What's wrong with my cat who is now mostly unresponsive after a day of vomiting?
November 22, 2009 7:52 AM   Subscribe

What is wrong with my cat? We've been to both the regular and emergency vets in the last 24 hours, and we still don't know what's wrong or why she isn't improving. (Details within.)

Our geriatric female cat (about 14 years old) is extremely listless, almost to the point of unresponsiveness. In the past six months, she has been drinking a lot more than usual (polydipsia), as well as urinating more than usual (polyuria), but our efforts to determine what was wrong through blood tests had not been successful (elevated BUN but normal creatinine and phosphorus; tyhroid panel normal). Behaviorally, otherwise, she seemed perfectly normal and active, perhaps even more hungry than in previous months (she's fed a tin of wet food a day, and always has dry food available).

On Thursday evening, she managed to trick my girlfriend and I into feeding her two tins of wet food, and seemed happy to eat both. On Friday, my girlfriend discovered that she had vomited all over the kitchen (food with chunks of solid kibble, some hairball) as well as left stool on the kitchen floor (highly unusual for her!). Friday night, there was more vomiting, of thin brown foul-smelling liquid. By Saturday, the cat was listless and showed no interest in eating or drinking. We took her to the vet, who ran a blood workup (elevated BUN, normal creatinine and phosphate, no elevated white blood cell count, still awaiting thyroid results) and provided sub-Q fluids and suggested a bland diet of baby food. The cat was down from ~ 8 lbs (six months ago) to ~ 6.5 lbs, which was very worrying. Feeding her baby food via syringe seemed fine at first -- she held it down for a few hours -- but it all came up eventually, as this thin brown foul-smelling liquid. Some urine was produced after the vet visit, but no stool.

Late Saturday night, as she became increasingly unresponsive (she normally would put up a bit of a fight if you picked her up) and she continued to sit in a hunched-over posture, we took her to the emergency vet. An examination suggested nodules on the thyroid, and the vet could feel stool in her abdomen. They provided her with more sub-Q fluilds, an antiemetic to help relieve the nausea and vomiting, and 1/4 of a 15 mg mirtazapine to stimulate her appetite. After the mirtazapine, she looks somewhat stoned, and her heartrate is very rapid. Her discomfort hasn't improved since we brought her home several hours ago, and in fact, the mirtazapine may have made her more uncomfortable. In principle, it was *supposed* to perk her up and get her interested in eating again, but it doesn't seem to be having this effect.

Longer-term, I'm hoping that the thyroid retest will give us some clue as to her excessive thirst/urination problem, and then we'll probably need to address any renal issues that show up as well as the possibility of irritable bowel disease or feline leukemia, but I'm honestly at a complete loss as to how to pull her through the current acute issue. The best I can do right now is to try to make it comfortable, it seems, and make sure she stays hydrated with sub-Q fluids and see if she will keep some force-fed bland food down.

But I wonder if we might be missing something obvious. She's an indoor cat, so parasites would seem unlikely. She's had similar vomiting/hairball issues in the past, but has always pulled through them in quick order. We've been in a number of times for urinal tract infections, but urination seems fine and there's no elevated white blood cell count.

Does anybody have any other ideas? Should we pursue other types of screening (X-ray, ultrasound) that are expensive and likely won't actually tell us anything definitive?
posted by enoent to Pets & Animals (34 answers total)
Did they suggest doing a urinalysis? Sometimes a UTI can go undetected in the blood test but would show in the urine. May I ask what kind of food you're feeding her? Sometimes the food itself can cause an allergy and the cat will respond in the way you're describing. An ultrasound, if done by someone who knows how to do it well, can be beneficial in dx'ing any abnormalities in the abdominal cavity.

The tell tale signs of UTI's in felines
posted by watercarrier at 8:04 AM on November 22, 2009

posted by watercarrier at 8:05 AM on November 22, 2009

Have they checked for diabetes? She sounds similar to what my cat was like when he had blood sugar issues.

Also, wrt:1/4 of a 15 mg mirtazapine to stimulate her appetite. After the mirtazapine, she looks somewhat stoned -
Mirtazapine may make people eat more, but it also helps sleep. Cat seeming stoned may be normal on this drug.
posted by kellyblah at 8:13 AM on November 22, 2009

If she eating? Is she still vomiting everything? An x-ray could determine if there was anything stuck in her stomach. Does your cat eat plastic bags or chew anything that is left on the floor? There's also a remote possibility that her digestive system may just be conking out and won't process food properly. I lost a 13 year old cat with similar symptoms to a very early cancer that left him with a belly full of food with nowhere to go. Blood tests showed nothing; x-ray and surgery confirmed the belly full of kibble.

