What is that bump? - Cutaneous mast cell tumors in cats

Just like any cat that comes through our front doors, Mr. A and Mr. B get wellness exams periodically. On February 7, one of our technician discovered a small, raised bump on Mr. B's hock.

Since new bumps on a cat should be looked at to ensure that they are not cancerous, we had Dr. Demos give Mr. B a thorough exam and take a sample from the mass with a needle. This is called a Fine Needle Aspirate (FNA), and can often give us a good preliminary idea of the kind of lump we are dealing with.

Once we had a sample of the mass, the images we saw under the microscope showed this:

 Very dark-staining cells filled with small granules and lots of small granules in the background. These are mast cells.

Mast cells

 Mast cells can easily be compared to other abnormal cells, like these white blood cells, called lymphocytes, that are abnormal due to the presence of a cancer called lymphoma.

Lymphoma

 Since we were suspicious of a mast cell tumor, we scheduled Mr. B for surgery to remove the mass. He fasted prior to surgery, and then was given preliminary pain medications. We anesthetized him and shaved and scrubbed the surgical site. Even though the lump was quite small, the surgery was very delicate, because the hock is an area with prominent blood vessels and tendons, and has very little fat.

Once the mass was removed, we placed it in formalin to send to a pathologist for analysis. Even though we have a good idea what the mass is before we remove it, we like to confirm it with the experts, and also have the mass checked to ensure that we removed all of it. This is done by measuring the "margins" around the edge of the abnormal tissue.

"Clean margins" (a ring of completely normal tissue around the mass) mean that the mass is less likely to recur. If the margin of normal tissue around the mass is too small, there increased risk of the mass re-occurring. The need to have clean margins around the mass is also the reason that you may notice the area where a mass was removed is often quite a bit larger than the mass was, originally. In some areas, such as the leg, face and tail or the top of the head, where there is not a lot of extra skin, it may be very difficult to create good margins for a mass without risking the integrity of other parts of the body. This is why it is a good

After surgery, we placed Mr. B in a cage, to ensure that he was fully recovered before we let him run around. Usually recovery from a short surgical procedure like a skin mass removal takes just a few minutes from the time that the anesthetic gas is turned off. In Mr. B's case, he was sitting up and asking for post-surgical treats within about 10 minutes.

First, Mr. B fasted for his surgery. He was not very excited about that.

Next, we set up for surgery.

We placed Mr. B under anesthesia, intubated him and shaved and prepped his surgical site.

Post-surgery, we cleaned the sutured incision site, and let Mr. B recover on his warm water blanket.

Mr. B completed his recovery in a cage, and then enjoyed a post-surgical meal. His eyes are very dilated from the pain medication we used. It made him VERY happy.

What is a Mast Cell? Mast cells are a normal cell type found in the body that is involved in various functions including the immune system, wound healing, allergies and inflammation. The granules that they contain are really little sacs that carry important chemicals such as heparin, histamines and antimicrobial chemicals.They are developed in the bone marrow and disperse throughout the body to the skin, connective tissues and the lining of the abdominal organs such as the stomach and intestines.

Despite their beneficial activities in the body, sometimes, mast cells go bad. Mast cells play a big role in anaphylactic reactions (the kind of serious allergic reaction many people experience due to bee stings). Also, in addition to forming mast cell tumors, they can also be involved in autoimmune diseases. In humans, mast cells have been implicated in rheumatoid arthritis.


About 20% of all skin tumors in cats are mast cell tumors, and these types of tumors occur less frequently in cats than in dogs. About 90% of cutaneous mast cell tumors in cats are benign, and excision (surgical removal) is the cure. Mast cell tumors in the internal organs are a different matter.

Once we had sent in Mr. B's mass for biopsy, we received the following report from the pathologist a few days later:

Microscopic Description	Small left hock skin mass contains a dermal solid proliferation of minimally pleomorphic small neoplastic mast cells. Mast cells efface adnexal structures. One mitotic figure per 10 high power fields is seen. Tumor free margins measure approximately 1 mm.
Microscopic Interpretation (Biopsy)	Cutaneous mast cell tumor
Comments:	Histologic features of this skin tumor are consistent with a benign dermal mast cell tumor. Cutaneous mast cell disease accounts for approximately 21% of all feline skin tumors. Grading scheme similar to canine mast cell tumors has not been developed for feline neoplasms. Mitotic count (over 5/10 HPF) is the only criteria that has prognostic significance in determining benign from malignant (Vet. Pathol 2010; 47(4); 643-653). Neoplasms with high mitotic rate may have concomitant increase in mast cell pleomorphism.

