Cholangiohepatitis/pancreatitis/fatty liver--1 month into treatment, need advice.

As I was searching the internet for information about cholangiohepatitis/pancreatitis/etc. I found your forum and was impressed by the knowledge base here!

I am hoping that some of you might have some experience with this and I am looking for any help I might get!

Let me give you a bit of history covering this past month. I noticed a "mood" change in Abigail, my 15 year old Balinese spayed female, on March 17th. At that point she was eating and drinking normally, but had changed her usual napping spots and seemed just "off". By the next day I noticed a decreased appetite. She vomited a small amount of bile, which I did not find unusual since she has always been a good self groomer and tended to ingest her hair, and her brother's as well when she groomed him. She would on occasion present me with a large hairball in a thick yellow liquid. This is something that was very normal for her entire life.

By the evening of the 19th she refused food, and the next morning I brought her to the vets on March 20th where she received fluids and Pepcid. I also took home Lactated Ringers to give 50ml every and transdermal Flagyl. We decided to give her a B12 injection, which I do already have at home, A superchem and urinalysis were done.

The following values were abnormal:
AST 190 (10-100 as normal)
ALT 497 (10-100)
Alk phosphatase 219 (6-102)
BUN/Creat 2.6 (.6-2.4)
Cholesterol 313 (75-220)
Amylase 1673 (100-1200)
Neutrophils 85 (35-75)
Lymphocytes 12 (20-45)
Monocytes 0 (1-4)
Absolute lymphocytes 960 (1200-8000)
The remainder was normal
Her T4 was normal and urine showed a high Microalbuminuria of 6.5 with

Hi and thank you for joining TCS, although I'm sorry for the circumstances.

I don't know much about pancreatitis but hopefully others will chime in, and in the meantime here is a very detailed thrad on the subject that's filled with links.

http://www.thecatsite.com/t/264363/sebastian-is-back-at-the-vet-suspected-pancreatitis-again

My kitty went through cholangiohepatis and fatty liver both of which were connected to IBD a little over three years ago.  He didn't have pancreatitis.  It's kind of difficult to treat the fatty liver and pancreatitis because he needs to be fed, my vet told me overfed for the fatty liver but underfeeding is good for the pancreatitis.  There is a long recovery period for fatty liver.  My kitty doesn't do well with syringe feedings so he had a feeding tube.  His ALT got up over 1200 before it started coming down, the only thing you can do for it is keep up the feedings.  I used Hills A/D.  It's a food that is both calorie and nutrient dense.

I would question stopping the buprenex with pancreatitis because it is painful.  I know someone else here has a kitty that had a pain patch when he had pancreatitis.  Did he have the specific test for pancreatitis, it's a blood test that is sent out.

Fluids also help with pancreatitis.  You could ask your vet about sub-q fluids, they can be given at home.  Many people with kitties that have CRF give them regularly at home.

Honestly, I think the initial blood tests done indicated pancreatic issues, and some inflammation was seen on the subsequent ultrasound. I don't think it was extreme, and the vet was always more worried about the liver issues. She also mentioned bile duct obstruction related to the pancreatic and liver inflammation as a possible cause of the jaundice.

I've had CRF cats, so I do have experience giving fluids and she gets 100mL daily, 60ish with her glutathione in the am, and 40ish with her Pepcid in the pm.

She does not behave like a cat in pain. She is still social, active and behaves much like she did before this incident. It's just that she's not eating well on her own (about a teaspoon at each feeding, but no more then that) and is extremely jaundiced.

How long was your kitty's recovery? Was he jaundiced as well? if so, how long did the jaundice take to clear?

Thank you for the link, that was very informative!

My kitty was jaundiced mainly inside his month, ears and his eyes.  He took about a month and half for his liver numbers to begin to normalize.  The main number the vet was watching was his ALT.  There is a supplement called Denamarin that can help    It contains milk thistle and SAM-e.  The pills have a protective coating on them so they break down in the intestines so they need to be swallowed whole.

Recovery times for this varies.  From what I have seen here my kitty had a quicker than average recovery.  The only thing you can do is keep up the feedings, I know it can be discouraging but it takes time to recover.

I think that at this point what's really worrying me is that the Total Bilirubin is just not going down. I mean she is VERY yellow. Her normally blue eyes are emerald. I just wonder if there may be a mass or blockage. I don't want to put her through all this treatment if this is never going to have a good outcome. I know that I've invested a lot of time and effort into her treatment, but I don't want it to be something I'm doing just for me. If she stands no chance of recovery, then I really wonder if this is a good thing I'm doing. I'm definitely having another ultrasound done. Maybe I'll get some sort of answer then.

