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Dr. Z.
Dr. Z., Veterinarian
Category: Cat Veterinary
Satisfied Customers: 5970
Experience:  Over 25 years of experience in caring for dogs and cats.
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My 13-year old cat just had dental work and two teeth pulled.

Customer Question

My 13-year old cat just had dental work and two teeth pulled. She has always been a picky eater and quit eating just before. She now has the following symptoms after 3-7 days: Very poor appetite that comes and goes, licks food and walks away, takes a few sips of fluid and walks away, excessive drooling, sitting hunched up. Her creatinine levels are 1.9, and all other blood work was good, just a little high in one WBC count. I've been having to give her Sub-Q fluids and force feed. Could she have excessive stomach acid or any ideas?
Submitted: 2 years ago.
Category: Cat Veterinary
Expert:  Dr. Z. replied 2 years ago.

Hello and thanks for trusting me to help you and your pet today. I am a licensed veterinarian and would be happy to provide answers your questions.

 

I have a few questions to get a better idea as to what is going on. Is 1.9 her current creatinine value or her pre-anesthetic one. If that was the value before anesthesia, has it been rechecked?

 

Was she sent home on any pain medications? Or given anything there before she left?

 

Why were the teeth extracted? (if you know) Has your vet looked at the extraction sites since the procedure?

 

Was she doing the drooling before the procedure or did that just start after?

 

Thanks and I will respond further after you reply.

 

 

Customer: replied 2 years ago.
Creatinine was checked before and after. It actually was higher before the procedure - probably because she was dehydrated according to the vet.

She was given pain med oral called meta something. It was in a small syringe to give by mouth. She got this for 5 days.

Two lower molars were extracted. The extraction sites look good now the vet says.

She did not drool before the procedure that I remember.

Also - She's had rather runny poop since being brought home (the litle she's had)

She was also given antibiotics for 5 days Clavamox 1 mL twice a day

Thank you!
Customer: replied 2 years ago.
Sorry the teeth were pulled because the roots were about gone and there was redness. Also probably infected
Expert:  Dr. Z. replied 2 years ago.

Ok, that is helpful and much as I suspected. It sounds like your vet is doing a good job. It doesn't sound like it has to do with any loss of kidney function as can happen sometimes after an anesthesia if there was not good fluid support. There are a few thoughts I have as far as why Kes may not be wanting to eat or drink well and I will list below.

 

1) Mouth pain - this doesn't sound likely as she was on the pain meds and it sounds like the extraction sites have healed up. Also if the roots were already gone, there would not have been a lot of oral surgery to remove them.

 

2) Adverse reaction to the antibiotics - making her nauseous. The Clavamox may have set it off but if you are still seeing soft stool, her GI tract may still be affected. Perhaps a round of probiotics may help to replace the good bacteria.

 

3) Adverse reaction to the metacam. This is a non-steroidal anti-inflammatory (NSAID), which is commonly used for pain, but can have GI side effects. In some cats, after prolonged use, GI irritation or even ulceration can occur. Even though her regime was only for 5 days, she may have been sensitive. Antacid meds like Pepcid AC (famotidine) - 1/2 of a 10 mg tab once daily may help. Your vet would be able to prescribe even stronger GI meds if needed.

 

4) This final one is the most worrisome, but I have seen it on more than one occasion. It is possible that there was underlying GI disease before the dental and the two teeth that were extracted were incidental and had no bearing on her decrease in appetite prior to the procedure. If this is the case, a further GI workup would be needed to rule out things like pancreatitis, inflammatory bowel disease (IBD) or even GI lymphoma. These are not uncommon disorders in cats and often when they first present, they signs are subtle and often can be thought to be due to something less serious, like dental disease. Unfortunately, IBD or lymphoma can be present and there can be no other abnormalities noted on bloodwork, xray or even ultrasound. The only way to confirm the diagnosis is with a biopsy of the intestine. This can be done via endoscope, but is better performed with an exploratory surgery. The problem with this is that many cat owners are not willing to pursue the diagnosis by these means. It is for that reason that many cats are "suspected" to have IBD or GI cancer as the cause of their weight loss and anorexia once all of the other easy to find things have been ruled out.

