The Covid-19 pandemic has delivered unprecedented challenges to all of society including those within the veterinary profession but sticking to certain aspects of my routine as best I can whilst homeschooling the children and continuing to work in practice has offered a comforting structure to these difficult times. Part of this routine includes watching regular webinars on the ‘The Webinar Vet’ and writing my monthly blog and although distraction by household members can be a challenge it does give me an opportunity to cling on to at least some normality of old.
I treated myself to ‘The Webinar Vets’ recent offering on the topic of feline triadits led by Martha Cannon BA VetMB DSAM(fel) who has always been an excellent speaker offering useful practical advice for the general practitioner in first opinion practice and this webinar was no exception. Martha explained that feline triadits is a combination of enteritis, pancreatitis and cholangitis and went on to use Chip, a 12-year-old Burmese cat as an example. Chip presented with an acute onset of anorexia, lethargy and frequent vomiting following a two-month history of weight loss and intermittent vomiting. On physical examination, Chip had abdominal pain and was found to be pyrexic and dehydrated. Lab work showed an elevated Alk-P, bilirubin and bile acids indicating the presence of cholestasis. ALT, however, was not elevated indicating there was no hepatocellular damage at this stage.
Chip’s lab work also demonstrated that he was neutropeanic with Martha explaining that a cat can have either acute or chronic neutropaenia. If chronic the list of differentials do not read as good news and include retroviral infections and neoplasia. However, if acute, the presence of neutropaenia could be secondary to a focus of bacterial infection causing a pre neutrophilic neutropaenia which could certainly be secondary to conditions such as cholangitis where bacterial infection is likely to be present. A snap fPLI was also performed on Chip and was found to be positive. The pros and cons of these tests were discussed by Martha within this webinar but her overriding advice was to always send the snap positive tests away for a follow up with a quantitative assay in order to differentiate between the borderline cases and those with higher levels of specific fPLI.
Martha went on to explain that abdominal imaging using ultrasound is an exceptionally useful tool when attempting to diagnose feline triaditis. The presence of certain findings on ultrasound should raise an index of suspicion that a cat may be suffering from feline triaditis. For example, diffuse thickening of the gall bladder wall (>1mm), echogenic content within bile and a dilated common bile duct(>4mm) are all indicators of acute cholangitis. Diffuse thickening of the small intestinal wall without any obvious loss to the layering is one of the findings expected in cases of IBD and although identifying pancreatitis may require more experience in the field of ultrasonography, hyperechoic peripancreatic fat can be identified alongside irregular pancreatic margins and an enlarged pancreas.
Once a diagnosis of triaditis was made, Chip was treated with IV fluids, maropitant , buprenorphine, and an omeprazole constant rate infusion. Ursydeoxycholic acid was also administered to thin down the bile and encourage bile flow. Martha questioned whether antibiotics should be also be given to Chip and went on to explain that most cases of acute cholangitis will have a bacterial infection of the bile duct and gall bladder. On the other hand, bacteria is rarely cultured in pancreatic tissue in cases of pancreatitis, however, bacteria have been identified when using the fluorescent in situ hybridisation technique. Given that Chip presented with pyrexia and neutropaenia and the fact that studies have shown withholding antibiotics is a negative prognostic indicator, it was decided to give Chip antibiotics in the form of amoxicillin/clavulanic acid and metronidazole.
Chip’s vomiting and pyrexia resolved after this initial treatment regime but he continued to be anorexic. Martha next questioned whether the use of corticosteroids could be justified? Ideally, a definitive diagnosis of IBD should be made prior to using corticosteroids and if a general anaesthetic was being given for other reasons such as the placement of an œsophagostomy tube it would be sensible to perform endoscopic biopsies at the same time. However, given Chip’s diagnostic findings offered a high index of suspicion that Chip was also suffering from IBD it was felt appropriate to use corticosteroids in this case and you will be glad to hear Chip recovered well ten days after presentation.
Further detail on the interpretation of laboratory results and the reasoning behind many of the treatment regimes was delivered in much greater depth within this webinar. As always Martha delivered an engaging, practical and highly useful overview of feline triaditis and I would highly recommend logging in to watch this webinar.
You can watch this webinar here