He had been vomiting, hyper-salivating and refusing to eat for the past 24hours. Phron’s owner was very worried as he had started to call out in pain and was deteriorating.
Pancreatitis and Cholangitis in Cats
Phrons had a history of pancreatitis/cholangitis which had been diagnosed following blood tests and an ultrasound scan during a period of hospitalisation a couple of years previously. Up until recently Phron’s condition had been well controlled with dietary management. On examination Phrons was stressed, vocalising in pain, salivating and had a very tender abdomen on palpation. His temperature was slightly low. Phrons was admitted for intensive care and investigations. It was important to determine whether this was a new problem or a progression of his previously diagnosed condition.
Intravenous fluid therapy was initiated, alongside analgesia (pain relief), gastrointestinal protective medications and anti-emetics (anti-sickness medications). Blood tests showed that one of Phron’s liver enzymes known as ALT was significantly elevated and his potassium level low. The elevated ALT could reflect insult to the liver, whether of an infectious nature (cholangihepatitis), neoplastic (cancerous), toxic, or due to an inflammatory condition of another organ, such as the pancreas, upsetting the liver.
The low potassium was considered to reflect lack of intake as he hadn’t been eating very well, and losses through the gastrointestinal tract in view of the vomiting and salivation. Potassium was supplemented via the intravenous fluids, and blood potassium levels regularly monitored. The following morning Phrons was better hydrated, had not suffered any further vomiting, was a little brighter and less distressed and painful. Phrons received a careful sedation to allow imaging of his chest and abdomen. The ultrasound scan confirmed severe pancreatitis, in addition to distension of the bile ducts, which transport bile from the gall bladder into the first part of the small intestine known as the duodenum. The bile ducts were distended as a result of partial blockage by cholelithis (gall stones). The diagnosis of pancreatitis and cholangitis with cholelith formation as a consequence of chronic inflammation within the biliary tract was made.
The findings were discussed with Phron’s owner and careful consideration as to the best course of action. Unfortunately, euthanasia had to be considered in view of Phron’s age, the severity of the findings and the need for surgical interventions as the success of medical management was likely to be poor due to recent lack of response to treatment. However, it was agreed that since Phrons had been very well up until recently, did not have any concurrent medical problems and was stable that he would undergo surgery.
The following day Phrons was referred internally to the surgical team who performed a cholecystectomy to remove the gall bladder and obstructed bile tract. Biopsies were taken of the liver, duodenum and pancreas to help assess for and hopefully exclude an underlying cancerous cause. A feeding tube, known as an oesophageal tube, was placed toensure that Phrons received adequate nutrition to aid a speedy recovery until he was able to eat sufficient amounts for himself.
It is as vital to provide a patient like Phrons with careful nutritional management as it is to medicate to control pain and inflammation.
Happily, Phrons made a remarkable recovery from his procedure and went home 3 days later. Since medications could be administered via the feeding tube it removed the potential for the stress of medication. Phrons started to eat voluntarily within a few days and the feeding tube was removed a week later. By this stage Phrons was gaining weight and much happier in himself. The biopsies confirmed the presence of a marked inflammatory response and helped to guide longer term management.
The pancreas is an organ that is closely associated with the digestive system, and produces enzymes to help digestion. Under normal circumstances these enzymes are carefully packaged and released only into the small intestine. However, in pancreatitis, the pancreas itself becomes inflamed due to a loss of the normal careful packaging meaning release of enzymes into the surrounding tissues. This leads to pain, lack of appetite and sometimes vomiting can also be seen. Due to the anatomy of the cat, cholangitis (inflammation of the liver and bile ducts) often occurs alongside pancreatitis since both the bile duct and pancreatic duct empty into the duodenum at the same point. This can also be associated with inflammatory bowel disease, in which case the term ‘Triaditis’ is often used. In Phron’s case, the long standing inflammation had resulted in the bile becoming dehydrated and forming stones which subsequently blocked the bile ducts and caused the presenting sigs.
Phron’s owner is delighted that her instinct to give Phrons a chance by undergoing surgery had been correct.
Phron’s case is a great example that with careful diagnostic and surgical management, and a lot of dedication and TLC from his owner and nursing staff, advancing age is not necessarily a reason not to pursue treatment.