# Sick cat - Elevated liver enzyme



## iqmgt (Apr 12, 2008)

My cat Zoe is a 10 yr old male. He is strictly an indoor cat. For a little background, exactly a year ago, he had a urethral obstruction from struvite crystals from which he made a full recovery. He has been on Prescription Diet C/D ever since.

Thursday night, he was fine and Friday when I left for work, he was sleeping in his favorite chair. I'll normally go up to him and rub his belly at this time which he enjoys. Everything seemed normal when I left the house. 

That evening, when I got home he didn't appear to have eaten or drinken. His litter box was also empty. He later vomited up what looked like yellow bile. He didn't appear in any pain, and I felt his bladder to make sure it wasn't enlarged, and it didn't appear to be. From that point, he became very listless. He would just sit stairing straight ahead and would not turn his head to ackowledge his surroundings. He would wag his tail as I was calling out his name. He then vomited up more bile around 11:30 and 1 AM. His demeaner remained the same and he would not eat or drink anything I put in front of him. He appeared dehydrated by this time. He skin would not bounce back when I pinched it.

First thing in the morning, we took him to the vet. This is the animal hospital that removed his obstruction during emergency hours. Our normal vet did not open until an hour and a half later and I was too concerned to wait. His temperature was 104.8. The doctor wanted to put him on IV right away and perform a full blood panel and an abdominal X-ray.

At the 3, the doctor called us and said that Zoe's ALT enzyme was elevated to 107, his WBC was a little elevated and she did notice a few toxic cells. All of his other levels were normal. His X-ray showed his liver was slightly enlarged. He has peed since beginning the IV so they are running a urinalysis but the results have not come back yet. His temperature has gone down to 103.9, They also put him on medication to stop the vomiting and to fight the infection if it is one. but he hasn't eaten yet and he has vomited a few more times. The vomit has turned into a greenish-yellow color. I asked if Zoe was jaundice at all when she examined him and she said no which was a good sign. But she is concerned that the vomiting has not stopped and that he is not eating. If he does not begin eating by tomorrow afternoon she want to insert a feeding tube into his stomach because she is concerned about fatty liver developing and complicating his condition.

Also, on Monday, she wants the specialist to perform an abdominal ultrasound if his symptoms haven't abated to rule out liver cancer. 

We just got back from visiting him and he appeared responsive. He had his frightened meow and was turn towards me as I was petting him. He would not do this last night.

They don't have visitors on Sunday so I'll only be in touch with the doctor by hone tomorrow. I'm very nervous for my little guy and would welcome any support and suggestions on his condition. Thanks.


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## Jeanie (Jun 18, 2003)

I wish I could help more. I can only offer my support and prayer. I hope your little friend recovers. It's obvioius that Zoe has a very caring family and the best of care. God bless.


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## Jimmyness (Dec 31, 2005)

Im so sorry to hear you're going through this


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## drjean (Jan 6, 2004)

Sorry your kitty is sick! 

Maybe it will help to know that 107 is a minor increase in ALT, so while the liver is annoyed, it isn't crashing. However, if he isn't better (specifically eating on his own) lby Monday, I'd agree with the ultrasound rather than x-rays--it is a much more sensitive diagnostic tool and can even assess movement in the GI tract that x-rays can't. 

A feeding tube sounds a little drastic this early; OTOH, feeding is crucial in liver disease and that is often the only way to accomplish it. If he is still vomiting, a feeding tube is not an option. Hopefully the ultrasound will tell you more!

Best wishes!


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## Jeanie (Jun 18, 2003)

Dr. Jean, you are such a blessing to this forum. Thank you.


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## iqmgt (Apr 12, 2008)

Thank you everyone for your replies.

Dr Jean I have some encouraging news. I just got off the phone with the vet.

He vomited once more early in the night and has since stopped. The vomit had also returned to a clear color. His temperature has also gone down to 99.9  

Tomorrow they are going to run another blood profile and the urinalysis results should be back.

He still isn't eating though. He is a very skittish cat around strangers so the doctor thinks it might be stress. They are giving him a medication to encourage his appetite. She also asked that I come by in a few hours, they normally don't have visitors on Sunday, to see if he'll eat from my hand alone in the examination room.

Dr Jean, if his symptoms and ALT return to normal, do you still feel the ultrasound should be performed? What about the feeding tube, how long a period of no eating is it normally recommended to insert a tube?

Also, I recalled last night and mentioned to the doctor which she said could be a key in his sickness. A baxterial infection. Warning, it might be a little gross to some readers. 

Zoe normally never drinks from the toilet. But Monday night I heard a slurping sound from the bathroom and caught him doing so. The housekeeper had been sick last week so the bacteria had a number of days to grow and multiply. She thought that this could have caused his illness but couldn't make a definitive diagnosis without further test results.

Dr Jean do you agree that the bacteria found in human waste could cause these symptoms in a cat? What tests should be run to confirm this type of infection? It would be a great relief to know that this is the true cause and not something more serious with his liver.


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## drjean (Jan 6, 2004)

Whew, glad to hear he is better!    