Now we can be confident that the tumor was removed entirely, and that it was benign.

Mr. B is now strutting his stuff as usual, with lots of commentary on his healing progress. In 10-14 days, he can have his sutures out and in 6-8 weeks, his hair will have regrown, and no one will even see his scar!

We wonder whether Mr. B is asking for a matching shaved spot on his other legs.

Cat Friendly Practices - How Does this Help my Cat?

George, summer 2014

Semi-Feral Handling

Meet handsome George. He is a young cat that has lived outside for all or most of his formative years. He avoids direct human approach. But, he sort-of wants a home. Two lovely people took him under their wings and tried trapping him. After about 8 months of evading the trap, they finally caught him and brought him to us.

Having had minimal handling, he climbed the walls and bit and scratched out of fear and anxiety when the owners first tried to put him in a carrier to bring him in for neutering and vaccination.

After his first experience with us, which was a short stay in a boarding cage after his surgery, and minimal, gentle handling, his second visit went as follows:

First, he was allowed to acclimate to the sounds and smells of the hospital. We have Feliway diffusers throughout the hospital to help reduce anxiety.

Next, we approached with slow but deliberate motions. Making many small, unnecessary motions around a nervous cat can cause increased anxiety, since a fluttering hand may resemble the motions of a bigger predator or fluttering prey. Many times, when handling stressed, anxious or shy cats, "less is more".

Next, we undid the clasps on the carrier, and held a towel over the front of the carrier while we opened the door, removed it, and then simultaneously slid the top of the carrier off and slid the towel over George. Most of his exam was performed while he was under the towel, sitting in the bottom half of the carrier. This allowed him to feel comfortable and protected. The restraint used for him was gentle pressure on both sides of the body, just enough to keep him from darting out of the carrier, but no more.

Once as much of the exam was completed as could be done while he sat in the carrier, the technician tested his response by gently lifting up his front end. When he did not panic, she lifted his entire body from the carrier and placed him on the counter. The exam continued, and we were able to vaccinate him, as well. Additionally, once the exam was complete, we were able to brush out the fur on his back for a few minutes, until we could feel his muscles begin to tense. It may not look like the technician in this picture is paying attention to the cat, but often, staring at a cat can cause the cat to become anxious or feel threatened, so often, technicians rely more on the information the cat gives them through touch - tensing of muscles, small movements that project the cat's intentions. That way, the cat, who is already being closely inspected by the doctor, does not feel overwhelmed.

We placed him back into the bottom half of his carrier and he relaxed a bit, and we were able to comb him for another minute or two before he tensed again, signaling that he was thinking about fleeing. We carefully replaced the top of his carrier and the door, and gradually removed the towel, completing our work with this semi-feral cat without undue stress, and without anesthesia. We placed treats in his carrier to end the visit on a positive note. Our hope is that with each successive visit, he will become more and more tolerant of handling.

George, winter 2014

He badly bit one of his owners in his panic over being placed in the carrier to come to the hospital, that day, so it is our concern that he become used to the practice of traveling in the carrier to avoid future harm to his owners as they try to provide him with good medical care. We recommended leaving the bottom half of the carrier out in the house, possibly with intermittent food in it during the day and a blanket at night, so that he will become more accustomed to the sight and smell of the carrier. If the food is in the carrier all the time, he will likely still run when his owners approach the carrier. If the food only appears in small amounts when the owners walk over to the carrier, he may begin to run to the carrier in anticipation of special treats! We discussed placing a towel over him while placing him into the bottom half of the carrier, and then "re-building" the carrier around him instead of trying to to force him in through the doorway. Additionally, placing a mild sedative in his food prior to the exam may allow him to relax enough to be placed in the carrier.

Stay tuned to see how things go next month, when George will need a blood sample collected!

