Hepatic Lipidosis - Help!

KrustiKakes

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Background: My cat, Tuvok, is 15 years old with Small Cell Lymphoma (treated since 01/2021 with Chlorambucil/Prednisolone. Prednisolone stopped March 2022 due to increased blood glucose).

A few weeks ago his appetite was slightly down. I figured this was likely because we had to switch from Mirataz transdermal to liquid Mirtazapine (doesn't seem to work as well, but his ears became allergic to Mirataz). He was still eating the same amount of food in a day, but was taking longer. Then 2 weekends ago he pretty much quit eating. My husband and I syringe feed him a little food mixed with his meds twice a day so when he quit eating we started giving him food. I emailed his oncologist that weekend to let her know and see if she could get us in on Monday (9/12). We were seen on Monday afternoon and we scheduled an ultrasound for Tuesday. Tuvok was antsy and they were only able to get enough blood for her main tests. They said they would grab more on Tuesday to run the pancreatitis test, and his thyroid test.

Monday night his oncologist emails us to tell us his liver enzymes are elevated and his bilirubin was 1.8.

Tuesday (9/13) he goes in for his ultrasound and more tests (we dropped him off in the morning and get a call in the afternoon). The pancreas does look inflamed and the liver is bright. We were told it looks like he has pancreatitis and hepatic lipidosis (shocking since he was getting some food every day). His oncologist suggested we work with an Internal Medicine doctor as she would be better informed on these topics. His oncologist also let us know his pancreatitis test would come back within the next few days. That afternoon we get to go in and see an internal medicine doctor (he does have one at this hospital, but she doesn't work on Tuesday). His new internal medicine doctor says she wants to hospitalize him. I ask for what as he is very easily stressed and I do not want to stress him out at the hospital. After she meets him she says he doesn't need to be hospitalized, but we need to come back tomorrow for more tests. She sugested a feeding tube as well, but at this point we want to try to syringe feed him since we do it daily anyway. She says she wants to see his liver numbers improving (is that normal to expect improvement overnight?!?!) we agree and go home.

On Wednesday (9/14) we go back and his numbers have gone down. Bilirubin is already at a .8. She says no need to hospitalize and no feeding tube but she wants him back on Thursday again as his phosphorous is now getting a bit too low. We decide we do want a feeding tube as it is too stressful to syringe feed him such a large amount.

On Thursday (9/15) he goes in to receive a feeding tube and gets phosphorous. We pick him up Thursday evening.

Friday (9/16) he goes in for another checkup with his orignal internal medicine doctor (his new one is off on Fridays). His phosphorous is low, but steady and he is able to take phosphorous supplements at home. His liver numbers are down again.

Saturday (9/17) we notice he sounds so stuffy and gurgly. He tried to eat cat food but couldn't swallow. We call and they say its likely irritation from the breathing tube during surgery. We take him in to be checked to be safe. He is given the all clear.

Monday (9/18) he goes back. Liver numbers are still down. We are told to give him a week off because he is stressed. By Wednesday (9/20) we notice he is incredibly stuffy/sneezy/etc and we call to let her know. She gives him an antibiotic for his upper respiratory infection (he gets them often with stress). Around this time his feedings have increased and he is no longer showing interest in trying to eat food on his own. We are less than a week in with the feeding tube and I know it takes time for him to get better so we are not too worried. But we keep track of this/his constipation and let his doctor know.

Today (9/26) we had a followup. He is still constipated (though he did poop on Saturday) and his doctor says she isn't too worried as cats tend to poop less with a feeding tube. When we mentioned he lost interest in trying to eat on his own she said maybe it has to do with the fact he is getting too much via his tube. We ran lab work and we were sent on our way. We received a call this afternoon and she said his liver enzymes are back up and now his bilirubin is up to 2.8!!! She said she wants him in tomorrow for a followup ultrasound and fine needle aspirate on his liver. She mentioned it could be cancer. I am STRESSED and upset.

I have read on this forum that sometimes numbers get worse before they get better. Is this true? I asked his doctor and she said that isn't a thing and said it's weird for his numbers to do this. Should I expect him to improve within 2 weeks? It's been less than 2 weeks that he has had a feeding tube! Is it a good idea to do more testing or is it too soon? Are there other tests or things we should have them look out for that could cause this?

