Another Hepatic Lipidosis tube fed cat in need of help

Hi, I've been reading and reading the trials and tabulations of those who've had a cat using a feeding tube for nutrition. Our story is our 17 year old male was diagnosed in Feb with HL and cholangiohepititis and possible pancreatitis. A tube was inserted and we've been on a roller coaster ever since.

The days are up and down. I've never been able to get in the needed calories for more than a few days before we encounter another issue - tube vomited out that was due to constipation. Tube reinserted and we started over with small feedings. He's continued to vomit here and there. I'm instructed to not feed again for 12 hours. But in doing this I'm never getting anywhere.

The vet had him on just Clinicare - 30cc per q 6 hours. 

2 weeks ago  I took him to a different ER for my concern of constipation. This vet was concerned he was not getting enough calories and suggested I add Max Cal and work to get more food into him.

I did this and noticed I heard less stomach noises as the food increased but he does continue to get nauseated and vomits. He's vomiting less volume but still seems to feel so crappy during these times. Other days when he's seeming to feel better he will sleep in the living room rather than hiding in the closet curled up in the corner.

Saturday Sunday he did well - got in almost 200 calories until late Sunday evening when he vomited. Since then I've been giving him maybe 5-6 cc's for Max Cal with water flushes and plan to do this through out the day. 

He does well, then does not do well. He is currently taking Regaln 1 mL 3 x a day; ursodial 0.8mL once a day; prednisolone 1mL daily. He was on Cerenia and Ondansteton and Lactulose but these were stopped 1 week ago with the thought that these were causing stomach distress and adding to the vomiting. 

I have given him Cerenia and Odansetron here and there as I'd rather he not feel nauseated and I've started Miralax instead of Lactulose to help reduce the constipation as I feel he needs something but his calcium was elevated at his last labs and I saw that Lactulose can sometimes result in elevated Calcium levels.

I have to say I've been underwhelmed with the care he's received at the clinic that inserted the tube and is following him for all of this. I'd been initially told the feeding tube would be easy for him and that cats tolerate these very well and that this was reasonable to proceed with given his renal issues are very stable and he was ok otherwise.

I've felt I've been inflicting so much torture on my poor sweet guy. His last labs had improved very much and the doctor was please and feels continuing is the right thing to do. 

At a prior weekend visit to the ER at the tube insertion clinic the doctor I saw left me reeling as she felt it was time for the "hard conversation" because he was constipated and dehydrated and weak. She implied this was all unkind for him. I asked that she do the enema and that I would consult with his regular doctors. 

Since then I feel so lost and really don't know where to turn or what to do. I took him to his regular vet who was concerned he was never getting enough hydration. She sent home fluids which has helped so much. She also said he NEEDS MORE CALORIES.

I feel I've only added to his deterioration listening to the clinic doctors who seemed ok with him getting 120 calories of Clinicare a day for a long time that he's been starving in spite of having a feeding tube. 

Any ideas would be appreciated.  I get the feeling from various vets that it's time to give up but at the same time I feel he's never gotten enough calories or proper hydration consistently. But in spite of this his labs have improved. I have to wonder how much better would he be had he received more calories and hydration early on? He's been a trooper through all of this. Last night he purred as he slept nest to me. He's weak and so thin but I have to think if he'd get more calories this could be lessened?

Is it ok to feed him sooner than 12 hours after he vomits? This morning he vomited a small amount of clear saliva after I gave him his Reglan and water flush. After that I gave him Cerenia. A few hours later I gave him 6cc of Max Cal plus water flush and he's not vomited since. I plan to give him another 5-6cc throughout the day in addition to 100mL of iv fluids.

Thanks for any ideas you might have to offer

I'm really sorry you and your kitty are going through this difficult situation.  As hard as it might be to accept, it might be time to start thinking about end of life care for your precious boy.  What kind of quality of life is he having?  Is he perhaps trying to tell you that he's ready to go?  I know it's not the kind of advice you're seeking, but it might be the best thing for your beloved kitty.

Thanks for your input. I ask myself what is he telling me often throughout the day. That's the thing for me - I don't see him wanting to be done with everything but more that he feels crappy he wants to hide.

