IBD or Small Cell Lymphoma - To biopsy or not to biopsy

Hey all,

Here's a quick summary:

In July I lost my baby, Burnie (10 years old) to what was most likely abdominal cancer or lymphoma (no biopsy) along with kidney inflamation and he was pts at home. It came on so fast and was so devastating to us, as he hid it well for what we're thinking was about a year or so.
 

His littermate, Crash (also 10 years old), within a week of losing his brother suddenly had an over-the-top allergy attack with swollen red, weeping itchy eyes and he scratched his ears bald and bloody. The vet gave him a steroid shot, as he stopped eating. Come to find out that he has developed a sudden, massive allergy to chicken and duck, as well as turkey to a lesser degree (I know because within 10 minutes of ingesting these culprits he starts obsessively rubbing his eyes and scratching again).

The steroid shot helped for a few weeks and he was eating really well, and then as it started to wear off he began scratching and acting nauseous, not eating again.

We've done 2 blood panels and a pancreatic test as well as 2 xrays, (and an enema because our vet saw via xray that he was quite backed-up). Everything came out "flawless" in my vet's words, so she tried all she could with Cerenia and an appetite stimulant and Miralax in his food and that had him good for another 5 days.

Well, we're back to not eating again for the past 24 hours. I called the internal specialist and took him in for an ultrasound... which also came back clear and perfect. She said his organs are all absolutely great, and she is leaning towards it being the dreaded IBD, but is insisting on doing a biopsy (endoscopy) to rule-out small cell lymphoma.

The cost is a lot. $1500-$2000, and of course that is after the $1600 I've already spent on his tests and meds up to now, and add to that $2500 in July when his brother Burnie was sick. I also don't want to put the little guy through any more stress than necessary, and anesthesia has me scared to death.

I've been researching IBD and Lymphoma via some of the threads on this site, and have learned so much. I was hoping to get your opinions on whether or not to do this biopsy, or to just treat Crash for IBD and skip it. I don't want to put him through anymore poking and prodding, as he has already suffered so much stress, discomfort and sadness this summer.

I would love to hear your experiences and opinions so that I can make a better-educated decision for my little love bug. The second we got home, he ran over to his food dish and gobbled down about 1/8 cup of his dry hypoallergenic kibble, and this has me thinking I could at least put off the biopsy for a bit and think it over and talk it over with my vet.

I'm sorry for your loss of Burnie and that Crash is sick. The decision of whether to do a biopsy or not is a hard one. I'm really of mixed mind about them. Does the vet have a very good reason to be looking for cancer? Meaning, is small cell lymphoma simply part of the differential diagnosis, as it often is? If the vet simply wants to rule it out for liability reasons, you need to decide what the risk is and whether the biopsy is worth it. I would recommend reading this article first however that was written by a vet pathologist who says,  "One of the great myths of our time is that endoscopic biopsy can diagnose inflammatory bowel disease."

See http://www.histovet.com/PDFs/HIS_Gastrointestinal.pdf

Personally, if this were my cat, I would treat for IBD now without the biopsy. If he didn't respond to the prednisolone, then I would consider a biopsy at that point or just push for leukeran which is known to treat acute IBD cases as well as small cell lymphoma. Whatever YOU choose, just remember that it has to be in your and your cat's best interest, not the vet's. Many many vibes for you and Crash.
 

I can only tell you what I did.  With Patches last big flare he ended up with fatty liver disease and it was the same thing everything but his liver enzymes were fine.  I didn't have the biopsy done.  The vet did a needle biopsy on his liver but it came back inconclusive because there weren't enough cells.  His enzymes were slow coming back down even after he started eating again.  The vet said if they continued to stay up much longer she would want to do a biopsy but they finally dropped.

The bad thing about a biopsy is that you may still not have a conclusive answer but it's really your decision if you want to go ahead and have it done.

Thank you so much for your kind words & thoughts vball91... it has been such a hard, hard time, and I miss my Burnie Bear so much. He and Crash were inseparable, and it breaks my heart to see Crashie depressed and in discomfort, I want to do EVERYTHING I can to help him, as since his brother has gone, he is glued to me 24 hours a day and sleeps curled up under my arm every night. Life is hard enough without this new IBD business to deal with!

Now, as to your question, I don't think the Internal Medicine Specialist has any good reason to suspect cancer at all, and she basically said as much... just saying that she "wanted to rule it out" but was explaining IBD and treatment for that, not lymphoma. My regular vet is much more hesitant to do invasive procedures, and I'm waiting to hear back from her on this latest situation. The specialist was so quick to insist on the endoscopy and biopsy and the receptionist had me scheduled in the computer even before I had a chance to fully look over or consider the estimate. It's so much money, and just to get a diagnosis that I'm not sure is worth it. I'd rather put the money toward good food, meds and care for my little angel.

