Oreo C.

Oreo1Oreo Cannon – Fort Collins, ColoradoOreo2
Female, Domestic Shorthair
Born 2001 – September 27, 2013
Diagnosed with suspected IBD in early 2012
Diagnosed with IBD, lymphoplasmacytic inflammation and
supperative enteritis in the proximal duodenum,
grade 3/6 heart murmur in January 2013
Diagnosed with septic peritonitis Sept. 27, 2013. Post mortem exam
found necrosupperative duodenitis with full thickness perforation,
as well as left and right ventricular dilation of the heart.

When Oreo first started showing signs of IBD we couldn’t tell for sure which cat the vomit was coming from. And like a lot of owners, though it was just hairballs. At some point we realized Oreo was vomiting nearly every night, right around 3am, about 6 hours after dinner. Then she would stop for a week or two or three, then start up again. Our initial exam by a vet was in December 2011 where she weighed 11.18 pounds. The exam indicated nothing abnormal on her bloodwork and we tried metoclopramide (which is supposed to help the digestive tract move forward. It made her very anxious and didn’t solve the problem), and famotidine, which worked well enough that I kept her on it for a couple of months. In May of 2012 Oreo had an episode of sterile cystitis for which she was given a dose of Convenia and sub-cutaneous fluids. Once she recovered we decided to revisit her vomiting issues. Although she was not vomiting every day she was still generally vomiting several times a week with intermittent periods of no vomiting. My vet recommended a TAMU profile, which evaluates GI function (within normal limits) and with urinalysis (normal), so we started her on prednisolone at 2.5mg/day. She stopped vomiting for a few days, and then started again at irregular intervals. This whole time Oreo was a happy vomiter and would often puke, then demand to be fed. She had a great appetite as well.

With the lack of success with prednisolone we went to the local teaching hospital in August 2012 and got full GI workup and blood panel done. The chemistry was normal but her neutrophil count was elevated. Normal urinalysis, but abdominal ultrasound showed thickened ventral stomach wall and thickened small intestine. They noted subjectively decreased motility in the small intestine. They also noted the liver could be decreased in size, possibly related to confirmation, positioning or chronic liver disease. Based on these findings, we were prescribed 5mg prednisolone once a day, Cerenia (an anti-nausea drug) and Purina HA or Hill’s Z/D. For one blessed month Oreo did not vomit AT ALL. The Z/D did give her loose stools, but she did well with HA. Just about the time we were ready to have the carpets professionally cleaned, she started vomiting again, gradually increasing to about 1-3 times per day. In January 2013, we got an endoscopic exam done at the same time as a dental. She was off pred for about 5 weeks at this point due to a scheduling problem (my husband fed her the morning of the first endoscope so we had to reschedule…normally they recommend 2 weeks). Oreo weighed 7.9 lbs. at this time. The vets osculated a grade 3/6 heart murmur but felt she was OK for surgery. She also had an elevated ALT at 174 (30-140 is normal), which may be an indicator of liver disease, or a normal side effect of long term prednisolone. On the endoscope (which I got to watch), there was a significant amount of digested food in Oreo’s stomach and upper small intestine, despite having no food for about 14 hours prior to that. This matched in my mind with her tendency to vomit literally hours after eating. Oreo’s upper small intestine was very inflamed and angry and they got about 2 dozen biopsy samples.

Without repeating the entire results, here’s the diagnosis summary:
1/Small intestine = Enteritis, suppurative, moderate, focally extensive.
2/Small intestine = Enteritis, lymphoplasmacytic, moderate, chronic, diffuse.
3/Stomach = Gastritis, lymphofollicular, multifocal, chronic with lamina proprial fibrosis and small numbers of surface-associated spiral bacteria. She was also mildly positive for helicobacter.

The really interesting thing on Oreo’s endoscope is the SUPPERATIVE inflammation, indicating a sort of pus-present inflammation. Normally cats have either inflammation or infection but not both. My vets at the teaching hospital with years of experience in internal medicine had to consult with in a world-renown GI vet to figure out what to do. He thought she may have cholangiohepatitis (inflammation of the liver and bile ducts), which was caused by a small intestine bacterial overgrowth. They prescribed Oreo 6 weeks of oral Clavamox. Meanwhile, Oreo had some FORL’s removed during her dental and whether because of the dental pain or as a result of getting 2 dozen holes punched in her GI tract (I’ve learned since that most humans get sucralfate to help with that discomfort after an endoscope), Oreo very slowly returned to eating She threw up a couple times here and there, but really wasn’t eating enough to vomit much. My specialist vet was difficult to get a hold of and seemed inclined not to have Oreo come back in since that might stress her out even more. She did get me some hypo-allergenic food to try, which Oreo would nibble at but not really eat.

