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Liver and Gall Bladder Problems in Cats
Congenital portosystemic shunt in kitten
Triad syndrome
Liver disease
Medications used to treat liver disease
Fatal liver problem
Liver problems
Feline Liver Disease
Liver mass and renal failure
Feline Liver Disease - prognosis and treatment
Liver Disease
Liver Disease and vomiting
Liver Disease and Diet
Poor Liver values - treatment and diagnostic tools
Polycystic renal disease
Lactic DehydrogenasePlease note: The most recent medical information is at the top of the page to least current at the bottom.
also see Renal failure
also see Cholagiohepatitis/Hepatitis
also see Triad Syndrome
also see Hepatic Lipadosis
also see Kidney Disease
also see Urinary Problems
also see Diabetes
Congenital portosystemic shunt in kitten
Question: Dear Dr. Richards,I have a question. I will try to be as brief as possible. In
September of last year I took in a stray black kitten. During the
Christmas holidays he had a seizure. He was diagnosed as being a "shunt
kitty". One of the signs according to my vet, is the gold/orange eyes.
That is the least of it. He went through a seizure which was horrible
to see. Head pressing, blindness, unable to stand and I simply can't
remember what else.He was put on valium at the emergency vets and spent the night. It took
about a week to get him back to his normal activity and he was placed on
Lactolose.We did a biopsy of the liver and a scan. My doctor said if we found the
blood vessel(s) responsible for this condition, an operation could
correct the problem. Nevertheless, the scan and the biopsy proved
nothing.Since that first awful seizure, he has one slight episode. I diligently
give him Lactolose three times a day (every time he eats, he gets his
medicine). Because of the unbelievable diarrhea it causes, I know mix
rice in with his KD Feline Science diet.
Okay, now to my question. What can I do for this little guy? He is
thriving, as a matter of fact he is standing on my keyboard right now.
My vet tells me to keep on doing what I have been doing. We could go a
step further and do exploratory surgery and a contrast liver scan. That
would cost $3,000. Besides the enormous cost, he would be in danger and
he has a 50% chance of surviving these procedures. Even then, we may
not have any conclusive information once both tests are done.According to what I have been told, there is very little information on
"shunt kitties" because they are usually put down once the owner finds
out what is wrong. I know his little life will be shortened because of
this. I will do whatever I need to as long as his little spirit is
happy and he continues to pester my older cats.Dr. Richards, is there anything new on the horizon that you know of to
help this little guy? I tried not to fall in love with him. As you can
tell by my letter, it didn't work.Thank you for your anticipated answer. I know you are really inundated
with questions so I will be very patient until you can get to me.Thank you again.
My sincerest regards, Pat
Answer: Patricia-
Congenital portosystemic shunts are not as common in cats as they are in dogs but they are not extraordinarily rare.
There was a correlation noted between copper colored eyes and cats with liver shunts but this has to be considered in light of the fact that there are lots of cats with copper colored eyes who do not have shunts -- while it might be a true observation, the eye color doesn't seem to occur because of the shunt. So this is probably something that should be taken into consideration but can't be depended on as a sure sign of a liver shunt.
I am not sure from your note whether there is a conclusive diagnosis of a liver shunt, or if there is documented liver insufficiency. I am assuming that the biopsy did not show another liver disease as being likely but this wouldn't rule out other causes of seizures. I can't tell for sure what type of scanning procedure was done. Plain X-rays are not very helpful in determining if a liver shunt is present. Ultrasound examination is more helpful, but often is inconclusive, as well. Transcolonic portal scintigraphy can usually establish whether a shunt is present or not and is not too expensive. The major drawback is that the equipment required usually makes this a test only done at veterinary schools. X-rays using contrast considered to be the most specific test for this condition.
I would want to know what the results of a bile acid response test were at this point. This will tell you if there is a decrease in liver function compatible with the diagnosis of a liver shunt. It is a relatively inexpensive test and it only involves taking two blood samples, one after a twelve hour fast and then one two hours later, with a meal fed in between. If there is a decrease in liver function then it makes more sense to continue the treatment long term.
If there is not a decrease in liver function then it would be a good idea to look for another explanation for the previously observed seizure activity.
The object with lactulose is to produce a soft stool that is just barely formed. If it is causing diarrhea, it would be best to reduce the dosage. Hills k/d (tm) diet is a low protein diet. While this has been documented to be OK in treatment of problems requiring low protein diets, even in kittens, adding rice further lowers the protein level. It is possible that you may be getting close to the lower limits of necessary protein with this mixture. Please ask your vet about lowering the lactulose dosage and about whether or not adding the rice in the amounts you have been using are a potential problem.
I can not provide exact statistics for survival and improvement post-surgically in cats. This isn't because there is a big lack of a available information, though. It is just because there seems to be some variation in the figures reported and in some cases because the reporting format makes it hard for me to be sure of what the figures mean. I think that your vet's overall prediction of a 50% long term success rate (both survival and continued recovery lasting longer than a year or so) looks about right, but I think it would be best to get specific information from the surgical facility that you might considering using for the procedure.
There is some chance that your cat may have hepatic microvascular dypslasia, which would not be treatable surgically. If surgery is possible, the prognosis is variable, depending on the shunt location, the skill of the surgeon and the complications encountered during surgery. In a cat that was doing well without surgery, I think I'd have to think really hard before considering it. However, I think that I might at least have the diagnostic procedures done. I would do this because I would want to know if this is the problem, so I didn't overlook something else and because I would want to have the most information possible to best determine the prognosis with and without treatment. Just because you go far enough to be sure of the diagnosis does not mean you have to proceed with the surgery.
If this note causes you to have additional questions, please feel free to send them.
Mike Richards, DVM
9/18/2001
Liver disease in cats- "triad syndrome" or "triaditis" possible
Question: Dr Richards:
My 12 year old male cat is starting to have some liver problems, after a blood test was taken on a routine exam. His count is 113, and he is on Lipo-tabs and S.A.M.E. also i am going to start him on Actigall. Can you explain the 113 count, is this a high number, and can you tell me anything else that will help him. He is not experiencing any problems at this time, is 12 young to be getting liver problems. Any thing else you can suggest, or is this the normal course for cats.
Thank you
Debbie
Debbie-
I need to know what the name of the blood chemistry value the 113 number is for. Is this the ALT value, alkaline phosphatase (alk phos) value or a different one? If you can let me know this information, I can give a more specific answer. If not, just let me know and I'll try to explain what the possible values are for the different liver enzymes.
Mike Richards, DVM
Yes, It was the ALT.
Thank you
Answer: Debbie-In cats, almost any rise in the ALT value is considered to be significant. So even though this isn't an extremely high value for an ALT, it is high enough to warrant concern.
ALT rises occur in cats for a number of reasons but the most likely possibilities in a twelve year old cat are hyperthyroidism, cholangiohepatitis, hepatic lipidosis (if the cat is not eating) and pancreatitis leading to secondary blockage of bile flow. There is a condition in cats in which pancreatitis, cholangiohepatitis and inflammatory bowel disease occur at the same time, which is being referred to as "triad syndrome" or "triaditis" at the current time. Keeping this possibility in mind is a good idea. Usually there is vomiting and variable appetite along with weight loss in cats with this condition.