Inflammatory Bowel Disease vs. Irritable Bowel Syndrome: Which is affecting my cat?

INFLAMMATORY BOWEL DISEASE

What is Inflammatory Bowel Disease and what causes it?

Inflammatory Bowel Disease (IBD) is a chronic disease of the intestinal tract. In fact, IBD is not a single disease, but several conditions that result in the accumulation of inflammatory cells in the intestinal tract. These inflammatory cells are normal cells that occur in the body, but problems within the body cause these cells to congregate in the stomach or intestinal tract, causing thickening of the linings of these organs and decreasing the organs' ability to perform their normal activities: digesting food and absorbing nutrients.The thickened lining also decreases the body's ability to protect itself from harmful invaders like bacteria and viruses. The lining of the intestinal tract normally functions similarly to the skin in providing a protective layer between harmful infections and the rest of the body's vulnerable cells.

Normal intestinal anatomy - the villi absorb nutrients and pass them into the bloodstream for distribution throughout the body

Most of the time, the primary cause of IBD is unknown or "idiopathic", but chronic inflammation may be caused by diet, environment, parasite infection, immune health or the relationship between the body's immune system and the bacteria that inhabit the digestive tract. While food allergy may not be a primary cause of  IBD, it may be a contributing factor to the severity of the disease.

What are the signs of Inflammatory Bowel Disease?

Inflammatory bowel disease is generally a problem found in cats of middle age and older, but can affect cats of any age. Most affected cats have a history of recurrent or chronic vomiting and/or diarrhea.  During periods of vomiting or diarrhea, the cat may lose weight but is generally normal in other ways. As a rule, most affected cats eat well (or even have an increased appetite) and appear normal, though some cats may have decreased appetite.

Depending on which part of the digestive tract is affected, the cat may be more likely to vomit (stomach, duodenum) or have diarrhea or bloody stools (colon). Mucousy stools may also be a sign of IBD. However, a cat that vomits due to IBD may vomit after every meal, or only once or twice a month. Vomiting may be intermittent or cyclical. The cat may be more prone to hairballs that disrupt the digestive tract - either vomiting hairballs frequently, or by having his digestive tract become obstructed by a hairball. If the whole digestive tract is affected, the symptoms may not necessarily directly correspond to the areas most affected.

How is IBD diagnosed?

Ultrasound examination of a cat

Diagnosis of IBD can be complex, because the common signs (vomiting and/or diarrhea) are symptoms that can be associated with many diseases. Because IBD often is idiopathic in nature, your veterinarian will recommend diagnostics that will rule out more specific diseases, first, such as parasites, viral or bacterial infections, metabolic diseases and cancer. This may involve various blood tests, a stool examination and abdominal radiographs or ultrasound examination. The veterinarian may palpate or feel thickened intestines during the physical exam, or may see evidence of intestinal thickening on x-ray or ultrasound studies.

For most cats with IBD, bloodwork chemistries may be normal. If the liver and pancreas are involved (triaditis), then elevations of pancreatic or liver enzymes would be expected. In cases where the cat is having bouts of severe vomiting or diarrhea, electrolyte imbalances would be a common finding. Additionally, long-standing IBD may result in "protein-losing enteropathy". In a normal cat, a small amount of protein leaks into the intestine as nutrients are absorbed into the bloodstream. These proteins are normally digested in the intestine and then reabsorbed. When the intestinal tract is damaged, as in IBD, more protein leaks out than the body is able to reabsorb.

The only way to definitively diagnose IBD is to collect surgical biopsies of the digestive tract and submit them for pathologist review. The types of cells seen by the pathologist will determine whether IBD is present, and categorize whether the IBD is lymphocytic-plasmacytic (the most common), eosinophilic, neutrophilic or granulomatous in nature. 

Here is what the lining of a normal intestine looks like under the microscope. The areas within the boxes are what we are looking at, below.

