Esophagostomy tubes (E-tubes) and cats

 There are a number of reasons that a veterinarian might recommend the placement of an esophagostomy tube or e-tube if your cat is ill. The most common reason to place a tube is due to poor appetite - whether from pancreatitis or cancer or other illness. Other reasons could be to give fluids and medication to a cat in renal (kidney) failure or in the case of an oral or facial injury that makes it difficult for the cat to eat. Many people are concerned about the idea of placing a tube in their cat's neck because they fear that it will bother the cat, or it may look strange, or it may be difficult to maintain, but in reality, most people find that their cats are not bothered, the tube is surprisingly easy to maintain, and it is not as strange to look at as they thought. We thought that we would share a couple of recent experiences with you, and we invite you to share your own experiences, if you have had a cat with a tube placed.

An esophagostomy tube is a tube that is placed in the side of a cat's neck and sutured into place. The opening to the tube is located behind one ear, and the other end is located near the spot where the esophagus meets the stomach. There is a cap on the end of the tube behind the cat's ear, and the cat wears a small cloth collar to help protect the tube site and prevent too much motion of the tube.

Ms. Poof - 

Ms. Poof with her tube

We would like to share our experience with the feeding tube that we decided to use for our cat. 

At age 15 she has develop kidney disease. After several weeks of trying different ways to maintain her weight and make sure she got enough fluids, Drs. Bailey and Demos spent a great deal of time helping us though several treatment plans 

They offered the potential use of the feeding tube.  It sounds much worse than it is!  We decided to try it

The procedure was quick. Our cat is fairly fussy, but she has had no reaction. The little cloth collar doesn't bother her at all- and she would never tolerate a regular collar.

This has made caring for her so much easier. We can get her the necessary fluids and can also administer any necessary medications-we all know how stressful it is the get a cat to take a pill! She plays and eats and sleeps normally with the tube. 

I would recommend giving serious consideration to using the tube if the doctors make the suggestion. The entire staff at Exclusively Cats are phenomenal.

They care for our cats as if they were their own. 

I'd be happy to talk to anyone about our experience. 

Peabody, our renal failure kitty -

Thanks for asking me to write about our experience with Peabody and using an e-tube while he was

Peabody snoozing with his buddy Lewis

in renal failure. Peabody was our second renal failure kitty. His sister, Kimba Girl, had it as well. Kimba lived to be 18, and she was on sub Q fluids for 18 months. She just kept going and going! Still, it was quite a commitment to give her the injections every day, more injections as time went on. She accepted them quite well.

Peabody and Lewis sharing a heated bed

We were given the option for an e-tube with Kimba, but we truly thought that once she was on fluids, it would only be a matter of months. We didn’t want to put her through the surgical procedure at 16. Since we had to give her injections for well over a year, we knew that, for Peabody, we would do the tube right off the bat, because he could be on fluids for quite a while.

Peabody enjoying the outdoors with his tube

I was, at first, surprised by how long the tube stuck out from his neck. I was concerned about his collar bothering the tube. He had to wear a little cloth sleeve to protect the tube incision site as well. For the most part, it didn’t seem to bother him and, while we did have a few challenges with the tube, I believe it was a good choice for Peabody overall.

Our cats do go outside in the yard a bit. This was the hardest adjustment, because Peabody could not eat grass once the tube was in. The grass-induced vomiting put him at risk of coughing up the tube. Still, he wanted to go out every day and enjoy the sun, roll in the dusty driveway, rub his face in the catnip, and eat grass. As a result, I spent plenty of time just following him around the yard monitoring him to ensure he didn’t eat any grass. Sometimes I stood in the sun, for 10, 20, 30, minutes, while he just nosed around, rolled, etc. I must admit it drove me nuts sometimes, but I’d love to do it one more time with him.

As luck would have it, he did vomit the tube up in our living room just a couple weeks after having it put in. It is something that happens. We just did not give him fluids that day, & got him back to the vet the next day, and the tube was replaced.

