Chronic loose stool caused by intestinal or pancreatic disease?

I met with Vivian's vet today. The B12 injections have put a pep in her step but she still has frequent loose stool with fresh blood. The vet said she still thinks the blood is because the stool is passing through the digestive tract so fast and irritating the lining. She doesn't recommend a diet change because she said she has rarely seen improvement in this set of symptoms through diet change alone. She does recommend a steroid but I need to decide first if Vivian will have a biopsy - guy comes to her clinic with ultrasound the pinpoints the area of inflammation and he biopsies using endoscopy or laparoscopy, apparently with reliable results. If she does the biopsy herself she opens up the cat and does the more invasive kind. What confused me is that she recommended I try a pancreatic enzyme powder, since Vivian has low B12. I said I thought low TLI indicates pancreatic insufficiency and Vivian has high TLI. She said that elevated TLI indicates pancreatic insufficiency - this is contrary to everything I have read so I am extremely confused. Can anyone speak to this? I will try Vivian on the pancreatic enzyme because it seems I have nothing to lose, but I don't know...  Also I suggested that high folate and low B12 could indicate bacterial overgrowth from what I've read. She hadn't thought of that but ordered up some metro to be put into gelcaps for Vivian. Also, I asked her about her previous statement that treatment for IBD and small cell lymphoma are the same, but  I asked what about Leukeran? She had not heard of Leukeran but is going to research it. From what I can gather on this site, Leukeran is kind of a well-known thing. Is it odd that my vet has not  heard of it? So the plan is: try pancreatic enzyme powder and if that doesn't help try metro and if that doesn't work decide whether to do ultrasound and biopsy or begin treatment with steroid, then maybe Leukeran pending research by the vet?

Does this seem reasonable? Should the vet have known about Leukeran? Can high TLI be an indicator of pancreatic insufficiency? I have a direction to head in, I guess, but I'm not really that much more clear than I was to begin with. 

I found this from Texas A & M which does the best blood test for pancreatitis http://vetmed.tamu.edu/gilab/service/assays/tli    According to this article, you have to go through a couple of paragraphs about dogs to get to the info about kitties, high tli is an indicator for pancreatitis.  From what I have read digestive enzymes can go either way, they can help or they can make things worse.  There is no way of knowing without trying.

The decision about whether to do a biopsy or not is one that many of us have faced and you will find people here who had a biopsy done and those who didn't.  I didn't have one done.  My kitty had anorexia and vomiting as symptoms and when I finally found a good vet he had gone into fatty liver.  I felt the important thing was to go ahead and get him treated given how seriously ill he was.  It's good that your vet knows that a reliable biopsy can't be done while kitty is on a steroid, you would be surprised how often I have seen that not to be true with kitties here.

Leukeran is mainly used as a chemo drug although it is sometimes used for severe IBD.  A general vet may not know about it because an oncology vet usually treats cancer kitties.

Thank you -

It seems pancreatic enzyme powder doesn't agree with Vivian. I just gave her some in a little canned food, the minimum suggested dose, and she began vomiting almost immediately after eating it. She's been sick three times now, first the food, then, water, then just heaving. Vivian has never vomited this whole ordeal, that is the one thing she has had going for her, a good appetite and no vomiting. Crap! Should I just not give her anything for a while and let her stomach settle? The vet is closed, don't know if I could get ahold of anyone there. 

I would give her stomach a chance to settle down.  Since she has been doing well with eating up until now I would wait until morning to give her some food.  It's kind of a balancing act if she does have pancreatitis.  The usual remedy for pancreatitis is fasting but kitties can't be fasted for very long because of the possibility of liver issues if they go too long without food.  

