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G A R R E T PA C H T I N G E R , V M D , D A C V E C C G A R R E T @ V E T G I R L O N T H E R U N . C O M

J U S T I N E @ V E T G I R L O N T H E R U N . C O M

TREATMENT OF THE YELLOW

CAT!

INTRODUCTION

Garret Pachtinger, VMD, DACVECC

COO, VetGirl

INTRODUCTION

Justine A. Lee, DVM, DACVECC, DABT

CEO, VetGirl

NAVC – THANK YOU!

NAVC – THANK YOU! CE CERTIFICATES

!  Emailed to you 48 hours after the webinar ! Active participation = no quiz ! Watching video later, must complete quiz !  Email / contact with ANY questions

! garret@vetgirlontherun.com !  justine@vetgirlontherun.com

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-  Fluffy, 4yo MC DSH -  Arrives with the PC: -  Decreased appetite for 1 week -  Anorexic for 2 days now -  Lethargic -  Vomiting x 2 days -  Urinating but not defecating for past 4 days -  Strictly indoor cat -  UTD on vaccines

CASE PRESENTATION

-  Physical Examination -  Previously 14 pounds, today 8 pounds -  QAR -  BCS 3/9 -  Mm pale-pink, tacky, CRT 1.5 seconds -  Moderate dental calculus / mild gingivitis, -  Yellow tint soft palate -  Slightly sunken eyes -  HR=180, RR=40, T=38C (101.5F) -  Thoracic auscultation – NSF -  Abdominal palpation

-  Doughy abdomen -  Moderate sized bladder -  Cranial organomegaly

CASE PRESENTATION

-  Inappetence/anorexia -  Weight loss -  Icterus -  Dehydration -  Dental disease -  Cranial organomegaly -  Lethargy / depression -  Vomiting -  Decreased fecal production

PROBLEM LIST

-  Hepatic Lipidosis-primary vs. secondary -  Cholangiohepatitis -  Cholangitis -  Cholecystitis -  Toxic hepatopathy -  Extra-hepatic bile duct obstruction -  Intussusception -  Gastroenteritis -  GI foreign body -  Pancreatitis -  Pancreatic cyst or abscess -  Cholelithiasis -  Neoplasia -  Diabetic ketoacidosis -  FeLV/FIV/FIP -  Anything that may cause hemolysis

DIFFERENTIALS

175 CASES CSU 175 CASES CSU

Histologic diagnosis Percent Hepatic Lipidosis 26% Cholangitis 25% Neoplasia 20% Reactive hepatopathies 16% Vascular anomalies 4% Toxic hepatopathies 5% Cystic lesions 2% Miscellaneous 2%

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-  Intrahepatic cholestatic process

-  Association with prolonged anorexia and catabolism.

-  Most affected cats are: -  Median age 7 years -  DSHA -  Obese or overweight.

Introduction

He

pa

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Intr

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" Feline Hepatic Lipidosis can occur as either a primary idiopathic disease syndrome or secondary to another disease process – examples include

" Pancreatitis " Small intestinal diseases " Renal disease or Neoplasia.

2 Clinical signs and Testing

H E P A T I C L I P I D O S I S

PRESENTING COMPLAINT

-  Inappetence -  Weight loss -  Vomiting -  Diarrhea lethargy.

-  Less commonly more serious illness…hepatic encephalopathy or weakness as a result of hypokalemia.

PHYSICAL EXAMINATION

http://www.infovets.com/demo/demo/feline/B115.HTM

PE FINDINGS

“A Clinically astute clinician should be able to see icterus when the bilirubin level is greater than 1mg/dl”

PHYSICAL EXAMINATION

-  Nonregenerative anemia

-  Stress leukogram.

http://www.merckvetmanual.com/mvm/htm/bc/cpphe04.htm

CBC FINDINGS

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Serum biochemical changes primarily reflect cholestasis.

http://www.heart-intl.net/HEART/Hepatitis/Comp/Liver%2054.jpg

BIOCHEMISTRY PANEL

http://www.heart-intl.net/HEART/Hepatitis/Comp/Liver%2054.jpg

BIOCHEMISTRY PANEL

http://upload.wikimedia.org/wikipedia/commons/thumb/b/be/Urea_cycle.svg/480px-Urea_cycle.svg.png

HYPO / HYPERGLYCEMIA

Hypoglycemia is uncommon, as more than 70% of the functional liver mass must be lost before hypoglycemia ensues.