The incision site needs to be cleaned daily. This did not prove to problematic; I just did it before or after giving the fluids, while the cat was already next to me. I kept the supplies in a little bowl, and I did it on the sofa. Peabody did not like to be carried to the bathroom counter for such things.

We did run into an unusual problem about 9 months in. We noticed some sort of black stuff –
possibly a mold – growing inside the tube. Very weird. Not sure how it ever got in there. We tried pushing a tiny syringe of coca cola thru it, but that did not work. I even bought some tiny pipe cleaners, dipped it in cola, and tried to scrub the tube interior, with no improvement. However, by doing that, I think I tugged a bit on the stitches attaching the tube to the neck, so we once again had to take him in and have that addressed. Since the tube had this mold, it had to be replaced – again – and it was stitched up again. We had no further problems with the tube. The good vets at E-Cats indicated they had never seen that before, so it’s unlikely you would run into that particular concern.

As far as giving the fluids, there are several advantages of using the tube. First, it is so much easier

Peabody's tube did not interfere with his favorite sport - extreme napping

than using bagged fluids, heating it up, filling syringes, and giving your cat several 2 oz injections. I just put warm tap water in a mug, filled a 2 oz syringe from the mug, and took the syringe and mug to the sofa. I would no sooner sit down and Peabody would hop up next to me, purring. He loved getting his water. He curled up and just purred loudly while I slowly pushed the water. I assume it felt warming, and filled his belly. He was always happy to have it. It was a very loving experience.

Another advantage of giving the fluids through a tube, is that it was easier for my husband to do participate as well. His eyesight is not the best, so filling the syringes quickly and making sure he was injecting the cat properly was difficult for him. That meant most of the work fell to me, and it was hard for him if I was out of town. With the tube, he could easily give Peabody the fluids and have some nice “sofa-time” with sweet Pea.

As Peabody occasionally got constipated, we needed to give him some Miralax every day. With
Kimba, we added it to her food, and could never be sure if she ate it, or one of the other cats. With Peabody, we just stirred the Miralax into the cup of warm water, and it went in with his fluids. Easy peasy.

The little cotton collars do need to be laundered. Peabody’s tube stuck out quite a ways, and I was always concerned about it hurting if he got in a tussle with another cat, or while scratching. I sewed a little piece of elastic to the collar so that I could tuck the tube under that, and keep it “hugging” closer to his neck.

A loving memorial to a singular cat

We now have our 3^rd renal failure kitty, Lewis. Lewis was recently put on fluids just for a few days, and he improved. Eventually we know we will have to make the choice again – do we give him daily injections or the tube? A major factor will be that Lewis likes to go outside much more than Peabody, and his favorite thing is eating grass. We will have to decide if we want the convenience and ease of the tube for ourselves, or to let him continue to enjoy the yard and eat grass. We’ll have to wait and see.

Does canned food cause diarrhea in cats?

A happy cat after having surgery to remove a piece of foam that was blocking his intestines

A very common thought among cat owners is that canned food causes diarrhea in cats. In fact, last Friday, one of our technicians had a conversation about that exact topic no less than three times!

1) Someone commented on a Facebook post with a question about her neighbor's cats. Her own cats thrive on a canned diet, but her neighbor objects, saying that it gives her cats diarrhea.

2) A woman brought in a kitten for a first visit that was having chronic soft stools and gas. She was concerned that the kitten was getting diarrhea from the canned food, but switching to a dry food did not significantly improve the problem.

3) At a dinner party, a friend leaned across the dinner table and said, "Not to be indelicate, but I'd like to pick your brain about my 3 year old cat's soft, smelly stools." His wife is concerned that canned food was the culprit, but the cat has been having diarrhea since they got her, and cutting out the canned food did not solve the problem. She has had her stool tested and she is up to date on vaccines. They had just moved to a new home and wondered how to approach a new veterinarian about the problem.

Most of the time, diarrhea in cats is not caused by eating canned food. Canned food is very close to what a cat would eat naturally, in the wild - the nutrient balance and moisture content of canned food is close to that of a mouse - and more natural than dry kibbles. It can be easy to blame diet for a cat's smelly, soft stools, but more often, we need to do some detective work to get to the root of the problem.