Cat Pal said:

 
I met with Vivian's vet today. The B12 injections have put a pep in her step but she still has frequent loose stool with fresh blood. The vet said she still thinks the blood is because the stool is passing through the digestive tract so fast and irritating the lining. She doesn't recommend a diet change because she said she has rarely seen improvement in this set of symptoms through diet change alone. She does recommend a steroid but I need to decide first if Vivian will have a biopsy - guy comes to her clinic with ultrasound the pinpoints the area of inflammation and he biopsies using endoscopy or laparoscopy, apparently with reliable results. If she does the biopsy herself she opens up the cat and does the more invasive kind. What confused me is that she recommended I try a pancreatic enzyme powder, since Vivian has low B12. I said I thought low TLI indicates pancreatic insufficiency and Vivian has high TLI. She said that elevated TLI indicates pancreatic insufficiency - this is contrary to everything I have read so I am extremely confused. Can anyone speak to this? I will try Vivian on the pancreatic enzyme because it seems I have nothing to lose, but I don't know...  Also I suggested that high folate and low B12 could indicate bacterial overgrowth from what I've read. She hadn't thought of that but ordered up some metro to be put into gelcaps for Vivian. Also, I asked her about her previous statement that treatment for IBD and small cell lymphoma are the same, but  I asked what about Leukeran? She had not heard of Leukeran but is going to research it. From what I can gather on this site, Leukeran is kind of a well-known thing. Is it odd that my vet has not  heard of it? So the plan is: try pancreatic enzyme powder and if that doesn't help try metro and if that doesn't work decide whether to do ultrasound and biopsy or begin treatment with steroid, then maybe Leukeran pending research by the vet?

Does this seem reasonable? Should the vet have known about Leukeran? Can high TLI be an indicator of pancreatic insufficiency? I have a direction to head in, I guess, but I'm not really that much more clear than I was to begin with. 

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This is my favorite document about laboratory tests for diagnosing canine and feline GI and pancreatic diseases: http://actualidadveterinaria.files.wordpress.com/2011/08/laboratory-tests-for-diagnosis-of-gastrointestinal-and-pancreatic-diseases.pdf. On page 90 (or page 5 of the PDF), it talks about TLI and says that a cat or dog with EPI would have a decreased TLI. There is a section that discusses how a cat or dog in renal failure can show an increased TLI, but that typically both PLI and TLI would be elevated in the case of pancreatic damage. There's also a chart on page 88 (or page 3 of the PDF) that shows a low B12 and high folate indicates SIBO.

As far as enzymes go, if a cat or dog is diagnosed with EPI, supplementing with pancreatic enzymes is the only way to treat the condition since the pancreas can no longer produce it's own. However, if your kitty tests positive for pancreatitis but not EPI, then the use of enzymes is more questionable.

My Sebastian has chronic pancreatitis. As of his last GI panel, everything was in normal range expect PLI, which confirmed pancreatitis. However, it's been over a year now and he's due to have the test done again since damage to the pancreas caused by chronic pancreatitis could eventually lead to EPI. I've been exactly where you are as far as deciding what treatment plan to pursue. I decided against a biopsy. Sebastian was already in such a frail state and I didn't want to put him through invasive surgery while also dealing with pancreatitis that caused violent, continuous vomiting.

Thanks to both for responses - I sent the Texas A+M link along with a couple of others that suggest high TLI does not indicate pancreatic insufficiency. She said she will look for an explanation of B12, folate, TLI and EPI that is more understandable. OK. I also told her Vivian got sick on the enzyme. She wants me to try it again next feeding at a smaller dose, she has never heard of such an adverse effect with this enzyme. Says she can meet me at clinic with anti-nausea injection tonight if she gets sick again. Hmm. I'll have to think about that one. Give the cat something that I know made her barf and then drive her 1/2 hour into town for an anti-nausea shot...at night or just give her some food if she teases for it. Right now she has no interest in food anyway. 

How is your kitty doing today?

Hey! Thanks for asking. Vivian is feeling better today. I actually mixed 1/8 tsp pancreatic enzyme - a tiny dose - w/ some canned food this a.m., she ate it and it stayed down - small victory! She also had her first semi-normal looking BM in recent history, even though it has some blood and loose stool at the end.  Can't be the enzyme because she didn't keep any of it down last night, I'm sure of that. But it could be that second B12 shot from Friday is kicking in. Wouldn't it be great if it were that simple. She has since has a not so great movement, but again, small victories. She is up and active and hungry - good stuff! I would love it so much if she didn't have to take antibiotics or steroids - but we'll see....