Patches didn't have any kind of blockage his was from not getting enough calories combined with the inflammation from the IBD going into his liver.  I know his bilirubin was high because he was jaundiced but I don't know what the number was.  The main number that the vet watched was the ALT.

I'm so sorry you're going through this @Wendykins. I do not have any direct experience with fatty liver, although we were close. Sebastian has chronic pancreatitis. His first acute attack back in July 2013 had him hospitalized and he didn't eat for four days. We were borderline feeding tube, but went with syringe-feeding since he started to show some interest in food on day five. I did have to syringe-feed him for two weeks, supplementing whatever calories he didn't consume on his own.

I've been syringe feeding Abbs four times daily, and one of the feedings is just before leaving for work. I just know one day I'll go in wearing a glob of cat food on my hair...

I hope Sebastian is feeling much improved--keeping pancreatitis at bay must be no fun at all. If he is your avatar, he is a handsome boy indeed!

Wendykins said:

I've been syringe feeding Abbs four times daily, and one of the feedings is just before leaving for work. I just know one day I'll go in wearing a glob of cat food on my hair...

I hope Sebastian is feeling much improved--keeping pancreatitis at bay must be no fun at all. If he is your avatar, he is a handsome boy indeed!

Click to expand...

 That is great that she's keeping the food down. Sending continued vibes for Abigail... 

Also, someone else on this forum just started a new thread and is going through almost exactly what you are going through. Here's the thread:

http://www.thecatsite.com/t/276511/another-hepatic-lipidosis-tube-fed-cat-in-need-of-help

And thank you! Yes, Sebastian is my "hunk." LOL.

Hi, Your thread was linked from a reply to my pleas for help. You sound like you're in much the same boat as I feel I am -  drifting,and feeling lost and helpless in which direction to turn.

I hope your kitty continues to improve. Consider yourself a tiny bit lucky in that the feeding are going well.

Feeding for my kitty have been tenuous. Today has been a bad day for both of us.

I had to laugh at your comment about wearing a glob of cat food in your hair! Yesterday evening I finally noticed a dried glob on my forehead that must of landed there during the afternoon.  I'm sure I had some in my hair too and finally took a shower today!  

This tube feeding stuff is not for the faint of heart.  I wish you and your beloved Abigail all the best!

I just replied to your post as well! Here we are in such similar circumstances. Go figure, you have a cat that has trouble with feedings whose numbers are improving, and I have one that tolerates feedings well whose numbers are just staying flat! Can we average them, LOL???

Patches had the same issue that you are having.  The vet was watching his ALT.  Even after he started eating well on his own his ALT continued to rise and that brought everything about Lymphoma back up.  Someone here told me that his ALT would take a while to come down.  I started giving him the Denamarin and his ALT started to drop.  I don't know if the Denamarin did it or it just coincided with it dropping.

I'll dig up some of our labs for comparison tomorrow.

One thing that happened at the beginning of the month that was very scary was they decided to do a repeat ultrasound because the round of labs were not as good as they hoped for. They planned to do another biopsy also.

During the procedure they noticed the gallbladder bile ducts were more inflamed than the previous U/S. I guess whatever they saw kind of freaked them out and the biopsy wasn't done.

Then the plan was to consider a CT scan with possible surgery, if warranted or if the CT found something that was not treatable then we'd be at the end of things.

After reeling from hearing this and coming to pick kitty up the doctor called me and said she had "good news" - that she'd talked to the liver specialist and the specialist said no way should any CT or surgery be done. Her recommendation was to continue with the pred and other meds. She was not as concerned with what was seen on the U/S and felt it was still inflammation and he just needs more time.

Perhaps your Abigale just needs more time also? This specialist said it can take a long time for this to resolve.  

I've never met this specialist and kind of have this idea she's like the Wizard of Oz - this all knowing entity that follows along and provides input and expertise but is never seen :-)  I hope she's correct for both our little ones - that they just need more time.

To add, the next set of labs (and most recent) that were drawn were much improved  and the doctor was very pleased.

I really want you to be right! I think that as good as my vet may be, she is not an internal medicine specialist, so she really doesn't know how slowly this can progress--I guess that the mist worrying issue for Abigail's situation in my eyes are not necessarily the liver numbers but specifically the total bilirubin. ( And that is something that the holistic vet I'm consulting with was also concerned about.)

Hi Wendy, So sorry to hear about last nights upchuck. How did it go thru the rest of the night?