What should I be doing at home? We have him on Denamarin (though I haven't been able to give it to him more than an hour before food) and Milk Thistle at home as well as giving him fluids a few times a week. We had to stop the buprenorphine as he was having too much of a reaction taking that and the Mirtazapine. Is there a pain killer that would be better and not cause a reaction? He doesn't show the obvious signs of pain (he sleeps with us, he stretches out/sleeps on his back, wakes us up in the morning, still jumps up to look out the front window, etc) but I know he isn't feeling great since he is sleeping a lot more. Am I missing something? Is there more I can do?

I know this is a lot of information. I just feel so sad and I want to hear about other experiences. I keep reading this disease takes time to heal and the process can be a wave, but his doctor made it seem like his numbers should only constantly improve. I am just not sure.

I also wanted to ask about supplements/vitamins. His doctor has suggested no such vitamin or supplement. I was the one that asked about Denamarin. I feel like it would be better for me to bring things up on my end. She seems to do treatment in one way and doesn't really adjust for each patient. I can ask for things, but I am not sure what to ask for.
 

Time 2 Recognize

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I'm so sorry. I dont know enough to contribute meaningfully, but wanted to send my love to you and Tuvok

One thing that might be worth trying if you can is to search for a feline only veterinarian, or a private vet perhaps, with great reviews near-ish to you. Even if they arent super close, maybe you can call, see if they can look over his records thus far and give some input and answer these questions since your vet isn't really. I've been going through a strange situation with my girl this past two weeks and have 3+ vets I've talked to. One in particular has been SUPER helpful and I'm having a phone consult with him shortly. He was the first person I spoke to who sort of knew what to look for, what tests and in what order should happen and answered questions very patiently etc. He has 20+ years experience in various big city hospitals so I definitely would recommend searching around and finding someone with a lot of experience with kitties you can maybe reach out to to consult.

How are things today?
 

kittywhisper

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When my former cat had fatty liver disease it took him months to want eat. He was not really pooping during that time. I syringe fed him and did not really know the numbers after the original diagnosis. He definitely got worse before he got better to where he was hiding in places he never hides, he stopped purring and was barely moving. We were going to bring him in to be put down because he seemed to be suffering and we did not think he would pull through. He ending up rallying at the last minute. I remember finding him upstairs which means he was not in his hiding hole and he made it upstairs. I started petting him and heard him purr. He eventually started acting more like himself besides the eating and pooping thing but it took awhile. Then one day he started pooping regularly and eventually he started eating and begging for food again but that was months later in January when he was diagnosed in October. He would only eat a low quality dry food but he was eating on his own. He was only 11 and it was the only thing he had going on at the time. He lived for 6 more years after that.
 

mrsgreenjeens

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We have had members here who've said their cats' numbers got worse before they got better. My own cat with H/L was really bad, but it was so long ago I don't remember what his numbers were and don't still have his records. What I do recall is that we didn't retest him. We based everything once he was diagnosed on how he was feeling and acting, not bloodwork, so I really don't know if his numbers went up and down or not. I also remember that he was on the feeding tube for four very long months because it took that long before he was eating a reasonable amount on his own.

For Tuvok, I'm thinking perhaps since you are using a feeding tube at the moment, you could probably stop using Mirtazpine and resume the Bup if you think he's in pain, however, it may be the Bup that is causing the constipation. Has that been an issue for a while now? The constipation? Have you tried adding in Miralax dissolved in a little water to his diet? That works extremely well for most cats. 1/8th to 1/4 teaspoon Miralax dissolved in a little bit of water, then added directly to his food, which then can be put through his tube. It doesn't gel up so should be fine, but I would run it past the Vet just to be sure. As to other items good for the liver, instead of Denamarin, you could give Sam-E, which can also be given with food. You can buy it in powder form (for cats) and mix it right in. I'm guessing that's how you do the Milk Thistle. Those two items are great for the liver. There is also Ursodial, a prescription medication that might be good depending on exactly what is wrong with the liver. It is to be given with food. As far as other pain meds, that's one you really need to ask your Vet about. Cats and pain killers really don't mix well, so I don't think there are too many out there.

Two weeks, in my opinion, is way too soon for recovery. Is the fact that he is sleeping a lot the only issue? He is, after all, 15 years old. My 13 year old cats sleep a lot! But if this isn't normal for Tuvok, then his body is probably in "recovery mode". I don't know if you want to rush into more tests or not. Do you have ANY Vet that you know well and really trust? If so, can you discuss this with them and get their take on this?
 