The images towards the left show normal intestinal anatomy, while the images to the right show progressively more severe Inflammatory Bowel Disease (human). There is a decrease in the size and surface area of the villi, the thickness of the intestinal lining , and a general degeneration of intestinal anatomy.  Loss of structure = loss of function

Surgical biopsies can be collected via endoscopy or via exploratory surgery. Endoscopic biopsies are less invasive, but are limited because only the upper end of the GI tract can be sampled, and only superficial samples can be collected. Surgical exploration to collect biopsy samples allows full-thickness biopsies of multiple sites throughout the digestive tract to be collected. Additionally, since many cats that have IBD may also have pancreatitis or hepatitis (inflammation in the pancreas or liver), samples of these organs and abdominal lymph nodes can also be collected to ensure that there are no additional complicating factors to the disease.

The first method is a biopsy of the affected part of the stomach or intestine.  The preferred technique to to use a flexible endoscope which allows access to the lining of the stomach, small intestine, and colon.  If the site of inflammation involves any of these locations, a confirmed diagnosis is achieved.  Sometimes, the small intestine may be difficult to enter because of the cat’s small size; in these cases, surgical biopsy may be needed.  Fortunately, this is rarely necessary. The second method of diagnosis is a therapeutic trial involving administration of particular drugs, along with certain dietary changes.  Since not all cats respond to the same drugs, the trial may involve a series of a number of drugs and may take several weeks.  Also, different diets may be tried, depending on which part of the bowel appears most involved.  These diets include hypoallergenic, low residue, or high fiber foods.  The cat is monitored during the therapeutic trial for a decrease in clinical signs and, in some cases, weight gain.

Is IBD treatable?

Treatment for IBD is focused on controlling symptoms such as vomiting and diarrhea and promoting appetite and weight gain. Any complicating factors such as pancreatitis, parasite infection or other diseases should be treated accordingly. Treatment may involve a special diet, anti-vomiting or anti-diarrheal medications, steroids, pre- or pro-biotics, dewormers, omega-3 fatty acids, and B12 supplementation.

What is the prognosis?

Once the appropriate drugs or diet are determined, many cats are maintained on these for life, although dosages of the drugs may eventually be decreased.  Occasionally, a cat will be able to stop drug therapy at some point. Most cats do well for many years; others require alterations in therapy every few months.  Unfortunately, a few cats will ultimately become totally resistant to treatment.

There is a correlation between IBD and gastrointestinal lymphoma in cats. It is not completely clear whether IBD causes or progresses to lymphoma (the most common type of cancer in cats) over time, or whether the same problems that lead to IBD also cause GI lymphoma. Either way, untreated IBD in cats can cause malnutrition and eventual gastrointestinal ulceration and possible perforation of the bowel. Perforation of the bowel allows partially digested food and intestinal bacteria to leak into the abdomen causing severe systemic infection, sepsis and death.

IBD vs. IBS

Irritable Bowel Syndrome (IBS) is not the same as Inflammatory Bowel Disease (IBD). Irritable bowel syndrome is a psychosomatic response that causes hypermotility in the intestinal tract (things move through too quickly). The most common reason for this to happen is excessive stress or anxiety - a trip to the veterinary hospital, the addition of a new cat or new baby to the household, etc. A biopsy of the intestinal tract would look normal, because the problem is not with the intestinal tract itself, but with the nerve signals sent to the intestine that tell it what to do. Treatment of chronic irritable bowel syndrome is aimed at increasing fiber in the diet and controlling the cat's anxiety through environmental management and behavioral therapy. One-time bouts of IBS resulting from travel, visits to the veterinary hospital or other planned events can be averted by acclimating the cat to the carrier, using calming products, such as Feliway or anti-anxiety medications prior to travel or veterinary visits, or by choosing a veterinary office that is a certified Cat Friendly Practice. These hospitals generally have staff experienced with handling stressed cats, have separate waiting rooms, cages and exam rooms for cats and dogs, and may be better equipped to soothe your anxious kitty, preventing the onset of an IBS episode.

Additional Resources
Merck Veterinary Manual: Disease Profile: Inflammatory Bowel Disease 

All Feline Hospital: Inflammatory Bowel Disease 

Cornell Feline Health Center: Inflammatory Bowel Disease

WebMD: Inflammatory Bowel Disease

Wild Rose Cat Clinic Case Study: Tigger, and is it IBD or Lymphoma?

