# pooping outside litterbox



## FooFootheSnoo (May 6, 2005)

Hi,
I posted part of this question in the health forum. My four month old kitten has diarrhea. He's been to the vet. No parasites were found, but they did prescribe dewormer, antibitiotics, and a medicine for coccidia. Anyway, several days before I took him to the vet he started pooping outside the litterbox. In the past, when he had an "accident" he would usually poop behind the couch or tv. This time he pooped right in the middle of the rooms. The poop was quite runny with blood and mucous. The day before our vet appointment he was crying while pooping in the litterbox. So, I think he's scared to use the litterbox because he's afraid it's going to hurt. He's been pooping outside the litterbox mainly at night and early morning(after he's fed). So, last night I set up a kennel with water, blanket, and litterbox. I put him in there while we were all in bed. He didn't poop in the litterbox last night, but has now pooped twice outside the litterbox today. I've caught him 3x on other occasions trying to poop outside the box. I picked him up and put him in his litterbox then praised him when he went. I am sure he's doing this because of fear of pain and I empathize with him. However, I really need for him to go in the litterbox. I have kids and it's just so unsanitary. The vet, besides prescribing the meds, offered no help. She just said if he keeps pooping outside of the litterbox to make him an outside cat. Please help!! p.s. I've also bought Cat Attract cat litter, it didn't help


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## coaster (Dec 1, 2004)

It sounds to me like you're very perceptive and on target with your analysis. Much more so than your vet. I do concur with you that it's a health issue, and I urge you to take him to another vet and get another opinion from a more sympathetic doctor. These symptoms could be caused by any number of things and just throwing the veterinary manual at him in the hopes something works, isn't the mark of a good vet.


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## Meowmie (Jun 4, 2005)

FooFootheSnoo, tell us two things please. What kind of food are you feeding and how long has your kitten had diarrhea?

Also, you only feed two meals a day to a four month old kitten? ((If so, not enough.) 

About the diarrhea. There are two strong possibilities here:
colitis and giardia

Colitis responds very well and very quickly to a grain-free and fish-free canned diet which, if necessary, can be adult food if such kitten food is hard to find in a certain area.

Giardia has to be diagnosed with a special test (they test one or more stool samples). Recovery is quick and complete after a _full_ course
of the necessary and proper medication. A _short_ course of medication does not work, even if the proper medication is prescribed.

First of all, please find another vet, preferably a feline specialist, someone who has a cats only practice. Then go from there. 

Here is some information for you about giardia:

http://www.sniksnak.com/cathealth/giardiasis.html

Please, if you are feeding dry food, switch immediately to canned.
Do NOT feed ANY dry food. Not one mouthful. 

In canned food you need to look for the all-meat varieties that contain NO grain of any kind and you also need to avoid all fish-based flavores. For example tuna, salmon, tuna and chicken, etc, etc, etc, any food that has the name of a fish on the main label. 

The grain ingredients you can't have in the food for this food trial:
corn and all corn derivatives such as corn gluten, corn flour, etc;
wheat and all wheat derivatives such as wheat gluten, etc;
rice in any form such as ground rice, rice gluten, brewer's rice, etc, etc, etc;
oats in any form;
soy in any form;
(I can't think of any more grain ingredients at the moment.)

You can start with the food trial right away, while you are looking for a good, caring vet and making arrangements for having your kitten tested for giardia.

Also, please leave plenty of food out for your kitten, let him eat whenever and however much he wants from _canned, grain-free food_. 
Do not try to restrict his food intake in any way.
The important thing at this point is to feed the right food and all he wants.


