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Oops, hit return too soon... It's a DSH feline, coming up on

Hi, ... JA: What sort of...
Hi, ...
JA: What sort of animal are we talking about?
Customer: Oops, hit return too soon...
JA: Maybe I'm confused. I thought you had a problem with a pet. Is that correct?
Customer: It's a DSH feline, coming up on 15 years. Progressive increase in frequency of vomiting over the past several months. History of vomiting, decreased appetite, weight loss, dehydration several months ago. Took her to my vet, routine labs significant only for elevated glucose. X-rays showed increased transverse colon gas, and some sort of jumbled stuff more ventral to that, kind of looking like full bowel (the vet did not feel confident in definitive radiological diagnosis). I took her home with a bag of saline and gave her fluids subQ for a week and she gradually improved, started eating and drinking again. She seemed to get back to normal, but then seemed like she seemed to get an upset stomach and vomit more and more easily. At first it was just after eating grass, which was not unusual for her. Then she seemed more and more likely to vomit if I gave her more than a tiny bit of milk. Lately she has been vomiting without having eaten anything unusual (or anything at all), maybe every two or three days now. Emesis is fairly clear, mucusy, with a tinge of pink/red like blood, and maybe a little tiny bit of "coffee-grounds." I have an appointment with the vet in two days. My concern is about a GI cancer, vs. maybe a chronic obstruction or torsion. I have the abdominal X-ray images, if there were some way to transmit them.
JA: I'm sorry to hear that. This sounds like it might be serious. I'll let the Veterinarian know what's going on ASAP. Is there anything else important you think the Veterinarian should know about the feline?
Customer: No.
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Answered in 3 hours by:
11/21/2017
Dr. Peck
Dr. Peck, Cat Veterinarian
Category: Cat Veterinary
Satisfied Customers: 376
Experience: Associate Veterinarian at Meadow Hill's
Verified

Greetings, I’m Dr. Peck, a small animal veterinarian in general practice. Hopefully I might be of some help. One moment while I reply…

Disclaimer: This communication is for discussion purposes only. Without seeing an animal in person, a valid veterinary-client-patient relationship does not exist, and therefore I am unable to diagnose, prognose, or treat. Any comments made during discussion here are based on the information provided and are simply my thoughts regarding what I’d be considering were this type of case presented to me in person. The best recommendation for any veterinary-related concern is to seek veterinary assessment in person with your local veterinarian.

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From what you've written here, I'd be concerned about occult kidney disease or lymphoma. There are certainly other possibilities. But in a senior cat with those clinical signs and fairly normal bloodwork those two would be at the top of my mind. If a urinalysis wasn't assessed in the routine labs (i.e. if that only included bloodwork) I'd suggest pursuing a urinalysis. Other tests to look at the kidneys more closely might be considered as well, such as a blood pressure check, a urine protein:creatinine ratio, and/or an SDMA blood test - including in some routine panels but not most, and can pickup on kidney disease earlier than routine monitoring values.

I'd also suggest considering an abdominal ultrasound. This could look at the kidneys closely as well as assess the intestines for evidence of thickening / loss of wall layering / other abnormalities. Intestinal / intra-abdominal lymphoma or other cancers in the abdomen would need an aspiration or biopsy to definitively diagnoses. Start with an ultrasound and if abnormalities are identified discuss with your vet where to go from there (exploratory surgery, fine-needle aspiration with ultrasound guidance, endoscopic biopsies - you're vet might not be able to offer all of these options and referral may be necessary).

Again, there are other possibilities, but I'd bank on ultrasound and more specific look at kidneys as the next things to consider in my opinion. This is assuming thyroid was checked with the routine labwork you mentioned. If not, that should be assessed as well.

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I hope my thoughts are helpful to you. Let me know if you have any follow-up questions, simply write me back! I’ll reply as soon as I’m able. Otherwise, please be sure to kindly rate using the stars, so that I receive credit for helping with your question today (this is how professionals on this site are compensated for their time). Thanks! – Dr. Peck.

