? UPDATED - extreme diarrhea in civvie with hyperT, CRF, possible IBD/SCL

[JL and Chip]

I could use some input here. I have an elderly (19ish years old) civvie who has been suffering from soft stools for awhile now but it has become extreme over this (holiday of course) weekend. He’s developed liquid diarrhea, no form whatsoever (normal brownish color) and multiple times a day. It seems that he can’t make it to the litter box anymore or perhaps it’s seeping out while he sleeps and he’s not aware of it (he sleeps in the same spot and doesn’t move around much and I never catch him in the act). He has always been diligent with his box habits so he’s clearly having a rough go.

We’ve been to the vet recently but not making a lot of headway. Here’s what we know—

Bubbs is hyperT, though T4 is still high (5.x) despite being on methimazole. We’re still tweaking dose.

He also has elevated kidney values (creatinine 2.8, BUN in 80s) even with the T4 still being high, so trying to balance that against the hyperT. Getting hyperT under better control will likely exacerbate (unmask) the kidney issues.

He needs a dental but the vet said he’s absolutely not an anesthesia candidate right now so that’s on hold. We have clindamycin but haven’t started it yet given how harsh it can be and don’t want to exacerbate the diarrhea or trigger vomiting.

X-ray doesn’t show anything notable.

Sent bloodwork to TAMU for GI panel. Results are slightly elevated fTLI, low cobalamin, low folate. The fPLI was supposed to be done but vet notified me after the fact that they didn’t have enough blood so excluded it.

He’s on methimazole 3.75 mg BID, psyllium husk powder, Proviable, and folate tablet daily, and B-12 cyanocobalamin injection (250 mcg) weekly.

He rarely vomits, but he’s losing weight and we’re heading in the wrong direction. The diarrhea isn’t sustainable and I can tell he’s in distress.

Any suggestions for emergency treatment of the diarrhea? I’ve contemplated trying canned pumpkin or slippery elm bark. I hesitate to try s-boulardii because in the past that seemed to make things worse. I’m open to trying food options too. I have a couple of freeze-dried raw options but he shows no interest whatsoever. I also have some Food Fur Life but no idea what to mix it with.

I suspect IBD or SCL but diagnosing those would require an endoscopy or surgical biopsy and I’m not sure Bubbs is strong enough for that. I also believe the soft stool started before the hyperT diagnosis/meds but can’t rule out that the methimazole is contributing.

I would consider I-131 but I don’t know that realistically he’s a candidate. This reminds me of what I went through with Charlie years ago— it all seemed to start with hyperT and blow up from there.

This is bad enough that I’m quietly considering euthanasia—not because I can’t deal with the messes or won’t spend the money on him, but because I’m concerned that my beloved stoic buddy might be suffering with no clear answers or path forward. I’ve already lost two in the past three months, neither of which went well, so I don’t want to make a mistake with Bubbs.

I can try the ER but, assuming they’d even take him, I’m guessing they’ll say they don’t have the ability to do too many diagnostics over the holiday and will probably just repeat the bloodwork we already have and put him in a cage until Tuesday. That doesn’t accomplish much other than stress the old man out, and I can give subQ fluids at home if needed.

So….. a couple of questions:

1) where does one get slippery elm, how do you use/dose it, and is it a good idea to try? I have a Walmart or grocery stores.

2) Is there a blood test that rules in/out IBD/SCL? Wendy, I think maybe you mentioned one in another post that can give data when a cat isn’t a candidate for anesthesia??

3) any suggestions for how to control, at least temporarily, the extreme diarrhea?

4) any suggestions for additional meds or tests to help get to the bottom of this before giving up?

@Wendy&Neko
@Bron and Sheba (GA)
@Suzanne & Darcy
@Sienne and Gabby (GA)
And anyone else who has experience or thoughts. Thank you!

 

[Wendy&Neko]

I hesitate to try s-boulardii because in the past that seemed to make things worse.