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## Meowmie (Jun 4, 2005)

Here is some detailed information for you about diarrhea in cats. It tells you how many different things can be involved. In my previous post I mentioned two of the most likely causes in kittens, but here is the rest, the full article:

Chronic Diarrhea--What's the cause 
ACVIM 2003 
Kenneth W. Simpson, BVM&S, PhD, MRCVS, DipACVIM, DipECVIM 
Ithaca, NY 

Pathophysiology of Diarrhea 

The most frequent clinical sign of intestinal disease is diarrhea-the passage of feces containing excess water, resulting in an increase in the fluidity, volume or frequency of bowel movements. The patho-mechanisms in the genesis of diarrhea can be categorised as osmotic, secretory, permeability and motility. Most intestinal disease in dogs and cats involves several patho-mechanisms so attempts to categorise animals presented for the investigation of diarrhea using these criteria are usually redundant. e.g., the accumulation of inflammatory cells within the intestine in response to antigenic challenge and other less well defined stimuli, can exert its effects both directly and indirectly by the production of inflammatory mediators such as prostaglandins and leukotrienes. The net result is abnormal mucosal absorption, secretion, permeability and intestinal motility. 

General approach 

Diarrhea which has lasted for 3 or more weeks is considered chronic. The approach to chronic diarrhea is based on the origin of diarrhea-large bowel or small bowel, and the presence of other specific or localising clinical findings. Differentiation is important as the diagnostic and therapeutic approaches to small and large bowel diarrhea are different. Differentiation is made on the basis of information furnished by the owner in response to questions about faecal characteristics, volume and frequency and related signs such as vomiting, weight loss, tenesmus and dyschezia. 

Small bowel diarrhea is a consequence of diseases that affect the small intestine or related structures such as the exocrine pancreas. 

Causes of Chronic Small Bowel Diarrhea 

Infectious 
Salmonella, Campylobacter, Giardia, FelV/FIV, Histoplasmosis, Phycomycoses, algae 

Metabolic 
Hyperthyroidism (cats), hypoadrenocorticism, liver disease, kidney disease 

Dietary 
Intolerance / allergy 

Exocrine pancreatic insufficiency 
Primary or secondary 

Small intestinal disease 

Structural 
Partial obstruction- intussusception, foreign object, neoplasia, lymphangiectasia 
congenital anomalies 

Inflammatory 
Eosinophilic, lymphoplasmacytic, granulomatous 

Neoplastic 
Lymphosarcoma, adenocarcinoma, leiomyoma, fibrosarcoma 

"Bacterial overgrowth" 
Secondary, idiopathic 

Functional 
Motility disorders, idiopathic 


Patient evaluation and diagnostic approach 

Signalment and history 

Infectious and parasitic diseases are common in young animals, whereas neoplasia and metabolic disorders are more common in middle aged to older animals. Certain conditions are more common in certain breeds e.g., protein losing enteropathies in the Lundehund and Soft Coated Wheaten Terrier. Small bowel diarrhea is generally associated with weight loss and large stool volume. Failure to thrive, changes in appetite, borborygmi, flatus, abdominal discomfort, ascites and oedema are also more common with small than large bowel diarrhoea. 

Physical examination 

Particular attention should be paid to hydration status and examination and palpation of as much of the gastrointestinal tract and abdomen as possible. The thyroid gland should be palpated in cats >6 years. A thorough rectal examination should be performed. 

Investigation of chronic small bowel diarrhea (see algorithm) 

The approach to patients with chronic small bowel diarrhea who are stable, have no specific localizing clinical findings and are negative for faecal parasites is usually to : 

I. Rule out endoparasites and pathogenic bacteria 
Fecal 

II. Screen for systemic disease 
CBC, profile, UA ± T4, FelV? FIV, ACTH stim 

III. Rule out exocrine pancreatic insufficiency 
TLI 

IV. Rule out partial obstruction 
Palpation, radiographs, ultrasound 

V. Evaluate intestinal structure and function 
Biopsy-endoscopic / surgical, cobalamin/folate /?Breath H2 / ?GI permeability 


Laboratory evaluation of chronic small bowel diarrhea 

Faecal analysis: Giardia (trophozoites, cysts), Coccidia, Tritrichomonas fetus in cats, other endoparasites, Fecal analysis for Clostridial endospores and endotoxin is fraught with difficulty in interpretation. Culture for Salmonella in animals with bloody stools, or fever, or chronic undefined diarrhea. Fecal culture cannot be used to diagnose small intestinal bacterial overgrowth. Fecal blood can be detected using appropriate detection system. These tests are usually very sensitive and the patient must be on a meat free diet for 72hrs prior to interpretation. Drugs such as cimetidine may cause false positive test results. 