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Customer reply replied 24 days ago
Thank you Dr. Peck. Those are good thoughts.I found the lab reports from that visit, which it turns out was about a year ago (sorry, I could have save you some effort by providing this earlier). I was wrong that elevated blood glucose was the only significant finding (lymphocytes borderline low, lipase slightly elevated; see attached). Does this help steer the differential toward lymphoma vs. renal disease?I could've sworn she had a UA but I can't find a report. I'll bring that up. She did have an abdominal US. I don't have a report for that either, but my my recollection is that it didn't provide any new information. Imaging was a year ago though, so probably worth repeating? (By the way, did the abdominal X-rays come through as an attachment with my original question? I'm attaching it again just in case.)Thank you again Dr. Peck,Jeff

Thanks for the update.

Lipase elevation can be seen with a variety of conditions, it and low lymphocytes are fairly non-specific and may or may not be significant - I see these often in healthy senior cats. Lymphocyte counts can do different things (up/down) in cats with lymphoma.

A year is an very long time in a nearly 15 year old cat. In my senior cat patients, I suggest monitoring bloodwork every 6-12 months for my healthy patients, ideally every 6 months, as again, a lot can change in that amount of time at that age.

I don't see a thyroid check on the labwork. A teenage cat with weight loss should absolutely have a thyroid checked.

Bloodwork needs to be rechecked (the blood count and chemistry panel that you did last year) as well. E.g. if underlying kidney disease is the culprit it may now be very clearly evident on that routine labwork. If the hyperglycemia was significant, she could now be clearly diabetic. Stressed cats often have a mild increase in their glucose so it can be a difficult call initially at times when the signs don't all quite fit. A fructosamine can be checked to rule a stress hyperglycemia out. Other changes on the labwork at this time might point you in a different direction (e.g. elevated liver values would indicate imaging the liver carefully is a good next step to take).

A urinalysis is very important to obtain to evaluate along with this routine labwork as well, especially in regards ***** ***** disease or diabetes.

I'd suggest a blood count, chemistry panel, urinalysis, and thyroid evaluation at this time before anything else. If there is no evidence of diabetes, kidney disease, or hyperthyroidism, then yes I'd recommend pursuing repeat imaging with x-rays and an ultrasound - again, a year is a long time, a lot may have changed.

You might ask your vet about FeLV/FIV viral testing depending on her vaccine history, risk level, and your areas incidence of these diseases.

Repeating routine "senior" labs is the place to start, get her in for those and go from there based on what's changed. Good luck! Let me know if you have additional comments/questions, and again, don't forget to please rate kindly with the stars, thanks! - Dr. Peck

Dr. Peck
Dr. Peck, Cat Veterinarian
Category: Cat Veterinary
Satisfied Customers: 376
Experience: Associate Veterinarian at Meadow Hill's
Verified
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Customer reply replied 10 days ago
Dr. Peck,Sorry I never responded to your last message. I know it's nice to have follow-up, so I will give you an update.Thank you for your advice; I followed it completely (CBC, CMP, UA, thyroid function) with one exception: I decided to go ahead and ask for some "therapeutic imaging," a repeat abdominal/pelvic X-ray series. I wish I had the lab results to give you, but they are still pending, since the clinic's on-site facilities weren't working and they had to send them out, with a delay because of the holidays. I also brought a stool sample and a bit of the emesis that I thought might have blood.My main fear was cancer, so I thought the X-rays might at least reassure me that there were major masses, and it looked pretty good. The only thing of possible significance was that she did appear to have thickening in the walls of the duodenum/proximal small bowel. My vet says this raises the possibility of lymphoma, a "small-cell" lymphoma being the most common. She felt this was low-likelihood, but should be included in the differential. Depending on lab results, she may recommend a biopsy.I have been advised to make sure she has a laparoscopic rather than open biopsy (I guess imaging-guided biopsy is not recommended since multiple sites should be biopsied and image-guided would not be as reliable?).I asked about treatment and prognosis -- in the event she does have lymphoma -- and while it sounds like the prognosis is good I am not happy about the prospect of chronic steroid therapy and all of the problems that come with that.I will update you on the ultimate diagnosis. Thanks again for your help,Jeffrey Gordon

Thanks for the update Jeffrey. It sounds like you are in great hands and moving in the right direction. Best of luck. - Dr. Peck

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Dr. Peck
Dr. Peck
Dr. Peck, Cat Veterinarian
Category: Cat Veterinary
Satisfied Customers: 376
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Experience: Associate Veterinarian at Meadow Hill's

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