Was he on B12 at the time? S. boullardi won't work if B-12 is low. Or if hyperthyroid. See here: https://www.ibdkitties.net/supplements/probiotics/

Might need a probiotics plan B. Which version of Proviable is he on? There is a Proviable Forte gel (I think) that is supposed to be good for diarrhea. Your vet might know other products with kaolin in it that are safe for cats. I've heard of people getting good success with Visbiome, which my IBD cat gets.

Raw food could potentially help, maybe a protein he hasn't eaten before? You'd add the FoodFurLife to that. Recipe on their website.

Questions:
1) I've seen slippery elm on both pet food stores and vitamin stores. Or search online. More here: https://felinecrf.org/holistic_treatments.htm#slippery_elm_bark

2) No blood test to rule out IBD vs. SCL. You can try a novel protein diet or hydrolized protein diet to see if it helps, then you may be dealing with IBD. A vet can make educated guesses with an ultrasound depending where the inflammation is, if it exists. The kicker is that a cat can have both IBD and SCL - voice of experience here.

3) see above

4) In the initial stages of SCL and for IBD, it's common to give prednisolone. That can help with the vomiting or diarrhea associated with those diseases. They aren't the complete solution, but rather a short term solution, especially in the case of small cell lymphoma where you'd give chlorambucil to treat the disease. The pred helps until the chlorambucil starts to do it's job.

 

[Sienne and Gabby (GA)]

My "go to" site for information is the Raw Feeding for IBD Cats webpage. The information on handling diarrhea is on the Meds and Supplements tab. I'm linking one of their two pages on managing diarrhea. This is the information on what to do if the diarrhea is at a frequent, liquid level. They recommend S. boulardii with MOS. Jarrows has this available.

 

[JL and Chip]

Was he on B12 at the time? S. boullardi won't work if B-12 is low. Or if hyperthyroid.

He was on B-12 shots but less frequently (monthly-ish). Once we got confirmation of the low cobalamin, we went to weekly shots.

Yes, he’s hyperT and T4 is still high. Still working on tweaking the dose.

Which version of Proviable is he on? There is a Proviable Forte gel (I think) that is supposed to be good for diarrhea. Your vet might know other products with kaolin in it that are safe for cats. I've heard of people getting good success with Visbiome, which my IBD cat gets.

He’s on Proviable DC daily. I’ve tried the Proviable Forte paste in the past but surprisingly it seemed to make things worse (could be coincidental, of course). I’m back to adding in the Proviable Forte paste now because it describes “emergency use” instructions and that’s pretty much where we are now.

HyperT can cause diarrhea. Methimazole can cause diarrhea. IBD/SCL can cause diarrhea. Screwed up gut biome can cause diarrhea. Or any of those things combined plus an host of other issues, of course. That’s why I’m grasping at straws. None of the standard tricks and tools in my arsenal have worked. I’m looking for any stop-gap measure that might help slow it down until we can get answers. He’s becoming more fragile daily, perhaps bordering on “suffering.”

I just ordered some Sliplery Elm bark. Am going to try that next. Am also trying again to get him to nibble on freeze-dried raw food and looking to make a batch of food using Food Fur Life. Maybe add in some canned pumpkin. But it’s feeling like I’m at risk of making too many changes all at once.

No blood test to rule out IBD vs. SCL.

I was thinking of the PARR test, which I had seen you reference but am not familiar with so need to read up on. Also saw reference to LymphoPro, another test I need to learn about.

In the initial stages of SCL and for IBD, it's common to give prednisolone.

Does it work if the diseases are more advanced?

My local vet doesn’t do ultrasound but might offer prednisolone or budesonide until we can get to an IM specialist. Are there any down sides to trying it in the interim?

This is the information on what to do if the diarrhea is at a frequent, liquid level. They recommend S. boulardii with MOS. Jarrows has this available.

