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Mystery Case: Vomiting in a 12-year-old MN DSH

Do you recall that 12-year-old cat that I briefly mentioned last week? Well, we had taken a blood sample, and performed some x-rays. The history was, he vomited and was eating grass and vomiting that. Then he stopped eating, was lethargic, but had a painful abdomen. When the owner went to pet his belly, he got mad.

On physical examination, he was obese, normothermic, euhydrated, no string under the tongue. He had a painful responsive to palpation of the right cranial abdomen, not on the left, but the caudal abdomen he was also reactive. I needed to figure out if the vomiting was gastrointestinal or secondary to something else. Due to his obesity and painfulness, I wanted to rule out urethral obstruction. I am lucky enough to be in a clinic with an ultrasound so I could get a quick look to make sure I wasn't missing a blocked cat.

I discussed diagnostic and treatment options. Given the age of the patient, it presented more like a cat with pancreatitis, than a cat with a foreign body or obstruction. So we prioritized blood work over x-rays. We took a blood sample and submitted that to our out-sourced laboratory.

I sent him home overnight with pain medications and an injection of an anti-nausea medication, as well as some cans of hypoallergenic food, essentially treating him like a cat with pancreatitis (and IBD or triaditis). I spoke to the owner the next day with the blood work results. The blood work results returned normal. The only thing on his urine was 2+ protein, so we added on a urine protein to creatinine ratio (UPCR). The blood work showed a normal pancreatic lipase, which suggests it is not acute pancreatitis. He had started eating, and had no additional vomiting. He urinated and had a small bowel movement. I advised that if he vomits again, we can schedule him in for x-rays. The owner wanted peace-of-mind, so we scheduled him in on her next day off, just in case.

The next day, he stopped eating again. No vomiting, but was more lethargic. The owner didn't know if this was due to the pain medication, so she stopped the pain medication, and we went ahead with the radiographs.

This time, he's not painful and still normothermic. He had not had any pain medications in 24 hours but was quieter than when I first met him. He did have some red regions on his tongue that I couldn't recall seeing on the previous oral exam, but wouldn't be ulcerations, yet. He was making motions like he was nauseous, but wasn't retching. I thought perhaps it could be esophagitis.

We did abdominal radiographs. The x-rays did not suggest a foreign body or obstruction, but the lung fields in the abdominal view didn't look normal. So I asked the technician to get a few shots of the chest cavity as well, just for completeness. Now I am stuck staring at lung fields that don't quite look normal. Is it old cat lungs, or is this some sort of metastasis, or is this just normal? I have my medical director look at them as well. Okay, we are both stumped. I think we need to send these off to a radiologist.

In discussion with the owner, the next step would be an abdominal ultrasound. So the owner elected to not send the x-rays off, but to have an ultrasound booked. Our mobile ultrasonographer was not available, so we scheduled him in for the next available day. I sent him home with an injection of anti-nausea medication, as well as some oral doses.

We got an update the next day. He had gone home after visiting us, and started eating again.

The abdominal ultrasound was performed. Pancreas normal. No evidence of a foreign object in the stomach or intestines. Liver normal. Then came the renal system - kidneys themselves normal in size, but these were surrounded by hyperechoic fat which was interpreted as possible pyelonephritis, in conjunction with echoic urine (urine should be anechoic). I thought it strange that the urinalysis did not pick up anything. No pyuria (inflammatory cells), no bacteria, no crystals, nothing to suggest that the urinary tract was an issue. Even the UPCR had returned in the normal range. The only other thing that was noted was some hyperechoic mesenteric fat around the jejenum, that was interpreted as either IBD or residual from a foreign body that passed.

The reason I wanted to discuss this particular case is because this cat is so fortunate to have a dedicated owner that was willing to do a full work-up on his condition. It shows that determining the cause of vomiting in a cat can be a bit of a puzzle to solve.

I started this patient on Marbofloxacin to treat a possible kidney infection (pyelonephritis) and we will see how he does. Stay tuned...

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