Four weeks after the endoscope I took Oreo into see my primary vet. At this time, she weighed 6.3 pounds. My vet was very disappointed that the referral hospital was not being more proactive. Blood work showed low protein, but otherwise normal and she had a normal urinalysis. We got SQ fluids and a return to prednisolone at 5 mg/day and 2.5 mg famotidine, and adjusted the Clavamox to 0.7 ml/day (from 1ml/day) due to her weight loss. Meanwhile, my vet talked to the referral hospital and learned that they believed Oreo’s infectious process was related to a liver infection. Basically, she had developed an intestinal infection that was spreading into her liver, thus the six whole weeks of antibiotics. They agreed with my vet that we should try steroids in addition to her antibiotics to reduce the inflammation from Oreo’s IBD and help her feel better. The pred was a miracle! Within two days Oreo was back to eating and delved into a new food, Royal Canin Venison. She ate and ate and ate, and it was so wonderful to see her suddenly bounce back. Once she started eating well I could grind up her pred and put them in some Viyo (a liquid gravy specifically for cats.) At our follow up visit three weeks later, she weighed 7.56 pounds. We agreed to give it another couple of weeks then try reducing her to every other day.

Then I got word from the teaching hospital that they were doing a stem cell study for IBD and we enrolled Oreo in it. Just days before our first stem cell appointment we reduced her pred to every other day and the day of the appointment she vomited for the first time in over a month. Maybe she knew she was going to the vet or that slight reduction in steroids was enough to start her auto-immune system up again. Either way, despite returning to 5mg every day for a week and a half, she continued to vomit periodically from then on. At our stem cell appointment we got blood work done and her ALT was at 333 (30-140 is normal). A follow up ALT at our local vet two weeks later was 147 (0-100), but everything else was normal. Either those were normal variations or reducing the pred to 2.5 mg every day had helped. For the stem cell study, we went in every two weeks for either a stem cell or a placebo injection (I wasn’t told which one.) A few days before the 2nd visit Oreo was not eating at all and hiding. This lasted a few hours, and then she came back out and was happy to eat dry food (Royal Canin).

We continued with the stem cell study and had either a stem cell injection or a placebo on April 4th and April 19th. On April 19th, Oreo had a fasted GI panel at Texas A&M. PLI was slightly elevated at 3.7 (normal is 0.1-3.5). Cobalamin, folate and TLI were all within normal range. We later learned that Oreo was in the placebo group for the stem cell study, though this was not surprising given her lack of improvement. I heard from her vet that the majority of the stem cell kitties improved, and a minority stayed about the same. Through the rest of April, May and June, we kept Oreo on daily prednisolone and famotidine. She would vomit periodically and happily, but would occasionally go through these bouts of not eating and throwing up clear or slightly foamy liquid. These periods were usually short, about 12 hours or so, and then she’d be fine. I think at first it was about once every few weeks. As time went by, these periods of inappetence and throwing up clear or slightly milky liquid were gradually increasing. Around mid-June I remember marking about 12 clear vomit spots with paper towels.

On June 22nd we arranged for another office visit, this time with Dr. Two at my regular vet’s office, as Dr. One was out of town. Oreo was 7.22 lbs. She had been feeling poorly the day before but was happy and eating that day. We mostly discussed Oreo’s condition and I expressed my concern that Oreo had an infection. But while we were treating her with pred and suppressing her immune system, were we in fact allowing that infection to come back? At the same time, I was worried about decreasing her pred because that would bring on more inflammation. Dr. Two agreed to contact Dr. Specialist to see if he had any ideas. She felt (as most vets do) that we couldn’t keep her on antibiotics forever. We went home with four-weeks’ worth of metronidazole and some injectable Cerenia to try the next time she had a bad day, as well as try to re-start the canned-only diet. Oreo did surprisingly well eating canned only and did not vomit for about a week, until one day my well-meaning husband fed her a large bowl of dry food, which she threw up. She did not have any bad days, though she did throw up some clear/foamy stuff a few times. But didn’t have that “I feel sick” for hours experience.