It's possible, but not likely, that he picked up some bacteria from the toilet--which typically has *less* bacteria than, say, a kitchen counter or telephone. Even so, they would ordinarily be exterminated by the stomach acid, which is the main purpose of having stomach acid to begin with! However, that's not to say it isn't a bacterial infection. Sometimes one or another strain of bacteria normally found in the GI tract will overgrow and cause problems. However, in most cases this would have been found upon microscopic exam of the feces (which I assume they did early on). 

If Zoe is truly on the road to recovery (and it sounds like he is!) then further testing and procedures is kinda like closing the barn door after the horse is gone. We may never know the cause, but hopefully we won't have to! I'm not sure I'd put a whole lot of weight on the ALT at this point, but it really depends on what the numbers are. Please let us know!


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## iqmgt (Apr 12, 2008)

I'm so distraught at the moment. Everything has been happening so fast.

When I went to visit Zoe Sunday evening, he wouldn't eat from my hand after being with him for a half hour. Thjen the doctor suggested we try to give him Valium. She administered the dose and left us a lone. A few minutes later he ate about 20 pieces from my hand. She thought it would be a good idea to send Zoe home that night to see if he would eat in familiar environment. I was supposed to bring him back first thing in the morning.

When he got home, he took a drink from his water bowl and then peed in the litter. But from there things went downhill. He became very quiet and unresponsive again and he vomited yellow liquid and had diarrhea during the night while we were sleeping. This was on the carpet, he didn't make it to his box.

First thing in the morning, I drove him back to the vet and she hooked him back up to IV and took his temperature. His temperature was still normal. After I left, they inserted a feeding tube in through his nose. Around 2 PM she called me and said that the radiologist looked over the x-rays and now they didn't think it was a problem with the liver but a problem around his upper small intestine. She asked for permission to perform an abdominal ultrasound.

I went back there around 6:30 and they let me in at 7 and the Dr. did not have good news. the ultrasound showed that the lymph nodes around the intestine were enlarged. She said it was either IBD or lymphosarcoma but they were leaning towards the cancer.

I sat with him in my arms for about 20 miutes and he wasn't responsive. She said they need to do exploratory surgery to determine which disease it is? But she also said he was weak from the dehydration and was concerned about him undergoing the surgery. But they also want to do it tomorrow. So I don't know what to do.

Is it dangerous to let him just be on the IV and feeding tube for a few days to see if he regains his strength? What will happen if the surgery gets put off a few days? My sister is at college and we want her to be able to see him but we don't want him to die on the operating table.

I've been googling since I got home and it says that they can do a needle biopsy. Would that be wiser? Would that tell us at least whether it is cancer and then we can do the surgery if it is to find out how extensive it is and do a full biopsy on the lymph nodes then?

I just don't know what to do at this point.


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## iqmgt (Apr 12, 2008)

Also, they said all of his major abdominal organs looked normal on the ultrasound. They had also done a chest x-ray and everything looked normal there too. His urine and fecal tests were normal and the only issue with his blood was the slightly elevated ALT level.

But he just won't eat and is so unresponsive. This is just happening way too fast. Thursday he was finr. I wish I knew what the best course of action was to take over the next few days.


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## Jeanie (Jun 18, 2003)

I'm so very sorry Zoe is this ill. My heart aches for you. I only wish I could give you the answers you need.


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## drjean (Jan 6, 2004)

Oh, no! I'm so sorry! But you asked for feedback, so I'll do my best to give you a bit wider perspective. 

Here's the deal: If the test won't change the treatment, don't do it. In his case it's risky, and I would be concerned about quality of life issues as well. In his case, it might change the outcome, but that depends on you. If it's cancer, do you want to treat it aggressively? If you *wouldn't,* then knowing if it's cancer *won't* change the treatment. Palliative treatment for lymphosarcoma (lymphoma) is steroids. The treatment for IBD is steroids. No difference, no test. 

Aspirates are generally done on surface nodes, like the jaw or legs. I doubt that they could do an aspirate on those nodes; they're deep in the abdomen and the needle would puncture other things on the way, making the sample worthless. 

Would it be okay to leaving him on fluids & a feeding tube? Sure. Will a few days make a difference? If it's cancer, yes. Lymphoma grows incredibly fast. However, there are also compelling reasons to go with the more conservative route: the surgery is very risky while he is so unstable, your sister wants to see him, and most importantly, you need time to absorb and consider all of this. 

I agree that cancer is more likely based on normal intestine, abnormal lymph nodes, and severity of symptoms. (Warning: I don't like oncologists, chemotherapy, or any of that other radical stuff, so bear in mind I usually recommend exactly the opposite!) My personal bias is to not do any extraordinary measures to prolong life, unless it will really make a difference. But of course it's impossible to predict what the outcome will be with either option. 

The vet may not have mentioned this, but even if they do a surgical biopsy, there is a small chance that the results could *still* be inconclusive. Then everyone's back at square one, but the cat will be the one with the scars.

