IBD - experience with gastric emptying issues?

[__caitlin]

Hey all - I'm back with another senior cat with multiple chronic conditions. Partially posting to see if anyone has any insight I haven't thought of, and partially to see if anyone else is as frustrated as I am with the overall healthcare system and how rudimentary our understanding of these illnesses still is.

My baby Cephas is about 16 and is the littermate sister of my cat, Max, who died of IBD->LCL a few years ago (I cannot thank you all enough for your support during that time - it made a world of difference as it was my first time dealing with this illness). Cephas has epilepsy (almost her whole life now), was recently diagnosed in Aug 2023 with early stage CKD -- and then diagnosed in Dec 2023 with IBD.

She has a bit of an unusual symptom profile which has made this very confusing and difficult to manage. Summarizing here:

• She started overgrooming in 2021, seemingly triggered by a food allergy, and never stopped no matter what I would try. She seems to be allergic to beef and fish for sure, but still grooms while eating other proteins. Blood tests, ultrasounds, everything were always normal, but I never did another ultrasound after early 2022.
• Because of suspected food allergy, she ate RAWZ food for years. In 8/2023 after the CKD diagnosis, I took a chance on a renal support diet + put her on Renadyl.
• She starts to get a little bloated; new vet suspects SIBO + wants to screen again for IBD given how her brother died. She has no other gastrointestinal symptoms.
• Ultrasound in 12/2023 now shows pancreatic inflammation, and her PLI si high; intestines are normal. I'm now realizing she probably had low-grade IBD for all these years and it was never caught.
• In Jan/Feb, she goes through a lot of changes: we start prednisolone; because of suspected SIBO, I put her back on RAWZ Turkey (because it has 0 carbs) + stopped the probiotic; we also increased her Phenobarbital epilepsy meds, because she's been having more frequent seizures.
• She stops overgrooming almost as soon as we start prednisolone.
• The bloating doesn't go away. In March, she has another ultrasound that shows all the swelling is from her stomach. Her intestines are now normal-to-mildly thickened (but still apparently within normal range), and pancreas situation hasn't changed. Because they don't see any obvious obstruction, they diagnose her with motility issues from the IBD and prescribe cisapride.

Well, I've been trying the cisapride for a few days now and it seems to have no effect. This is in addition to Miralax 2x/day. I am really at a loss for what to do. Her vet is very conscientious but can't really give answers; for any symptom, there are 3-5 different possibilities; we just keep trying different things. Her phenobarbital may be exacerbating the gastric issues (but I don't want her to have more seizures!); the RAWZ food may be harder to move through the system (but what about the suspected SIBO? it's hard to find another low carb food with ingredients she isn't allergic to, that isn't horrible for her kidneys that meets this criteria). Does the cisapride need time to work, or does she possibly have some obstruction that the ultrasound couldn't see that's it's actually making worse?

Throughout all this, she eats consistently and poops around 1x/day. The bloating is persistent but doesn't seem to bother her. I feel she's in a weird spot because she doesn't have traditional gastrointestinal symptoms, and she is still healthy enough that it looks like nothing super serious is happening so to a vet who only sees her 1x/month, she seems relatively stable. But from my perspective, I'm sitting here frustrated that I've put her on all these medications and rather than getting better, her symptoms seem to have only progressed / been switched out for new ones.

tl;dr - does anyone have any experience with the motility issues with IBD, and found any solutions if the cat doesn't respond to cisapride?

 

[stephanietx]

My IBD kitty deals with bloating. We give him Simethicone drops (baby gas drops) twice a day when it's really bad. This is the ones we buy.

Amazon.com

 

[lisahe]

I can't answer your question directly but I can say that our (now retired) vet offered a motility drug (she didn't say what it was) for one of our cats some years ago because Edwina occasionally barfed a combination of acid, digested food, and fur during the night. The vet thought the nature of the vomiting likely indicated a motility issue. I refused the drug because I was convinced the problem was more general... basically, that Edwina came to us with what I thought of at the time as pre-IBD. She had food sensitivities even as an adolescent and I suspected her digestive system was worsening.