Hematology: Anemia-Microcytosis (MCV < 63fl), decreased red cell haemoglobin and thrombocytosis are common in dogs with iron deficiency secondary to GI blood loss from intestinal parasites or tumors (Ddx portosystemic vascular anomalies or fibrosing liver disease in young dogs with signs of gastrointestinal disease). Macrocytosis (MCV> 53fl)-regenerative anemia, or cats with hyperthyroidism, FeLV or cbl/ folate deficiency. 

Eosinophilia-intestinal parasitism, mast cell tumors, hypoadrenocoticism, eosinophillic enteritis or hypereosinophilic syndrome. 

Neutrophilia ± a left shift may be encountered in inflammatory or infectious conditions. Lymphopaenia is commonly associated with stress, protein losing enteropathies and immunodeficiency. 

Lymphocytosis or lack of a sterss leukogram in a sick patient is suggestive of hypoadrenocoticism. 

Serum Biochemistry: R/O non-intestinal diseases which cause gastrointestinal signs i.e., kidney disease, renal disease, hypoadrenocorticism. 

Metabolic consequences e.g., hypokalemia, hyponatremia. Hyperkalaemia combined with hyponatremia suggests that an ACTH stimulation test should be performed to detect hypoadrenocorticism or pseudo-hypoadrenocorticism associated with Salmonella / whip worms / GI ulderation. Mild to moderate increases in liver enzymes such as ALT (up to 500 IU/l) are common in cats with hyperthyroidism and cats and dogs with intestinal disease. 

Hypocholesterolemia-dogs with protein losing enteropathy, EPI and other chronic enteropathies. Plasma bile acids and ammonia-liver dysfunction or shunting in patients with GI signs. 

Hypoglycaemia with signs of gastrointestinal disease should arouse the suspicion of sepsis, liver disease, hypoadrenocorticism or pancreatic tumor. Hypoalbuminemia + hypoglobulinemia R/0 protein losing enteropathies 

Hypoalbuminemia with normal or increased globulin concentration has to be distinguished from protein losing nephropathies and liver disease. 

Chronic diarrhea associated with hypoalbuminaemia usually requires intestinal biopsy to define the cause. Non-intestinal causes of protein losing enteropathy such as congestive heart disease, caval obstruction or portal hypertension should also be considered. When globulin concentrations are normal or elevated renal and hepatic causes should also be pursued. 

Protein losing enteropathies 

Lymphangiectasia 
Primary lymphatic disorder 
Venous hypertension e.g., right heart failure, hepatic cirrhosis 

Infectious 
Parvovirus, Salmonella, Histoplasmosis 

Structural 
Intussusception 

Neoplasia 
Lymphosarcoma 

Inflammation 
Lymphoplasmacytic, eosinophilic, granulomatous 

Endoparasites 
Giardia, Ancylostoma 

Gastrointestinal haemorrhage 
HGE, Neoplasia, ulceration 


Urinalysis: Part of a baseline evaluation to detect or rule out urogenital disorders in patients with signs of intestinal disease. Urate crystalluria may prompt the investigation of hepatic dysfunction as a cause of clinical signs. Urine Prot:creatinine for determining if the kidney is involved in the development of hypoalbuminaemia in patients with intestinal signs. 

Serology and hormone assays: T4, FIV and FeLV. ACTH stimulation to confirm hypoadrenocoticism or pseudohypoadrenocorticism where this is suspected from serum biochemistry. An ACTH stimulation test may also be used to screen for atypical hypoadrenocorticism (pituitary dependant) in patients with unexplained chronic diarrhea, eosinophilia, inappropriate lymphocytosis. Serology for Histoplasma, pythiosis. 

Tests of pancreatic function: Pancreatic function tests are most commonly employed in dogs with chronic diarrhea who are bright and alert with few signs other than chronic diarrhea, occasional vomiting, weight loss or polyphagia and normal to mildly abnormal clinicopathologic test results. 

Trypsin-like immunoreactivity (TLI) is a sensitive and specific test for detecting exocrine pancreatic insufficiency (TLI <2.5µg/l) in the dog and is performed in dogs with chronic small bowel diarrhea. The TLI assay is species specific and a cat specific assay has recently been developed. Exocrine pancreatic insufficiency is uncommon in cats and is usually associated with chronic diarrhea and polyphagia, fTLI < 8µg/l. 