World Journal of Gastroenterology: Inflammatory Bowel Disease in the Dog: Similarities and Differences with Humans

Pitch the Perfume and Toss The Talc: Reuniting Cats Following a Visit to the Vet

Reuniting cats following a visit to the vet

Steven J. Bailey, DVM, DABVP

2015

Traditionally, veterinarians have speculated that new odors on the cat returning home from the veterinary practice were a stimulus for antagonistic behavior between cats. I do not believe this is entirely true, and perhaps leads to clients (and professionals) further antagonizing these stressed cats by applying unnatural scents (perfumes and Baby Powder) with the intent to cover, mask, or replace other scents.

Cats have the ability to detect many more odors and pheromones than we people can even imagine. I have never appreciated that our feeble attempts to address these 'odors' has had any positive impact on feline behavior with respect to these homecomings. 

My perception of some of the causes has been:

- When a cat leaves a clowder of cats (even if the clowder is just a pair) it appears that they need to receive permission to rejoin. If this reintroduction is rushed and stressful, then antagonistic behavior is more likely to occur.

- The client's stress of bringing the cat to the veterinary hospital and then returning the cat to the home is undoubtedly perceived by the cat. Despite our efforts, cat owner’s actions don't always do a good job allaying feline anxiety. Often, we make it worse. Time and again, when clients are planning on a vet visit, cats hide from owners "even before they get the cat carrier out." Cats seem to have the ability to read us. They indeed have a ‘sixth sense’.

- The patient returning from a visit to the clinic has experienced a lot of stress. The cat may be experiencing pain from treatments or surgery; additionally the cat may have altered physiological reactions due to various administered drugs (even pain medications). The sympathetic nervous system is ‘turned on’ and they want to hide, fight, or flee. 

- Undoubtedly, new smells abound, but I suspect that fear pheromones, postural changes, facial expressions, eye contact, and other sympathetic reactions to the presence of other cats are far more important than simply the new scents acquired at the veterinary clinic. While friendly pheromones have been studied in cats, I am not aware that feline fear pheromones have been demonstrated in this species¹. On the other hand, fear pheromones have been demonstrated in other species (man, cattle, pigs, rats, & fish) so I expect they exist for cats². There is even a report suggesting that ‘feel good’ pheromones can have a negative effect in the face of preexisting antagonism³. Many of us in feline practice report that having a terrified cat in an exam room early in the day seemingly triggers previous relaxed cats to be reactive for the remainder of the day. I can’t imagine that adding new odors to a cat's coat will somehow negate the presence of fear pheromones.  I can imagine that the application of additional smells would serve as an additional stressor to both the cats returning home, and the others accepting them.

My recommendation to avoid anticipated antagonistic reunions is to isolate ALL potential  antagonistic cats to a separate environment (e.g. an isolated room). The returning cat is given free access to all the 'normal' inhabited regions of the home, while the others are confined to the ‘spare’ room.  Once the returning cat's behavior and physiology returns to normal, and fear pheromones have dissipated, then the other cats can be let out, one at a time.  Depending on how serious the antagonistic behavior is, this transition time could take 2 hours, or 2 days (or more?).  This time period also allows the owner's subliminal behavior to return to normal, and it creates a situation where the newly-isolated cats have to ask permission to be accepted back into the normally inhabited home environment. I believe we reinforce antagonistic behavior when the returning cat is isolated to the ‘spare’ room as this furthers the need for this (treated and stressed) cat to get permission before reuniting with the clowder.

If antagonistic cats are food motivated, then feeding them, or offering them a treat during reunions may be helpful as well. Cat nip has a variable effect on cats, and it will make some cats more aggressive so I would somewhat discourage this.

My opinion as a feline practitioner is we should not be trying to mask odors on our cats. Please pitch the perfume and toss the talc.

1.  Ogata N, Takeuchi Y. Clinical trial of a feline pheromone analogue for feline urine marking. The Journal of veterinary medical science/the Japanese Society of Veterinary Science 2001;63:157-161.

2.  Grandin T. Assessment of stress during handling and transport. Journal of Animal science 1997;75:249-257.

3.  Simpson BS, Papich MG. Pharmacologic management in veterinary behavioral medicine. Veterinary Clinics of North America: Small Animal Practice 2003;33:365-404.