I copied your labs here:                                                    Mine to compare - LAST LAB results from April 13, 2014                                              INITIAL LABS - Feb 7, 2014

The following values were abnormal:                           
AST 190 (10-100 as normal)                                            AST was not drawn but the previous one on March 31 was 1074 (normal 14-42)     AST was not drawn but first one drawn on Feb 19 was 262 (14-42)                                                                                                                                                                                                                                                

ALT 497 (10-100)                                                              ALT 617 (12-130)                                                                                                                          *ALT 2726 (12-130)
Alk phosphatase 219 (6-102)                                            ALK PHOS 224 (12-111)                                                                                                               ALK PHOS 289 (14-111)
BUN/Creat 2.6 (.6-2.4)                                                      BUN/CREAT 18 (No range listed)                                                                                                 BUN/CREAT 12 (no range listed)
Cholesterol 313 (75-220)                                                  CHOL 250 (65-225                                                                                                                        CHOL 396 (14-111)
Amylase 1673 (100-1200)                                                 AMYLASE 1238 (500-1500)                                                                                                         AMYLASE 1030 (500-1500)
Neutrophils 85 (35-75)                                                       Neutrophils  14.25 (1.48-10.29)                                                                                                   Neutrophils 26.64 (1.48-10.29)
Lymphocytes 12 (20-45)                                                    Lymphocytes 4.53 (0.92-6.88)                                                                                                     Lymphocytes 2.91 (0.92-6.88)
Monocytes 0 (1-4)                                                              Monocytes 0.64 (0.05-0.67)                                                                                                         Monocytes 1.49 (0.05-0.67)
Absolute lymphocytes 960 (1200-8000)                             Absolute lymp Not listed                                                                                                              Absolute lymp  Not listed

                                                                                           GGT 4 (0-1)                                                                                                                                  GGT 14 (0-1)

                                                                                           Total Bili 0.7 (0-0.9)                                                                                                                       Total Bili 4.2 (0-0.9)

Bloodwork on the 31st showed elevations in her liver values, including a very high bilirubin, which have remained at about the same level as for the last three consecutive weeks.
I'll list the numbers as in date order for 4/2, 4/11, 4/18
ALT 223, 658, 727 (10-100 being normal)
Alk phosphatase 151, 350, 346 (6-102)
Cholesterol 288, 247, 242 (75-220)
GGT 9, 16, 18 (0-1)
Total bilirubin 10.8, 11.3, 13.7 (0.0-0.9)

Here are my labs in between for: 2/19, 3/10, 3/23, 3/31

ALT 1405, 130, 1873, 2141

ALKP 472, 38, 259, 663

CHOL 251, 269, 280, 404

GGT  88, < 3, 7, 11

Total Bili 2.3, 0.4, 0.6, 0.9

AST 262, 71, 1526, 1074

*Wendy, I just saw you had more recent labs in your first post further down so I added them here to compare. I deleted some of what I wrote as I didn't see these earlier and was thinking the first labs you posted were the most recent. My apologies for not reading thru better before hitting SUBMIT.  Now I do see what is very worrisome for you. This is all so very difficult to get thru. You are in my thoughts and prayers. 

Sure hope today goes well without any thing returning up, back and out at you!  Mine has... so far 

One more thing to add, in the several vets I've seen at various appointments and ER clinics I've had 2 who seemed to not have a lot of knowledge about this diagnosis. The one vet who went down the "time for the hard conversation" road later retracted her comment and apologized when I told her what I'd just heard thru the attending vet about what the specialist was still feeling. This ER vet said she surely didn't have the expertise or knowledge that the specialist did and would never go against anything that she may have said. She also said she didn't really know about the prognosis about HL and that her speciality was surgery not internal medicine. Another vet seemed to imply a similar idea, which only adds to ones confusion when you've been told by other vets it can be worked thru plus all that I've read online about the 90% recovery rates. So hang in there! It's a tough rope to balance on with our kitty's. 

My vet always seemed the most interested in the ALT.  Your kitty's ALT has dropped a lot and it was much higher than my kitty's went to, his went over 1200 before it started dropping.  The vet told me that the ALT measures the enzyme that liver cells release when they die.

Denice, Yes the vet who did the first lab draw was freaking out about his results. She was young and kind of mumbled she'd never seen one this high and had to dilute it to even get any reading. I had no clue what she was even taking about but was aware it was not very good. This ER place didn't even want me to keep him there and preferred I take him to the Vet School Hospital and Clinic for treatment.

So if this measures the liver cells that have died and the number has decreased then does this mean the cells have slowed down in dying - which I presume is a good thing..? I am such a fish out of water with medical stuff. I find it all scary and even more so when its about those close to my heart.