Thanks Sienne. I have s. Boulardii but not that brand. Will order. Might try it again since he’s been getting B-12 shots so hopefully doing better on the cobalamin front.

I could use any and all suggestions. Diarrhea is still darkish brown but has now taken in a yellowish fluorescent cast as I clean him up. So I know this is evolving.

 

[Suzanne & Darcy]

Oh wow. This is a tough one. My heart goes out to you. You already have gotten some good advice and you know most of the tips and tricks already. Pro Pectalin with Kaolin can help, but it requires dosing several times a day. Visbiome Vet is the Probiotic I use in my IBD boy with good results. It might be worth investigating if it’s inflammatory via ultrasound… or if that is not possible just treating with some prednisolone to see if it helps. But there could be downsides to that - things to discuss with your vet - but I am thinking of this as a Hail Mary type of thing where you are already wondering how much time he has left. If the pred helped it would be wonderful. I am so sorry you have recently lost two cats! ​

 

[Wendy&Neko]

I was thinking of the PARR test, which I had seen you reference but am not familiar with so need to read up on.

That is done on samples that can be taken via fine needle aspirate from the lymph nodes (if enlarged), or the biopsy samples taken via endoscopy or surgical biopsy. It basically tests for cloning.

Also saw reference to LymphoPro,

Debunked according to SCL group I'm on.

Does it work if the diseases are more advanced?

Are there any down sides to trying it in the interim?

Some of the SCL cats arrive in the SCL group are in pretty bad shape at first. Treatment for SCL uses pred as a bridge until the chemo drug starts to work. Down sides are if any heart issues are present, then pred can't be used so should go to budesonide. The other down side is that if you start pred, it can mask symptoms and can't do a biopsy (if planned) until after they've been off pred again for some time. As Suzanne said, a good discussion topic with the vet.

I also agree with her on Visbiome which my IBD + SCL (in remission) kitty gets.

 

[Suzanne & Darcy]

The other down side is that if you start pred, it can mask symptoms and can't do a biopsy (if planned) until after they've been off pred again for some time.

Exactly what I was thinking, but it seemed to be a last ditch effort. How is your kitty doing?

 

[JL and Chip]

How is your kitty doing?

Not well. He’s now not eating, which is new. The liquid diarrhea persists. He can move around but doesn’t go far. He’s still alert but clearly feels awful and I’ve been around enough to know that he’s slipping away. You are correct that I’m in “Hail Mary” mode.

I’ve called E.R. but the world of vet medicine has changed a lot in the past few years, I’ll just leave it at that. My local vet is pretty much at the limits of what he can do but I have an appointment tomorrow so will see if we can come up with anything else.

Visbiome vet won’t ship until next week. Hopefully that’s not too late.

Thanks for checking in on us, by the way. These end of life decisions are never easy.

 

[Suzanne & Darcy]

Not well. He’s now not eating, which is new. The liquid diarrhea persists. He can move around but doesn’t go far. He’s still alert but clearly feels awful and I’ve been around enough to know that he’s slipping away. You are correct that I’m in “Hail Mary” mode.

I’ve called E.R. but the world of vet medicine has changed a lot in the past few years, I’ll just leave it at that. My local vet is pretty much at the limits of what he can do but I have an appointment tomorrow so will see if we can come up with anything else.

Visbiome vet won’t ship until next week. Hopefully that’s not too late.

Thanks for checking in on us, by the way. These end of life decisions are never easy.

You are so right! They are the hardest decisions to make, to experience… to agonize over.

 

[Wendy&Neko]

Some vets carry Visbiome, maybe call around? Sending massive vines your way.

 

[JL and Chip]

So now the past two episodes of diarrhea there are small blood clot “beads” in the liquid. There were only a couple the first time, but quite a lot this past time. Poop is now basically colored water.

Does anyone know if this clot phenomenon is common in IBD/SCL, and whether it means anything (especially if ominous)? I’ve seen “threads” of blood in cats with GI distress but not so much these clot things.