In contrast, hyperglycemia is present in about 50% of cases due to either a stress hyperglycemia or the underlying disease process, a primary example being diabetes mellitus.

•  Important electrolytes to assess include:

- Potassium - Phosphorus

- Magnesium.

ELECTROLYTE PANEL

Evaluation of Prothrombin time (PT) and Partial Thromboplastin Time (PTT) is an

essential part of the diagnostic evaluation in feline hepatic lipidosis

BLOOD GAS EVALUATION

Common venous blood gas abnormalities include: - Metabolic acidosis - Ketones - Lactate

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An abdominal ultrasound allows a non-invasive evaluation of the abdominal organs, notably the liver, pancreas, stomach, small intestine, large intestine, spleen, and

kidneys.

ABDOMINAL ULTRASOUND ABDOMINAL ULTRASOUND

ABDOMINAL ULTRASOUND NORMAL ULTRASOUND

With hepatic lipidosis, the liver is characteristically large (hepatomegaly) with diffuse hyperechoic parenchyma, hyperechoic to the falciform fat and renal cortex, and

isoechoic to the spleen.

ABDOMINAL ULTRASOUND

http://www.soundeklin.com/academy-of-imaging/case-studies/feline-pancreatitis

ABNORMAL ULTRASOUND

Abnormal Normal

Additional concerning findings on ultrasound include: - Pancreatitis - Triaditis - Biliary disease - Inflammatory bowel disease. Triaditis is a term referring to inflammatory diseases involving three specific organs, namely the liver, pancreas and small intestine. A wavy, ‘spastic’ appearance of the duodenum, thought to be secondary to pancreatitis

ABDOMINAL ULTRASOUND

http://www.soundeklin.com/academy-of-imaging/case-studies/feline-pancreatitis

ABNORMAL ULTRASOUND

Liver aspirates may also be considered for a presumptive diagnosis of hepatic lipidosis.

The expected cytological finding is hepatocellular lipid vacuolation

ABDOMINAL ULTRASOUND

http://classconnection.s3.amazonaws.com/330/flashcards/837330/jpg/picture31334113809999.jpg

SAMPLING? CONFIRMATION?

3TREATMENT

W A Y S T O M A K E A H E P A T I C L I P I D O S I S C A S E B E C O M E A S U C C E S S F U L C A S E !

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FEEDING OPTIONS?

FORCED FEEDING PHYSICAL EXAMINATION

For this reason, adequate nutritional support often involves the use of a large bore feeding tube,

nasoesophageal (NE) tube, esophageal tube (E-Tube) or Gastrostomy tube (G-Tube).

FEEDING TUBE!

However, when the patient is not stable enough for the placement of an E-tube, initial feeding via a NE- tube is an accepted alternative.

-  Risk of anesthesia? -  Coagulopathy? -  Nausea / Trickle feeding?

A NE-tube is inexpensive and does not require anesthesia in most cases.

ABDOMINAL ULTRASOUND

http://cp.vetlearn.com/ME2/Audiences/dirmod.asp?sid=F0E2AE6B0B7E437588DFCF8A9FCA8CAC&nm=CE+Programs&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=28126F6EF06E40C18C2E6BFB7F57B465&AudID=43A035C1ADDF4F5F823E087E3BEE4975

NASOESOPHAGEAL TUBE NE TUBE PLACEMENT

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ABDOMINAL ULTRASOUND E-TUBE PLACEMENT E-TUBE PLACEMENT - PROCEDURE

E-TUBE PLACEMENT E-TUBE PLACEMENT

Securing the E-Tube is imperative. While traditionally, gauze and Vet WrapTM has

been used…

The Kitty Kollar (http://www.kittykollar.com) has been

used with success.