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

Client question: How often should my cat have his teeth cleaned?

Question:  I clicked on your dental care link and thought it was very educational. At what age should a cat have it's teeth cleaned? And how often? Thanks.

Exclusively Cats Veterinary Hospital Thanks for a great question! 

Fractured canine tooth with exposure of the nerve and blood supply

 
A cat's dental health is dependent on many things: age, overall health, FeLV/FIV status and breed or hereditary characteristics. Many cats may need a dental cleaning as early as 4 years of age, if we are talking about preventing dental disease. Breeds such as Persians, who have short noses, still have the same number of teeth in their mouths as longer-nosed cats, and develop dental disease more rapidly due to tooth-crowding. Cats that are FeLV or FIV positive or have other diseases that decrease the effectiveness of their immune system may need dental cleanings more frequently because they are more susceptible to the bacteria that build up in the mouth. Cats that are adventurous explorers and fall and break a tooth, or those that chew on hard objects frequently may need more frequent care or emergency care. 

This Abyssinian kitten has all her adult teeth except her upper canines. X-rays show that she has no adult canines! When and if she loses her baby teeth, she will be missing two teeth.

Generally, we recommend that cats come in for a fluoride treatment around the age of 7 months, when all the adult teeth should have erupted. At this time, fluoride can be applied to the teeth (some cats will already have a little tartar buildup, which we will clean!) to strengthen the enamel - this application is most effective at strengthening before 18 months of age. After that, fluoride applications help prevent pain due to exposed dentin in inflamed mouths. We can also check to see if there are any abnormalities - extra teeth, missing teeth, retained baby teeth, teeth out of position, etc. that will cause problems later in life and require more care than the average cat.

This kitten has an upper tooth that is causing injury to his lower gum

We like to examine cats' mouths annually and their wellness exams to decide whether the cat will need a dental cleaning in the near future. Most cats will benefit from annual cleanings, but some cats may need cleanings every 6 months, and others may be able to go 2-3 years between cleanings. We try to balance the aggressiveness of our recommendations for treatment with the cost of treatment - since they require anesthesia for cleanings, we know that it may be daunting to consider the cost of a dental procedure. However, just like human dentists, veterinarians who advocate good oral health care for cats would prefer to perform a "dental prophylaxis" or cleaning, versus performing "dental surgery" and tooth extractions! We are sure that our patients would prefer it, too!

Flooding the Litterbox: Chronic Kidney Disease and your cat

CHRONIC KIDNEY DISEASE: An Overview

Before we re-write the book on Chronic Kidney Disease, please note that there are two extremely thorough and excellent resources for people with cats that have Chronic Kidney Disease (CKD) that we would like to recognize: 

Feline CRF (Chronic Renal Failure) Information Center
Tanya's Comprehensive Guide to Feline Chronic Kidney Disease

What is meant by the terms “Chronic Kidney Disease” and "Chronic Kidney Failure"?

The term "chronic kidney failure" suggests that the kidneys have stopped working and are, therefore, not making urine.  However, by definition, kidney disease is the inability of the kidneys to remove waste products from the blood.  This definition can occasionally create confusion because some will equate "kidney failure" with "failure to make urine".  Kidney disease is NOT the inability to make urine.  Ironically, most cats in kidney failure are actually producing large quantities of urine, but the body’s wastes are not being effectively eliminated. This is why many people avoid the term "kidney failure" and prefer "kidney disease". Because the kidneys are so efficient at their job and because cats are so adept at hiding their illnesses, it has been determined that a cat can lose up to 75% of normal kidney function before they begin to act sick. This is one reason that annual checkups with your veterinarian are so important!

There does come a point in CKD at which a cat's kidneys have been destroyed to the point where urine is no longer produced (anuria), but hopefully, the problem is recognized, discussed and treated before this is the case.

When is this likely to happen in my cat?

Commonly, chronic kidney disease is considered to be the result of aging - a “wearing out” process.  Most of the time, when chronic kidney disease is diagnosed, the cause is unknown. Biopsy of the chronic kidney usually results in a non-specific assessment called "chronic interstitial nephritis" - a hardening and inflammation of the filtration structures in the kidney. 