I'm glad we didn't put her on the drug. Her problem did turn out to be inflammation and what is now presumed IBD. She had (inflamed) chunks of her stomach surgically removed in 2022 and has been doing pretty well since then, particularly well after we started giving her Adored Beast's Feline Gut Soothe last year. She no longer vomits the way she did when the vet offered the motility drug. FGS (and Vet's Best Hairball Relief tablets) also eases our other cat's constipation. Egg Yolk also helps lots of cats' constipation (though it wasn't very helpful for us!). Slippery elm bark syrup can be helpful, too. Our cats' symptoms sound very different from your cat's and I feel fortunate that some natural remedies, particularly Gut Soothe, have been so useful.

Every cat is different and, thus, mysterious in its own way so I guess what I'm saying is that -- based on our experience, which is so different from yours! -- I'd be cautious about depending on the motility drug for long, particularly in a case where nobody really knows what to do because the cat's situation is so unusual. Then again, we've been very, very fortunate that our cats have responded remarkably well to gentle herbal remedies... which, I found because nobody knew what to do. I'm also very fortunate that our vets have been supportive (or at least indifferent!) about using them.

 

[mrsgreenjeens]

To the original poster, I'm a little confused, because SIBO typically causes loose stools, yet your girl is on Miralax, which is for constipation, and you said she poops around once per day. WHY is she on Miralax? Is she constipated or not? If so, why do they suspect SIBO? AND, again, typically, for SIBO the treatment is specific antibiotic, yet you made no mention of her being put on ANY antibiotics. Was she ever put on them, or not? One of my cats had a bacterial overgrowth recently (similar to SIBO but not called that) and the "fix" was to have him eat the highest fiber food we could find, plus adding S. Boulardi with MOS. It worked very well, but he did not have IBD or any pancreatic issues.

 

[__caitlin]

To the original poster, I'm a little confused, because SIBO typically causes loose stools, yet your girl is on Miralax, which is for constipation, and you said she poops around once per day. WHY is she on Miralax? Is she constipated or not? If so, why do they suspect SIBO? AND, again, typically, for SIBO the treatment is specific antibiotic, yet you made no mention of her being put on ANY antibiotics. Was she ever put on them, or not? One of my cats had a bacterial overgrowth recently (similar to SIBO but not called that) and the "fix" was to have him eat the highest fiber food we could find, plus adding S. Boulardi with MOS. It worked very well, but he did not have IBD or any pancreatic issues.

I appreciate you asking because I was confused too! No, she's never had diarrhea. Right now, she does have mild constipation but it's unclear whether it's from decreased motility from IBD, or from the RAWZ food, or both.

The vet suspected SIBO during that small window of time that her only symptom was mild bloating, prior to the decreased motility diagnosis. Because I was feeding her probiotics at the time, the vet theorized it could be bloating from a bacterial imbalance, but didn't think it was serious enough to put her on antibiotics with all the other stuff she has going on.

That's basically it. After the decreased motility diagnosis, I even asked the vet "So does this mean it was a motility issue and not SIBO?" And she told me no, mild SIBO could still be a possibility. So I don't really know what to think anymore except that I somehow have to concoct a magical diet for her that addresses all these issues. It is a bit maddening.

 

[silent meowlook]

Hi. IBD doesn’t always cause diarrhea. It can also cause constipation.

With what is going on with your cat and her Comorbidities, CKD, epilepsy, pancreatitis, she needs to see a specialist. Ask for a referral to a board certified veterinary internal medicine veterinarian asap and they should be able to help you. There is just too much going on here for a regular vet to be of much help.

 

[lisahe]

Hi. IBD doesn’t always cause diarrhea. It can also cause constipation.

With what is going on with your cat and her Comorbidities, CKD, epilepsy, pancreatitis, she needs to see a specialist. Ask for a referral to a board certified veterinary internal medicine veterinarian asap and they should be able to help you. There is just too much going on here for a regular vet to be of much help.

I so agree with S silent meowlook 's suggestion. We brought a cat to an internal medicine vet last week and it was well worth the visit (and money), despite not reaching a definitive diagnosis. Sometimes seemingly small things that come up can help explain a larger issue.

Fingers crossed, C __caitlin

 

[__caitlin]

Hellooo everyone, just thought I'd bounce back here and give an update, in case anyone is curious how this turned out with my cat's many competing medical issues.

