show what is going on in the abdominal organs. They can see if the lymph nodes are enlarged or if there is a mass anywhere indicating cancer. That is where you will get the most information.

As stated in the previous post there is a specific test for pancreatitis. There is even one that can be done in house in 10 minutes.

Hepatic lipidosis can be secondary to numerous other diseases, or just because a cat has stopped or greatly reduced the amount they are eating. Over weight cats are at a higher risk for developing this. Is his skin yellow? Did his bloodwork show elevated liver enzymes? An ultrasound is also the way to diagnose this disease. Otherwise they are just guessing. There are other diseases that can cause elevated liver enzymes.

You can't really treat without knowing what you are treating. You can treat symptoms, but not get to the bottom of the issue.

I have known cats that developed hepatic lipidosis after being nervous when their owners were out of town and ate very little.

You can't syringe enough food into an in appetent cat to help them without severely stressing them out and risking aspiration pneumonia. So an esophagostomy feeding tube is an excellent way to treat them. You can also put medications directly into the tube so you don't have to struggle to pill them. It you are feeding A/D, you should be getting 1 can a day into your cat. You can't do that with syringe feeding. It isn't worth the risk.

Cerenia is a valid choice for this cat. I wouldn't think that Gabapentin would be a good idea because it is not a pain killer. Your cat is in pain if it is pancreatitis. He needs a good medication for pain such as Buprenorphine.

Hope some of this helps.

 

[FeebysOwner]

To expound on the above response. If your cat had tests to look at diabetes and hyperthyroidism, I presume they would have shown liver enzyme values as well but check on that to be sure. Most times if they are doing testing for glucose, then they probably also checked the liver enzymes (both are part of a blood Chemistry panel; the thyroid is typically separate). The problem is that pancreatitis can also impact liver values.

Gabapentin can be, and is often, used as a pain med, so if given the proper doses, frequency, and consistently, it should suffice before leaping to Buprenorphine. And, while Cerenia is often a 'go to', sometimes ondansetron works better. But as I said, both can be given if needed.

Ultrasounds, alone, will often not be able to diagnose pancreatitis. It is hard to decipher on most ultrasounds, so I still think doing the pancreatic testing is the way to go. It doesn't mean that in the long run you won't end up needing an ultrasound, but with the pancreatic testing being the best way to look for pancreatitis, at least you can rule it in or out. The other issue with ultrasounds when one goes digging for lymphoma is that they are often inconclusive too unless other testing is done as well.

 

[stephanietx]

I would definitely get an ultrasound to rule out anything like intestinal lymphoma which can cause them to stop eating.

 

[silent meowlook]

With the ultrasound it can show enlarged lymph nodes. It can also show masses that may be in the abdomen that won’t show up in X-ray. If this cat has been diagnosed with pancreatitis then there must have been a FPLI done. Otherwise how would they know. Gabapentin works for some neuropathic pain but the pain from pancreatitis would be abdominal pain and of a moderate to severe level.Gabapentin is used far to much off label for pain that it isn’t strong enough for. We have to remember it is actually an anti seizure medication.

 

[jazee]

We didn't get a chance to proceed with more diagnostics. Like all major medical decisions human or animal I strongly feel it's best to get a second opinion so I had a phone consultation with another vet at the same clinic as it would be easy for them to review his records.

In general we could tell her outlook was pretty pessimistic but I think vets are cautious and try to be as matter of fact as possible when discussing diagnosis and treatment options, their costs and their potential benefit, without pushing you in one direction or another saying something like "if it were my cat..."

I've had either personally or lived with at least 20 cats in 54 years. And the vet reminded me that it is commong for cats to be really good at hiding symptoms until illnesses have progressed pretty far. I think that was essentially the case here. She explained on one hand she's seen owner opt to euthanize quickly when there's no signs of improvement of initial relatively low-cost solutions and many times she's watched owners spend $5,000-$10,000 over the course of a couple weeks then do a feeding tube for 2 months only for the pet to still die anyway.

Since we already knew we had ruled out diabetes, kidney disease and hyperthyroidism combined with the fact we would definitely not treat if it was cancer, this only left us hoping for chronic pancreatitis without hepatic lipdosis, most most likely it was either cancer + hepatic lipdosis from not eating or accute pancreatitis with hepatic lipidosis which the survival rate for the latter is about 20% when both are present at the same time. So we tried for a miracle in giving him steroids as if it was pancreatitis we'd see improvement pretty quickly and if he did, we'd than do imaging to rule out cancer and if no cancer, consider a feeding tube. Whether we did things in the right order or quick enough or not is a matter of opinion as each pet owner can have a different outlook and/or financial resources.

We picked up the steroids when they opened the next morning as the phone consult was right before close of business. Unfortunately our beloved American Shorthair, Theo, rapidly declined that morning to where he couldn't walk so we decided to end his suffering that afternoon.

This was a particularly hard one for me to go through as in the past I've always had at least 2 cats, 4 at one time. So I don't believe I've ever come home to a house with no pets at all and I'm self employed and work from home so I'm used to seeing/hearing my pet throughout the day. Now the house feels empty and silent. It is the worse feeling I can possibly imagine as others who have gone through this I'm sure can relate. It's especially heartbreaking as although we don't like to admit it, over the course of many years and pets you do (or at least I did) have favorites. And I've lived with a variety of breeds. He was my favorite tempermant of all the cats I ever lived with. I feel like an apendage of my body has been torn off. I feel blessed to have enjoyed the 13 years I spent with this very special cat.

 

[silent meowlook]

I am so sorry about Theo. Your analogy of having a limb ripped off is exactly the feeling. That hollow empty. For lack of a better word, it ducks so bad. You did the right thing by him. He was very ill. It’s hard to put their well being above your own, but you did and I commend you for that. I know for a while it will be as though the sun doesn’t rise anymore. Please take the time to honor your grief and be kind to yourself. Try to remember when he was healthy and had fun. You gave him a wonderful life. It wouldn’t have mattered what order you had done things in or when. He is right where he was destined to be at this time. Chasing birds that can’t fly and brightly colored butterflies. He is at peace and no longer in pain. You did everything you could. Sometimes all the love in the world isn’t enough.

 

[stephanietx]

I'm so very sorry to read your update. Big hugs to you.

 

[Furballsmom]

I'm so sorry

 

[Norachan]

I'm so sorry to hear this J jazee



We always lock the threads as a sign of respect whenever a cat passes, so I will lock this one now. When you feel ready it might help to start a thread in Theo's memory in our Crossing the Bridge forum.

Rest in peace dear one. You will be missed