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KrustiKakes

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We have had members here who've said their cats' numbers got worse before they got better. My own cat with H/L was really bad, but it was so long ago I don't remember what his numbers were and don't still have his records. What I do recall is that we didn't retest him. We based everything once he was diagnosed on how he was feeling and acting, not bloodwork, so I really don't know if his numbers went up and down or not. I also remember that he was on the feeding tube for four very long months because it took that long before he was eating a reasonable amount on his own.

For Tuvok, I'm thinking perhaps since you are using a feeding tube at the moment, you could probably stop using Mirtazpine and resume the Bup if you think he's in pain, however, it may be the Bup that is causing the constipation. Has that been an issue for a while now? The constipation? Have you tried adding in Miralax dissolved in a little water to his diet? That works extremely well for most cats. 1/8th to 1/4 teaspoon Miralax dissolved in a little bit of water, then added directly to his food, which then can be put through his tube. It doesn't gel up so should be fine, but I would run it past the Vet just to be sure. As to other items good for the liver, instead of Denamarin, you could give Sam-E, which can also be given with food. You can buy it in powder form (for cats) and mix it right in. I'm guessing that's how you do the Milk Thistle. Those two items are great for the liver. There is also Ursodial, a prescription medication that might be good depending on exactly what is wrong with the liver. It is to be given with food. As far as other pain meds, that's one you really need to ask your Vet about. Cats and pain killers really don't mix well, so I don't think there are too many out there.

Two weeks, in my opinion, is way too soon for recovery. Is the fact that he is sleeping a lot the only issue? He is, after all, 15 years old. My 13 year old cats sleep a lot! But if this isn't normal for Tuvok, then his body is probably in "recovery mode". I don't know if you want to rush into more tests or not. Do you have ANY Vet that you know well and really trust? If so, can you discuss this with them and get their take on this?

Tuvok is at the vet now getting his fine needle aspirate and followup ultrasound. I decided to move forward just to get a better picture. Hopefully this is enough and we can just give him more time vs constant lab work. I really hope he is just at the point of getting worse before better.

He pooped again last night! He gets Miralax, Lactulose, and we started him on some pumpkin. He has always had chronic constipation (they said not super common with a SCL cat) but we have kept it in check with Miralax daily. Before he got the feeding tube he was pooping daily with every now and then it taking a couple of days. His vet still thinks it is just due him being on a highly digestible diet with his feeding tube and to keep up what we are doing. If it gets worse she said we can look into a motility drug.

At 15 Tuvok does sleep a lot normally, but he is also surprisingly active. He appears a lot younger than he is (very muscular, still loves to play). Normally when we get home he is up and about and wanting to play/get our attention. He has been sleeping a lot more since he got sick. He will still have moments where he is interested in light play but for the most part he is sleepy.

His current issue other than sleeping are his numbers have increased, and I am seeing a hint of jaundice starting, and no interested in eating on his own. Today he seemed better than he was yesterday so I am hoping it is a good sign.

He did throw up food I fed him for the first time this morning, but it was my fault. I feel awful. I fed him at midnight but also wanted to get a little extra in since I didn't want him fasting for 15+ hours. I fed him again at 4 am. I thought it would help, but it was just too much in such a short period of time. I will not do that again. We have been so careful in his feedings by always spacing them out an really taking our time. I cannot believe I messed up like that. I was just too nervous about him fasting in his current state.

New plan is to start him on Ursidol, and prednisolone again for a few days as well as keep up with everything else. We should know the results of the ultrasound today and have the aspirate results tomorrow.

Fingers crossed this is just part of the healing process. We are not even 2 weeks in from the time we started treatment so I am hoping better results will happen in the next week or 2.
 
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KrustiKakes

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Tuvok is at the vet now getting his fine needle aspirate and followup ultrasound. I decided to move forward just to get a better picture. Hopefully this is enough and we can just give him more time vs constant lab work. I really hope he is just at the point of getting worse before better.

He pooped again last night! He gets Miralax, Lactulose, and we started him on some pumpkin. He has always had chronic constipation (they said not super common with a SCL cat) but we have kept it in check with Miralax daily. Before he got the feeding tube he was pooping daily with every now and then it taking a couple of days. His vet still thinks it is just due him being on a highly digestible diet with his feeding tube and to keep up what we are doing. If it gets worse she said we can look into a motility drug.