We usually test for hyperthyroidism when there are rises in liver enzymes in older cats which are discovered in lab work but are not causing clinical signs. This is especially true if there is weight loss, an increase in appetite or an increase in heart rate. Your vet may be reasonably certain this is not present based on the examination. If so, it is just something to file away in case further symptoms develop. It is also a good idea to be sure that there is no evidence of feline leukemia virus and to try to rule out liver cancer through X-rays, ultrasound or biopsy of the liver.
We usually try antibiotics early in cholangiohepatitis because they seem to help some cats. We use amoxicillin and sometimes amoxicillin/metronidazole combinations. I think that it is justifiable to try antibiotics without doing a biopsy or culture of bile, but some vets prefer to do this testing first and that is also definitely justifiable. If there continues to be evidence of liver disease after antibiotic therapy and recheck of the lab values in two to four weeks, then we usually do feel best if we can get a biopsy of the liver to see for sure what is happening, if that is possible. Sometimes biopsy results don't help much but it is still worth the effort, I think.
Over the long run, we have had the best luck with ursodiol (Actigall Rx) and have just started using SAM-e within the last six months. I really don't have a feel for how well SAM-e is working, yet, but it is recommended by several veterinarians who are very knowledgeable about liver disease.
Most cats with cholangiohepatitis seem to do well for a long period of time and many of our patients have lived out their normal life span despite having this condition and it is possible to treat hyperthyroidism and the triad syndrome, as well.
Mike Richards, DVM
4/6/2001
Liver disease in CatQuestion: Hi, I have some questions regarding liver disease in
cats. My,female,cat is called Ginger and she is 16
years old. She has always been in good health and vets
can never believe she is that age. The vet here in
Prague had one look at her eyes and told us that
Ginger had very serious liver damage and when the eyes
are as yellow as this it's usually too late to do
anything. A blood test seemed to confirm the
diagnoses. One result, the ALT, was 41.7(norm being
0.17-2.00).We were told we'd have to put her on a
protein free diet, no more cat food,no more chicken,no
more tuna,no more anything! She took to the food
o.k.,for a few weeks,then she got fed up with it.I
wasn't going to starve her so I asked the vat if I
could give her her normal food. She said I could give
her boiled chicken and fish, no catfood.She's still
eating like a horse. She still doesn't seem ill. The
vet is quite surprised by this but still thinks that
it's just a matter of time. I can't believe it because
she seems so well and happy. Is there any chance that
the diagnoses is wrong? Or is there any other reason
why her eyes would be yellow? Blood tests can be
wrong, or at least inconclusive, can't they? Any
advice would be greatly appreciated.Thanks
Sheila-Answer: When the scleras (the white portion of the eyes) turn yellow, it is usually
due to liver disease or to internal bleeding. It is unlikely that this is a
case of internal hemorrhage since Ginger continues to feel well and eat
well. So some sort of liver disease is likely. This may be a primary
disease or a secondary problem, such as hyperthyroidism which has raised
the blood pressure enough to cause liver damage. This seems possible due to
the continued strong appetite, which is characteristic of hyperthyroidism.The most common form of liver disease in cats is probably
cholangiohepatitis. This sometimes occurs in conjunction with pancreatitis
in cats and sometimes this will lead to sudden jaundice. Cats may live a
long time when they have cholangiohepatitis. Controlling the levels of
dietary protein does sometimes help to make cats with cholagiohepatitis
feel better and may slow the progression of the disease. It is important
that cats eat, though, so we often compromise on the diet.Hepatic lipidosis is the other common liver disease in cats. It usually
occurs after a cat stops eating for three or more days but sometimes can
occur more quickly. It would be unusual to see this problem without at
least some period of inappetance, but we have had a couple of hyperthyroid
cats or diabetic cats, apparently as a side effect of those conditions.It is more important to evaluate the patient than the lab symptoms. It is
likely the lab values are correct but since Ginger continues to eat and
feel OK, it is important to consider the long term implications of her
problem. It is helpful to consider a liver biopsy or an educated guess as
to the most likely liver disease and then to provide appropriate therapy.
For cholangiohepatitis, ursodiol (Actigal Rx) is helpful in many cats and
low dose prednisone has been used successfully in some cases, as well.
Using a lower protein diet is helpful, as well.If hyperthyroidism is present based on elevated T4 (thyroxine) levels, it
would be a good idea to treat that problem, as well.Hopefully Ginger continue to feel well.
Mike Richards, DVM
9/15/2000
Medications used to treat liver disease in cats
Question: Dear Dr. Mike,
I think veterinarians must be some of the nicest people in the world. My
local vet, puts up with our nine p.m. panic calls and now I feel we have another
compassionate and talented vet in our corner. Thank you. I will let him
know of your service as I think it will interest him.Woofy's blood work was a mixed bag- he is evidently producing enough
lipase and amylase but his liver is is still infected, though he runs no
temperature, his weight has stabilized at seven lb.. 4ozs. We still have
him on Urisidol twice a day and Carafate which seems to help him keep
things down. I have noticed that the whites of his eyes are more white
and less bloodshot. His appetite and energy level of the last few days
has not been great, but it has gotten warmer in Southern California too.
He still appears interested in the world, and mostly comfortable. The
diet of Hill's L/D and K/D are what my vet has recommended too, though
it has take some grated turkey breast to get him to eat it. Lord this is
work!I am going to write the nutritionist you recommended, and I will let you
know what his next blood panel shows. My only question is in the arena
of antibiotics- is there anything other than the Urisidol that might
help him out? He has had the Metradiazanole. Doug is being careful not
to give him anything to upset his tummy.Thanks again, Teal
Answer: Teal-
Antibiotics are helpful in two circumstances in cats with liver disease.
In some instances, cats have bacterial hepatitis. This isn't especially
common, but many vets are more comfortable if they give an antibiotic like
amoxicillin, sometimes in combination with metronidazole, in order to rule
out this possibility. This is especially true if a liver biopsy or culture
taken during surgery has bacterial growth.More commonly, veterinarians use the antibiotics metronidazole and neomycin
to decrease ammonia absorption from the gastrointestinal tract, making it
easier for the liver to do its job and lowering serum ammonia levels, which
cause problems like hepatic encephalopathy (inflammation of the brain due
to high ammonia levels). Lactulose is also helpful for this effect. We
usually start with lactulose and then use antibiotics when there are signs
of systemic problems relating to ammonia but some vets like to start
antibiotics sooner.Another medication to consider is Denosyl (Rx), which is a "SAMe" product.
This medication is favored by some of the leading experts on liver disease
but there isn't a lot of documentation for its beneficial effects, yet.
Still, it is something to consider.Hope this helps some.