Crash has never had diarrhea, and rarely vomits (only when he eats chicken meal or freeze-dried chicken treats, and not all the time), and every other test is perfect. For him, his only symptoms are allergies and nausea (which causes him not to eat), and we've successfully treated that with a steroid injection previously, and recently an appetite stimulant and Cerenia.

Yesterday, while he wouldn't touch food, he was enthusiastically chomping on organic wheatgrass all day without any repercussions and his energy levels were fine. The day before, I believe he did sneak a few Wellness Core bits leftover in his sister's bowl... which is what I believe caused this flare-up, so i'm donating that bag, along with all the other foods I have containing chicken meal or poultry to the local shelter, so now he can't even sneak it.

Your advice is so appreciated, and I'm heading over to read that article right now! Thank you for the positive vibes for Crashie and I

I just wanted to post an update on Crash... my poor baby is back to not eating for the last two days, has been nauseous and scratching a bit (maybe he's allergic to the hypoallergenic Royal Canin Rabbit and Pea) so I've been forced to syringe feed him last night and this morning. I've spoken with my vet, and she wants to put him on 6mg of prednisolone twice a day for the next two weeks and see how he's doing, and then start to make adjustments over the next month or two with the hope that when he stabilizes we can take him off.

In the meanwhile, I'm not having any luck with his food... it seems everything i've tried is making him feel sick, although there isn't any vomiting at all. He just refuses it, runs away, and he is licking his lips as if nauseous. I feel so terrible assist-feeding him, as he hates it and runs away from me even when I'm just walking by him now. He will come up to me on his own, but the second he sees me move he runs in the other direction.

The vet is having me give him 1/8 of a Mirtazapine today... which I'm nervous about because the last time he had 1/4 he was really manic and it scared me. She thinks he may do better with 1/8, so I will try that with the hopes that it will start him eating on his own. Should I also be worried about treating his nausea at the same time as giving him the Mirtazapine? I still have 1/2 a 16mg tablet of Cerenia, so I can give him that as well, but I wanted to try and give him as few meds as possible because he is going to start the Pred today.

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And here's Crashie and his best buddy and beloved brother, Burnie

The prednisolone often acts as an appetite stimulant as well as being anti-inflammatory. I would ask your vet why BOTH pred and Mirtazapine, especially if the Mirt made him manic in the past. I'm a big believer in treating the nausea before giving appetite stimulants. Giving appetite stimulants without addressing the nausea is a good way to set up food avoidance, which you do not want. I would ask your vet if Cerenia and pred would make more sense than Mirt and pred.

Oh! She wants me to try the Mirtazapine until the Pred kicks in, since he hasn't eaten voluntarily in a day and a half, so it would be just a one-dose situation. She says it will be 12 hours to 3 days before the Pred will likely help with his appetite, and then it would be just Cerenia and Pred like you suggested.

Ah, that makes sense.

But... last time I gave him a full 16mg pill of Cerenia, it did get him eating voluntarily again. It seems like a half tab doesn't do much of anything for him at all. Nausea is still there and he doesn't want to eat

  So maybe I will wait and do the full tab Cerenia with the Pred at the same time and see if that helps?

I would definitely tell your vet that about the Cerenia. Are you picking up more Cerenia with the pred?

Yes, she has refilled the Cerenia for me, and her initial dosage for him was a whole tab, but I told her I wanted to try him on half first to see if it worked. It doesn't, so I will go back to the full tab as she had suggested originally. Do you think it's too much? Thank you so, so much for your advice on all this! It's so helpful and wonderful to hear another opinion and experience!

I would follow your vet's dosing on the Cerenia. My cat got the injectable version, so I'm really not familiar with the tablet dosage.

Well, I picked up the Cerenia from the Vet's office and will get his Prednisolone later this afternoon from the compounding pharmacist. I gave him a Cerenia and 1/8 tab of Mirtazapine, and within 20 minutes, he's wanting to eat! Oh my goodness, knock on wood!!! He isn't acting weird or manic either on this lesser dose of Mirtazapine, just mellow and quiet. It's actually probably good for him because he's been so anxious since i've been chasing him down to pill him and syringe feed him... he's even comfortably sitting up in his window perch on my desk! He was hiding under the bed all night and most of the day, so fingers crossed all will be good tonight and I will start his transdermal Pred in the morning!   Thank you so much for all the advice and support! I will keep updating on his progress

Hooray that he's eating. I know what a huge relief that must be. Hope he continues to feel better.