At 15 Tuvok does sleep a lot normally, but he is also surprisingly active. He appears a lot younger than he is (very muscular, still loves to play). Normally when we get home he is up and about and wanting to play/get our attention. He has been sleeping a lot more since he got sick. He will still have moments where he is interested in light play but for the most part he is sleepy.

His current issue other than sleeping are his numbers have increased, and I am seeing a hint of jaundice starting, and no interested in eating on his own. Today he seemed better than he was yesterday so I am hoping it is a good sign.

He did throw up food I fed him for the first time this morning, but it was my fault. I feel awful. I fed him at midnight but also wanted to get a little extra in since I didn't want him fasting for 15+ hours. I fed him again at 4 am. I thought it would help, but it was just too much in such a short period of time. I will not do that again. We have been so careful in his feedings by always spacing them out an really taking our time. I cannot believe I messed up like that. I was just too nervous about him fasting in his current state.

New plan is to start him on Ursidol, and prednisolone again for a few days as well as keep up with everything else. We should know the results of the ultrasound today and have the aspirate results tomorrow.

Fingers crossed this is just part of the healing process. We are not even 2 weeks in from the time we started treatment so I am hoping better results will happen in the next week or 2.
Not sure if I can edit posts, but I forgot to mention that we trust his Oncoloigist. She loves him so much but just didn't feel like oncology would be the best department when dealing with pancreatitis/liver issues.
 
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KrustiKakes

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When my former cat had fatty liver disease it took him months to want eat. He was not really pooping during that time. I syringe fed him and did not really know the numbers after the original diagnosis. He definitely got worse before he got better to where he was hiding in places he never hides, he stopped purring and was barely moving. We were going to bring him in to be put down because he seemed to be suffering and we did not think he would pull through. He ending up rallying at the last minute. I remember finding him upstairs which means he was not in his hiding hole and he made it upstairs. I started petting him and heard him purr. He eventually started acting more like himself besides the eating and pooping thing but it took awhile. Then one day he started pooping regularly and eventually he started eating and begging for food again but that was months later in January when he was diagnosed in October. He would only eat a low quality dry food but he was eating on his own. He was only 11 and it was the only thing he had going on at the time. He lived for 6 more years after that.

How often were your cats numbers being tested in the process? The first week it was daily and now we are doing once a week. Is this too often? It's only been 2 weeks since diagnosis and less than 2 weeks since we got a feeding tube. My cat is currently not hiding (other than when he hears his kennel come out) and will still purr and snuggle. He even does light play here and there (rolls around, scratches his scratcher, grabs his toys). How long before you saw positive changes? What did you do to help with the pooping until he was pooping regularly on his own?
 

kittywhisper

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How often were your cats numbers being tested in the process? The first week it was daily and now we are doing once a week. Is this too often? It's only been 2 weeks since diagnosis and less than 2 weeks since we got a feeding tube. My cat is currently not hiding (other than when he hears his kennel come out) and will still purr and snuggle. He even does light play here and there (rolls around, scratches his scratcher, grabs his toys). How long before you saw positive changes? What did you do to help with the pooping until he was pooping regularly on his own?
They only did the initial test to diagnose it then did not test again and we went by behavior. They told me that him not pooping much was ok and to not worry about it since it was because of his condition. He was not acting bothered by that or like he had to go but could not. At 2 weeks he definitely was still acting tired. It took weeks for him to start moving around more and playing a bit. Eventually he was acting normal just not eating on his own. It was 7 years ago now so I don’t remember exact timelines.
 

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Hi. I would stop the mirtazapine and give the buprenex. If he has pancreatitis, it is very painful. I am sure having a feeding tube doesn't feel good either. Since you are tube feeding, you don't need the mirtazapine. It seems like he has had allot of visits for any cat, let alone one that stresses out. I am sure you have cleared your home of anything that could cause liver damage such as essential oils etc. Why are you unable to give the denmarin as directed? Also, does your vet know you are giving the milk thistle? It is very similar to the Denmarin.
Make sure the feedings you are given are warmed up to cat temperature. Don't feed to much at a time. How much are you giving at one time?
 