Mike Richards, DVM
8/4/2000
Liver Disease in elderly diabetic cat
Question: Dear Dr. Richards:
Our 15 year old male American shorthair tabby names Thor was diagnosed about
a year ago with diabetes. By the time he was diagnosed, he already had
peripheral neuropathy on both his back legs and was shuffling about on his
hocks. He was eventually well-controlled on Humelin Insulin twice daily. We
also decided to treat him with biweekly and then weekly acupuncture which
miraculously restored the use of both of his legs. We also treated him with
homeopathy and eventually could reduce his insulin to 1/2 Unit in the AM and
1 Unit in the evening. His fructosamine level remained below 450 and he was
doing remarkably well. This is the good news...About 4 months ago he started vomiting on occasion and was diagnosed with
mild hepatitis. We again treated him homeopathically with good results and
that episode appeared to subside. However, about 6 weeks ago, he was not
doing well: vomiting almost every night and generally having low energy. His
bloodwork at that time revealed SEVER hepatitis with his alk. phos. and
enzymes off the charts. He refused to eat or drink for about 3 weeks. We kept
him alive by hydrating him daily and force feeding him as often as we could.
We treated him homeopathically and allopathically: Amoxicillin for about 2
weeks. Actigall daily, Pepcid AC daily, metocloprimide 1 ml before meals,
hepatic enzymes, etc. An ultrasound and liver biopsy revealed nonspecific
hepatitis, cholangeitis and inflammations of the bowel. At that time, no food
seemed to be passing his stomach area and he would simply vomit everything we
fed him after a few hours. He rapidly lost weight and eventually was skin and
bone. His ears glowed bright yellow from the jaundice == his bilirubin at the
time was about 10. We were preparing to take leave of him and reconciling
ourselves to the fact that he was very close to transitioning to death.As a final desperate measure, we tried Prednisone -- 5 mg per day. He
immediately started eating and drinking voraciously and proceeded to steadily
improve. Everyone was astounded at this miracle. He has now regained his
former weight (approx. 10 LB) and his jaundice has all but resoled (last
bilirubin was 0.6). He remains on the Prednisone 5 mg per day (now 5 weeks)
and 3.5 U Humelin twice daily. A recent fructosamine was 420. However, his
liver enzymes remain extremely high although they have all improved
substantially since the initial values. Alk phos. is 252 (N 102); ALT 770 (N
10-100; down from 886); AST 266 (N 10-100). We continue to give him Pepcid AC
daily, hepatic enzymes, sylimarin (Milk Thistle) to help repair the liver,
chromium picolinate for the sugar regulation, a product from Ameridan labs
called Mega Beta (Beta 1,3-D Glucan) that has been found to support the
immune system and in certain cases of hepatitis C to bring about a total
remission. His appetite remains good but he does drink excessively -- due to
the Prednisone and diabetes. His energy level is excellent, as is his general
mood. We feed him a combination of Petguard and Wellness wet food and W/D
dry food (that he absolutely loves!).We live in a state of uncertainty however as our Vet suspects that he may
have underlying lymphoma. If this is the case, it is only a matter of time
before the Prednisone stops working and he crashes again. He has palpable
lymph nodes in his abdomen that since we have been giving him the above
regimen, have decreased in size from 3 cm to 1 cm. What, in your opinion,
could still be cause damage to the liver cells resulting in them leaking
these enzymes at such a high level? Could this be some form of
cholangeio-hepatitis and if so, what is the cause? Is this similar to hep C
in humans, caused by a virus? Is there anything else that we could possibly
be doing to support the liver and help it repair the damage to the liver
cells? How long do we continue with the Prednisone (our Vet has suggested at
least another tow weeks at this dosage before reducing to 2.5 mg per day)? Is
there any other way of establishing a more definitive diagnosis of lymphoma
other that a gut biopsy that we have decided to forego?As you may have deduced, we are devoted to our beloved kitty and companion
and have done all that we can think of to support his life and make him
comfortable for as long as possible. Any suggestions you may have would be
much appreciated. I have been unable to obtain much info regarding support of
a damaged liver in cats anywhere and also relatively little info on lymphoma.
Your website is a fantastic source of information. Thank you for you
dedication to helping us all take better care of our furry friends. Kind
regards, John & Adrian.
Answer: John and Adrian-
It is going to be hard to figure out what to do next without a biopsy of
the liver. It may be possible to get a diagnostic sample of the liver using
a fine needle aspiration technique. This can be done using a regular
hypodermic needle to aspirate cells from the liver and can be done in most
instances without sedation or anesthesia. Only a small sample can be
obtained in this manner and that sometimes isn't enough but it is still
worth considering this approach if a surgical biopsy is not possible.
Another alternative is an ultrasound guided biopsy of the liver, using
special biopsy needles that take a larger sample, which avoids surgery but
usually does involve sedation or anesthesia.Cholangiohepatitis, a fairly common form of liver disease in cats, will
sometimes respond to prednisone. When it does the usual recommendation is
to taper the prednisone off over the course of two to three months. Some
cats require low doses of prednisone for longer than that, though. As time
goes on you will be able to work out which is the case for Thor, whether
you know what the actual diagnosis is, or not.Lymphoma is a strong possibility, as well. It will sometimes respond to
prednisone for a long time. Chemotherapy is helpful, as well, but it would
not be reasonable to start chemotherapy without a diagnosis. A liver biospy
may, or may not, be helpful in making this diagnosis, since it wouldn't be
possible to rule it out if it didn't show up in a biopsy of the liver.I understand why you want to avoid surgery at Thor's age and with Thor's
problems. You and your vet have worked out a treatment protocol that
appears to be working well, despite the fact that some liver enzyme levels
remain elevated. I think it would be reasonable to stay on this course and
to see if the prednisone dosages can be lowered over time. If it is too
hard not to have a diagnosis, then you might want to consider one of the
less invasive liver biopsy techniques and try to get a diagnosis so that
you have a better idea of why the medication is working and what the
prognosis might be.Except for feline leukemia virus, feline immunodeficiency virus and feline
infectious peritonitis, I am not aware of a virus that can cause hepatitis
in cats but it is possible that there may be one.I wish I could help you more with this.