I am having pretty much the same issue with my cat. Diarrhea.  My cat improved greatly with digestive enzymes. But he still is having bouts of diarrhea. It is amazingly SMELLY and often is a "cow pie" type of thing. Meaning it looks like poop pudding. I am currently testing for Titrich because both those symptoms are symptoms of it. Also I went to the pet store and this lady asked if I had tested for it.  I said no but I said, well how would he have gotten it? He is an indoor cat. She said to me that hers was as well. But hers was infected as a kitty and just was able to fight it off due to a strong immune system. But, if, for whatever reason, the immune system slips... the titrich can get a grip on the system.  Similar to Shingles and Chicken Pox in people. Ie... you get chicken pox when you are a kid and when you are elderly you can get shingles because your immune system slips.

For me, that makes some sense because my cat has recently started taking predlinsone for asthma and that suppresses the immune system.

Vivian's vet contacted me yesterday and said, after speaking with her consultant, she agrees that the problem is not pancreatic disease, so she recommended stopping the use of pancreatic enzyme on food. Just as well, it wasn't helping and the recommended dose made her very sick... They are in agreement that Vivian has SIBO - small intestine bacterial overgrowth and again recommended biopsy to find the cause for this: IBD, lymphoma, fungal -

I told her I am not ready to put Vivian through the biopsy, and could I try Metronidazole without a biopsy. She said yes but if it is IBD or cancer the loose stool problem will return the second the Metro is discontinued. She is also now recommending a diet change, though last weekend she said diet changes usually don't help cats like Vivian - maybe that's because she was thinking it was pancreatitis/insufficiency? So at this point I am ready to try the antibiotic and see what happens. Three questions:

1. Would folks recommend a diet change right away, or wait and see if what Metro alone does?

2. What have people tried to eliminate the nasty taste of the pill?

3. Would folks recommend starting a probiotic at the beginning of antibiotic treatment?

Thank you 

Cat Pal said:

 
1. Would folks recommend a diet change right away, or wait and see if what Metro alone does?

2. What have people tried to eliminate the nasty taste of the pill?

3. Would folks recommend starting a probiotic at the beginning of antibiotic treatment?

Thank you 

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1.  I would say change the food now. That way when you come off the pill you may be able to tell better if it worked.

2. I actually had NO problem giving my cat the pill crushed up in food. He didn't even notice. Just cover the pill well with good tasting food.

3. I don't recommend probiotic because the antibiotic will wipe it out.

My kitty couldn't stand the taste of it.  My vet would cut up the pill and put it in an empty gel cap.  Several people have done it themselves.  You can get them at Amazon and The Vitamin Shoppe, I am not sure what size the vet used but the smaller numbers are smaller sizes.

I would look into this yeast based probiotic http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296087/.  It has been shown in clinical trials to reduce inflammation.  It can be given with an antibiotic because it isn't a live bacteria that needs to grow and reproduce in the digestive tract.   Here is a thread about it started by LDG http://www.thecatsite.com/t/283161/saccharomyces-boulardii-use-for-diarrhea-and-gi-disease-incl-ibd    She is the real expert here about all things in the realm of natural and dietary ways of helping our kitties.  Her initial post has a lot of links in it.

Cat Pal said:

 
1. Would folks recommend a diet change right away, or wait and see if what Metro alone does?

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I, personally, don't like to change multiple variables at the same time because then I don't know what worked. I typically change one thing at a time.

Cat Pal said:

 
2. What have people tried to eliminate the nasty taste of the pill?

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I put everything in small empty gel caps, coat the gel cap with a little coconut oil or butter, and pill the cat directly. Size # 3 is what I use the most, but I do put a lot of stuff in one gel cap. The next size down (smaller) would be size # 4. I cannot find them locally, so I buy them online.

