Constipation Confusion

Hello everyone, this is my first time here. I hope you wonderful people can help me understand what is up with my beloved 5.5 year old male neutered indoor cat Peanut. 

Peanut has always been a very happy, healthy energetic kitten with no health issues. He has a regular check up each year and all of his necessary vaccinations are up-to-date.

For a few months Peanut would occasionally lick his bum a lot, so we thought he might have some pooping trouble but he was regular and a routine check-up showed no issues. However, some of his stools were quite hard.

Then, 2 months ago Peanut got sick one night. He started vomiting and meowing.

A quick trip to the Emergency Vet  followed. The doctors checked his anal glands but they were not impacted. His belly felt full but not bad. They ran x-rays and found that he was constipated quite a bit. He received an enema, an anti-nausea med and sub-q fluids. As soon as he got home he pooped a lot. He was unhappy from the enema but otherwise ok. He was started on 2ml of lactulose twice a day (three times the first day then twice a day). We also discovered that his food (Go! Chicken formula) was very very low in fibre. So, we switched him to a combination of Hill's Prescription w/d and i/d foods. As long as he was on the lactulose he did amazingly well, but occassionally when I tried to lower the dose he would poop less and have difficulty. 

A blood test showed that Peanut is perfectly healthy - not a single anomaly. The doctor said he had never seen one so perfect.

The vet advised to keep him on two doses a day of lactulose for the foreseeable future and switch him to a new kibble called Royal Canin Fibre Response. I have read the reviews for this food and it sounds amazingly successful for this issue.

The next day, before I even had a chance to start the new diet, Peanut started vomiting again. It had been two months since the first incident. He had been pooping but not very much and x-rays showed that he was constipated again. We couldn't figure out why since he was still on two doses a day of lactulose. He was given another enema and an anti-nauseant. His lactulose has been increased to 2ml three times a day. He was also started on the new diet. He doesn't like the fibre response that much so he is getting a mixture. First he was on i/d and fibre response and now he is on w/d and fibre response so that he will eat the fibre response. The long-term goal is to increase the percentage of the fibre response and hope that this new food will make a big difference.

His enema was 6 days ago and since then he has steadily improved. His behaviour has returned mostly to normal and his appetite has come and gone, but is fairly good.

He is having large poops every 24-40 hours.

Yesterday, however, he pooped TWICE: A large poop at 5:30am and then at some point in the afternoon he went again. The second poop was quite loose when I scooped it, so he received only 2-and-a-half lactose doses yesterday.

The doctor ran one more blood test to check his pancreas and it also came back 100% normal.

He has received a number of x-rays of different views of his abdomen and they have all come back normal. One showed maybe a slight mineralization in his kidney but it didn't show to be anything and his kidney blood test results were 100% normal.

The vet says that some cats just have constipation issues and he is hoping that over time his new food will help.

He says there are other tests that can be done including an ultrasound, although I am hesitate to do that unless he gets sick again. The reason is that Peanut is extremely terrified of the vet and even car rides. If he leaves the house he panics, howls, sneezes, even hyperventilates sometimes.

I am concerned that he will have a heart attack going through the shaving and work of an ultrasound. And if they have to sedate him there are risks with that. I had a friend whose cat died at the vet during a test!

The vet has also suggested two other things if things look worse:

1) giving sub-q fluids myself at home;

2) switching from lactulose 3x a day to 1x a day and also doing 1x a day of miralax (peg)

So, I'm hoping you lovely people can help me with somethings:

1) Do you have any suggestions regarding cat constipation?

2) Any experience with lactulose vs. miralax in cats?

3) any thoughts on sub-q fluids?

4) on ultrasounds?

Thank you so much!!!

Jonathan

Oh and one other thing - occasionally peanut will look uncomfortable. 99% of the time he looks great but occasionally he will hunch over and lick his lips. This lasts maybe 5 minutes and then he is back to himself. Can lactulose upset his stomach? I feel like the increase in lactulose has made him a bit off. After he has his dosage he doesn't want to have his belly touched for a while.

Sorry you're going through this! Chronic constipation is difficult.

The very first thing I'd recommend is switching to an all WET diet if the food he's eating right now is dry. Hydration is so so important with constipation, and wet food is the very best way to keep a cat hydrated.