Mike Richards, DVM
6/13/2000
Question: Dear Dr. Richards:
I'm devastated over the loss of my cat, Kitty Kitty, on 1/31/00. I had him a little over 9 years and didn't know his age. The vet thought he was about 13 or so. Blood work about 4 years ago showed high liver levels. He would vomit once in a while, but other than that he seemed fine, so I left him alone. (At the same time, our dog also had liver problems. Can a dog and cat contract something from one another?) On 8/13/99, Kitty Kitty had blood work before his first teeth cleaning. His liver levels were so high that the vet's office didn't do the cleaning, fearing the anesthesia, and also whatever problem he had because it was the highest liver reading they had ever seen. I was given a 2-week supply of antibiotics to see if maybe the problem was infection related, and told they'd do the teeth cleaning if the levels were better. He fought so much trying to get the pills down him, I felt bad and didn't pressure him; he seemed fine, and all we were doing was trying to clean his teeth, so I felt it was best to just leave him be at that time. Please note
that I've always taken care of my pets. Kitty Kitty was well cared for and made his routine visits for shots and whatever else was required. Cost is not an issue, just the wellbeing of my animals. I should also mention that he was an inside/outside cat until about 4 years ago. He was neutered, but liked to fight and at least once a year he'd make a vet visit for a severe infection. He seemed susceptible to infection. (He was pure white with a pink nose and ears - does that have any bearing?). When I made him strictly an indoor cat, he had a feline aids test, which tested false positive. We did another test that was negative. Upon adopting a kitten 3 years ago, both cats were given blood tests and the leukemia and feline aids tests were negative. The kitten has always been inside (except for when I found him). Back to the August blood test. On 8/13/99, the ALT was 1670; AST 296; and billirubin .1 (white cell not available). (Prior test 7/17/99: ALT 361; AST 140; billirubin .1; white cell count 4.8.) Kitty would vomit, usually by his food bowl, maybe a couple of times a month, but on the evening of 1/19/00, he vomited about 10 times around the house; some was food, some liquid that included brownish color. He seemed OK the
next day, Thursday, and I believe he ate that day, but that evening I put all the food up and just left water out. That night he vomited a couple of times after drinking the water; the vomit was clear. On Friday I took him to the vets. He weighed in at about 15 pounds; I know he was overweight. They drew blood, gave him a Vitamin K shot, and did an ultrasound test on the liver, which looked OK. The blood test on 1/21/00 showed ALT 670; AST 128; billirubin .2; white cell count 10.3. The vet said normal ALT is 5 to 60, and normal AST 60. The following day the vet did a needle aspiration of the liver and we later found out that the test was inconclusive. My cat was back home after this test and seemed fine. He wasn't all that active, but would still romp around with the other cat, and chase the dog. He ate well and was always eager to eat. I felt it was time to see if his liver ailment was treatable and decided to do a liver biopsy with the needle. He went to
the vets 1/31/00, at a time when he seemed to feel good and was very loving. They planned a blood clotting test that day, Monday, and then I was to bring him back the next day for the procedure. As it turns out, Monday evening I went to pick him up and the vet said the clotting test was normal (PT 9.7 seconds; PTT 15.5 seconds), but that they'd like to do the biopsy that evening since their internal specialist wouldn't be in on Tuesday. I said OK and off I went. About 1 1/2 hours later I got a call that the actual biopsy went well, but my cat stopped breathing afterwards. I think they were helping him breath, and then his heart stopped. They tried to get his heart to start, but it didn't and he died. I was shocked, and the vet said it was quite unexpected.
I asked the vet to go ahead and send in the tissue for testing. I also found out that the doctor opened his abdomen, before he went to the mortuary for cremation, and she said there was hemorrhaging, which surprised her because the clotting test was normal. I have read some of the other letters people wrote to you about liver ailments, and mostly they refer to cats that wouldn't eat or were really thin. This wasn't the case here. I will certainly let you know the results of the biopsy, but can you offer me any insight at this time? I'm loaded with guilt, wishing I had just left him alone instead of dragging him out of his warm bed Monday morning, subjecting him to this. My heart is broken. Thank you, Dr. Richards.Sincerely, Clarissa
P.S. Should I have any concerns about my two other animals in the house; a cat (Lucky)and dog(Bailey), both about 3 years old? We lost our dog referred to above on 1/18/97; she was 15 years old.
Answer: Clarissa-I am nearly certain that you do not have to worry about Lucky and Bailey as a result of Kitty Kitty's liver problem. The most common liver diseases in cats are not contagious to other cats and I don't know of any problem with contagiousness between dogs and cats for liver disease.
I suspect that Kitty Kitty probably had cholangiohepatitis. This is a fairly common liver disease in older cats. Sometimes this disease is caused by bacterial infection so it was a good idea to use antibiotics. More often it is not, so the fact that you had difficulty administering the antibiotic may not be all that important. Pancreatitis seems to be an inciting cause of this problem in older cats, or at least to occur concurrently pretty frequently. This is not thought to be a contagious problem, either, though.
When cholangiohepatitis is not caused by bacterial infection it is difficult to treat. At the present time, Actigall (Rx) appears to be the most favored medication for treating cholangiohepatitis in cats. It is much better to confirm what type of liver disease is present with a biopsy than to try to treat without knowing which of the possible liver diseases is present. Your vet did the right things to try to keep Kitty Kitty safe and it is extremely disheartening that they did not help.
Many antibiotics come as both a liquid and a pill, so if you have problems giving pills in the
future, it may be possible to substitute a liquid. Compounding pharmacies can sometimes make flavored gels from antibiotics, too. Again, I think there is a very good chance that not receiving antibiotics had little impact on the outcome of Kitty Kitty's illness but this information may be useful in the future.What happened to Kitty Kitty is a nightmare for pet owners and for veterinarians. When the right steps are taken to try to diagnose and treat a condition and a bad outcome occurs,
anyway, it leaves everyone second guessing their actions. But the bottom line is that you took the right steps and so did your vet. Sadness is unavoidable but you shouldn't feel guilty.I wish I could help you more. Hopefully the pathology results will help to set your mind at ease.
Mike Richards, DVM
2/11/2000
Question: Dear Dr. Mike,
I can't thank you enough for such a prompt reply. The
situation here has become quite complex and frustrating.Zoe's bloodwork is not back yet this morning. I am
interested to see if she is anemic. I will have the vet go
back and recheck Fletcher's and Lily's bloodwork for anemia
as well, but as far as I can remember neither of them showed
any signs of anemia.I know that Tularemia occurs here as well as Yersinia. I
don't know about hemobartonella or leptospirosis, but will
ask the vet to look into them. Another potential problem is
Hanta virus. This fall was the first reported case in the
area I now live in. As far as my vet and I know Hanta virus
is not something that cats contract like plague.None of the cats involved are related. All my cats were
strays. The interesting thing is that the three kittens I
have, who joined my household after I moved here are not
sick. So far it is my three cats that I moved here from
Minnesota that have gotten sick. Fletcher's illness was
very perplexing until the hepatic lipidosis developed. He
was a fat cat, even when he was little. The only thing we
could come up with was the possibility of the odor destoying
chrystals in the clumping litter I used as a possible
causitive agent. The vet called the manufacturer and they
said that the chemical in the chrystal would cause liver
damage if ingested. I stopped using scoopable litter at
that time. With Lily getting sick, we thought maybe it was
still that, although I had not been using the litter for
several months.Now with three other cats, outside of my household, having
shown up at the vets with similar symptoms this possibility
doesn't seem likely.I have been concerned about my property being contaminated,
but am not sure about that now either. The one thing that
is common here is dust. I live in a very rural area and the
roads are dirt and base course gravel. This produces an
alkaline dust that is blown everywhere on windy days.
