Friday, June 5, 2009

Kitties Aren't Supposed To Be Yellow

So when Snaps came to see us and we saw the very bright discoloration of her skin, gums, ears-even what should have been the "whites" of her eyes, well, we knew there was something serious going on.

Her owners said Snaps just wasn't herself. She had vomited a few times, but really wasn't eating well and the once very obese cat now just looked moderately overweight-a very dramatic and rapid weight loss for her. Her owners knew something was wrong, but hadn't realized their kitty was practically glowing in the dark.

Jaundice or icterus is the name of this whole body yellowing, resulting from a yellow pigment, bilirubin, normally kept in check by the liver. Diseases of the liver, of course, can result in this icterus, but so can primary diseases of the biliary system itself-the gall bladder or bile ducts. Other less common causes include hemolytic anemias, where red blood cells are destroyed, often by the body's own immune system. Snap's blood tests led us in the direction of her gall bladder-her liver and red blood cells seemed to be just fine.

You have probably heard of bile ducts but may not really be sure what bile is all about. Bile is a greenish material the liver makes, then transports to the gall bladder via small bile ducts. The gall bladder is a small greenish sac about the size of a large cherry in a cat where bile is stored. When the appropriate hormonal signals are present, the gall bladder contracts and squirts bile into the small intestine via one very large duct called the common bile duct.

Bile has several functions. It emulsifies the fat in our diets so that we can absorb it into our bodies. It also serves as a medium to dump toxins that the liver has removed and processed from our bodies. Mixed and bonded in bile salts, these cannot be reabsorbed from the intestine back into the body and are harmlessly excreted in feces.

Diseases of the gall bladder can be infectious, usually bacterial or neoplastic (cancerous) especially in older patients. We also see mechanical problems with the biliary system-sludging or thickening of the contents (bile) or even gall stones blocking passage of the bile through the bile ducts. These can be very painful conditions, and often cause anorexia because every time the patient goes to eat the gall bladder contracts to empty its contents into the small intestine to aid in digestion. If there is a blockage or infection/inflammation, contraction produces pain- the cat will associate eating with pain, so will simply stop eating to avoid that pain.

Now, one would think that weight loss in an obese cat would be a good thing. But cats are difficult creatures, for sure. As obligate carnivores, they require protein daily. If they aren't ingesting it, they will find it somewhere-even utilizing their own liver tissue as a source of that protein. The body will use the liver cells and replace these hepatocytes with adipose or fat cells causing a very serious condition called hepatic lipidosis or "fatty liver disease." Sometimes this is actually the primary disease, but usually there is some reason that the cat stopped eating well.

Since Snaps was essentially starving herself, we anesthetized her and placed a stomach feeding tube. This made it much easier for us and her owners to syringe feed her calculated needed calories each day (rather than trying to do so by mouth and having more of the food end up ON her rather than IN her!) It was also a good way to give her medications-just mixing those pills and capsules with liquids and foods and putting them directly in the tube rather than fighting her for that, too. We prescribed a long course of antibiotics and antimicrobials as well as anti-nausea medication and pain relief drugs. She was also given a whole bunch of fluids under her skin to help start flushing her liver of those built up toxins and pigments. Snaps was also started on a type of medication known as a "cholorectic." Ursodiol or actigal is this medication that makes bile more liquid so that it can flow smoothly without sludging. Flow of bile in the proper direction helps remove not only the toxins the liver is trying to remove in bile but also helps prevent bacteria from swimming upstream towards the liver tissue. We were hoping that her bile ducts were not actually blocked or that Snaps did not have gall stones present as cholorectic drugs would not work for these issues-surgery would be her only option in those cases.

So, Snaps was sent home with a whole lot of nursing care expected of her very devoted owners. They did a fabulous job with her-at one point it even looked like she was less jaundiced and had even gained some weight. But Snaps never did begin eating on her own, and it wasn't long before she began to vomit the food her owners gave in the tube if they tried to give any more than just a minimal amount. It wasn't enough to maintain her weight any longer, and she started getting more yellow by the day. She was licking her lips and acting nauseous if she even saw her owners approach her with food. I strongly suspected a biliary duct blockage or gallstones, but would need an ultrasound exam to be sure.

We referred Snaps' owners to a veterinary internal medicine specialist for that procedure. Unfortunately, their costs were estimated to be quite high, as was to be expected of such a specialized procedure with biopsies and lab reports involved. I had scanned many abdomens but was far from an expert, so offered my services for free just to visualize the gall bladder and liver only and determine the presence or absence of gallstones or big dilated biliray ducts-signs indicating likely blockages. Snaps' owners were very grateful, and it did give me more experience with this procedure.

Well, the ultrasound scan was pretty quick and easy-a homogenic (even throughout) liver-no obvious masses or other defects with a very large gall bladder and hyperechoic (very bright white) structures in the lumen. (center) Snaps has gallstones. No amount of medications will fix these-she has to have surgery to relieve the pain felt every time the organ contracts down on those stones each time she eats (or is tube fed for that matter.) What a horrible situation that must be-to be in pain just because of a basic need and a generally pleasurable function-eating.

We have talked with her owners and will try to come up with a plan for her. While referral to a veterinary surgeon is highly recommended for a cholocystectomy, (gall bladder removal) money of course is a big factor. We might be able to use some funds from our Flake's Angel Fund if the owner can match those funds and attempt to do this surgery ourselves. I have done a few others-it is a very difficult surgery but am hoping to get some tips for better visualization (I have found this to be the key to this surgery) from the veterinary surgeons we work with. They are very helpful that way.

Snaps' owners are saving up their money deciding what they want to do (and what they are able to do.) In the mean time they will continue to try to get food into her, even if it is just small amounts very frequently. Her liver medications aren't as important, but her pain relief meds certainly are.

I'll try to post some pictures of her surgery when/if we get to do it. She is a great kitty and she has very nice owners who are doing a great job with her care. Not all owners would be this devoted, that's for sure.

I felt so bad neglecting my blog this long-it is good to be back!