The prescription fiber diets are really problematic, and I know it's counterintuitive to go against your vet's advice, but most vets have some really misguided ideas when it comes to cat nutrition. First of all, most of those foods are kibble, which is not healthy for a cat, especially a constipated one! And they contain a lot of really unhealthy fillers like corn and wheat that can cause weight gain and allergies. Most importantly, more fiber is NOT always better for constipation! And it can sometimes make things worse.

Most vegetables are a mix of soluble and insoluble fibers. Insoluble fibers can provide temporary relief from constipation because they push everything through really quickly, but cats are not built to digest insoluble fibers very well and it can be pretty rough on their digestive system. Soluble fiber is good because it absorbs water, making the stool softer and easier to pass, and it's also what the good gut bacteria eat, and gut bacteria have a lot to do with the health of your cats colon. BUT, both soluble and insoluble fiber add bulk to stool. So, it's really important not to add too much fiber. Adding more and more fiber will make stool bulkier and bulkier, and stool becomes more and more uncomfortable and difficult to pass, sometimes making constipation worse. And, over time, large bowel movements put too much strain on the colon and can cause megacolon.

I like to find a healthy, low carb, high protein wet food and then add some soluble fiber to it if needed, that way I can control what type of fiber and how much my cat is getting. If it's too much I can cut back, or too little I can add more. One good soluble fiber is canned pumpkin, which can be mixed in with wet food pretty easily. Some cats don't like it though. I finally found a vet who new a lot about nutrition and she recommended acacia fiber powder as a soluble fiber, and my cat likes that because it's tasteless.

It seems like some cats do better on lactulose and some do better on Miralax. They both work the same in principle by drawing water into the stool from the colon to make it softer (this won't work if your cat is not hydrated enough, which is why wet food is so important!). It does seem, though, that both of these medications lose effectiveness over time. I just give Miralax every couple of days now for that reason, and it seems to work better that way. It might be worth a try switching over to Miralax. With all the stuff I've tried for Delilah's constipation, most new things work at first even if they do lose effectiveness later, so just switching up the medication a bit might help. I was warned to make sure to get the brand name Miralax, because the generic does not work as well.

Why my cat gets constipated I've never really figured out. Of all of the various supplements and medications I've tried, the very best thing that has worked the longest is probiotics! You can get probiotics specifically for cats, but I use just human capsules of acidophillus that I open and empty into her food. She still doesn't go every day, and sometimes her stool is hard and small or infrequent without the use of Miralax and/or fiber, BUT I know her bowel movements are much more comfortable because she reliably uses the litter box when she's on probiotics! When she's in pain, she will go outside the litterbox. So I really recommend some kind of probiotic.

 When constipation gets really bad, it gets painful, the cat may stop eating, and vomiting can happen just from straining to hard. It's very good that you took him to the vet and he got that enema and fluids, even though it was a miserable experience. Once they get that blocked up, an enema is about all you can do. The key is staying on top of the symptoms to keep things from getting that far. I'm not very sure about the side effects of lactulose. You might want to try stopping it completely and starting with the Miralax, just to see how he responds when he's off it. Constipation itself can also be pretty uncomfortable.

My cat had x-rays and an ultrasound, but she did not need to be shaved for the ultrasound, and she's a fluffy long haired cat. It was a very stress-free experience compared to all that she'd been to up to that point, and it basically just confirmed that her motility was good so that was not the problem.

Most cats do not need to be on sub-q's if they are getting enough water in their diet. I always add a splash of water to Delilah's food just to be extra sure. But there are always special cases.

One other thing that has made a noticeable difference is increasing her brushing to get excess hair off her. The more hair I get off when I brush her, the less she ingests when she grooms herself, which means the less hair ends up in her colon getting in the way and making it difficult to pass.

I've also tried slippery elm bark, which didn't agree with my cat, but might work for you. Agar agar is another source of soluble fiber, but I haven't tried that one.

Something my vet prescribed when things got really bad was cisapride. It works by stimulating the bowels to start contracting again, which kind of jump-started things a bit, but normally she does not have a problem with motility so she was only on that for a couple of weeks.

I sympathize with not wanting to put your kitty through more vet visits! I often wondered if the stress of it all was making the constipation worse than it needed to be. After going through 3 different vets with Delilah's constipation saga, I would emphasize with the vet and vet techs that I wanted to make things as low stress as they could possibly be and only do what procedures really needed to be done to avoid aggravating her condition further.

Slippery Elm Syrup can be used to relive both diarrhea and constipation.  This syrup soothes the entire GI tract.  Hopefully, this will work as well on Peanut as it does on my baby.