However, since it has always been this way (before I moved
here) it doesn't seem likely this would be the causative
factor for a sudden increase in liver problems in the cat
population here.As I said this is a very rural area, semi arid with the
rainy season being in july and august, where we get rains
everyday. There are a lot of cats in the area, most being
barn or "outdoor" cats that are not vaccinated. There are
many strays as well. FIP is something that has been in the
forefront of our concerns, but 4 of the six cats were tested
and came up negative. The fact that most cats here are not
well looked after brings up the possibility that more have
been affected by something and no one recognized it. If a
cat goes "missing" or dies most people here don't think a
think about it. Basically the cats are wanted for one
purpose only and that is to keep the rodent population down
due to fear of plague and hanta virus.Before Fletcher got sick I had no idea about the dangers of
hepatic lipidosis. I have never "free fed" the cats. They
all have their own dishes and get fed morning and night. I
make sure to see that everyone is eating and not whether or
not they eat all their food.You also mentioned the fact that SD should not be fed for
longer than six months. This is concerning, since Zoe has
been on it for four years. My vet her just recently
switched her over to cd/s. I am hoping that this is a
better long term choice. Zoe gets bladder infections as
soon as she is switched over to other food, even science
diet feline maintenance.I can't tell you enough how greatful I am for your response
the the suggestion of areas to look into further. Thank
you!Denise
Answer: Denise-
I checked with Hill's today and asked them why their feeding guides say
that s/d should not be used long term. The vet I spoke with, whose name I
can't remember, said that s/d diet is very acidifying and that is contains
a high level of sodium. This can cause problems if any other disorders
develop that are affected by these effects, such as heart disease, kidney
disease or hypertension. It is necessary to monitor the acidity of the
blood, potassium levels and kidney function on a periodic basis when using
s/d diet long term. There are patients who do better if they stay on s/d,
according the technical vet for Hill's but they do not recommend this on a
routine basis.This is not likely to have been a factor in the development of increased
bilirubin levels but it would still be a good idea to get a general blood
chemistry panel that allows assessment of the above parameters. Hopefully
these values will be in the panel your vet has asked for. The pH can be
estimated using total CO2 from a blood panel.I hope that Zoe is improving at this time and that the blood work is good news.
Mike Richards, DVM
4/10/2000
Q: We have a 16 yr. old cat with diagnosed health problems. An initial
thyroid condition was recently improved to a level 1.5 reading after 3
wks. of Tapazole dosage (5mg daily). Our cat had not been active or
showing much signs of an appetite prior to this and had dropped to
5.25 lbs. (vs. 8 lbs normally), but has shown imrovement as a result
of the medication. The local vet would like to now do a biopsy due to
elevated readings on ALP (373) and ALT (489). In light of the extreme
levels of both tests and the age of the cat, we are wanting to know
what the chances are for treatment and a return to a normal, painless
life. What type of biopsy would you recommend, and what are the risks
from anesthesia, etc.? Also, the vet wants to perform an ultasound,
is this necessary in conjunction with the biopsy in your opinion? The
initial thoughts are that the liver condition might be one of three
things:
1)Colangeo Hepatitis, 2)Fatty liver, or 3)Tumor. What are your
overall thoughts and recommendations. We love our cat very much and
we are willing to do what is neccessary to help her, but we also do
not want to see her suffer or be prolonging her life when it may
naturally be near its end. Thanks very much for your help.
-New subsciber
A: Mark-
There is a critical bit of information that I can't tell from your email.
Were your cat's liver enzymes normal prior to the administration of
methimazole (Tapazole Rx)? While it is not the most common side effect
there is not much question that Tapazole can cause liver toxicity in some
cats. The elevations in liver enzymes can occur very rapidly and side
effects such as lack of appetite, lethargy or vomiting can follow the rise
in liver enzymes pretty quickly, as well. If labwork for liver values was
not done prior to administration of Tapazole or if they were normal prior
to administration of Tapazole, the first thing to consider is stopping the
drug. There are alternative treatments for hyperthyroidism which may be
necessary to use if your cat does not tolerate Tapazole.If there is reason to believe that the liver disease is not related to the
administration of Tapazole (i.e. --- there was lab work to show it might be
a problem prior to administration of Tapazole), then liver biopsy makes a
lot more sense at this point. If ultrasound examination is possible it can
be very useful in determining if a tumor is present and if so, in helping
with determining where to take the biopsy sample and in increasing the
safety of biopsy techniques such as needle biopsies.It isn't possible to tell you if the Tapazole is the problem but it should
be very high on the list of suspicions at this point. When Tapazole does
cause liver toxicity the cat usually improves rapidly once the medication is
withdrawn. (There is a good section on using Tapazole in Kirk's Current
Therapy XI).Radioactive iodine therapy is considered to be the safest treatment for
hyperthyroidism at this time and surgery is an acceptable option if
radioactive iodine therapy isn't available or is too expensive to be an option.Please call your vet and discuss the possibility that the liver problems are
related to the Tapazole. Hepatic toxicity is reported to occur in 4% of cats
treated with Tapazole in the Current Therapy XI chapter.Mike Richards, DVM
3/4/99
Liver mass and renal failure in 15 year old cat - Prednesone treatment
Q: Dear Dr. Mike:
Last week we took our approx. 15 year old cat to Cornell for diagnostics
because his appetite was poor and he was losing weight. They found chronic renal failure and a mass in the liver. We chose not to treat it aggressively--he is old and weak--and basically took him home to die. The vet gave us prednisone for him--5 mg twice a day--advised us to have him euthanized in about a week. It is now a week and he is eating well and seems comfortable. My local vet says prednisone provides a sense of well-being but that the disease will eventually be overwhelming and he will stop eating again. My question is: how long might he last? I know there is no hope for him, and we really want to do the right thing and not have him suffer. Yet it doesn't seem right
to have him put to sleep when he seems to be doing fine. Can you give us any insight as to howthings might progress? Your website has given us much information;thank you.
A: James-
I can't give you an average lifespan for the liver mass without knowing
what the mass is. But that probably isn't very important, because averages
really don't apply to an individual patient very well, anyway. I think that
your philosophy is just right -- while your cat feels comfortable, continue
to enjoy the time that you do have and when signs of discomfort or
progression of her illnesses progress, then consider euthanasia.It is important not to give up on the treatment of one life-threatening
illness due to the presence of another. In this case, the renal failure is
important to treat even though there may be a potentially fatal liver mass.
There is a lot of information on our site on treating kidney failure. A
more recent recommendation that is not on our site is consider the use of
angiotensin converting enzyme inhibitors (ACE inhibitors) such as enalapril
(Enacard Rx) to keep hypertension under control and improve circulation in
the kidneys. The rest of the recommendations on our site --- subcutaneous
or intravenous fluid therapy as needed, potassium supplementation,
phosphate binders if necessary, appetite stimulants if necessary and good
supportive care still hold.I am pretty sure that the Cornell veterinarians have given you their best
estimation of the time that they thought your cat had left for a
comfortable life but often these estimates turn out to be wrong. You
should feel confident in your ability to judge your cat's general well
being after living with her for 15 years. Trust your instincts and ask your
vet for advice when you have questions about how well she is doing.I do not want to give you false hope but there are two or three patients in
my practice who I thought would surely die within a few days --- more than
six months ago. Take this one day at a time, spoil your cat a little and
trust your instincts. You almost certainly will know when the time has come
to consider euthanasia.Good luck with this.