Radiography: Survey abdominal radiographs are low yield in patients with chronic diarrhea. Contrast radiography is useful in evaluating partial obstruction and transit time/ gut length. 

Ultrasonography: Ultrasound is useful for detecting intestinal lesions such as intussusceptions, masses and foreign bodies, and for assessing intestinal wall thickness. The results of radiography and ultrasound provide a rational basis for selecting endoscopic biopsy (± duodenal juice analysis) or a laparotomy. Normal or diffusely thickened intestines can initially be evaluated endoscopically while focal lesions usually require guided aspiration or laparotomy. 

Tests of intestinal function 

When a clinical problem cannot be adequately defined or localised to the small intestine a variety of tests can be used to assess small intestinal function. Intestinal function tests have the potential benefit of allowing an overall assessment of SI function, rather than the small snapshot provided by a biopsy. They should always be critically evaluated in the context of the whole patient. 

Cobalamin and folate 

The measurement of circulating concentrations of cobalamin and folate may give an indication of the site and cause of intestinal dysfunction. Plasma concentrations of cobalamin and folate are labile and reflect the balance between dietary intake, bacterial utilisation and production, and intestinal absorption and body losses. 

The interpretation of circulating cobalamin and folate concentrations with regard to small intestinal disease is only valid if exocrine pancreatic insufficiency, dietary supplementation, parenteral administration have been excluded and attention is paid to dietary vitamin content. 

Dogs: Low serum cobalamin concentrations have been observed in dogs with EPI, severe intestinal disease and apparent idiopathic small intestinal bacterial overgrowth (SIBO). Cobalamin deficiency has been recognised in Giant Schnauzers with inappetance and failure to thrive with laboratory findings of anaemia, leukopaenia and methyl-malonyl aciduria. These abnormalities appear to be a consequence of the defective synthesis of the ileal cobalamin-intrinsic factor receptor and are completely reversed by the parenteral administration of cobalamin. Some Sharpeis also appear to have a deficiency of cobalamin. The physiological significance of the low cobalamin concentrations detected in other gastrointestinal diseases has not been reported. 

Low serum folate concentrations have been observed in dogs with severe jejunal disease and some Irish Setters with a gluten-sensitive enteropathy. High folate concentrations have been reported in experimentally induced SIBO (blind loops), EPI, German Shepherds with apparent SIBO and some Irish setters with a gluten-responsive enteropathy. Plasma cobalamin and folate concentrations may also be affected by dietary content, supplementation and certain medications e.g., sulphasalazine. 

In my experience the finding of a low folate or low cobalamin concentration is useful in supporting the presence of an intestinal problem. Where low cobalamin is detected and EPI, intestinal obstruction and presumed idiopathic "SIBO" have been excluded localisation of the problem to the ileum can be inferred. Cobalamin and folate are insensitive indicators of "SIBO" in dogs. The combination of low cobalamin and high folate is more suggestive of idiopathic "SIBO" than finding increased folate alone. Concomitant increases in folate and cobalamin are more consistent with high dietary intake or supplementation than SIBO. Finally, normal serum concentrations of cobalamin and folate neither exclude nor support a diagnosis of intestinal disease. 

Cats: Subnormal concentrations of cobalamin are common in cats with EPI, intestinal, pancreatic or hepatic disease: Forty-nine of 80 serum samples submitted from cats with signs of gastrointestinal disease during the period of January 1996-January 1998 had cobalamin concentrations below the reference range for healthy cats (range 900-2,800 pg/ml ; mean ± SD = 1775 ± 535 pg/ml SD ; n=33). Cats with subnormal cobalamin concentrations (mean ± SD = 384 ± 272 pg/ml, range 3-883pg/ml) were middle aged or older and were presented for weight loss, diarrhea, vomiting, anorexia and thickened intestines. Definitive diagnoses in 22 cats included inflammatory bowel disease, intestinal lymphoma, cholangiohepatitis or cholangitis, and pancreatic inflammation. Serum concentrations of cobalamin were particularly low in cats with intestinal lymphoma, 3/5 of which also had subnormal serum concentrations of folate (< 9ng/ml). The simultaneous presence of disease in the intestines, pancreas or hepato-biliary system in many cats made it difficult to determine the cause of subnormal cobalamin concentrations. The circulating half-life of parenteral cyanocobalamin was shorter in two cats with IBD (5 days) than in four healthy cats (12.75 days). 