In short, what happened was that ever since I put her on the prednisolone in January, her system went totally out of wack -- every month, there was a new symptom or something wrong with her, with many different DVMs each telling me different possibilities for causes. The longest we'd ever go is about 3 weeks of no issues before something popped up again. Just some of the different things she experienced between Jan-now:

• Pot belly / bloating
• Abnormally high liver values + high cholesterol
• Hair stopped growing (after only 2 mos on pred)
• Decreased appetite
• Worsened constipation
• Continued overgrooming (at her normal rate; aka, after 1-2 mos, the pred stopped helping with this)
• More frequent vomiting of hairballs
• Serious multi-day bouts of nausea accompanying hairball pukes
• Reflux/regurgitation problems, which she'd never had before
• UTI! -- which then recurred, so she went on 2 courses of antibiotics
• Random explosive diarrhea upset (about 2 weeks after finishing the UTI antibiotics, so I suspect it upset her gut flora) -- this got better when I did the s. boulardii protocol

It's been a bit of a nightmare to say the least. Halfway through, I started weaning her off the pred very slowly (which made some of these symptoms better), but was afraid to take it off completely. In the last few months, her blood tests + ultrasounds were coming back normal -- even as she continued to have these random infections, puke sessions, and essentially be clinically sicker than even before. So I finally coughed up the $$ and travel time to take S silent meowlook 's advice and brought her to an internist at a fairly well-rated vet specialty center.

And the internist said.....

• IBD cannot be effectively diagnosed just based on ultrasound (lol?) - he did not seem to care that ultrasound presumptive diagnosis of IBD seems to be standard practice for most DVMs. After reading her charts, he was immediately skeptical that she actually has IBD
• The only way to definitively diagnose IBD is through endoscopy
• He performed another ultrasound for her and said everything looks normal (totally opposite of what other ultrasound reports showed in the Spring)
• Unlike other vets who thought she would not be a good candidate for anesthesia (due to CKD, IBD, and history of heart murmur), he thought we would be able to manage anesthesia just fine given her stable bloodwork -- BUT did not advocate for an endoscopy and seemed to think it wasn't necessary
• If she was not showing clinical signs, why have her on these treatments?
• Cisapride + miralax may help with her constipation issues; but to treat the constipation as just that -- constipation; not necessarily indicative of something more without conclusive diagnostics (i.e., endoscopy)
• He believes her overgrooming is psychological
• He's not sure what her most recent bout of diarrhea is caused by, but agrees it could just as easily be antibiotic imbalance (even if other DVMs will cry IBD) and is basically agnostic to whatever combination of supplements I might use to try and treat it

So... at the end of the day, I am weaning her off the prednisolone and I suppose we are going to start all over. I feel like I should have just listened to my gut earlier in the year and taken her off the pred sooner, but it went so against her DVM's protocol that I wanted to give it a chance. Sigh :/

 

[lisahe]

So... at the end of the day, I am weaning her off the prednisolone and I suppose we are going to start all over. I feel like I should have just listened to my gut earlier in the year and taken her off the pred sooner, but it went so against her DVM's protocol that I wanted to give it a chance. Sigh :/

I'm glad you went to see the specialist -- it sounds like he was very helpful even if there was ultimately nothing definite... other than weaning Cephas off the prednisolone. I know that feeling of wishing I'd listened to my gut.

It's interesting about the ultrasound: so much of it is in the interpretation. And sometimes the ultrasound fails in its own ways: everybody thought Edwina's spleen looked normal on her ultrasound but (susprise!) the surgeon took it out because it was ruptured. (Maybe that happened in the four days between the ultrasound and the surgery? We'll never know.)

It's also very interesting that the specialist thinks Cephas's overgrooming is psychological. Our other cat had an overgrooming episode in late 2020 and I was convinced it was psychological. But the vet was convinced it was allergies so Ireland took an antihistamine for several years. She's now on a different one... but for pollen, only as needed. She hasn't had another barbering episode since. (I think she licked her hip clean because she killed a mouse and I took it away from her, which confused and disappointed her terribly!)

"Psychological" for our cats usually equates to "reaction to stress." They're rescues (they came to us underfed, from a too-many-cats situation) and have always been jumpy about noises, sudden motion, and the like. They've calmed a lot during the 11 years they've been with us but we notice that lots of other things continue to stress them, too, including the weather, which changes frequently in ways that nobody can understand. They both do worse in heat and sharp changes in barometric pressure bother them, too. Anti-stress supplements -- everything from sprinkles of catnip in their food to Rescue Remedy drops and supplements with L-theanine -- help quite a bit. And, as I mentioned above, they both get daily doses of Feline Gut Soothe, which makes them feel physically better, thanks to the combination of anti-inflammatory herbs and probiotics. (It's also great for helping with Ireland's constipation; I give her additional slippery elm bark, too.)