There are some known contributing factors to kidney disease:

• Polycystic Kidney Disease:  an inherited disease seen in certain purebreds where one or more fluid-filled cysts start to gradually replace normal kidney tissue 
• Kidney tumors: lymphoma is a common type of cancer seen in cats, and it can affect many different organs, including the kidneys. White Blood Cells called lymphocytes become affected and interfere with normal kidney structure
• Infections: bacterial infection of the kidneys (known as 'pyelonephritis') may cause enough damage to the kidneys to cause CKD. Kidney infections are usually a complication of a long-standing, untreated urinary tract infection, but can occur more quickly in older cats with dilute urine, cats on immunosuppressive drugs, or cats with concurrent diseases such as diabetes or FIV.
• Toxins: certain toxins and drugs can damage the kidneys - for example, cats that eat plants from the lily family, drink antifreeze or ingest pills from the pain-reliever family like acetominophen or ibuprofen
• Glomerulonephritis: there are small filtration units in the kidneys called "glomeruli" that filter toxins from the bloodstream. These filters can become inflamed for a variety of reasons and if the inflammation is prolonged, this can lead to CKD

For most cats, the early signs occur at about 10-14 years of age. However, some cats may experience early onset kidney disease at 5-7 years or younger. About 20-50% of cats will be diagnosed with CKD at some time in their lives.

What changes are likely to occur in my cat?

The kidneys are the body's filters, removing toxins from the blood and excreting them in the urine. When aging causes the filtration process to become inefficient and ineffective, blood flow to the kidneys is increased in an attempt to increase filtration.  This results in the production of more urine.  To keep the cat from becoming dehydrated, due to increased fluid loss in the urine, thirst is increased so the cat drinks more water.  

Other job functions of the kidneys:

• Maintaining hydration - the body's water balance
• Maintaining balance of salts and electrolytes
• Maintaining the acid balance of the body
• Maintaining normal blood pressure
• Producing hormones involved in calcium processing, red blood cell production, blood clotting and immune system health

Early signs of CKD:

• increased water consumption (polydipsia)
• increased urine production (polyuria) with or without litterbox avoidance
• mild or gradual weight loss 

Signs of more advanced kidney disease include:

• loss of appetite/severe or rapid weight loss
• depression or lethargy
• vomiting
• diarrhea
• poor coat
• anemia
• very bad breath (uremia)
• occasionally, ulcers will be found in the mouth

Additionally, cats with kidney disease tend to have associated high blood pressure.

How is chronic kidney disease diagnosed?

The diagnosis of kidney disease is made by determining the level of two waste products in the blood:  blood urea nitrogen (BUN) and blood creatinine.  A urinalysis is also needed to complete the study of kidney function, with special attention paid to the "specific gravity" of the urine. Urine specific gravity is a measure of the "stuff" (such as proteins) in the urine that make it different than water. Since cats are descended from desert animals, they are very good at concentrating their urine - eliminating a lot of "stuff" and conserving a lot of water. Average specific gravity of cat urine is greater than 1.035, and may be as high as 1.060 if they eat a dry-food only diet. If the urine specific gravity drops below 1.035, it can be a red flag that indicates the cat is not concentrating urine well for some reason - for example: drinking more water than usual or losing kidney function. Comparing the BUN and creatinine levels in the blood to the urine specific gravity can be very informative to the veterinarian.

Although BUN and creatinine levels reflect kidney failure, they do not predict it.  A cat with marginal kidney function may have normal blood tests.  If that cat is stressed with major illness or surgery, the kidneys may fail, sending the blood test levels quickly into the abnormal range. Additionally, other factors can affect the body's BUN and creatinine levels, such as kidney infection, hyperthyroid disease, muscle loss, and anorexia (lack of food intake).

Since this is basically just a wearing out process, can it be treated with anything other than a kidney transplant?

Yes, it can. We must recognize that your cat’s kidneys have reached this point due to aging, so they will never be normal again, but many cats still have enough functional kidney tissue so treatment can be very rewarding.