It took Dr. Two about a month to get a hold of Dr. Specialist, directly as they played phone tag. Dr. Specialist agreed that the metronidazole was a good idea and we should probably finish the current round and try Tylosin if she got worse. Dr. Two also asked about chlorambucil which is also the drug we combine with Pred in cases of GI lymphoma and is sometimes useful for IBD. But Dr. Specialist didn’t think that was really warranted at this time. He suggested trying some FortiFlora, which is a pro-biotic and taking things one step at a time. I think we could all agree that although Oreo’s vomiting was not “under control”. It was being managed somewhat, she was not losing tons of weight and still had good energy and appetite most of the time. I don’t feel like this consult was particularly useful and feel like Dr. Specialist, despite having access to Oreo’s endoscope, didn’t really get the full picture. At some point in late summer when Oreo’s condition seem to be slowly worsening and her appetite decreasing, I got onto an IBD support website and learned a lot about the dynamic nature of IBD. There were a lot of good recommendations for grain-free foods and some holistic therapies, which gave me hope that we still might be able to figure something out. I tried rotating Oreo’s diet and using some novel proteins. One of the challenges I had was figuring out what she would and wouldn’t eat. Some things she would eat readily one day but not at all the next. I visited some specialty stores and acquired some raw foods, none of which she would eat. I also tried some slippery elm, which seemed to work for a few days, but one day I came home and she didn’t look too good. So I syringed her slippery elm. I felt really bad when she started throwing up the usual foamy stuff and felt pretty lousy. I don’t think it was the slippery elm, but I felt rotten for forcing her to take anything orally. After that, I stopped using it. I think I was scared of doing too much, especially since I hadn’t discussed herbal therapies with my vet.

Toward the end of August I got news that Oreo would be getting real stem cells, starting in about a month, as part of the study. I was pretty excited and hoped this would be the magic cure that everyone thought it was. On Saturday September 14, we had another vet visit to see where Oreo’s bloodwork was at. She had not been feeling good the day before, but seemed to be rallying the day of the visit with Dr. Three and had a good appetite that morning. We did a chemistry blood panel, which showed a slightly elevated BUN (32.3, normal is 15-32), Albumin of 3.6 (2.3-3.5), and ALT of 191 (0-100). Dr. Three thought the BUN was to be expected since Oreo was still dehydrated. We also sent out a Total T4, which was 3.4 – higher than previous, but still within normal limits. She weighed 6.9 pounds. One of the things I specifically remember commenting to Dr. Three about was that I was afraid of the prednisolone, if she still had an infection that the pred was making it worse. I was also concerned that if we stopped it that the inflammation would cause her to have a ruptured intestine. She said that was very unlikely, but agreed that the pred wasn’t doing its job. That if it was going to work, it would have by now. We agreed to keep the pred to 2.5mg every day and maybe reduce it to every other day. Dr. Three got Oreo some Sub-Q fluids, a shot of Vitamin B-12, some Cerenia and mirtazapine (an appetite stimulant) to be taken at home, and some Buprenorphine for pain. When we got home that day Oreo ate really well. Sat on the couch with us and on our laps, and even chased my other cat out of the room. Then later chased her off the bed, something I have rarely seen Oreo do, and certainly not for a long while. She seemed to be feeling miraculously better, purring and running around the house, just like her old self. This continued into Sunday. I remember thinking that this was like in the movies where someone says, “I would give anything for one more day with a loved one,” and I got my day! In fact I got 48 hours! The $400ish I spent at the vet was so worth it! here’s no telling what the difference was, whether it was the Buprenex, the Vit B shot, or combination of all, but the transformation was amazing. I only wish it could have lasted.

Monday, Oreo’s appetite declined and by Thursday she was back to vomiting foam again, all this despite continued Buprenex and Cerenia. I talked to Dr. Three at the end of the week and we scheduled another consult at the vet teaching hospital with Dr. Specialist. We just had to make it through one week. On Monday, Tuesday and Wednesday, Oreo had a good appetite. I supplemented her with a dose of mirtazapine once a day in hopes of keeping her appetite up. It was really heart-warming to come home and find she had knocked a bag of dry food or treats off the counter. Despite her recent vomiting with dry food, she did not this time around, and seemed to be doing really well. Thursday rolled around and Oreo didn’t eat her food. She seemed to be back to not feeling quite right, but didn’t vomit. Thursday night, she still was not eating, but sat on the bed with me a purred and kneaded. I thought she smelled a little funny, like she had thrown up, though I hadn’t actually found any vomit. I felt her abdomen, which she tended to like, and it felt ropey like it always did. But there seemed to be a bit of a pooch in one spot. I thought it might be my imagination, or maybe some kind of intestinal aneurysm, but if it was, she shouldn’t be purring, should she?