How do you diagnose the cause of diarrhea?

Usually, when presented with a cat that is having diarrhea, the veterinarian will recommend that the cat be checked for intestinal parasites. That is usually a very treatable reason to have chronic diarrhea. In Michigan, in Oakland County, in 2014, 1 in every 15 cats was positive for roundworms (compared to 1 in 46 dogs). It can also be a very difficult diagnosis to reach. When we test cats for intestinal parasites, the accuracy of the testing has a lot of contributing factors:

- the age of the stool sample. The older the sample, the less accurate the test. Usually a sample should be tested within 24 hours. Some parasites may be absent from the stool unless it is taken directly from the cat to the microscope! Tapeworms are mobile when they are deposited in the litterbox with your cat's stool, so they may wiggle off the stool before it is collected for testing. Tapeworms are more frequently diagnosed by observation of tapeworm segments on the hairs around the cat's anus than by bringing in a stool sample.

- the amount of stool. If a cat is having frequent, terrible diarrhea, it may be difficult to collect a sample, because only small amounts are produced very frequently.

- the life stage of the parasite. Some intestinal parasites do not shed eggs with every stool sample. When we look at a stool sample, we are most commonly looking for the eggs of the parasite, not the worm, itself. Other parasites are single-celled organisms and shed frequently, or their populations may wax and wane. Toxoplasmosis is an infection with a single-celled organism. Cats that are infected with this parasite will start shedding eggs (oocysts) in their stool  between 3-10 days after becoming infected and will only shed these oocysts for a total of 10-14 days. Ever. If you don't test a stool sample within that period, a stool sample will not diagnose this parasite. After that time frame, Toxoplasmosis infection must be diagnosed with blood titers that check for Toxoplasmosis antibodies.

For more information about cats and parasites, visit the Pets and Parasites website.

Sometimes, it may require that we test multiple stool samples before we are able to locate the parasite in the stool. One of our technicians had to check her cat three times before we were able to locate the Giardia that she was pretty sure was infecting her cat.

In cases where we suspect a difficult to diagnose parasite, or a viral or bacterial cause of diarrhea, we may recommend a "diarrhea panel". This test requires a larger stool sample and checks for two species of Campylobacter, Clostridium perfringens alpha toxin (CPA) gene, Cryptosporidium spp., feline coronavirus (FeCoV), feline panleukopenia virus, Giardia spp., Salmonella spp., Toxoplasma gondii, and Tritrichomonas foetus with PCR testing. A PCR test allows for certain types of DNA to be sorted out of a mixture of different types of DNA so that they can be identified. In this way, the laboratory can sort out the normal intestinal bacteria from bacteria that cause disease (are pathogenic), and find traces of parasites that may be present in small quantities, or identify viruses that may be present.

Hairballs can often be a culprit of intestinal maladies in cats. Sometimes, when the hair builds up in the system instead of passing normally, it can be a sign of a bigger issue - skin allergies or external parasites causing the cat to groom excessively, or decreased gut motility (the speed at which food moves through the digestive tract).

Another hairball - too large to pass through the stomach sphincter

Sometimes, a cat may have abnormal anatomy - here, the cat has a gastric diverticulum - a dead-end pouch off the stomach

This cat has a duodenal diverticulum - a dead-end pouch off the upper part of the small intestine

Sometimes, the intestinal problem is related to something the cat ate...anything from rubber bands, shoe strings and hair scrunchies to difficult to digest plant parts, to creepy, grinning toy parts...

Additional testing that might be recommended is highly dependent on the age of the cat, its unique symptoms, and the veterinarian's physical exam. It is highly likely that abdominal x-rays will be recommended. Special contrast studies may be recommended based on the results of the first films - for this, either barium or air will be introduced into the cat's intestinal tract for better imaging. Various blood tests may be recommended - from FeLV/FIV testing, to metabolic testing of kidneys, liver, glucose levels, thyroid levels, or pancreatic function testing.

 

What causes diarrhea in cats?