Mike Richards, DVM
2/28/99
Feline Liver Disease - prognosis and treatment
Q: Dear Vet Mike. Our cat, Kali, is an 8 year old, fixed, mixed breed,
female. A few weeks ago she got very ill and the diagnosis was liver
disease. That diagnosis was based on interpretation of x-rays (the liver
appears swollen), a blood test (which shows abnormal liver function), and
palpitation (liver feels swollen).Though Kali's acute problems are gone and her liver feels normally
sized, she's not quite back to normal yet-not quite as active as she used to
be. Also a recent blood test showed improved liver function, but her liver
enzymes are still quite high. If she continues to improve we're considering
a liver biopsy. Our question is, if we do a biopsy exposing Kali to its
risks, is it likely we'll find out anything which will change either her
prognosis or treatment?Her current prognosis is rather unsure. She may live another 2
weeks, 2 years, or more. It just depends on how long her liver is able to
adequately function. Her treatment consists of a special diet-Hills
Prescription Diet c/d-s.
We do have one additional question: Do you have any other
suggestions with respect to treatment?Thank you very much.
Sincerely, Brian and Heidi
A: Brian and Heidi-
I think that the best way to help you with this problem is to briefly
describe most common liver diseases and hope that will help you to figure
out the best approach to Kali's problem. I do have a couple of specific
questions and suggestions which I'll put at the end of the note.There are five conditions that affect cat livers which could be called
reasonably common. The first is toxic injury -- which may be due a
poisonous substance, to injury from bacterial toxins or from lack of blood
supply to the the liver. The second is hepatic lipidosis. This is a
metabolic condition that occurs when cats do not eat. There are two
problems when this condition occurs, the one that caused the cat not to eat
in the first place and the liver failure that results from it. It helps if
both conditions can be identified and treated but that is not always
possible to do. This condition can appear to come on rather suddenly, much
like toxic injury. The third condition that affects cat livers is
cholangiohepatitis, which can show up in several different variations and
is a chronic condition. The fourth condition is a group of conditions in
which the liver circulation is not functioning correctly, known as
portosystemic shunts. The last condition is cancer of the liver. There are
several cancers which affect cats which have a tendency to spread to the
liver. Figuring out which of these conditions is present involves
understanding each of them a little more and also understanding the
limitations of lab values and diagnostic techniques which can be used to
determine what is happening to the liver.Lab tests that are commonly used to evaluate liver condition include the
ALT (alanine aminotransferase), AST (aspartate aminotransferase) and ALKP
(ALP, SAP, serum alkaline phosphatase). These tests do not indicate how the
liver is functioning at the present time. They are associated with specific
types of damage to the liver and help to determine if these types of damage
are a current problem. Liver function can be evaluated using bile acid
response testing, which does give an indication of the liver's ability to
do its job at the time the test is done. X-rays and ultrasound can give
indications of the liver's size and ultrasound can sometimes pinpoint
specific lesions in the liver or the gall bladder. Liver biopsy is
currently the only sure way to identify many of the liver conditions that
affect cats. Liver biopsy can sometimes be done simply by inserting a
hypodermic needle into the liver and aspirating contents, a relatively safe
procedure or it may involve specialized biopsy needles or exploratory
surgery to remove a small wedge of tissue from the liver. Each method of
biopsy has its advantages in specific circumstances.The ALT value is specific to the liver, almost, in cats. A rise in the ALT
occurs when the hepatocytes (liver cells) are damaged enough to leak
through the cell membrane and release this enzyme. This can occur due to
toxins, bacterial infection, blood supply deficiencies, bile duct
obstruction and hepatic lipidosis. When an acute injury to the liver occurs
the ALT rises rapidly as it is released from damaged cells. In general the
level will rise for the first few days and then decrease gradually over two
to three weeks if no further injury occurs. This makes the ALT useful in
determining if a liver condition is due to an acute injury or due to
ongoing damage, making it a chronic condition. There are times when other
systemic illnesses, such as hyperthyroidism or feline leukemia virus
infection, can cause enough liver damage to slightly elevate the ALT
chronically.Aspartate aminotransferase (AST) is found in the liver and other organs,
including the muscle and brain tissue. Rises in the AST can indicate a
problem in any of the organs it is common in, so it is not as specific to
the liver. However, when it rises in conjunction with the ALT it can help
to confirm that liver disease is present. It may rise faster and to higher
levels than the ALT when obstruction to bile flow is present, which can
also help to differentiate one cause of liver disease. In order for
aspartate aminotransferase to be released, the liver cell usually has to
die. Due to this, there can be situations in which the ALT rises because
cells are damaged, but the AST remains low because they are still alive. A
rise in ALT without any rise in AST would normally be a good prognostic
sign since it would indicate damage without cell death.Alkaline phosphatase (ALP) is found in many tissues but in cats the
majority of this enzyme in the bloodstream comes from the liver. This
enzyme is excreted in response to bile duct obstruction, making it pretty
specific for this problem in cats. It can take awhile for production of the
enzyme to start and it will be produced as long as the condition persists,
so levels tend to start out low and then rise over the course of an illness
in which bile flow is obstructed. Large rises in the ALP level tend to
indicate pretty severe obstruction to bile flow which has been present for
some time.These tests show the amount of damage to the liver cells which are present.
The reason that they can not be considered "liver function tests" is that a
liver with only a few normal cells, such as one in which cancer is
widespread or cirrhosis has occurred, may have little or no cell damage in
the remaining cells --- but almost no ability to function. Conversely, a
large number of liver cells can suddenly die due to a blood clot or toxin
and the rest of the liver can function normally. A large rise in ALT, AST
or ALP may occur even though the liver is able to do its job. The test that
is currently used to assess the functional ability of the liver is the bile
acid response test. Bile acids are removed from the circulation by the
liver. If this does not occur, it is a good indication that the liver is
not able to function. Bile acid response testing can help to determine if
disorders have damaged the liver's ability to do its job and are useful in
finding conditions, such as portosystemic blood shunts, in which the
functional amount of liver tissue is decreased.In our practice, hepatic lipidosis seems to be the the most common liver
disorder that we encounter. Typically, cats with this condition are
refusing to eat. Many of them approach food as if they want it but then
refuse to eat at the last minute. If they do eat they may vomit
immediately. Some cats do eat and manage not to vomit but only eat small
amounts each day, not enough to meet their caloric needs. Cats with this
condition appear to be depressed. Often, they are heavy cats prior to the
onset of the illness but lose weight rapidly once it starts. As time goes
on cats with this condition may develop severe neurologic signs such as
head pressing, seizures or coma. Jaundice develops pretty quickly in cats
affected by hepatic lipidosis. The best treatment for this condition is
aggressive force feeding, often requiring placement of a stomach tube to
allow for adequate caloric intake. Hepatic lipidosis is usually fatal if
untreated but approximately 80% of cats will recover with aggressive
nutritional support. Cats with this condition respond better to high
protein, high carbohydrate diets (like kitten foods), which is the opposite
of diets prescribed for most other liver conditions. Hepatic lipidosis can
often be diagnosed using a fine needle aspirate of the liver, a relatively
safe form of biopsy that most veterinary practices are capable of.We see a fair number of cats that appear to have had toxic insults to their
liver for reasons we rarely discover. They are often depressed, often
vomiting, sometimes have jaundice and sometimes don't. They also are
reluctant to eat. We tend to suspect this problem when the fine needle
aspirate doesn't look like hepatic lipidosis but we suspect liver disease
based on the lab values and clinical appearance. We look for an underlying
cause we can identify and then usually try antibiotic therapy and
nutritional support for a few days prior to looking for definite cause
because cats with toxic insults often improve fairly rapidly. If the cat is
seems to be getting worse we may progress to further diagnostic testing
more quickly. It takes a week or two for rises in liver enzyme levels to
start to drop towards normal levels in these cats but their attitude and
clinical condition seems to improve more rapidly than the lab values.We also see a fair number of cats with cholangiohepatitis of some sort.