I hope this is something relatively minor and repairable, but please try an x-ray as well.
posted by maudlin at 8:21 AM on November 22, 2009

She sounds very similar to my cat who had hyper-thyroid and kidney failure. The thyroid didn't show up on tests right away even though she showed all the symptoms. My vet decided to assume the problems were due to the thyroid so we tried some thyroid medication to see how she would do on it. It worked like a charm and she was on thyroid medication for a few years. She made it to 18 before the kidneys got so bad she had to be put down.
posted by sadtomato at 8:21 AM on November 22, 2009

My thoughts are along the line with what maudlin is saying. Have they tried anything to move the stool? My cat (only 4!) had a similar vomiting episode once from severe constipation/hairballs.
posted by PhoBWanKenobi at 8:25 AM on November 22, 2009

(Oh, and the vet was reluctant to do an enema in case he'd eaten something he shouldn't have, but they--ew--manually extracted the stool and everything was fine.)
posted by PhoBWanKenobi at 8:26 AM on November 22, 2009

My cat had something like this - episodes of vomiting on and off which he always pulled through - but when he was 13, he started vomiting more and losing weight.

In his case, it ended up that he had intestinal lymphoma. Have they done an ultrasound? Apparently it's almost impossible to tell the difference between that and other GI disorders (for example, eosinophilic fibrosing gastritis) without doing a physical biopsy. If they treat your cat with prednisone, however, and she starts to improve and continues to do well, then it's probably one of the "lesser" disorders, not cancer.

However, IANAV, this is only my personal experience.

Regardless - you'll want x-rays and an ultrasound, if they haven't been done.

As for getting the cat to eat - try using some catnip first, then the 'Fish and Shrimp Feast' made by Fancy Feast. It's the stinkiest stuff imaginable, but cats seem to love it.
posted by HopperFan at 8:38 AM on November 22, 2009 [1 favorite]

Response by poster: Thanks for all of the fantastic suggestions so far. Some brief responses:

@watercarrier: We didn't do a urinalysis this time (she was dehydrated when we brought her to the vet the first time), but that's a good piece of information to get when we go back. She's had UTIs before, but they've manifested themselves with more "typical" symptoms: Many trips to the litterbox, producing urine in only small quantities, vocal distress, elevated WBC. This didn't seem to match those symptoms, as she's producing normal, expected quantities of urine.

@liketitanic: Yes, we're definitely keeping her hydrated with sub-Q fluid administration. We certainly haven't ruled out kidney issues -- her symptoms sound very much like those of a cat with chronic renal failure, but to diagnose CRF, you look for elevated BUN *and* creatinine (and generally phosphate) levels, from what I understand. While BUN was elevated, creatinine and phosphate were normal in her blood workup. That doesn't mean there aren't any kidney problems -- they could be masked by hypothyroidism, which also could explain weight loss despite good appetite, polyuria, polydipsia. It's something we definitely want to follow up on once we get her through this bad spell. Diabetes is a possibility, but we don't have enough information to be able to diagnose that yet. The glucose levels were high, but the vet explained that any cat you bring into a vet will have high glucose levels because they're generally scared to death. I'll look more into this, though.
posted by enoent at 9:02 AM on November 22, 2009

Response by poster: Update: We just got a call from the vet, who was able to check on the thyroid results. She *is* hyperthyroid, which helps explain the excessive thirst/urination, good appetite, but weight loss.

The vet also suggested that her failure to improve really makes him think of the two most likely causes that might be causing intestinal bleeding (which he thinks is responsible for this acute episode): inflammatory bowel disease (IBD) and leukemia. While it's hard to diagnose one or the other for certain (IBD requires a biopsy of intestinal tissue, it seems) both respond positively to steroid treatment, so this might be an option to start today. The long-term prognosis for leukemia is bad, of course, but we would be doing what we can for now.

I believe the hyperthyroid issue can be treated effectively with a daily medication in pill form. We'll look into this once we get through the current rough spot.
posted by enoent at 9:08 AM on November 22, 2009

Response by poster: @kellyblah: Thanks for the heads-up on mirtazapine. It's good to know that this isn't completely unexpected behavior.