Sometimes, a cat may have a sensitive stomach that causes them to have diarrhea when their food is switched too rapidly. If they have eaten only dry food all their lives and are suddenly offered only canned food, in this case, canned food may cause diarrhea. However, if you transition food gradually, this should prevent diarrhea related to food transition. Cats may have a sensitivity to a certain protein in their diet. Very commonly, we hear of cats with beef sensitivities, though more in the context of vomiting versus diarrhea. (It make some sense, since we're pretty sure that domestic cats do not naturally hunt down cattle for dinner. Lions, yes. Fluffy, no.) It may be that a cat will have an intolerance to a particular brand of canned food, too, but rarely does canned food as a whole food group cause diarrhea. This would be similar to a human being unable to eat any type of soup or stew without digestive issues.


Besides intestinal parasites and food transitions, other problems that can cause diarrhea in cats include:
- viruses such as Distemper, Feline Leukemia, FIV, and Coronavirus/FIP
- toxin ingestion - plant or others
- Salmonella
- fungal infections
- body-system diseases including: kidney disease, hyperthyroid disease, pancreatitis, and diabetes
- cancer
- inflammatory diseases such as inflammatory bowel disease (IBD), fiber-responsive diarrhea, colitis
- pancreatic insufficiency
- foreign body ingestion (your cat ate a toy!) or other bowel obstruction (hairball, constipation)
- spoiled food
- certain medications (for example, some antibiotics are commonly known to cause diarrhea)

It may be yucky to look at, but using this chart to score your cat's stool can be very helpful!

What can I do to help the veterinarian diagnose my cat?

When trying to hunt down the cause of a complex diarrhea case, it may be helpful to keep a diary of what food you fed your cat each day and rate their stool consistency. We tend to sort cats' stools into the following categories:

- solid, normal stools - "Tootsie Rolls"
- soft stools with some form, but may appear to be "melting", also known as "soft serve stools"
- soft stools with little to no form - "pudding stools"
- liquid diarrhea, may be confused with urine in clumping litter, may be volatile, often the cat may be  unable to make it to the litterbox. This liquid may be brown in coloration or may be clear and difficult to distinguish from vomit.

Note any blood or mucus in the stool. Fresh red blood (frank blood) may be related to irritation of the intestinal tract or anus. Dark, tarry stools or blood that looks like coffee grounds contains older, clotted blood and is a more critical and severe concern than fresh blood. Mucous in the stool is often thick and clear and can be passed with the stool or separately. You may want to snap photos of the diarrhea to show your veterinarian. It can often be helpful, and we will never be offended. Note the frequency of the diarrhea and any other symptoms your cat may have.

When should you see the veterinarian?

Diarrhea is often considered to be a smelly nuisance, however, significant, chronic diarrhea can cause dehydration and malnutrition and can become a life threatening situation.

Contact your veterinarian right away if your cat’s diarrhea:

• is accompanied by repeated vomiting, lethargy, loss of appetite, abdominal pain, generalized weakness, or fever. Vomiting of a dark green liquid (bile) is commonly an indication of a complete intestinal blockage.
• contains large amounts of frank blood.
• is black or tarry in color.
• might be related to ingesting something toxic.
• occurs in a kitten under nine months of age, particularly if vaccines were missed.
• occurs in an elderly or medically frail animal.
• fails to respond or gets worse despite 48 hours of symptomatic home care.

Your cat wants to stop having diarrhea as much as you want him to!

 If you are new to an area and are not sure how to approach a new veterinarian with your problem, it may be best to simply collect a fresh stool sample and take it into the office. A stool sample can often be analyzed without first seeing a cat, though if medication needs to be dispensed, an exam will be necessary. This is because pharmacy laws in most states require an established doctor-patient relationship before any medication can legally be dispensed. If the parasite exam is negative, you will also need to bring your cat in for an exam and consultation about your cat's lifestyle and unique characteristics, so it may be best to contact the new veterinarian and schedule an appointment and bring a stool sample with you at the same time. Having your records sent from your old veterinary hospital to your new hospital will also be helpful, because it will give your new veterinarian an idea of your cat's past weight gains and losses, vaccine history, and any bloodwork or x-rays that have been done in the past.