There are several types of these disorders. Cholangitis is inflammation or
infection of the bile ducts. This is sometimes the first stage of
cholangiohepatitis, which is inflammation of the bile ducts and liver
tissue. Suppurative cholangiohepatitis is inflammation with pus production.
It can be acute or chronic. Cats with this condition tend to have
unexplained weight loss, sometimes fevers, decreased appetite, sometimes
vomiting and sometimes just a "not doing right" appearance. Antibiotics and
medications to stimulate bile flow may be helpful. Surgery can sometimes
aid in the treatment of this disease, if a way can be increase bile flow.
Another form of this condition is nonsuppurative cholangiohepatitis. This
may be the chronic form of the suppurative condition or it may occur
without evidence that suppuration ever occurred. Cats with this condition
often are losing weight but have normal attitudes. They may have occasional
vomiting or may not. Often, the first sign that owners notice is yellow
discoloration of the white portion of the eyes or the oral tissue. This
condition tends to occur in middle aged or older cats but can occur at any
age. There are cats with this condition whose liver enzyme levels stay
almost normal or only show slight increases. Anemia is often present and as
the disease progresses protein levels may decrease in the serum. Even
though there is a decrease in protein production by the liver this
condition seems to respond better to a low protein (but high quality
protein sources) diet than to higher protein. Chronically administered
medications are used more commonly in treatment of this condition than in
the other liver diseases. Corticosteroids may be helpful. In the end,
cirrhosis may occur with either suppurative or nonsuppurative
cholangiohepatitis. Diagnosis of the type of cholangiohepatitis and even
whether cholangiohepatitis is present often requires biopsy of the liver.
Suppurative cholangiohepatitis may be apparent on surgical exploration of
the liver area but it usually is a diagnosis made after examination of a
biopsy sample. For this condition biopsy normally requires at least the use
of specialized biopsy needles and may require surgical removal of a small
section of the liver.Portosystemic shunts are connections between the arterial and venous blood
flow in areas in which that shouldn't occur. This condition is usually
congenital and occurs when fetal circulation does not change after birth
properly, leading to portions of the liver not receiving adequate blood
supply and therefore not functioning properly. Since this occurs at birth
most cats with this condition are diagnosed when they are young but cats
may not show sufficient clinical signs to make a diagnosis until they are
young adults. It has to be considered in cats less than 4 or 5 years old
which have unexplained liver disease. Lab values for ALT, AST and ALP are
often close to normal or slightly elevated but bile acid response testing
shows a severe deficiency in liver function in most cases. Poor growth and
neurologic problems such as incoordination, head pressing, blindness and
seizures usually are the reasons this condition is brought to the
veterinarian's attention.Liver cancer is not especially common in cats and is usually the result of
metastasis of lymphoma or pancreatic tumors to the liver. Some tumors do
grow directly from liver tissue. Tumors may show up on X-rays and
ultrasound exams or may be discovered during surgical exploration of the
abdomen during a biopsy procedure.Liver disease of any origin can lead to blood clotting problems because the
liver makes most of the clotting elements. Even though this is always
theoretically possible with liver disease actual problems from uncontrolled
bleeding after biopsy are not very common. It is still a good idea to test
blood clotting prior to doing any type of biopsy other than a fine needle
aspirate, though.OK, that is the background information.
If Kali is eating well -- eating at least a normal amount of food and if
her liver enzymes levels (ALT, AST, ALP) drop to normal levels, then biopsy
may or may not be necessary. I tend not to do it when I am reasonably
convinced that some sort of acute liver insult occurred and the cat is
eating well and acting normally. If the liver enzymes are even a little
elevated over normal or if liver function testing revealed significant
decreases in liver function, then I think that liver biopsy is a lot more
useful. The long term management of the liver disease present is much
easier when it is clear which disorder is present. With cholangiohepatitis
it is important to know which form of the problem is present, too.I am not sure why the c/d-s diet is being used. There may be a reason that
I am not aware of for using that particular diet but it is not low
protein/high quality protein and it is not high protein, so it doesn't fit
either of the dietary scenarios I am familiar with using. It may be
worthwhile to ask your vet what his or her reasoning is in prescribing this
particular diet.A liver biopsy would give more information for obtaining a prognosis, so
that you would be more sure what sort of future scenario you are dealing
with and also in guiding treatment. However, if Kali is eating well and
feeling well, it is reasonable to wait a bit and see if the liver enzyme
levels return to normal levels prior to making the decision to biopsy.Hope this helps and doesn't just add to the confusion.
Mike Richards, DVM
Q: Hello Dr Mike,
I was hoping you may have a suggestion for my cat. On wednesday my cat
(approx. 5 yr. old) seemed depressed and not herself. On Thursday I
took her in for a blood panel and Friday the results were back. On
examination, my vet was able to feel her liver easily and when the
results came back it was apparent that something is wrong with her
liver. All the levels pertaining to her liver were elevated. She spent
the weekend on fluids and antibiotics to flush this out of her, but she
doesn't seem to be responding to treatment.There is nothing toxic in the house that is accessible to her. She used
to be an indoor/outdoor cat before we took her in, but she hasn't been
outside for at least 5 months.On Monday she will be getting an x-ray and we may have something else to
go on. At this point we don't know what's going on, whether it's a
congenital problem, a shunt issue, or ???
Her liver isn't functioning and she is running out of time and I don't
know what, if anything, can be done. My vet suggested other options
after the x-ray such as a biopsy or ultrasound.I know this may be premature and you don't have the test results in
front of you, but can you offer any suggestions about any treatments --
conventional or not?Thanks,
Marc
A: Marc-
I will try to think about this more later but I wanted to let you know that
I think it is pretty important to get a liver biopsy in a cat with liver
disease that isn't doing well. It is a good idea (almost imperative) to
check blood clotting times prior to doing a liver biopsy, except perhaps a
fine needle aspirate, because the liver makes some of the clotting factors.We do fine needle aspirate biopsies first, looking for signs of hepatic
lipidosis. If we find none, then we look further.If we had ready access to ultrasound and someone good at reading them, we
might lean in that direction prior to doing a more involved biopsy after the
fine needle aspirate. We don't, so we usually do the biopsy and then arrange
for ultrasound since it usually takes us a few days to arrange that.Bile acid response testing is not invasive and gives a good idea of how
well the liver is actually functioning so that is another thing to consider.If she starts to feel better then there is not as much reason to rush from
one test to the other but it is still a good idea to try to get a diagnosis
if the condition seems as if it will remain chronic (and since her liver
seems to be enlarged) because the long term goals are different depending on
what liver disease is present.Good luck with this. I hope she is doing better by now.