@maudlin: She does have an affinity for chewing on sheets of paper or plastic bags, but I hadn't noticed anything bad had been eaten in the last few days. Thanks for providing some arguments for having the X-ray done. We had opted not to do the X-ray last night because (1) the cat was miserable already, (2) it would have cost $240 without a guarantee of providing us with definitive information (after an already tremendously-expensive day), and (3) the things it was likely to find (solid tumors, foreign objects) were all difficult and even more expensive to correct through surgery. We'll re-evaluate whether that seems like a sensible idea today and tomorrow. I've managed to feed her some baby food diluted a bit with water and force-fed via syringe (the recommended "bland diet" by the regular vet) -- if she can't keep this down, that might be a persuasive argument that an X-ray would help reveal a blockage.
posted by enoent at 9:15 AM on November 22, 2009

Response by poster: @sadtomato: I was thrilled to see this. I think this is the "best-case scenario" for us right now, in my mind. I'm so glad that this helped your cat enjoy another few wonderful years, and hope that we might be in a similar situation, especially now that we have a firm diagnosis of hyperthyroidism.
posted by enoent at 9:17 AM on November 22, 2009

Response by poster: @PhoBWanKenobi: I'll ask about the possibility of manual stool extraction. We know there's stool in there (the vet could palpitate it), so if it doesn't come out in the next 24h, it certainly makes sense to try to move it out somehow.

@HopperFan: It's good to have another vote in favor of X-rays and ultrasound. The steroid treatment option is the one advocated by the emergency vet right now, and I'd hope that things improve and stay that way for a while. I don't think I'd want to put her through a biopsy, and if it did confirm there was cancer, there's not much we could afford to do about it.
posted by enoent at 9:22 AM on November 22, 2009

Response by poster: @HopperFan: Oh, we'll definitely get some 'fish and shrimp feast' to try to tempt her into eating on her own -- Thanks! :)
posted by enoent at 9:23 AM on November 22, 2009

Oh, and let this be a third for at least an X-ray: that's how they found the stool plug (ewewew) in my kitty when he was stopped up.
posted by PhoBWanKenobi at 9:30 AM on November 22, 2009

to diagnose CRF, you look for elevated BUN *and* creatinine (and generally phosphate) levels, from what I understand. While BUN was elevated, creatinine and phosphate were normal in her blood workup.

You're correct about the BUN and creatine BOTH being CRF indicators (as I just learned myself, with my own cat, two days ago :-<>
It sounds like you've gotten an answer by now, but I did want to confirm this for you, anyway.
posted by EmpressCallipygos at 10:10 AM on November 22, 2009

Extreme thirst and hunger with weight loss are symptoms of diabetes, among other things, but glucose so high that it would be symptomatic would not be explicable through stress alone. Was the glucose very high, or just a little elevated?
posted by palliser at 10:33 AM on November 22, 2009

Sorry your kitty is sick. Something for the back of your mind when the current drama is over: a common treatment for hyperthyroidism is methimazole. If your vet suggests that, know that there's a topical ointment form available. My pharmacy calls it "QuickDose 2.5 mg/turn TDGPen". Just a little dab of goo in kitty's ear, much easier than getting them to reliably take a pill. Only mentioning it because many of the vets I've talked to have never heard of it, but it seems to work well and conveniently.
posted by Nelson at 10:36 AM on November 22, 2009 [1 favorite]

Having a sick cat is so stressful. I went through something similar (but not similar enough for me to tell you what's wrong with your cat) earlier this year.

My advice to you, if it is financially feasible for you, is to get as many of the tests, xrays and ultrasounds out of the way as you can as soon as possible. We went the conservative route when our kitty got sick and spent months taking care of him and taking personal days off work and staying up all night at the emergency vet only to finally pony up for an ultrasound that showed he was dying. It would have have saved him a lot of discomfort and us a lot of stress and heartache if we had just done the damn ultrasound first. We were trying to save money but it really wasn't worth it.

I hope the prognosis for your kitty ends up being better than it was for ours, though.
posted by Jess the Mess at 11:38 AM on November 22, 2009

Every cat is different, I'm not necessarily suggesting this is what's wrong, but the symptoms you've described (the foul-smelling brown liquid, the palpable stool, the lethargy and hunched-over posture) sound very similar to what one of our cats experienced when she had an intestinal twist/blockage.

I hope you get answers soon and your kitty recovers quickly.
posted by cooker girl at 12:36 PM on November 22, 2009

For a cat that old it's entirely reasonable to not have x-rays or ultrasound done. Particularly since right now you've got a few options which all respond to similar treatment. The tests may just confirm steroids vs steroids, in which case why not just try steroids (which should be prednisolone btw, more expensive than prednisone but more effective in cats).?