 

I hope her reluctance to eat is one of the more easily treated possibilities and not the last one, but just to be aware, I wanted to describe it to you. I would continue with supportive care as mentioned and perhaps add an appetite stimulant like mirtazipine. Give her a little more time and see if she starts to come around and if not, you can discuss a further workup with your vet.

 

 

I hope this is helpful. If you would like any additional information or have additional questions please don't hesitate to ask!

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Dr. Z., Veterinarian
Category: Cat Veterinary
Satisfied Customers: 5970
Experience: Over 25 years of experience in caring for dogs and cats.
Dr. Z. and 2 other Cat Veterinary Specialists are ready to help you
Customer: replied 2 years ago.
Thanks so much Dr. Z,

Kes has been hospitalized since yesterday and did eat a little last night after the vet gave her some antinausea meds. She is now getting an acid-blocker to see if it helps. She had a test for pancreatitis which was negative. I'll talk to the vet about the other underlying possibilities.
Expert:  Dr. Z. replied 2 years ago.

That sounds good and it sounds like your vet is on the right track. Good luck to her and I hope all goes well.

Customer: replied 2 years ago.
Hello Dr. Z,

Some follow-up information please.

Kes is still not eating (about a teaspoon a day). She appears to not want to swallow, only licks the food. The vet has tried anti-nausea and acid-blockers now with no luck. X-rays show nothing other than she looks empty. She is trying the appetite stimulant you mentioned. Kes is now losing weight rapidly. Before this happened, she was heavier than she's been her entire life at 7.5 pounds. She has had no vomiting or history of vomiting (except for the occasional hairball) and prior to the antibiotics, no diarrhea. However, when I force fed her before being hospitalized on Monday, she did act like she was going to vomit a couple of times and had the "hairball gag". She did not want to swallow more than 6 or 7 mL at a time.

About a year and a half ago we went through a period of her not wanting to eat. It turned out that time that she was constipated with hair balls. Since then I've consistently given her hair-ball remedy. She was a little constipated this time starting when she didn't want to eat and was passing quite a bit of hair.

The vet is at a loss. The next plan is to give her barium and watch it go through to see if something shows up. Then, a feeding tube.
Her thoughts are maybe ulcers, inflammed esophagus, cancer of the esophagus. Her mouth and throat as far as can be seen look fine. She does sometimes appear to swallow hard when she does swallow. The vet says she doesn't act like a cat with cancer or in a lot of constant pain because she is somewhat active when they let her out of her cage. She's starting to get weak though.

Any other ideas? The vet is very open to any suggestions and we have a good relationship.

Thank you so much. I'm getting pretty worried and stressed out! So is my vet!
Expert:  Dr. Z. replied 2 years ago.

Thanks for the update and sorry for the delay. I was working in the clinic today. I can understand why you are stressed. This is all very concerning. Barium is not a bad idea, but even if abnormalities noted, will likely not give you the diagnosis. I would be tempted to be a little more aggressive in the hopes of getting a definitive diagnosis. A feeding tube is a necessity at this point as I think as she needs more aggressive nutritional support now. I would opt for a gastric feeding tube versus an esophageal tube since it seems there may possibly be something going on in her throat. I know a feeding tube sounds extreme, but they are a great way to support a poorly eating cat for whatever reason. If it is a problem that can be resolved, the tube can be a temporary measure, but if needed long term, they can be used for a long time. The cats tolerate them well. My own personal cat who had GI lymphoma had a gastric feeding tube for over 3 years and loved when we would feed him (he would just purr away).

 

As far as what diagnostics, I think an ultrasound would be a good place to start if one has not been done yet. It may help to decide what to do next if any abnormal organs are noted. Ultimately I think the decision needs to be endoscopy or exploratory to visualize and get biopsy samples. There are pros and cons to both.