The presence of subnormal serum concentrations of cobalamin in 49 of 80 cats evaluated suggests that the measurement of serum cobalamin may be a useful indirect indicator of enteric or pancreatic disease in cats. The rapid depletion of circulating cobalamin in cats indicates that cats may be highly susceptible to cobalamin deficiency. 

Other function tests 

Measurement of fecal alpha-1-antiprotease concentrations is useful for confirming the GIT as the site of protein loss, especially in dogs with hypoproteinemia but minimal diarrhea, and monitoring response to therapy. Breath hydrogen, intestinal permeability testing and measurement of deconjugated bile acids have yet to be shown to be useful in clinical practice. 

Intestinal Biopsy: Biopsy of the intestine is frequently required to achieve a diagnosis in patients with chronic diarrhea due to malabsorption. In diffuse intestinal diseases and in animals with hypoproteinaemia endoscopy provides a minimally invasive low risk way of obtaining a biopsy. 

Endoscopic biopsies are restricted to the mucosa and are small, difficult to process and orientate, and can be obtained only from the proximal duodenum and occasionally the distal ileum. Thus surgical biopsies are necessary in patients with focal intestinal lesions and in those whom endoscopic biopsy has not yielded a result. Surgical biopsies should be taken from multiple sites along the small intestine even if the intestine looks grossly normal. A small dermatologic punch aids the surgeon in obtaining full thickness biopsies and biopsy sites are sutured in an appropriate fashion. Extreme care is required where the bowel looks grossly abnormal and in hypoproteinaemic patients to ensure leakage does not occur. Precautionary measures such as serosal patch or omental wraps are indicated Biopsies of mesenteric lymph nodes should also be obtained. Other abdominal organs such as the liver, and pancreas can be grossly examined and biopsies obtained if necessary. 

The information which can be obtained from intestinal biopsies depends on the expertise of the pathologist. Minimum evaluation should include routine microscopic examination of H&E stained sections. In surgical biopsies the pathologist should be able to give an indication of villus height, ratio of crypt to villus and the type and degree of cellular infiltrate and intraepithelial lymphocyte count. Staining for different lymphocyte sub-types, assessment of marker enzymes, electron-microscopy and mucosal enzymology are restricted to specialist centers, but may be useful in sub classifying intestinal disorders.


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## FooFootheSnoo (May 6, 2005)

Thanks Timskitties and Meowmie. The more I think about the vet saying that, the madder I get! I paid good money to hear that? Even my brother, who does not like cats, thought the vet was not doing her job. But, whatever, I'll look for a feline vet. 
Meowmie, thanks for all the info on diarrhea. I was feeding Natural Balance dry and Fancy Feast. (I know the Fancy Feast is not good, but his mom is such a picky eater, I got her addicted to the Fancy Feast before I found out how bad grocery store pet foods are  ). I have given them the Natural Balance because it's a good food and, again, because his mother won't eat anything else. I actually called Natural Balance this morning and they are sending me a sample can of their Venison and Green Pea. I'll look for a food like you mentioned. I doubt I'll have a problem finding it around here. There's a pet store and feed store near me that are well stocked. I was feeding them 2x a day and leaving a bowl of dry out for them to snack on.
I think Murray has had this problem for a long time. I could be wrong, but he's just in the last month totally weaned and I wonder if the breast milk from mom was helping to protect his digestive system? I know human babies with digestive problems do better if they nurse longer. He's always had loose stools, I just didn't realize how loose because they were usually covered by litter. Now that he's stopped using the litter box, I can see that they are much worse than I thought. I feel so sorry for him. He's just the sweetest, laid back kitten I've ever met. Thanks so much for your help! We'll start a search for a new vet and new food tomorrow morning.


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