The question I'd be asking is how much of a difference will the extra tests make? For example, what if she turns out to have lymphoma? Chemotherapy for that is very expensive and has something like an 80% response rate (so does nothing 20% of the time). You may decide you can't afford it in which case the expensive test that got you that diagnosis was wasted money, you might as well have stuck with the steroids. Alternatively that extra test result may be the difference between giving her a life saving treatment vs one that makes things worse, in which case it would be helpful to find out. I understand the need to have a diagnosis but really it's only a tool to guide and improve treatment.

I have made the decision not to have tests when my cat's symptoms were clear enough that diagnosing the cause wasn't going to change the treatment. He had gotten sick very fast so a cure wasn't possible and we managed his symptoms and gave him a comfortable extra ten months. I recently went the other way, had an escalating series of incredibly expensive tests for his sister (now 15 years old). It was a difficult decision particularly as once you start down that road there's strong impetus to keep going, otherwise the first tests are wasted (e.g. why have an ultrasound to show a lump if you're not going to biopsy the lump to see what it is?). For us it was worth it, we eventually got a diagnosis which is progressive but treatable, but at the same time we didn't have any clues as to what it was until we'd been through all the tests so the cost/benefit ratio was different.

Only you can decide the cost benefit ratio of each option. It's entirely reasonable to have a money limit to what you can afford to spend as well as a limit for how much stress you can put your cat through, and a good vet will discuss all the options with you without being judgemental or pushy. The people here telling you absolutely that you must have tests don't really know what they're on about, they're not your vet and not qualified to give that advice.

Lastly, Mandy's currently on steroids and when they say increased appetite is a side effect they aren't kidding. She's never been so hungry so often and she's pretty oriented already. So if you do go with that treatment option it should help the eating issues too.
posted by shelleycat at 1:04 PM on November 22, 2009

Ug, that was supposed to say she's pretty food oriented already.
posted by shelleycat at 1:14 PM on November 22, 2009

For a cat that old it's entirely reasonable to not have x-rays or ultrasound done. ... The people here telling you absolutely that you must have tests don't really know what they're on about, they're not your vet and not qualified to give that advice.

I'm one of the people who advised the x-ray earlier in the thread, before the test results came back, if the cat was still not eating or crapping, or if the vomiting was continuing. I hope she can keep down the bland food, but I'm encouraged, enoent, to see that you are considering an x-ray if she continues to show these symptoms.

But I really must object to shelleycat's argument that old cats can reasonably skip x-rays or diagnostic tests, or that anyone here who disagrees with her doesn't know what they're talking about.

I had a 13 year old cat whose usual pattern of regurgitation lasted longer than usual. I brought him into the vet after a day of very little eating and drinking. Bloodwork showed nothing, and I was offered an x-ray but decided not to get it because of the cost and the extended time he'd have to spend in the clinic. I have never brought my cats in to the vet for the hell of it and I have eschewed heroic measures before. But after another day of seeming recovery, then a relapse, I brought him in again, where the x-ray showed a mass which, at first, we thought had to be some kind of blockage from a foreign object. He underwent immediate surgery to take care of this immediate and repairable issue with a great prognosis. When it was obvious it was not a blockage, but a few days worth of undigested food, and that heroic treatment would not likely to give him much more time, I agreed to have him put to sleep while still on the table.

There is no reason to say that a reasonable diagnostic test equates to an embrace of extended treatment. If the possibility exists, however, that the animal is in immediate distress, it's better to know sooner than later. X-rays are expensive, surgery is expensive, but in some cases, they are a valid way to proceed.

I'm not saying this to alarm you, enoent. I hope your cat is just having a tough time as, perhaps, IBD and thyroid issues combine, and that the steroids and bland diet return her to health very soon. But if you judge that x-rays may be necessary, go for it.
posted by maudlin at 1:42 PM on November 22, 2009

(You know, on second reading, shellycat and I aren't that far apart. Sorry about that.)
posted by maudlin at 1:56 PM on November 22, 2009

I'll chime in here to refute shelleycat's statement that owners of old cats should skip x-rays and diagnostic tests and to encourage enoent to get ultrasounds or x-rays, if those are still needed.