When he is feeling well he seems much like he's having a somewhat normal day other than he has the tube and isn't interested in eating.  Now he is weak and thin but as far as being interested in whats happening around him, wanting to be held and purring, checking his dishes to see if something might taste good, and seeming to look well, compared to where he was when this all started he is doing better.

He's not been eating well for the past year, after he had some dental surgery.

He ate but until I became aware he was not eating much but was only licking his food and it was being pushed out of his way. After that I helped him to eat more by keeping the food up against a spoon and he ate until he was finished.

I've mulled this idea over many many times but it's hard to put into action when his labs are improving and he is seeming to get a bit better, but then it seems to unravel when he has a bad day of vomiting.

I was hoping he might continue to improve as he continues to get more calories and nutrition, if possible,  into him. You seem to doubt that?

I really do appreciate your input.  

I can only tell you my experience with a fatty liver kitty.  He was very ill when the feeding tube was put in and remained hospitalized for several days until they could get him up to a point where he could keep the feedings down.  They removed his IV and I brought him home.  He was still very sick, it was a long recovery but he steadily improved.  From what I have read here this is normal recovery from fatty liver especially when the right medications are included which your kitty is on.  It is true that kitties need to get enough calories to stop the process that leads to fatty liver but kitty can only be given as much food as they can keep down.  

I am so sorry you are going through this.

Hi, thank you  for your input.

I wanted to add that this morning after he vomited the small amount of saliva and went off to his hiding/napping spot in the closet I asked my husband if he felt I should continue or let sweet kitty be free of all of this.

My husband said he felt kitty looked the best yesterday than he'd looked since this all began in Feb. He felt the increase in real food and calories with the Max Cal - plus the fluids has helped a lot.

Does it matter that the vomiting amount is less than a few weeks ago?

I mean, I'm wondering if he is continuing to improve but still  vomiting, albeit less amounts is he's heading into the right direction? Or is this just my wishful thinking?

I've never encountered anything like this in my life and have never felt so inadequate. I sympathize with all of you who've encounter this and feel encouraged by the stories that made it through and kitty got better. This has been so helpful for me to continue along.

I just want to be doing the right thing for kitty.

Thanks so much.

To add, last month when the tube was getting replaced I had a long discussion with the doctor he's seen for a while and was the doctor doing this surgery. I asked the vet if I should be doing this given his vomiting and the fact that he and I have struggled with the feedings in that he tolerated them sometimes but then other times he was not into it.

I told he I felt I was torturing him and she was surprised and said that he's doing good and his labs are improving. That I was not hurting him, in her opinion but if I didn't wish to continue she understood.

My concern has always been is there merit in doing all of this? If he can get thru I will do whatever I can. I just don't want to be harming in. It is so confusing to hear positive encouragement for some vets and then the opposite from other's. 

The specialist involved also felt it was reasonable to continue given the improvement of his last labs.

I am so frightened I'll cause him to vomit and worry my fear is also adding to his stress. This is so difficult. 

It's obvious to me that you care a great deal for this little guy and only want the best for him .  From what I am reading, it does seem that with more food, and hydration, he seems to be getting better, and in my personal opinion, I would stick with it for at least a little while longer to see if he continues to get better with even more food and hydration.  I see no reason to wait 12 hours after a  vomiting session to feed him again. 

My girl has kidney disease and is prone to vomiting that saliva stuff, and she's always ready to eat a  little something almost immediately .  It's an empty acidic stomach that causes that type of vomiting.  The Reglan should certainly be helping with that, but obviously not stopping it completely.  My old guy (who is no longer with us) used to take Reglan 3 times a day, PLUS Pepcid A/C twice a day and even that didn't always do the trick .  AND he took Miralax twice a day, everyday to keep him regular.  If I ever missed a "serving" of that, he would get constipated, even though he was getting sub-q fluids every other day.  He didn't have HL, though.  He also had kidney disease, like his sister

I think you will know when the time comes, and from what you describe, I honestly don't think he's ready yet, but  you know him best . 

I see you just posted while I was typing.  Remember, you are not hurting him when you do things to him...you are helping him

If he is showing some improvement than there may still be hope.  I know that often vomiting bile or saliva first thing in the morning is often an indication of excess stomach acid.  I don't know what kind of feeding schedule you have but lessening the time between the last feeding of the day and the first feeding the next day helps.  You could also ask your vet about including Pepcid to help reduce the amount of acid in his stomach.  You could also ask about a supplement called Denamarin which is SAM-e and milk thistle.     It has a protective coating so that it passes through the stomach and breaks down in the intestines.