In the end, I keep coming back to the fact that our internal medicine specialist mentioned "trial and error" when we brought Ireland in for her lung issues. I appreciate her willingness to admit that she didn't have a solid diagnosis or plan without doing invasive diagnostics. I feel like we've been very fortunate in lots of ways but particularly finding good vets willing to (like your specialist) be "agnostic" on what we might try for the cats as we monitor them. Not everything that we try works but lots does help! I hope you find some helpful treatments for Cephas, too.

 

[__caitlin]

I'm glad you went to see the specialist -- it sounds like he was very helpful even if there was ultimately nothing definite... other than weaning Cephas off the prednisolone. I know that feeling of wishing I'd listened to my gut.

It's interesting about the ultrasound: so much of it is in the interpretation. And sometimes the ultrasound fails in its own ways: everybody thought Edwina's spleen looked normal on her ultrasound but (susprise!) the surgeon took it out because it was ruptured. (Maybe that happened in the four days between the ultrasound and the surgery? We'll never know.)

Right -- it's just interesting that in (a very expensive) 30 minutes, the specialist basically went against the advice - and ultrasound interpretation - of at least 3 other DVMs I had brought her to. At one point, a regular DVM did a mini-ultrasound of her stomach about 1 month after she had gotten it done by the specialist and said, "Wow, she definitely has IBD, her intestinal walls are all ruptured and inflamed" -- but just 4 weeks ago, the specialist said everything was normal. I believe her intestines are what they are...and the specialist interprets it as "normal," while apparently 3 other DVMs interpret it as IBD. Not really sure what to make of it all as I don't easily have access to another specialist for a 2nd specialist opinion.

Either way, the only consistent truth is that, despite everything, she was doing much better clinically before the pred than after it, so I think I have to at least try to wean her off to see what happens.

And yes -- Cephas is not really stressed on a daily basis, but is quite neurotic (dilute tortoiseshell?). I've tried everything over the years to get her to stop overgrooming. I believe the initial cause of the grooming was food allergies (because she'd vigorously bite and scratch 30 mins after eating certain foods, seeming really itchy; she'd never had an overgrooming issue for the 12 years she lived before that) -- but the reason it continues is probably more psychological at this point. It's like once she got started, she never wants to let it fully grow back, and every few weeks will shave it off her legs again. Then again, she also has epilepsy and possible weird nervous system stuff going on, but nothing that's worth spending the burden on her + money to check out at her advanced age.

I'm now in the process of trying different supplements/probiotics for her. I wish I could try Feline Gut Soothe, but I saw it contains beef liver (and I believe beef is one of the foods she's allergic to). :/ Will continue to try other ones slowly and see if they make any difference!

 

[Jabzilla]

Hey there, you can give her the dog version of Gut Soothe. That’s what I give my cat since he can’t eat beef either. I spoke to someone at Adored Beast since the dog version contains aloe, and they said the toxic latex is not included so it is safe for cats as well. My cat has been getting it daily for a year and a half now and hasn’t had any issues with it. Adored Beast said if using the dog version, give half of the recommended amount for your pet’s weight. My cat is 16lbs so he gets 1/4 tsp of it.

 

[silent meowlook]

Hi. This is why I always recommend ultrasound with a specialist. It is very subjective and few regular veterinarians use their ultrasound machine for more than checking bladders or simple tasks. Most regular vets rarely use their ultrasound at all. The quality of an ultrasound in a regular vets office is most likely on the lower end like $5,000.00 where as a specialist’s equipment is going to be more like $70,000.00 and up. This is a case where the cost does reflect the quality. The images of an expensive ultrasound are incomparable to a cheap one.

Then you have the education of the person using them. With specialists, it’s like after they went to vet school, they went to it again, but focusing on only one aspect. That is allot of additional schooling. Schooling they have to keep up with a certain amount of additional study each year.

Then there is the experience. An internal medicine veterinarian will do a very large amount of ultrasounds a day, week etc. The one I worked for did at least 4-6 a day. Where as the regular vet does maybe one a day or even one a month.

All of that education, experience and the quality of equipment ads up to a much more diagnostic ultrasound.

Sure there are bad specialists just like bad vets. And, they can get things wrong.