Additional resources:
Pet Education: Diarrhea in cats: Causes, Diagnosis and Treatment
Cat Diarrhea Causes, Symptoms, Treatment and more

Care and Feeding of a Cat with an Esophagostomy Tube

If your cat has been diagnosed with pancreatitis, oral pain or other condition that makes it difficult or painful to eat, your cat may have had a feeding tube placement procedure recommended. The procedure is relatively quick and, with proper pain medications, painless. Once the tube is placed, a high-calorie, vitamin-rich diet can be given to the cat with minimal stress while he or she is brought back to health. In these cases, placement of a feeding tube often means that the cat is able to go home from the hospital much sooner than would be possible, otherwise.



The type of diet and vitamin or mineral additives that should be fed will be determined by the doctor, based on the individual needs of your cat. Generally a syringable diet will be mixed with water and nutrient powders and placed into the blender to smooth the mixture. Store the food in the refrigerator, and warm a portion of the food to body temperature (101.5 degrees F) in the microwave before using. Do not heat above body temperature!

For most cats with an esophageal feeding tube, food in the stomach may cause nausea, so start slowly. We generally recommend that the average 10 pound cat should start with 50ml of food through the E-Tube four times daily for two days, then increase to 55ml five times daily. Gradually increase the amount you are feeding.  Your eventual aim will be at least 300 to 350ml (over 1 cup) per day.  If  your cat continues to tolerate the feedings you may increase feedings by 5ml per day; up to 75ml per feeding if there is no vomiting. This will allow you to feed fewer times each day.  It is important that you feed enough so that your cat gains weight!

Administer the feedings slowly over 5-10 minutes; slower if vomiting occurs.  Observe for swallowing during the feedings.  Some vomiting (especially at first) is anticipated. If your cat vomits, you should wait an hour and start again. Be organized so things go efficiently with as little handling of the patient as possible.  If feedings are well tolerated, you may gradually become quicker. For some cats, quicker feedings will go more smoothly.

Be sure to flush the esophagostomy tube with 6ml of warm water after each feeding and replace the cap. If the tube becomes clogged, try flushing a small amount of diet cola through the tube with a small (1 to 3ml) syringe.  The esophagus is very stretchy, so your cat CAN eat and drink with this tube in place, however please do not allow your cat to consume grass if they are allowed outside. Grass ingestion is more likely to cause vomiting, and the more frequently your cat vomits, the higher the risk that they will vomit the tube.

Clean the ostomy site (the hole where the tube enters the skin) daily with warm water and surgical scrub. Warm soapy water is ok to use too. Report any concerns.

DAILY MEDICATIONS

It is likely that your cat will be on several medications if this tube is in place. An antibiotic should be given to prevent infection at the tube site. Cats with pancreatitis or hepatic lipidosis (fatty liver) will likely be taking anti-nausea medications such as metoclopramide (Reglan) or maropitant (Cerenia). Cats with certain liver diseases may be taking Denamarin or Ursodiol. Cats with kidney disease may be taking Calcitriol, famotidine (Pepcid), potassium supplements, or aluminum hydroxide. Some of these medications can be given in powdered form and mixed with food or water, others come as tablets and must be crushed before putting through the tube.

Your cat’s esophagostomy tube will be sutured in place and there will be a light bandage placed around his neck.   Observe closely to make sure your pet is not pawing at the tube or bandage.  

If  your cat vomits the esophagostomy tube—carefully use scissors to cut off all exposed tube protruding from the mouth.  Do not try to feed!   Your cat  will need to have the remainder removed and the tube replaced.  If the patient is comfortable, tube replacement can wait until morning. Call as soon as possible; if it is after hours and you are in doubt, contact the nearest emergency clinic.  The portion of the tube left in your cat’s neck can be used as guide for replacing the next tube through the same ostomy site, so don’t pull the remaining portion of the tube from your cat's neck.

If you end up at a veterinary hospital that is not familiar with the replacement technique, please direct them to this video.