This is a washable, fabric collar designed to wear in conjunction with an

esophageal feeding tube.

E-TUBE PLACEMENT

Following the placement of any feeding tube (NE tube, E-Tube, or G-Tube) a radiograph is recommended to confirm placement.

ABDOMINAL ULTRASOUND E-TUBE PLACEMENT CHECK

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Common formulas used to calculate the RER for a feline patient: 1) RER = 70 x (current bodyweight in kilograms)0.75 (for > 5 kg) 2) RER = 30 x BWkg +70 (for < 5 kg) 3) RER = 60kcal x BWkg

Example: 5kg cat 30 x BWkg +70 (30 x 5) + 70 150 + 70 220KCal / 24 hours

http://4.bp.blogspot.com/-SZCTrLHvXEE/TrfFN8z4H3I/AAAAAAAAAC8/_X9RlB-MnXM/s1600/cat_with_calculator-600x450.jpg

RER = RESTING ENERGY REQUIREMENT PHYSICAL EXAMINATION

•  For example: a cat that has a 5kg ideal body weight:

•  5kg cat = 220Kcal over a 24 hour period. •  Day 1 RER = 220kcal * 25% = 55kcal total, or

approximately 14kcal every 6 hours. •  Day 2 RER = 220kcal * 50% = 110kcal total, or

approximately 28kcal every 6 hours. •  Day 3 RER = 220kcal * 100% = 220kcal total, or

approximately 55kcal every 6 hours.

RER CALCULATION EXAMPLE

•  We commonly use Hill’s A/D.

•  Undiluted Hill’s A/D contains 1.2 Kcal per ml.

•  1 can + 50ml of water = 1.0 KCal per ml + better consistency

Diet Choices

Essential for: -  Rehydration -  Maintenance -  Correction of electrolyte abnormalities

A balanced electrolyte solution is recommended

FLUID THERAPY

ELECTROLYTE MONITORING ELECTROLYTE SUPPORT PHYSICSAL EXAMTION

•  Supplementation is indicated at PO4 levels less than 2mEq/l.

•  Kphos can be supplemented at 0.01 to 0.12 mmol/kg/hr IV for 6 hours and PO4 level reassessed.

•  Magnesium is supplemented with magnesium sulfate at 1mEq/kg/day.

PHOSPHORUS / MAGNESIUM

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Serum K+ K+/Liter fluids (mEq/L)

> 3.5 20

3.0-3.5 30

2.5-3.0 40

2.0-2.5 60

< 2.0 80

POTASSIUM SUPPLEMENTATION

**Kmax 0.5 mEq/kg/hr

ADDITIONAL THERAPY

Key Drug Dose Range Frequency Route

Dolasetron 0.5-1.0 mg/kg Q 12-24 hrs IV, SQ Famotidine 0.5-1.0 mg/kg Q 12-24 hrs PO, IV Ondasetron 0.2-0.4mg/kg Q 8-24 hrs IV, SQ Vitamin K1 1-5mg/kg Q 24 hrs SQ

- Primary? - Secondary? .

ANTIBIOTICS DRUGS / MEDICATIONS TO AVOID

- Stanozolol (a 17-alpha alkylated steroid)

- Tetracyclines; drugs imposing oxidative challenge

- Propylene glycol carrier in diazepam and etomidate

- Sedatives requiring glucuronidation (diazepam, oxazepam)

- Drugs associated with idiopathic hepatic necrosis (benzodiazepines, cyproheptadine) .