Cat Pal said:

 
3. Would folks recommend starting a probiotic at the beginning of antibiotic treatment?

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I give my cats probiotics all the time, but even if I didn't, I would absolutely give them if they were on antibiotics. They have been on antibiotics in the past, and I would just give the probiotics 3 hours after the antibiotics.

Cat Pal said:

 
1. Would folks recommend a diet change right away, or wait and see if what Metro alone does?

2. What have people tried to eliminate the nasty taste of the pill?

3. Would folks recommend starting a probiotic at the beginning of antibiotic treatment?

Thank you 

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I don't know which should be done first, diet or drug, but as @GoHolistic has pointed out, you should do one change at a time so you can attribute cause and effect.

You can use a probiotic alongside an antibiotic, and often it is recommended to maintain the digestive tract while on antibiotics. The probiotic should be administered a couple hours after the antibiotic to avoid being completely destroyed by the antibiotic.

Thanks for responses! I will actually be putting two cats on antibiotics this week, as my other cat Willis -age10- needs to go on tetracycline to treat a bacterial infection in his sinuses that has been going off and on for months and treated unsuccessfully with antibiotics and lysine - finally cultured last week. I am expecting he will get diarrhea from this as the dose is pretty high (two capsules twice a day for three weeks) and he is extremely sensitive to antibiotics. So I don't want to add a diet change to the mix with him until I know he's "stable in the box" -

In healthier times and when they were younger Vivian's system was much more resilient to things like medication and diet change than her buddy Willis. He had a hell of a time with all foods until I put everyone of Hills ID, which they have been on for years.  The transition to a novel protein will have to be gradual. I have been down the road of feeding different foods to different cats in different rooms, and I don't want to go there again. So they will both change diets if at all possible.

Does anyone use a pill gun and water chaser in one device? I have two separate devices but have heard of the other kind.

Then with Vivian, I emailed the vet and asked about putting her Metro in gel caps, no response yet. I had to use this drug on both cats many years ago and it was a war! If I remember correctly they may have even given it to me in liquid form and Willis would foam copiously at the mouth with each dose - ack!

Giving probiotic 2 or 3 hours after antibiotic will be tricky, as I am at work by that time, but I can try to work something out later in the day, if probiotic is indicated. 

It's ironic that the very medication I'll be giving Vivian to treat diarrhea may in fact cause diarrhea - ah well. 

What we won't do for our cat pals - 2 pills x 2 cats twice a day is a lot of pilling - and I'm already on litter box patrol inspecting every turd and now that's about to get more "interesting". I love these guys and will do all this and more if and when the time comes.  I just lost my beloved Nina -age 10ish- to kidney disease after years of relatively good health and some special care. I've never had cats who reached 10 years of age and had stuff start going downhill in a hurry like this, not something you necessarily think about when you bring that cute youngster home from the pound, or the side of the road in Nina's case. I long for those healthier times when nobody was on drugs and you just put the food down, not laced with this supplement for this one or that additive for that one, and let the cats do their thing.  Onward -

Cat Pal said:

 
Giving probiotic 2 or 3 hours after antibiotic will be tricky, as I am at work by that time, but I can try to work something out later in the day, if probiotic is indicated.

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I had the same challenge. I ended up just giving the probiotic at night 3+ hours after the antibiotic. So if I gave the antibiotic at 7:00 p.m., then I would give the probiotic before bed (between 10:00 and 12:00). It was the best I could do with my work schedule. Someone has to pay their vet bills!

Vivian's novel protein food is on order and expected Thursday. Her Metronidazole capsules are on order at the compounding pharmacy. The vet thinks I should just do them both at the same time, so that once Vivian comes off the antibiotic for treatment of bacterial overgrowth, the new diet will already be in place and, if food is the reason for the overgrowth, the problem will have been addressed - or something like that.

Personally I am thinking I will start the food transition first, it will take a while and I might start to see some results while making the transition.