In the gastro-intestinal tract, Slippery Elm acts directly. It can be thought of as a sort of natural  “Pepto-Bismol.” (Pepto-Bismol itself should not  be used because it contains salicylate, a.k.a. aspirin). Its mucilage content coats, soothes, and lubricates the mucus membranes lining the digestive tract. Slippery Elm is an excellent treatment for ulcers, gastritis, colitis, and other inflammatory bowel problems. It is high in fiber, and so helps normalize intestinal action; it can be used to relieve both diarrhea and constipation. It may also help alleviate nausea and vomiting in pets suffering from non-GI illnesses, such as kidney disease. A syrup made from Slippery Elm Bark can be used to help heal mouth ulcers from all causes (see recipe below).

Author Anitra Frazier gives the following recipe for Slippery Elm Bark syrup in her book, The New Natural Cat, which applies equally well to our canine companions when adjusted for weight: Into a small saucepan place 1/2 cup cold water and 1 teaspoon powdered slippery elm bark. Whip with a fork. Bring to simmer over low flame, stirring constantly. Simmer 1 or 2 minutes or until slightly thickened. Cool and refrigerate. Keeps 7 or 8 days. Give a teaspoon of syrup (5 cc) for an average-size cat (again, about 10 pounds) 5 minutes before a meal to minimize diarrhea, or to soothe and heal mouth ulcers.

Thank you, everyone!

I have felt so alone going through all of this, so it's really amazing to hear from other people who are going through stuff with their pets. 

Peanut had his ultrasound, another blood test and a urine test - and they all returned NORMAL!

That means no cancer, IBD, or other serious diseases. At this point they think he just has constipation and motility issues. He has been switched to a new food (Royal Canin Fibre Response) and to slightly more lactulose. The lactulose works because the stools are softer, but he still has issues.

He was pooping every 24-48 hours like clock work and then suddenly stopped again. An x-ray and exam showed that the stool was soft but that it was just sitting there from his rectum all the way upwards. The vet thinks he has low motility and has started him on cisapride as of last night. He was also given an enema to empty things out and and sub-q fluids to get him started fresh. The hope is that the combination of lactulose and cisapride will help him stay normal.

I feel so horrible about all of this. When he isn't having poop trouble, he is still a super happy, playful and affectionate cat. But he is terrified of these visits to the vet. He cries the whole way there and back and screams if they even touch him. I feel so horrible having to put him through this. I'm hoping at least we are done with all the tests.

This is no way for a kitty to live! I'm terrified that we won't find something that works and eventually he will be euthanized to put him out of his misery 

I have been in tears all day. I just wish I knew what to do to make this all better. Does anyone have experience with cisapride?

Cisapride should be very helpful with the motility issues. Vets always would find that my cat had good motility, but even so she was on cisapride for a couple of weeks to jumpstart things at one point. It worked very well for her. It works by stimulating the bowel muscles to contract and get things moving. Hopefully it will only be necessary for the short term, and you will eventually be able to wean him off of it and he will return to normal. He didn't used to have this problem, so it's just a question of adjusting the right variable to set things back the way they were. What that is, I don't know. I will re-emphasize supplementing with probiotics and enzymes. Those definitely provided the most help for my cat, and I wish I'd tried them sooner. But whatever the key is, I do think you can figure it out. Don't give up, even though it's rough right now and you may have to try a few different vets and a few different remedies along the way. The cisapride should be a good fix for the meantime, though, and you can take a step back and breathe for a minute.

I'm so sorry you have to put your kitty through this! The same thing happened with Delilah. She was getting really tired of being taken into the vet every few days to have an enema. I felt absolutely terrible. She started hiding from me all the time, and she's not a very fearful cat. Eventually she decided that I wasn't going to stuff her in a carrier after the sun went down (although I would have taken her to an emergency clinic if I ever needed to, but I didn't tell her that!) and she would come out at night for cuddles and petting. During the day, she went back under the bed. We did eventually get figured out to the point where she wasn't getting blocked up enough to need to go to the vet, and within a few weeks we were back to our normal level of trust. Now she doesn't even get too upset when we go to the vet for her regular check-up anymore. It helped that we finally found a vet that we both really liked and trusted and understood both of our anxieties, and also she doesn't have to get enemas anymore! And of course going to the vet once every six months is a lot better than once a week.