I don't have any direct experience with fatty liver and feeding tubes, but my Sebastian has chronic pancreatitis. I'll be following this thread and holding out hope for your old boy. 

Also, there's someone else on this forum who is dealing with almost the exact same thing. I had to double-check usernames because I thought you were her at first. Here's the thread:

http://www.thecatsite.com/t/276410/...atty-liver-1-month-into-treatment-need-advice

He was on Pepcid but that was stopped a week and a half ago. He was RX'd the SamE but he vomited after getting the first 1/2 tablet last month and the vet didn't restart it since. Bu in hindsight the reason he vomited the night he got the SamE was due to him being constipated as he vomited the tube up the next night.

I'd taken him to ER both nights. The first visit he was sent home w/ Lactulose. But, again, in hindsight, he perhaps needed an enema also which may have prevented the tube from coming out the next night.

This is something that troubles me so much. The lack of concern from the vet regarding the lack of fluids he was getting every day at that time. Stupid me trotted along with what I was told and didn't realize he needed more fluids until his primary vet saw him a week ago and said he needed more fluids and sent them home. 

I still have some liquid pepcid and maybe will restart him?

Another question I have regarding the gastric reflux. Today when I went to feed him 5 or 10 cc's of food his tube was back flowing out the water flush. He was fidgety so I only gave him 3 cc's of Max Cal and flushed w 5 cc's more water end stopped.  The water is backing up and out the tube concerns me. Most times the water drops right down into him when I remove the water syringe or food.  Is the gastric reflux causing this back flow?

I asked the vet back a bit if I was imagining this or was I feeling a push back at times when feeding him? She indicated it might be that the tube is blocked - but I never felt this was the case - or that is was gastric reflux. If it's gastric reflux should I continue feeding thru this? It seems to make him feel uncomfortable.

What's so frustrating is at other times he'll sleep thru the feeding or relax and purr thru them. It's these other times where he's not into it and it makes him feel worse that are the problem. Does the nausea lessen as the labs improve or might there be something else causing him the problem?

The vet is not sure why he's not tolerating the feeding and said cats usually do well. But I've read where that's not always the case!

I appreciate everyone's thoughts and input. It means so much. Thank you for the links to the other threads. 

When I was given the SamE I was told to give him 1/2 tablet and dissolve it in water and give thru the tube. Maybe he did vomit from it if the coating was no longer intact!

I pray the pills I was given were without the coating. If not this will be one more thing that has frustrated me so much! There's been so many little things I've seen now, way after the fact that I've been told to do that may not have been the right thing, It's so frustrating

The backing up with the feeding tube is an issue with the tube being blocked.  I don't think it has anything to do with acid reflux.  

Denice said:

 
The backing up with the feeding tube is an issue with the tube being blocked.  I don't think it has anything to do with acid reflux.  

Click to expand...

I agree completely with this.  I've never had anything come back out if if wasn't blocked, especially the water flush.  Could there possibly be a kink in the tube when this happens?  I've never used a feeding tube that was installed directly into the esophagus, Bashful's was directly into his stomach, so the tube was larger around, from picture's that I've seen. 

Oh yes, I don't see anything wrong with giving him some of the liquid Pepcid.  Lots of us give that

Serious? I've had stuff come back out here and there. This happened at the ER vet recently when I took him there with the thought of leaving him for 12-24 hours to see if some of his fidgetiness is from being adverse to me and the syringes. When the tech attempted to do the feeding kitty was not cooperating and we didn't want to chase his but she did flush the tube and water back flowed over her too. She was not concerned and I told her this happens to me here and there. She said it just stuff that has not passed into the stomach.

Maybe I need to take him to get the tube X-ray'ed this evening. I just tried to do a small feeding and this happened again. Could it be his position? He's laying on his side with his head down. He does some gulping and flinching. I flushed with 4 cc's water and had water that stayed. When I capped it and then reopened it the water dropped. I tried 2 cc's of food but he was uncomfortable. I stopped and flushed with another 4 cc water that did finally drop but I did get some that backed out.