 

1)Obviously, scoping her is less invasive and would allow visualization of the upper GI tract to rule out problems with the esophagus as well as stomach and in most cases with cats, proximal small intestine too. Biopsies of GI lining can be taken with a scope to look for inflammation or cancer, but there are limitations. Full thickness biopsies of the intestine cannot be done so there is a possibility that even if there is cellular infiltrate of the intestine it could be missed if in the deeper layers (this is a small risk). Also, endoscopy will not allow visualization of organs not within the GI tract, like pancreas or liver/spleen. This is where an ultrasound may help first to see if these organs look normal or not. A feeding tube can be placed with an endoscope.

 

2) An exploratory allows visualization of all organs and biopsy (including full thickness of GI) of the organs of concern as well as placement of a feeding tube. Of course, it is a much more invasive procedure with a little more involved recovery, but you are not likely to miss the diagnosis with this route. Even if everything looks grossly normal, biopsies of potentially involved organs should be taken. In the hands of an experienced surgeon, this procedure would not take too long.

 

I am starting to feel more and more that the teeth or the dental procedure was not the problem and they just brought the problem to light. I hope I am wrong, but with cats, I think you need to move fairly quick on this and not wait too much longer to get a definitive diagnosis.

 

There is not a right or wrong way to proceed her, so I would discuss with your vet and see what sounds best for her. I am sending good thoughts her way and hope you have an answer soon and can move towards resolving this for her. Good luck and please keep me updated as to how things progress.

Expert:  Dr. Z. replied 2 years ago.
Hi Nancy,

I'm just following up on our conversation about Kes. How is everything going?

Dr Z
Customer: replied 2 years ago.
Hi Dr. Z,

Thanks for asking, I really appreciate your concern. Well, on Thursday afternoon the vet gave Kes some of the mirtazapine and she ate 1/2 can fancy feast pretty quickly after that and another meal later that day. I took her home Friday afternoon with famotidine inj. and the mirtazapine. She ate some Friday evening and ate quite a bit yesterday, two cans of fancy feast and a little chicken. Most of it was hand fed, but I was very optimistic! She had a bowel movement Friday evening which looked good.

This morning she got the mirtazapine again and ate about 3/4 can. She has been drinking a lot of water today and urinating more than usual, about 4 x a day since Friday. This afternoon she starting looking like she wasn't feeling so good again and her appetite has decreased, so she's only eaten one can. She sits kind of hunched over and just doesn't look happy. She had another bowel movement which was kind of dry and hard. No vomiting. I did give her two fiber chews which she ate this morning. Afterwards I remember that the last time I gave these to her it upset her stomach. Stupid me!

I do have to remember that she's been through a lot and it may take some time to recover her appetite, I just hope there's nothing else major wrong. We didn't do the feeding tube or all the other work you recommended because she did start eating after the appetite stimulant. Also, my vet is a small-town country vet and doesn't have an endoscope. I have to thank you for recommending that drug. The vet didn't know about it which was why it took until Thursday for her to try it, she had to get some at a pharmacy. She thought that maybe Kes had developed a kind of food aversion after being force fed for so long on an upset stomach.

The vet is out of town the entire week next week, (of course!) so I'm nervous she's going to stop eating again. I do use another vet in a nearby town that I absolutely love but he's never seen Kes before, I take my dogs to him.

She's getting 1/4 tablet mirtazapine every three days, famotidine injections twice a day until today, then decrease to once a day until Friday. Does this sound reasonable? Do either of these drugs make cats thirsty as well as hungry? I want to give her probiotics, but she won't eat yogurt and she won't eat the powder I have sprinkled on food. Do you know of a tasty probiotic I can get somewhere?

I really appreciate you following up on Kes. It's kind of stressful not knowing. I bet you've heard a million times, "I wish they could tell me what's wrong!".