Treatment generally has two phases.  If your cat has reach a crisis, the first phase is to “restart” the kidneys.  The cat is hospitalized and large quantities of intravenous fluids are given to “flush out” the kidneys.  This flushing process, called diuresis, helps to stimulate the kidney cells to function again.  If enough functional kidney cells remain, they may be able to adequately meet the body’s needs for waste removal.  Fluid therapy includes replacement of various electrolytes, especially potassium.  Other important aspects of initial treatment include proper nutrition and drugs to control vomiting and diarrhea.

There are some exciting new developments in diagnosis and treatment of feline chronic kidney disease that will hopefully be very beneficial when they become available outside of university research settings.

A newly discovered biomarker of kidney disease may provide earlier detection and allow for closer monitoring and better, earlier treatments.

Stem cell therapy has been showing some promise in treating feline kidney disease, too. The stem cells for this therapy are cultivated from the fat of young, healthy cats; donor animals are not harmed.

What can I expect from this phase of treatment?

There are three possible outcomes from the first phase of treatment:

1) The kidneys will resume functioning and continue to function for a few weeks to a few years. 
2) The kidneys will resume functioning during treatment but fail again as soon as treatment stops. 
3) Kidney function will not return. 

Unfortunately, there are no reliable tests that will predict the outcome. The best your veterinarian can
do is assess the response of the cat's blood values and attitude while hospitalized and draw on their experience as to whether they recommend continued treatment, and if so, how aggressive that treatment needs to be to keep your cat healthy. A close relationship with your veterinarian will help them design a continuing treatment plan to keep your cat feeling healthy for as long as possible. That plan will need to be continually adjusted based on your cat's progress.

 If the first phase of treatment is successful, what happens next?

The second phase of treatment is to keep the kidneys functioning as long as possible. This is accomplished with one or more of the following, depending on the situation:

1. A high quality diet.  This helps to keep the blood tests as close to normal as possible, which usually makes your cat feel better.  We can recommend a commercially prepared food that has the quantity and quality of protein needed by your cat.

2. Potassium supplementation.  Potassium is lost in the urine when urine production becomes excessive.  A potassium supplement will replace that loss.  Low potassium levels have been shown to further reduce kidney function.  This is the second reason that a potassium supplement is recommended.  Monitoring of your cat’s potassium will guide our decision to supplement.

3. A phosphate binder.  One of the secondary things that occurs in kidney failure is an elevation of the blood’s level of phosphorus.  This also contributes to lethargy and poor appetite.  Certain drugs will bind excess phosphates in the intestinal tract so they are not absorbed, resulting in lower blood levels of phosphorus.  Phosphate binders are helpful only when feeding a phosphate restricted diet, as there is far too much phosphate in a  “normal diet” for these binders to be of benefit.

4. Fluids given at home.  Once your cat is stabilized, fluids can be given under the skin (subcutaneously). This serves to continually “restart” the kidneys as their function begins to fail again.  This is done once daily to once weekly, depending on the degree of kidney disease.  Although this might not sound like something you can do, you will be surprised at how easily the technique can be learned and how well most cats will tolerate it.

5. A drug to regulate the parathyroid gland and calcium levels.  Calcium and phosphorus must remain at about a 2:1 ratio in the blood.  The increase in blood phosphorus level, as mentioned above, stimulates the parathyroid gland to increase the blood calcium level by removing it from bones.  This can be helpful for the sake of the normalizing calcium:phosphorus ratio, but it can make the bones brittle and easily broken.  Calcitriol  can be used to reduce the function of the parathyroid gland and to increase calcium absorption from the intestinal tract.

6. A drug to stimulate the bone marrow to produce new red blood cells.  The kidneys produce erythropoietin, a hormone that stimulates the bone marrow to make red blood cells.  Therefore, many cats in kidney failure have a low red blood cell count, anemia.  Epogen, a synthetic form of erythropoietin, will correct the anemia in most cats.  Unfortunately for some cats, the drug cannot be used long term because the immune system recognizes the drug as "foreign" and will make antibodies (immune proteins) against it.

How long can I expect my cat to live?

The prognosis is quite variable depending on response to the initial stage of treatment and your ability to perform the follow-up care.   However, we encourage treatment in most situations because many cats will respond and have good quality life for up to 4 years.