Friday morning, Oreo had the same inappetence, but this time she did vomit just as I was heading out the door to work. In the past, vomiting was usually the turning point where she’d feel crummy for a bit longer, but then start feeling better. My husband was out of town so there was no one to watch her throughout the day, but I decided that if she didn’t feel better by after work, I would take her back in on emergency. When I came home that night, Oreo did not greet me at the door. I quickly found her, stretched out on the floor, cold but alive. I grabbed a blanket and my Oreo and got in the car, calling the emergency vet on the way. I remember saying to the receptionist that she was trying to die on me. A few minutes later I called back and explained more. Oreo was in the seat next to me, and at one point seemed to rally and try to get up out of the blanket. I got the blanket and her onto my lap and held her on the longest 20-minute car ride ever. The technicians quickly got Oreo into the back and a little bit later one of the vets came out and told me they were having trouble getting a catheter in. They had her on oxygen, but might have to intubate her soon. I talked her into letting me come back and be with her. By this point, she was pretty much non-responsive. I asked the vet to do an ultrasound and he found a lot of free brownish fluid in her abdomen. They were able to get an aspirate and view it under the microscope. There was a lot of debris, including plant material, which made them think she had ruptured somewhere in her digestive tract. We discussed surgery as an option, but that she was in shock and it would be risky. I knew Oreo had fought and suffered for so long that it wouldn’t be fair to keep her going just because we could. We might repair the rent, but whatever was causing it had eluded us and would likely happen again.

So on September 27, 2013, Oreo went to heaven. I was very angry after Oreo died. First, I was angry with myself for discarding or downplaying the signs that clearly told me what was going on in the last few days. Especially as that stem cell appointment day came and went, I wished I was more proactive and gotten her to hang on for just a little longer. Second, I was angry with the vets who couldn’t help her, who should have known better, especially Dr. Specialist, who I have never seen in person, but apparently sits on a high throne and dispenses his wealth of knowledge at tiny intervals to the minions below. Then I would get angry at myself again for not demanding that these vets see what was going on. I knew it, but I was a poor advocate and couldn’t make them see what I saw. As a veterinary technician, I have been trained to stand behind the vets. As an owner, I couldn’t step out from that shadow and make myself heard. I feel like they downplayed some of the remarkable signs, the slow stomach emptying, the supperative inflammation, the heart murmur and worst of all the periods of clear to milky colored liquid she would throw up on an empty stomach. I suspect it was related to infection, maybe a sort of pus-type of vomit that would backup into her stomach from her upper intestine and come out.

I had Oreo necropsied. The main cause of her death was septic peritonitis. Of note in the report: “PROXIMAL DUODENUM: Ten to fifteen 2 mm to 1 cm diameter ulcers were present in the proximal duodenum. Each ulcer was minimally depressed (<1 mm), rimmed by a thin band of hyperemic tissue, and occasionally coated by a thin mat of tan fibrin. A single ulcer near the gastro-duodenal junction was transmural (perforating). This ulcer was approximately 1 cm in diameter and had grey-brown borders (necrosis).” They also found she had left and right ventricular dilation in her heart, which was once common in taurine-deprived cats. Taurine is present in raw (uncooked) food and commercial cat diets, so this heart condition is pretty uncommon these days. As Oreo was on commercially-prepared diets, the only explanation for this is that she was not absorbing taurine, which is absorbed in the duodenum. As I was writing this up, it became clear to me that the cause of her death was the same supperative inflammation that we had seen at the beginning of the year. We had gotten rid of it with that 6-week course of antibiotics, and decreased the inflammation that probably caused it in the first place with pred, thus leading to that blessed, short period of health in February. Although I had been told you can’t keep cats on Clavamox forever, I have since learned that there are some occasional cases where a vet will keep an animal on Clavamox for years. One vet I worked with said he had a Bassett with a pericarditis that he kept on Clavamox for five years before she died at 18 of an unrelated problem. In Oreo’s case, it didn’t matter what food we gave her, though a food allergy may have started the whole problem. I have many regrets and am most sorry that I didn’t advocate for her harder, as well as allowing my work schedule to interfere with my ability to get her to see a consistent vet. If I had someone working with me more closely, we may have realized what was going on. I can only hope that my experience with this unique case will help other owners and vets recognize it if it occurs in their cat. Please, don’t ever stop fighting for your animal, and remember Oreo.

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