I have a 14 year old cat who nearly died earlier this year from kidney stones that were blocking the tubes from the kidneys to the bladder. Blood tests and urine tests showed nothing; x-rays showed her kidneys were swollen; ultrasounds finally showed why (big ol' stones!). She's now the picture of health again, thanks to the diagnostic tests, x-rays and ultrasounds. Without those, she'd be gone now. Her doctor thinks she'll live to a ripe old age of 20 or older (holy carp... I have another six years with this animal??).
posted by LOLAttorney2009 at 2:03 PM on November 22, 2009

Hello, please read what I wrote. I said that this is a decision that the OP needs to make with their vet, that it can be reasonable to go either way based on the specific circumstances, and that none of us can say definitively one way or the other. You guys really think you're qualified to make medical decisions for someone else's pet?

(LOLAttorney2009 maybe you need to follow maudlin 's lead and REREAD)
posted by shelleycat at 2:20 PM on November 22, 2009

Can cats get gastroenteritis?
posted by gjc at 2:21 PM on November 22, 2009

Arg. And on my rereading the first sentence I wrote should say it may be entirely reasonable. Although the second paragraph makes it clear anyway for those who bothered to read that far.

And gjc cat's can get pretty much anything humans can, in some form or other. They have somachs and immune systems after, after all so of course the stomach can get inflammed.
posted by shelleycat at 2:25 PM on November 22, 2009

Has the calcium level been checked? High calcium can cause these symptoms.
posted by neuron at 3:01 PM on November 22, 2009

Response by poster: Update: Brought cat back to vet this afternoon for steroids, counseled by emergency vet over phone as he was going off duty. By the time we saw the vet around 1 pm, cat was dehydrated again (more fluids) and had a temperature of 104.6 F -- a new development. As a result, the vet didn't want to give steroids that suppress the immune system, and prescribed antibiotics instead. The vet was unable to find stool in palpating her abdomen. She got a shot of antibiotics (Polyflex) and a shot to combat stomach acid (Zantac) before going home. While pretty active at the vet, she has remained pretty listless, though she purred when we petted her after she got home, which she hadn't done all of yesterday.

The doctor sent us home with some antibiotics (Baytril, as she doesn't tolerate clavamox well) to follow up on, as well as medication for the hyperthyroidism (methimazole), both of which I'm to start tonight.

A few hours after the visit, her temperature is 105.0 F. I'm supposed to bring her back in if the temperature gets much higher than that. She urinated normally, but is clearly quite "out of it". With a fever that high, it's totally understandable.
posted by enoent at 5:43 PM on November 22, 2009

Response by poster: @palliser: Regarding diabetes: Previous urine and bloodwork haven't shown signs of diabetes, though we haven't had a chance to run a urine sample this time. The glucose level from her blood test yesterday was 230 mg/dL, way above the standard range of 60-120 mg/dL, but our vet specifically told me that this elevated level was not uncommon for cats visiting the vet, and that it didn't seem like something to panic over. Two other vets have seen the bloodwork results and said it seemed fine.

@Nelson: Thank you for letting us know about the topical methimazole! This will certainly be incredibly helpful, especially if we have to show cat-sitters how to take care of her when we're away in future.

@neuron: Thanks for the heads-up on calcium levels. The bloodwork from yesterday had the calcium level reported as 9.2 mg/dL, within the standard 7.8 - 11.3 mg/dL range.
posted by enoent at 5:49 PM on November 22, 2009

Response by poster: @Jess the Mess and @cooker girl: Good points. I'll see if we can get ultrasound or X-rays with our regular vet in the morning, where everything costs half the price of the emergency vet clinic we've been to today.
posted by enoent at 5:51 PM on November 22, 2009

Response by poster: @shelleycat and @maudlin: Thank you both for your stories and insight on this. I think we're going to reassess the X-ray and ultrasound situation with our regular vet in the morning.
posted by enoent at 5:55 PM on November 22, 2009

@enoent: We have a 11.5 yo indoor cat who has become very listless after several vomiting episodes 2 nights ago. We took her to the vet yesterday and did x-rays, which came back negative for masses or blockage. She had a lot of gas. They gave her sub-Q fluids and sent her home with metoclopramide syrup for the vomiting. She is still acting listless and we're hoping she perks up by tomorrow or we're back to the vet. A week ago she had a seizure and was worked up for brain tumor, diabetes, and thyroid, all of which came back negative. She was doing well over the past week until the vomiting episode.

We were wondering what happened with your kitty, as the symptoms sounded similar.
Did you end up doing x-rays and ultrasound? Did you ever get a definitive diagnosis?
posted by nnorland at 12:24 PM on December 30, 2009

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