If they do get a good biopsy and it is lymphoma, chemotherapy (usually steroids plus one or two other agents) is actually about 70% successful at putting feline lymphoma into remission. You may want to talk to a vet oncologist about it. Again, quality of life would be a big concern for me. (Did I mention I hate oncologists and chemo? So if even I grudgingly admit that one of them might be okay, it probably really is okay.) 

IF it's lymphoma, and you *don't* want to do chemo, then there is no point in putting him through a surgery that will take weeks of painful recovery, or could kill him. Or, they could open him up and find such a mess of cancer that they'd have to euthanize him on the table. 

This is just a horrible situation for you, and you have some very difficult decisions to make.  However, I always tell my clients that whatever decision they make from the heart, with love and compassion, can never be wrong. 

Just don't let the vet bully (or sweet-talk) you into doing a procedure that has such serious ramifications for the cat. If you need more time, take it. Your cat, your decision. Do what you think best for Zoe, not for you, or your sister, or the doctor--Zoe. 

BTW, don't blame yourself for not picking up on this sooner. As you said, Thursday he was fine. Cats hide illness until it is very advanced. There's nothing you could have done sooner.

May God bless you and help you through this. We're here for you.


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## Gudewife (Jun 27, 2004)

I don't have Dr. Jean's expertise, but I've been through some similar questions with Assumpta's pancreatitis...the only way to make a clear diagnosis was a biopsy, but even if it was positive, it wouldn't have really changed our options at all, and probably would have ended up setting Assumpta back, so my vet and I decided that there just wasn't any point (as Dr. Jean said, if the test won't change the treatment, don't do it). Even though we agreed that without opening her, we couldn't definitively rule out cancers or diagnose anything, we agreed that we would rather watch and wait (though Assumpta's overall condition was better than Zoe's, so we felt more at ease with being conservative)

Oddly, Assumpta's only lab abnormality in the beginning was an ALT of 863, at which point my vet ordered me to the ultrasound clinic immediately (and my vet is not the strongarm type, so she was serious...I have never seen her so adamant, actually). We had discussed doing needle-guided biopsy if we saw any suspicious lesions on the liver, but they needed some major coagulation blood profiles done first and there was no time (in the end, we didn't find anything worth sampling...her liver and pancreas were very slightly enlarged, but nothing looked grossly abnormal).

I guess that I'd echo Dr. Jean's question of "if it is cancer, how aggressive do you want to be?" I can only tell you what my feelings have been on it, because my vet asked me the same question early on...my answer was that I did not want to put Assumpta through chemo and lots of vet time or hospital stays, and that I would rather treat symptoms, make her comfortable, and let her decline at her own pace (this has become the basis of our treatment plan in general). But that may not be the right answer for you...my decision was tailored to an older cat who hates the vet, loves her home, hates any disruption in her routine, and seems to be happiest with less intervention. Even as sure as I am about my choices, I know that I will reach a day when I question it (and this is where my vet will step in and gently remind me of why we made those decisions in the first place). So what I'm trying to say is that you're capable of making the right choice, just consider Zoe first, as Dr. Jean suggests. What is best for him?

Sorry to be so long-winded, but I recently sat down alone with my vet and had a long discussion about just this subject, and we came to some agreements and understandings about how we want to proceed if and when the time comes (we're both pretty conservative about these things), so I've given a lot of thought to these issues lately and your situation struck a chord with me. I wish you and Zoe all the best...it's a very hard time.


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## iqmgt (Apr 12, 2008)

Thanks for the kind words.

Zoe's condition has deteriorated. He had 2 episodes of projectile vomit with blood in it and his body temperature has dropped to 95. They took another xray after the vomiting and some got into his lungs. They've given him a morphine like pain killer. I forget the name. But he is suffereing. He just sits there hunched down making a barely audible moaning sound with every breath. I don't think he would survive the surgery at this point.

I just keep thinking, what if the steroids help. But I don't want to prolong his suffering if he is in really bad pain.

My family is deciding whether to put him to sleep this evening. We have an appointment at 6.

To clarify the condition of the intestines. They did say it looked like there was a partial growth/obstruction in the upper intestine near the enlarged lymph nodes. Which they are leaning toward being a tumor.


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## treeh (Apr 9, 2008)

My heart breaks for you and your family. My thoughts are with you all.


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## melysion (Mar 12, 2007)

I'm sorry your family and your kitty are going though this. 

[[[[hugs]]]]


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## iqmgt (Apr 12, 2008)

We had to put Zoe to sleep yesterday evening. He had developed pneumonia from the vomit that entered his lungs and was having a difficult time breathing. They had to keep him in oxygen just so we had time to get there and say goodbye.

Euthanizing him was the hardest thing I ever had to do, but I know it was what was best for him.

He will be greatly missed.

Zoe - October 31, 1997 - April 15, 2008


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## drjean (Jan 6, 2004)

I'm so sorry to hear the sad news!  But you made the right decision. I know you'll miss him terribly, but remember, his spirit will always be with you. 

Consider yourself hugged!


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## Jeanie (Jun 18, 2003)

I am so very sorry. I know this was very hard on you, but I believe little Zoe is purring in the arms of angels. Some day you'll be together again.


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