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KrustiKakes

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Finally back from the hospital. We will have results from the aspirate tomorrow. The ultrasound showed his pancreas looking more inflamed than before with liver looking about the same. She did mention something happening with ducts (liver? gall bladder?) and wants to start Ursidol. He was on prednisolone for a few days at first so maybe it helped. They took him off because his glucose was raising. He was on prednisolone for 1.5 years due to his SCL and we just stopped this past spring when his glucose was getting out of control.

Current plan is to start Ursidol, and short term prednisolone to see if it will help. Along with everything else we are doing. We will go back in 2 weeks for a recheck unless there is some reason to go in before. I need to email his doctor about his medications. There are so many to fit in a day and I am not sure how to space them out.

Right now we are happy because he ate a little food on his own after getting home. His sedation hasn't worn off and it has put him in an excellent mood. First time he ate on his own in almost 2 weeks. Wasn't much, but it was something!

Fingers crossed the FNA comes back cancer free.
 

mrsgreenjeens

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Just wanted to mention that there is another steroid out there that apparently has a lesser chance of causing diabetes in cats. At least that's my understanding. It's called Budesonide. artiemom artiemom is familiar with it. For her little guy, I believe it works much better that the Pred too.
 
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KrustiKakes

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Any news? What were the results of the FNA?
Thanks for checking in !

His FNA had some cells and mentioned something about some intermediate cells? But the amount was low and usually doesn't mean anything? Not sure.

He is doing okay. Was doing well, and the past couple of days seems to have gone backwards. He was eating more on his own, but is back to not eating much. I can tell his energy is a bit lower. I will say the past 2 weeks have had more good days than bad days but right now we are having a bad day.

He had his labs retested today (but he wasn't seen by his doctor) and his liver values are still high but his bilirubin went down to 1.8 (from 2.8 two weeks ago). She said his bilirubin is where she has the most concern. Should we not worry about everything? His ALT has gone up a bit since last time.

She wants us back in 2 weeks to check him again.

Is there something we are missing? He was diagnosed about a month ago. How long should it take to expect numbers to come down? How long until he is eating on his own again? Is it expected for his energy/appetite to be a rollercoaster?

She also wants him back on his Chlorambucil. He has been off it for a month. I told her I was nervous as I do not want to hurt his liver any more but she seems to think it will be okay. I have her checking with his oncologist. She said it might actually help him feel better. I just wasn't sure if it could be what caused the pancreatitis/hepatic lipidosis to begin with.

Should he be on antibiotics? He had them for short bouts during all this (for a URI, and right after his feeding tube surgery since he is immunocompromised) an he seemed to do a bit better with them.

What he is currently taking:
Zofran
Denamarin
Prilosec
Miralax
Ursodiol

Also, when all this started happenign his T4 was checked and it was at 2.1. This is in normal range but I was told can be considered higher for an older (15 yr old) cat. It has been in the 3+ range before as well. Should we be having them take a closer look at his thyroid?

Thanks again!
 
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KrustiKakes

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Just wanted to mention that there is another steroid out there that apparently has a lesser chance of causing diabetes in cats. At least that's my understanding. It's called Budesonide. artiemom artiemom is familiar with it. For her little guy, I believe it works much better that the Pred too.

We got some Budesonide just in case! His doctor said prednisolone will be better for what is currently happening but we can give it a try. His glucose has stayed down with only 1 mg of prednisolone a day (I forgot to list that on my previous post).

Thanks!
 

mrsgreenjeens

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I would say the fact that he is eating anything on his own is a bonus, at least compared to my own cat who had H/L. HDoes he still have the feeding tube in, just to make sure he's getting enough nourishment?

Not knowing what actually caused the liver issues in the first place, there is no way of knowing whether or not he should still be on antibiotics or not. That is something your Vet would need to determine. Same with the Thyroid. All these things are items you can definitely discuss with your Vet and have them tell you why or why not they are relevant at this juncture in time. I think it's definitely a good idea to have the oncologist involved with these decisions.

It's good news that he's had more good days than bad :hugs: I do know, though, that when they are having a bad day, one always wonders if they are doing the right thing. I've had three "terminal" cats (not counting the H/L cat) and became quite the helicopter cat mom. Every bad day had me questioning myself, but I let them guide me. Hang in there. Remember, my H/L cat was on the feeding tube for four long months, never eating on his own until that last month!
 
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