#shitty digestive and urinary organs

[need-me-a-tiger]

i dont even know how the fuck and whyyyy do i have kidney stones it's like i don't even eat outside foods that much and anytime i do i am like tummy hurty gets diagnosed with some shit and whyyyyyy whyy meee others eat junk foods all the time and they don't get sick their stomachs don't hurt and i drink a lot of water too but still i fucking don't know ughhhh i just want to have some savoury spicy junk foods right now 😭 buttt i waaaaa

[theflashisgone]

This is not going to be as clear and concise as @drferox​, but this is what the situation is with Twinkie, my 9-year-old tortie cat:

Twinkie had a previous history of intermittent weight loss and not gaining the weight back. A few weeks ago, I noticed that she wasn’t finishing her food, she had lost more weight, she wasn’t being affectionate anymore, and she was exhibiting unusual grumpiness and grimacing that is indicative of pain or serious discomfort in cats.

The thing about Twinkie is that we’re really not sure of the diagnosis. Also, she needs to be anesthetized to do anything more involved than a butt shave and nail trim at the vet. Diagnostic possibilities include the following, listed with approximate costs for someone who does not have an employee discount:

Thorough physical exam ($50)—no abnormal findings for a cat under gas anesthesia, except for some very mild dental tartar and having been declawed with her previous owner. 

FeLV/FIV test ($50)—previously tested negative for both and is not at risk

A routine blood panel in house, which at my clinic includes blood chemistry, thyroid, SDMA (a kidney test), and complete blood count ($180)—results both inconclusive and not suggestive of any disease

Urinalysis in house ($50)—no abnormal findings

Urine culture ($115)—not really indicated, as there are no urinary symptoms, and no bacteria or blood was found on urinalysis

Lab test for valley fever, a local fungal infection ($110)—tested negative

Other specialty blood tests, such as hemobartonella, toxoplasmosis, heart disease, protein electrophoresis ($50-$150 depending on the test)—not indicated

Radiographs ($150-$300)—x-rays are useful for looking at limbs, chest, and some parts of the head, but can only show organ outlines at best in the abdomen. Rads are not indicated by Twinkie’s symptoms. This will change if she develops labored breathing or a cough.

Abdominal ultrasound ($300-$900)—could very well provide a diagnosis (probably 50/50 chance), would have to refer elsewhere, I can’t afford to pursue it

CT scan ($2000-ish)—not indicated, would have to refer to specialty hospital

MRI (maybe $2500-$4000?)—not indicated, would have to refer to specialty hospital

Exploratory laparotomy with biopsies ($800)—opening up Twinkie’s abdomen and taking bits of the organs might or might not provide a diagnosis, but is extremely invasive, would cause Twinkie significant pain and discomfort during recovery, risk of peri– and postoperative complications up to and including death

Sometimes, a pet owner absolutely needs to have a firm diagnosis for their own peace of mind. If I felt that need, I would pursue radiographs, abdominal ultrasound, and possibly even surgery. However, I am comfortable with still not having a firm diagnosis, not that we have ruled out all the things that would be easy to treat. Also, the risks and discomfort of surgery are not acceptable to me, given that it might or might not provide a diagnosis, and would almost certainly not actually cure whatever the problem is.

So as it stands, we’ve done all the diagnostics that are both indicated and within my budget. We’ve ruled out kidney disease, thyroid disease, diabetes, obvious liver problems, dental problems, bladder/urinary problems, and obvious cancers. Of the remaining possibilities, 3 are most likely:

Inflammatory bowel disease—causes weight loss due to poor absorption of food, usually causes vomiting and/or diarrhea, occasionally causes constipation instead of diarrhea. As with other conditions that involve chronic inflammation, can eventually turn into cancer. Twinkie doesn’t have any obvious digestive symptoms, but IBD can sometimes present with only weight loss.

Cancer—Twinkie doesn’t have any obvious masses or lesions, but cancer can be extremely sneaky and hard to prove. It usually causes weight loss both by making the cat feel shitty and uninterested in food, and by using up the cat’s nutrients to grow itself. It also often causes discomfort and pain, which Twinkie does seem to have.

Feline infective peritonitis—FIP is a massively shitty coronavirus disease that usually affects either kittens or senior cats. It tends to show up and progress quickly. Previously, it was considered a death sentence, but I’ve recently seen some small studies on treating it that may or may not pan out. We’re not sure if FIP can persist in the environment, but we’re pretty sure cats can get it from their mothers. The virus can sometimes stay dormant for the cat’s entire life and not do any harm, but sometimes it’ll suddenly activate and kill a previously healthy, happy kitten or senior cat. It can be hard to diagnose, as only one form of it has really obvious symptoms, and the blood test for it doesn’t reliably distinguish between FIP and other feline coronaviruses.