FELINE INFLAMMATORY LIVER DISEASE (CHOLANGITIS)

#  Inflammatory disorder of the hepatobiliary system. # Disease complex that may be concurrently associated with

#  Duodenitis #  Pancreatitis #  Cholecystitis #  Cholelithiasis.

#  Three histological groups #  Neutrophilic cholangitis #  Lymphocytic cholangitis #  Cholangitis ass. with liver flukes

.

http://www.vetnext.com/fotos/Cholangiohepatitis_full.jpg

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NEUTROPHILIC CHOLANGITIS DIAGNOSIS

# Acute, neutrophilic - neutrophilic or suppurative #  Chronic - inflammatory pattern - neutrophils, lymphocytes and plasma cells # ALT and ALP are increased but variable #  Cats are frequently icteric #  Ultrasound to rule out:

# Pancreatitis # Biliary obstruction

#  Histopathology to confirm the diagnosis #  Liver should always be cultured

NEUTROPHILIC CHOLANGITIS THERAPY

#  Fluid and electrolyte therapy as needed #  Antibiotics #  Ampicillin / Ampicillin-clavulanic acid # Treated for at least 1 month #  Ursodeoxycholic acid (Actigall 10–15 mg/kg/day) # Buprenorphine (pain?).

#  Infection ruled out? Lack of response? #  munosuppressive therapy

# Prednisolone at 2–4 mg/kg daily #  Tapering over 6 to 8 weeks

LYMPHOCYTIC CHOLANGITIS

#  Represent a later stage of neutrophilic cholangitis or a separate disease entity # Moderate to marked infiltration of the portal areas by small lymphocytes ± biliary hyperplasia, portal or periductal fibrosis, or bridging fibrosis. # Diseases associated:

# IBD / pancreatitis.

FELINE TRIADITIS

#  Cholangitis-cholangiohepatitis, chronic pancreatitis and duodenitis. #  Common bile duct and pancreatic ducts join a common channel before they enter the duodenum #  Some of these cats also have lymphocytic, plasmacytic infiltrates within the duodenum (IBD) #  Often associated with chronic, intermittent vomiting, lethargy, and anorexia.

http://csnanatomy.pbworks.com/f/1238682073/duodenitis.jpg

TOXIC HEPATOPATHY

#  Limited hepatic glucuronide transferase activity. #  Relatively uncommon due to picky nature #  Idiosyncratic reactions? #  Drugs:

# Acetaminophen, acetylsalicylic acid, megesterol, ketoconazole, phenazopyridine, tetracycline, oral diazepam, and griseofulvin.

#  Environmental toxins # Pine oil , isopropanol, inorganic arsenicals, thallium, zinc phosphide, white phosphorus, amanita phalloides, aflatoxin, phenols can also contribute to liver pathology.

HEPATIC NEOPLASIA

# Primary neoplasms uncommon. # Cholangiocellular carcinoma and hepatocellular carcinoma

# Metastatic neoplastic causes are more common

# Lymphoma, systemic mast cell disease, hemangiosarcoma, and myeloproliferative disorders.

# Clinical signs are non-specific # Imaging studies (radiography, ultrasonography

http://www.floppycats.com/wp-content/uploads/HLIC/842620f960545ebe4d554220e82f6a12.jpg

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EXTRA-HEPATIC BILE DUCT OBSTRUCTION

# Pathogenesis # Extra-hepatic cholangitis, malignancy, pancreatitis, cholelithiasis # Progressive cholangitis accounts for over 50% # Marked persistent hyperbilirubinemia # Marked elevations in ALT, AST, ALP, GGT # Ultrasound!!! # Exploratory laparotomy and biliary decompression.

http://www.ultrasoundcases.info/files/Jpg/lbox_477.jpg

•  Prognosis for feline liver diseases is fair to good.

•  Many of our patients respond dramatically to therapy

•  Specifically regarding hepatic lipidosis, the prognosis is good.

•  The earlier they are treated, the higher the recovery rate – which is why I do not delay nutrition

•  Most owners are able to manage the esophagostomy tubes well at home

•  Don’t give up on these patients!

Summary

G A R R E T PA C H T I N G E R , V M D , D A C V E C C G A R R E T @ V E T G I R L O N T H E R U N . C O M

J U S T I N E L E E , V M D , D A C V E C C , D A B T J U S T I N E @ V E T G I R L O N T H E R U N . C O M

QUESTIONS?