Also, I am currently pilling my cat Willis two pills twice daily for 3 weeks for a sinus infection, and this alone is a challenge. You really have to make sure they get water after meds, and you need to make sure they have food on their stomach, I found that out the hard way when Willis threw up his meds last night and there was only liquid in his stomach - no food. Holding him, pilling him, reloading the pill gun and repilling while holding him and then getting him to drink water (he spits it out if I syringe fed) AND eat is very difficult. His stool is getting a bit loose after 5 days of antibiotic, not too bad yet. Vivian runs for cover after just watching Willis get pilled; she will be much more difficult to pill. 

Sometimes I don't think the vet remembers what she said to me from one time to the next. First she recommended diet change and antibiotics and said high TLI (with normal PLI) is probably just a function of intestinal disease, a "sequela" to high folate and low cobalamin. Next she said diet changes don't work, any improvement with antibiotics would vanish the second they are stopped, that I should put Vivian on a pancreatic enzyme for insufficiency. She has never heard of Leukeran and was going to look into it but hasn't. After saying a biopsy is just to confirm iBD or cancer but doesn't change the treatment, she now recommends a biopsy. When I asked what the prep is for biopsy she didn't know exactly so emailed the biopsy guy. She forwarded me the correspondence in which I saw she wrote that Vivian has "blow-out" diarrhea (it's loose to liquidy stool not blow-out diarrhea); that was "gray" in color (it is not gray) and that the cat will have a novel protein and antibiotic trial "the owner insists" (she was the one who suggested this approach at the outset!). Sometimes I think it must be that I don't understand what she says because the story seems to change so often. Still, I live rurally, I like the vet and there aren't a lot of them located reasonably close by. 

In any case, in my mind the plan remains:

Continue B12 injections, begin diet change, do Metro trial, assess.

If no improvement then I need to decide if I will go directly to steroids or have an ultrasound and maybe biopsy done - prep for biopsy is brutal.

Is there anything of value to learn by just having an ultrasound done with no biopsy?

The fact that the vet keeps changing her story (or even perhaps getting your cat mixed up with someone else's) concerns me, but I understand if you only have so many vets to choose from.

An ultrasound can be helpful to see what may be going on inside, but it's only as good as the person performing and reading it. It should be done by someone with experience, perhaps they only do ultrasounds for a living, and ideally by an internal medicine specialist. An ultrasound can show thickening of intestinal walls, inflammation of organs, gallstones, tumors, etc. If it shows thickening and inflammation, then you're still left with the uncertainly of whether it's something like IBD or intestinal lymphoma (cancer). This is when you have the the option of a biopsy, although sometimes biopsies can also be inconclusive.

When we were initially trying to figure out what was going on with Sebastian, I was presented with the option for a full thickness biopsy. I declined. That was 1.5 years ago.

When the vet forwarded to me her correspondence with the biopsy guy, I actually googled his name and learned that he is an ultrasound and endoscopy specialist who travels to rural clinics with his ultrasound and other equipment, for a price, to make these procedures available to small animals across rural New England, such as Vivian. He is based in a town about 1/2 hour from my vet's clinic. I have actually driven a cat that far to have an ultrasound of her kidneys, and I could drive Vivian another 1/2 hour and potentially save his $175 charge just to drive to the clinic. I drafted an email to him directly to ask if I could do this and also if he would just do the ultrasound with no biopsy and what it might show him. But I didn't send the email because I didn't know if it was overstepping my bounds with my vet. I don't really think it would be since the guy advertises on the internet through his business website and invites enquiries. So if we get to the point where Vivian needs more - steroids or - whatever she needs I may send him an email directly. He can't get really specific without having seen the animal, but he can give general answers, such as whether he could use ultrasound alone as a diagnostic tool. I am SO hoping to avoid putting her through a biopsy -

I had just the ultrasound without a biopsy and that was 4 years ago.  Patches was very sick at the time, he had gone into fatty liver, so I started the steroid without a biopsy.  Of course he still had to have anesthetic to have the feeding tube put in but that is a much shorter and less invasive procedure.