I had a hyperT cat years ago with severe diarrhea but he ended up having helicobacter pylori in the stomach (diagnosed via endoscopy). They didn’t diagnose IBD/SCL but were clear that just because they didn’t see it in the sample they took, didn’t mean it wasn’t there. I suspect it might have been. By the time he started shedding bloody tissue in the diarrhea, he was in crisis and we were done. So I might have a negative bias here about what I’m currently seeing with the blood clots.

@Wendy&Neko @Suzanne & Darcy any thoughts or input?

I just got Slippery Elm powder. Might try that out next. I suppose I should ask about transdermal methimazole in case he’s not absorbing his pills properly or they’re contributing to the GI issues. Anyone have thoughts/experience with transdermal in this type of situation?

Bubbs is dehydrated and still not eating. SubQ fluids on board. I have injectable Cerenia if needed. I gave a dose of famotidine earlier because he’s had it before and tolerated it well. I know it’s fallen out of favor in lieu of meds such as ondansetron but I’m going with what I know rather than another new variable. Will probably syringe feed at some point depending on timing of the slippery elm. The vet and I bounce ideas off each other but I don’t think we have many more tricks up our sleeves. If we’re going to lose the fight, at least we’re going to go down swinging.

edited to add——
Questions re: presnisolone:
1) how long before see effects?
2) what’s best can hope for? Might it completely resolve diarrhea?
3) how long must cat be off it prior to scoping/sampling for IBD/SCL?

 

[Wendy&Neko]

Sorry, no experience on the bloody stool. Though I have heard it happens when the GI system is really beat up due to the disease. Not sure about the clots though.

As for questions on pred. My first civvie with GI disease saw improvement within a couple days, but he, like the rest of the GI disease kitties here, was a vomiter. I don't know if it will completely resolve diarrhea - again, not experience there. As for going off of pred before sampling, 2-4 weeks or until symptoms come back.

Have you checked with any of the hyperT groups about side effects of it? I've heard it can also cause diarrhea.

 

[JL and Chip]

Update:
We added prednisolone as of Friday. No change in stool consistency yet although there’s less blood. BUT, he did nibble on food today for the first time in days. Prognosis is still guarded.

Regarding food, can anyone recommend a good novel protein limited ingredient canned (or even dry at this point) food that’s palatable? I looked at Koha, Ziwi Peak, Instinct, and quite a few others but I have to order online so don’t have the option to pick up a can or two to try. I’m thinking rabbit, venison, alligator (!!), or maybe even pork or lamb (not sure if he’s ever had those). I haven’t had luck getting him to eat freeze dried raw rabbit but will keep trying. It’s been quite a few years since I dealt with IBD in a cat and my go-to foods have either changed formulation or gone off the market, so I appreciate any suggestions.

Have you checked with any of the hyperT groups about side effects of it? I've heard it can also cause diarrhea.

Do you know of any good hyperT and IBD groups you can point me to? I used to be a member of a few but many groups in general moved to different platforms or Facebook so I’ve lost track. I’m not on Facebook.

 

[Wendy&Neko]

groups.io has a good feline thyroid group. The moderator there really knows her stuff. You can search there for and IBD group too. I'm on their SCL group.

This website https://www.rawfeedingforibdcats.org/has an FB group as does this one: https://www.ibdkitties.net/ (I'm not on FB either). You could search groups.io for a feline IBD group. A number of the groups have migrated there.

What palatable mean depends on the cat. Merrick has an LID duck that Neko really liked. Note. Dr. Lisa's list has it higher carb but I think that was an error, it didn't bump her numbers and the ingredients list looked similar to the other LC flavours. Duck is another protein option, as is kangaroo. Identity is another brand with different protein options, as is Hounds&Gatos. If you want to go really crazy, check out the Mouser brand. Not single protein but you can guess what one of them is.