Thanks again for caring!

Nancy
Expert:  Dr. Z. replied 2 years ago.

Hi Nancy,

 

Well that is encouraging news. Yes that sounds like a good plan for now. I'll keep my fingers crossed that she continues to eat. I have not seen an increase in drinking due to either of these meds so it may just be coincidental. As far as probiotics, the one that I use most frequently is Purina Fortiflora link here Unfortunately, it is a powder, but the cats seem to accept it pretty readily.

 

If she stops eating again, you really will need to have her seen by someone. Even if they do not know her, another set of eyes may see something new and if you already know and trust this vet, even better. Good luck with her this week.

Customer: replied 2 years ago.
Hello Again Dr. Z,

Well Kes is now at a critical care hospital in Fresno, 75 miles away. She quit eating Sunday into Monday and was feeling bad so I took her to the other vet like you recommended. They suspected GI disease also, so I was referred to Fresno for an ultrasound. What they found by rechecking kidney function was acute renal failure! No signs of GI disease except for a small area of inflammation. She was constipated because of being dehydrated. Now I know why she was drinking so much.

The vet there is optimistic that she will make a full recovery since we caught it fairly soon and her values were not as high as some he's seen, creatinine was 3.5, don't remember when BUN was but it was further out of normal range. Her urine was cloudy and very pale.

He said sometimes after teeth are pulled and antibiotics are not given long enough afterwards, this can happen. I cut the ABs short because I thought it was upsetting her stomach.

Today, Wednesday her creatinine was down only a little but BUN was down more, only 1 point above normal. They will continue to hospitalize her for now.

I want to thank you so much for your advice. I'd be happy to give more of a payment or donation, how do I do that?

Nancy

Expert:  Dr. Z. replied 2 years ago.
Nancy,

I am very happy to hear all of this news and it sounds like Kes is in good hands. I'll bet you are very relieved.

The system is in a state of transition at the moment so I am not even sure what your screen looks like, but in the past, you have been able to leave a bonus after an accept or positive rating. That really is not necessary, but if you can't find a way to do that, you could contact customer service.
Dr. Z., Veterinarian
Category: Cat Veterinary
Satisfied Customers: 5970
Experience: Over 25 years of experience in caring for dogs and cats.
Dr. Z. and 2 other Cat Veterinary Specialists are ready to help you
Customer: replied 2 years ago.
Hello again Dr. Z,

Kes is feeling really good now, eating, being social, and grooming herself! I have a quick question please:

The vet said she should be urinating four times a day and I can give her Sub-Q fluids if she isn't drinking enough. I don't know if this guideline was because she needs to stay extra hydrated. Her normal frequency before all this happened was twice a day, and when she went into kidney failure she was urinating four times a day. For the past two days I've given her 150 mL fluids and she still is only urinating 3 times a day. She doesn't drink as much when I give her the fluids. Kes goes in to have her kidney levels checked tomorrow afternoon.

I haven't given her any fluids yet today and she hasn't urinated for 11-12 hours. Should I continue to give her fluids? Will this help her kidneys or keep her from drinking normal amounts? I saw her drink twice today and she's eaten about 5 ounces of wet food since 6:00 this morning.

When I give her the fluids, the "bubble" lasts for at least 10 hours and last time a little bit leaked out.

Did you get the bonus? If it wasn't for your advice, Kes probably wouldn't be doing so well now so thanks a million!!

Nancy
Expert:  Dr. Z. replied 2 years ago.
Nancy,
............
Sorry for the delay, but I was not around a computer much today. Yes, I would give her the fluids tonight. They will continue to help her kidneys if they still need support. Don't worry if she doesn't drink much when she gets the fluid. That is not uncommon for their intake to decrease when they are being supplemented.
It sounds like everything is going well with the fluid administration.
............
Thanks for the continued updates. Yes, I did get the bonus and really appreciate it. I hope all goes well tomorrow.

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