IBD can’t be cured, but it can be controlled with steroids and by feeding a hypoallergenic diet if the cat also has food allergies, as allergic reactions can make IBD symptoms worse.

Some types of cancer can be treated by removing the affected body part, but Twinkie does not have an obviously affected body part, much less one that can be removed. Some cancers respond well to chemotherapy, but it would take an actual diagnosis to know if Twinkie had one that would do so. However, I would be unlikely to pursue chemotherapy anyway, as I feel that the length and quality of life it affords isn’t enough different from palliative care to be worth the cost or the stress and risk of Twinkie having to be anesthetized for oncology visits. Palliative treatment for cancer is steroids, with appetite stimulants and pain control as needed.

FIP is not something for which treatment is available to me. Palliative care would be steroids, appetite stimulants, and removing fluid from the abdomen or chest if it turns out to be wet FIP.

What I’m doing with Twinkie is giving her steroids in the form of transdermal prednisolone ear gel, and feeding her the hypoallergenic diet that she’s already eating because I have another cat with food allergies. Since I started the prednisolone, her appetite has improved greatly and she’s gained back some of her lost weight. She’s somewhat more affectionate, but not back to her usual cuddliness, and she’s still having intermittent episodes of grumpiness and signs of pain. She’s much less playful than she was, but at least is getting along with Biff again (her favorite of my other two cats).

I will have Twinkie euthanized if and when she loses so much weight that her body can’t sustain itself, she stops eating and won’t start again, she seems to be in significant pain or distress, she stops doing her favorite things, or she becomes too ill to maintain her position as the dominant cat and the other two bully her enough to have a significant impact on her quality of life.

(🐈 1/2) Could you discuss how you talk clients through the process of deciding how far to go when treating a serious problem, and how to decide when it's time to euthanize? One of my cats has recently developed idiopathic weight loss with poor appetite and mild to moderate pain grimacing that we can't find the source of. My boss and I suspect it may be cancer, and

(🐈 2/2) I'm finding it very comforting that I knew before her symptoms even presented how my decision tree was structured. I feel like pet owners who are not themselves in the veterinary industry probably don't have the experience to know at what points they will have to decide one way or the other, and I think a lot of people might find it helpful to have a vet's perspective on that. 

@drferox here.

As you probably know by now, my cat Wonka has lymphoma. While I already knew more or less what decisions I was inclined to make, the LSB was caught unaware so I’ve had to be guiding him through it. It’s a much more personal decision tree than I’m used to.

I tend to start with trying to find the end point, the point at which you either decide treatment is too invasive, too expensive, or the quality of life isn’t good enough. In this case, before we knew Wonka’s diagnosis, the questions were:

Would you do surgery? Yes, if it’s a chance to cure.

Would you do chemotherapy? Maybe.

And it was a solid yes to just about any diagnostics we’d might require. When his lymphoma diagnosis came back, we had to decide whether chemotherapy was worth it, and that’s a big decision. It boiled down like this:

Overall lymphoma in cats has about a 30% response rate to treatment

But if you look at gut lymphoma only, it’s more like 50%

Of cats on chemo for gut lymphoma, about 30% survive to one year and 25% survive to two years. It’s hard to find studies beyond that.

So if he responds and survives to one year, there’s a good chance he will survive two years, which is a pretty decent result.

There is no other test I could go to figure out whether he’s likely to respond other than treating him and seeing what happens in the first 8 to 9 weeks. If he’s not responding by then, he will not respond.

The main side effect of chemo in cats is loss of appetite.

Wonka is normally a bin-diving, pantry-sabotaging, snack-stealing labrador appetite in the body of a cat, who’s greatest hits include diving head first into a box of biscuits while I was eating them, chewing a hole in a carton of chicken stock to lick the tasty goodness within, eating fish bones out of the bin and eating so much dry food that he threw up, contemplated his poor life choices, and then went to repeat the process.

So I was pretty sure I could manage any chemo side effects he might have, and that 30% chance was good enough to commit to two months treatment. Chemo is expensive, so if he’s not responding we’ll switch to palliative but at the moment he’s still well in himself.

For some people, chemo and its side effects will be harder to manage, or those odds above will not be good enough to justify the treatment, and that’s okay. The numbers are what they are, it’s my feelings and thoughts on them that influence my decision.

As for that future day where he is not well in himself:

If he no longer seeks his favorite things: my boyfriend, sunbeams, salmon and chicken

If I cannot coax him to eat, with or without medication

If he develops bone marrow suppression or lymph node enlargement affecting his airways

The boyfriend looks at him and ‘just knows’

Those are my cut offs. It’s the quality of life that matters most, more than the quantity. There’s no point keeping a cat around if he can’t enjoy his life, or at least the majority of his life.