Mike Richards, DVM
Q: My kitty was diagnosed with fatty liver 2-1/2 weeks ago. He's now got a stomach tube through which I'm feeding him as he's lost so much weight and is not interested in eating on his own. After a week in the hospital, I've had him home for a week and he's vomited food up every day. The time of day varies and sometimes it's right after eating; other times it's an hour or two later. I was feeding prescription a/d food and have now switched over to baby food hoping it would help. He's on regulan to help with the nausea but I'm not sure how much difference that is making. A few days ago someone suggested to not microwave the food but rather put it in very warm water in a cup. This worked great for a day but yesterday the vomiting was back. I'm sorry this is so long, but I'm really in despair. Any thoughts on how I can control the vomiting? Thank you! Joyce
A: Joyce- It is not uncommon for cats with hepatic lipidosis to vomit after feeding through a stomach tube is begun. There doesn't appear to be a clear consensus on medications to help with this condition but cimetidine (Tagamet Rx), cisapride (Propulsid Rx), metoclopramide (Reglan Rx), and other medications similar in effect to cimetidine are most often recommended.
There is a clear consensus that feeding small quantities very frequently will often help. For hospitalized cats the use of gravity or pump controlled feeding from a reservoir such as an IV bag is utilized to ensure continuous small quantities of liquid food. At home it may be necessary to just use very frequent small meals for a week or so to gain control of this situation.
I hope that everything is already looking a lot better by now.
Mike Richards, DVM
Q: I just discovered your web page today after returning from our vet. Our 8 year old cat, Amnesty hasn't been eating well for two days so I thought we'd best get him checked out. Apparently his physical exam was unremarkable so I brought in a urine sample. It showed elevated bilirubin and protein. Subsequent bloodwork revealed an alk phos of 670. I was told the normal high range was 200! He was put on Clavamox 125 mg bid and Metronidazole 250 mg od. I was told to check in with the vet in a week and let him know if his appetite has improved. I'm wondering what the prognosis might be and if there's anything else I should be doing. He normally eats Medical-W wet and dry food but I found a web site that suggests we might try Hill's Prescription Diet k/d. Any suggestions would be greatly appreciate. Thank you. Sheila
A: It is pretty important in cats to determine the nature of the liver disease prior to choosing a diet. Cats most commonly have either cholangiohepatitis or hepatic lipidosis. These diseases require an entirely different approach to dietary management. Cats with cholangiohepatitis probably do better on a diet that has very good quality protein in limited amounts. Cats with hepatic lipidosis probably do better on diets that are high in protein since their problems tend to relate more to fat deposition in the liver cells from not eating well. The higher protein diets are more attractive to cats and the excessive protein is used as an alternative energy source to fat metabolism. If your cat is doing well at this point it may not be necessary to worry over this issue. Hope that is the case. If not, working with your vet to establish the cause of the liver disease and using the correct diet along with other appropriate treatment could make a big difference.
Mike Richards, DVM
Poor liver values - treatment and diagnostic tools
Q: My cat is about 16 years old and has had poor liver values over the last couple of years, during these episodes he would refuse any food offered. He has been receiving injections to boost his liver values, but his episodes of poor liver values seem to get more frequent. Do you have any diet or treatment recommendations !? Thanks a lot ! Alexa
A: Alexa- It would be a good idea to try to identify the cause of the liver enzyme increases if possible. Cats get two liver conditions most frequently, cholangiohepatitis and hepatic lipidosis. They can be affected by other liver problems and it is also possible to get elevations in liver enzymes that are related to other conditions that are only indirectly affecting the liver. An example of this would be a rise in alkaline phosphatase enzyme levels in response to administration of cortisones or rises in liver enzymes due to circulatory problems.
Liver biopsy is the most reliable test for differentiating between liver diseases. It is always a good idea to make sure there isn't a contributing problem by taking bloodwork and possibly X-rays prior to biopsy. Also, it can be important to confirm that the blood clotting system is working properly prior to doing a liver biopsy.
Cholangiohepatitis is the most likely diagnosis when the condition seems to wax and wane. There are several possible causes of this problem and they have to be treated appropriately. It is often possible to tell from a liver biopsy which is the most likely cause. Infections need to be treated with antibiotics and supportive therapy such as dehydrocholic acid (Decholin Rx) if bilirubin levels are high. Appetite stimulants may be necessary. Immune mediated cholangiohepatitis may respond to administration of corticosteroids or other immunosuppressive medications. Dietary changes may be beneficial depending on the exact cause.
Many vets are uncomfortable about performing liver biopsies. If your vet doesn't want to do this and you do want to pursue a diagnosis ask about referral to an internal medicine specialist.
Mike Richards, DVM
Polycystic renal disease/ liver disease
Q: Dear Dr. Mike, What can you tell me about poly cystic liver disease in cats. Also can you refer me to any references or journals on this subject. Any help that you can provide would be greatly appreciated. Thank You
A: I can not tell you much about this disease except that it seems to be mostly a problem of Persian cats and that it is probably the same disease as polycystic renal disease. The cysts seem to occur in either organ system but cause problems earlier when they develop in the kidney. I haven't even seen any conjecture about why these cysts occur, except mention that they can be associated with cancer in some cases. At present, it appears that draining the cysts by guiding a needle into them using ultrasound may make the cat more comfortable and may help to preserve kidney or liver function. It doesn't appear to be a long term solution but there doesn't appear to be a better approach at present.
I wish we all knew more about this problem.
Mike Richards, DVM
Q: My cat had some blood tests done recently as since she is overweight (although she is losing weight on a Feline RD diet prescribed by my vet) I was afraid she might be becoming diabetic. She has gone from 16.8 lbs. to 14.2 lbs in 10 months. When her blood tests came back, her lactic dehydrogenase was 1065, almost twice the normal level. In speaking to my vet he says it is difficult to tell what this means, since lactic dehydrogenase is produced by almost every organ in the body and prior efforts he has made with labs in other cases to break this down has not provided much useful info. Any thoughts on how I can get more info. into what this test result means? By the way, her ALT(SCPT) and AST(SGPT) were slightly elevated also.
A: I think that it is important to take any rise in liver enzymes seriously in a cat that is losing weight, even if it is on a dietary program. Cats that are losing weight are prone to hepatic lipidosis. If your cat becomes anorexic (doesn't want to eat) it is much more important to keep this particular disorder in mind. I would recommend rechecking these particular values again in a week or so, if possible.
Your vet is absolutely correct about the value of lactic dehydrogenase (LDH) testing. It is found in a great number of body tissues and it is difficult to assign much meaning to a rise in LDH. I think that we would not choose to run this test if it weren't included in many laboratory profiles in which all of the tests chosen by the testing lab are included. However, there are a few instances in which increases in this enzyme level are meaningful. When no other lab values are elevated it is possible that the increase is due to malignant cancers and LDH increases do occur with liver disease and this helps to point out liver disease when other liver enzymes like the ALT and alkaline phosphatase levels are increasing.
Please have all of these values rechecked in one to two weeks - or sooner if your vet advises that.
Michael Richards, DVM
Last edited 12/05/02
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