Can it be blocked or kinked when stuff does drop into it? I felt it could't be if water flows thru and I get a small bubble with at first with pulling the syringe back. I've never got any food debris - always bubbles or the feeling of negative pressure. The vet said when / if I feel resistance in the pull back that that is what I should have.

Thank you for the quick reply. Now I'm freaking out that he's endured something else that has been glossed over

Well, as I said, I've never used an esophageal feeding tube, but I just read up on it, and it does say to raise their head and/or front paws so the food will go quicker into their stomachs.  Here's what I was reading:  http://www.mygracevet.com/downloads/Esophageal_Feeding_Tube_Care.pdf

this article discusses nausea too, and says if fed too fast it can cause nausea. 

I have a 15 year old with cholangiohepatitis/pancreatitis/FL. It's four weeks into treatment, and I've been lucky because she has not needed a tube, since she has tolerated syringe feeding quite well. My vet strongly encouraged a feeding tube, but I was resistant--I know this cat, and for her syringe feedings were going to be fine. When she did discuss a feeding tube, she proposed a stomach tube, not a naso gastric, or the tube that's inserted via incision at the neck. She mentioned that some cats have irritation from the tubes alone, and the stomach tubes are much easier on their systems in the long run.

Along with other meds, Abigail was on Cerenia for two weeks, but on Pepcid throughout her illness. I've been giving her 100 mL fluids daily and have managed to get her to 300 cal per day which has maintained her weight. I purée a can of Hills AD and 3 tsp Wysong PDG with 1/4 cup organic unpasteurized goat milk I get from a friend's farm, though if I didn't have access to fresh I would do powdered, which you can generally find in any grocery store. (Don't worry about the unpasteurized milk--I mentioned that to a vet tech and she had a meltdown--I've met the goats, I've seen the farm, I drink this myselfI, it's perfectly safe snd healthy) I pulverize this in a Magic Bullet (which I bought thinking I was going to make fruit shakes...don't think I'll be using it for that any more! LOL!!!) If she constipates, I've added the 1/4 tsp Miralax in with a feeding. I started feeding her about 12 cc at a time, but now can feed her 25cc at a clip, without it being deposited right back (on the carpet, of course). She's been pretty good about not vomiting, but, she's been on injectable Pepcid from the start--I've had CRF kitties that benefited from Pepcid, so I asked for that at the outset--if I hadn't had experience and didn't gave an attentive vet, who knows?
Another thing I have done is consult with a holistic vet, who suggested some tinctures for pain and nausea that are also helping.

So in one respect (in that she's maintaining weight and hydration, she's also stronger and more active and she feels better) we are lucky, but sadly her numbers are just NOT getting better. So at this point we look for additional causes for her "flat" numbers--but that's my story. Yours on the other hand...if I had a cat that was not as robust, but had increasingly good numbers, I would definitely continue treatment, perhaps even more aggressively? I know that GoHolistic sent you a link to my post, feel free to compare meds/dosages and if I can clarify anything I'll be more then happy to.

And I would definitely have the tube checked. The whole "backing up" situation does not sound right to me.

I didn't have this issue with Patch's tube.  I would think if it is blocked then nothing would go through.  Patches did always have his head up when I fed him.  When he was still feeling really bad he would be in the classic  'meatloaf' position.  As he started feeling better he would be sitting kind of like 'well let's get this over with'.  I would think if he is laying completely down on his side that might affect things.

The following is the reply I received form the vet when I asked her about the back flow and resistance issues back in late March:

 If you're getting consistent backflow up the tube and resistance, it could indicate a

partial blockage of the tube, in which case you can try flushing with
some Coke (usually about 5 ml) as the carbonation can help break it
up.  The other possibility is that Justin is having reflux, which could
certainly be happening given that he seems to be getting nauseous, but
hopefully adding in the ondansetron will help with that.

My vet told me the same thing about trying soda if it got blocked to save an extra trip across town to get the tube unblocked.  I never tried it, I fortunately didn't have an issue with the tube so I didn't need to.  I thought about mentioning it but I was afraid that was going into the area of medical advice which I can't give, I'm not a vet just someone that has been through this with a kitty.  I really think it's something with the tube.