 

[Shelley & Jess]

Regarding food, can anyone recommend a good novel protein limited ingredient canned

RAWZ rabbit pate worked really well for Jess. Pretty smooth consistency, a little 'grainy' and on the wetter side.

 

[Sienne and Gabby (GA)]

My cats like the ZiwiPeak venison. They also have a lamb and rabbit combo but one one of my kitties is less than thrilled with it.

 

[JL and Chip]

Update 9/15/2024 for anyone who is interested:
Bubbs is doing better, albeit nowhere near normal.

Despite the desire to be methodical and change one thing at a time, he was in crisis so we resorted to pretty much throwing everything at him simultaneously, including steroids and novel protein food (hey, why slowly transition the food when he already has catastrophic watery diarrhea. ). It was truly a Hail Mary pass to the end zone because, for his sake, I’d already made the phone call to prep for euthanasia.

Something is helping, although I don’t know what. He’s now on prednisolone, Visbiome, Proviable, famotidine, subQ fluids, psyllium husk powder, slippery elm bark (as needed), his standard methimazole, B-12 injections, folate, and a novel protein diet. I realized that he’d been fed both rabbit and (likely) lamb earlier in his life, so the next choice was venison—went with ZiwiPeak air dried and canned to start.

The blood-clot laden stools stopped shortly after the first dose of slippery elm. The watery diarrhea eased up shortly thereafter (he couldn’t control it so I’d find him lying in a pool of watery yellow/green-tinged liquid and was changing his underpads and cleaning him with a spray bottle every couple of hours…it was absolutely incessant and he was clearly in pain and distressed). The improvement followed closely behind the switch to venison, but also added the prednisolone and Visbiome around same time so could be any or all of those things.

I opted against transdermal methimazole given the more limited bioavailability and risk of worsening the hyperT. He was actually due a dose increase anyway, so bumped up the methimazole dose slightly in the middle of all of the other changes (he is very “symptomatic” when it’s time for his next dose).

Stools are the consistency of clay or play-doh and definitely formed/tubular. He’s much more relaxed and settled now. However, I don’t trust that this will continue as the improvement seems very tenuous. And although better, the stools are not what I’d call “normal.”

Questions:
1) Visbiome should replace Proviable, correct? I’ve been “cheating” and throwing in a Proviable capsule here and there because he’s been on it so long, but now that we’re past the crisis (for now), I’m thinking I should eliminate it.

2) Can anything at all be gleaned from X-ray/ultrasound/endoscopy now that he’s on prednisolone? I realize steroids can mask the problem and that he needs to be off for several weeks to get the most accurate results, but there’s no way I’m willing to do that until he recovers a bit of ground. So just wondering if a trip to the IM vet would tell us anything at this point or be a total waste.

3) Any idea how long steroids can help if it’s IBD and/or SCL? Especially with SCL, I’m thinking pred is merely a bridge treatment to chlorambicil (so am weighing urgency of getting actual diagnosis given risk of “blowing things up” again).

@Wendy&Neko
Anyone else?
Thanks for any thoughts.

 

[Wendy&Neko]

Good news that Bubba is headed in the right direction. Fingers, toes, paws still crossed for more progress.

Answers:
1) yes, you don't need both and not sure of the impacts of too much probiotic.
2) might be able to get answers if he's still somewhat symptomatic, but otherwise no.
3) I've seen the analogy that the prednisolone mops up the excess lymphocytes, making them feel better, but the pred can only do so for so long.. The chlorambucil shuts down the factory making the lymphocytes, which is when remission happens. And then you can start tapering down and possibly off the pred. Note, in my kitties case, she had both IBD and SCL and remains with IBD so still needs pred. As far as how long pred by itself will help if SCL, I don't know if there is an answer for that. I've seen one kitty here, confirmed SCL, only on pred. I don't know how well the cat was doing as I haven't seen an update in over a year, but she was doing well about the 1.5 year mark. That might be a good question for the IM vet.