Problems after enema.

Dr. Marie replied:

*Note*...just as I started to answer your question, I got the second part. I'll include it here, rather than as a whole new question:

I am continuing my question about Linus Our 2 year old cat( I sent a question hours ago); because the evening has revealed much more to the story. I think the more you know, the better in regards to your thoughts on this.

Recap: Linus growling and acting as if in discomfort this past Thurs; called vet; brought him in; 2 enemas; he did nothing at the vet’s, even overnight; brought him home Friday am; he promptly pood when we got home ( good amount; normal, formed; not hard). Vet gave him Cisapride; and said he thought he needed it for life; we are reluctant to go there right now . (He did have an xray when this first happened in March; it showed nothing remarkable except really backed up stool. )

Now:
After the Friday ‘clean out’ Linus had no bms until Monday mid morning. Eating well; seemed ok. We started the Cisapride on Sat. am. ( ½ pill 2x a day morning and evening).

Monday: He pooed am; normal bm, normal consistency; about 3 “ long.
Multiple litter visits all day
About 1 hour after evening cisapride, he acted as if he was uncomfortable; and ‘growled’ as if at his back end: then he pooed shortly after ( about 2” long, not hard, normal size and shape).
Then all evening he made many, many visits to the litter ( all 3 litter boxes); only drops of ‘mushy poo bits; I went down to observe; he was constantly in and out; licking his bum; he made small ‘straining’ sounds, he walked out of the litter holding his rear end as if still in litter box and growling; he lay on his side and growled. This has continued, but broken up with playing, some eating, and getting pets and purring.
I have been cleaning and checking the litter boxes constantly.( He has peed.)

Is the Cisapride a problem? Should we be giving it still if he displays this discomfort and difficulty? Is it a side effect of cramping? But why so unproductive and straining?

- If he pooed ‘normally’ at first, why is he having trouble now and the liquid drops and mushy bits? Is this constipation?

Is there a cycle set up here? - of the clean outs ( as I explained in my previous post to you; he‘s had several recent vet visits) , and enemas, that result in more constipation ( the delay in pooping after his colon is handled like this; I’ve read can be a normal thing after enemas and clean outs; but he’s still eating , so a constipation Cycle that even the vet visits /procedures can result in?

-I am worried about calling the vet again: if we bring him in yet again this will be the 5th stressful hour long drive for him since Thursday ( we are in a remote BC location; vet visits are even more stressful and problematic; an hour there; an hour back; he often has to be left overnight because we have to drive so far) ; I’m worried about the cycle continuing; If we leave him there ;he clearly holds it after enemas ( he’s never ‘produced’ there); and I’m worried about the stress on him; he’s been there so much recently; yet it is still all continuing unresolved. More enemas?

I am up all night here; worrying about what is the right thing to do for my poor little cat. I do admit; I’m feeling very distrustful of the benefit of multiple vet visits at this point ( and even now worrying that they could do some harm);I’m afraid to call yet again.; but we have so few options in our remote location. I am very eagerly looking forward to your advice; and grateful that you give advice online like this.

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Here is my answer:

These are tough questions to answer. When cats have motility problems with their bowels we often don't know what the issue is. There are some cats that can have a serious condition called megacolon where the nerves in the colon stop working and they get a HUGE colon. When we see this (on an xray) then we know for certain that these cats need lifelong medication and possibly even surgery. (You mentioned in your second reply that his xray did not show megacolon, so this is good news.)

But, for most cats with intermittent constipation issues the cause is unknown.

I have had a large number of cases like yours and I can tell you that a constipated cat is one of my least favorite things to deal with because often the case does go on like this with repeated discomfort and issues that are not clearing up. And often, I require repeated visits and quite often a hospital stay in order to clear things up. And, unfortunately, sometimes, I end up with cases where I can't solve the problem.

So, let's see if I can answer some of your specific questions and then I'll give you my opinion on what should be done.

1. Is it normal to go a few days without a bowel movement after a "clean out"? The answer to this is yes and no. If I have a cat where I have done a really thorough clean out under an anesthetic and I got loads and loads of stool out, I don't worry too much if the cat goes 1-2 days without another stool, provided that cat doesn't seem uncomfortable. But if I've just given an enema and gotten a normal sized stool from the cat, then he really should continue to have regular bowel movements each day. *And* an important factor here is the fact that he is making repeated visits to the box and straining. This is not normal. This means he is still having some type of issues with his bowels.

2. What is the deal with the liquid stool? Could that be because of the Cisapride? This is a tough question to answer because we don't know. Cisapride on its own does not cause diarrhea. It does nothing to soften the stool. Sometimes we will give a drug called lactulose to constipated cats. Too much lactulose can cause soft stool, but Cisapride won't.

What Cisapride does is help the small intestine move. In turn, it pushes along whatever is in the large intestine. (Unfortunately we do not have a drug that helps to move the large intestine on its own.)

It's not uncommon to see a little bit of mucousy stool immediately following an enema as often we will put some lubrication in the enema solution. But if it is continuing more than 24 hours afterwards then this probably means that Linus is still having motility issues. It is highly possible that there is some type of blockage (most likely very firm stool) that is very high up in his colon. He may be able to get a bit of liquidy stool past the blockage and that's it.

You will need to discuss with your vet on whether or not to stop the Cisapride. (I can't legally make medical decisions on medications for you.) On one hand, it may be really helping him to continue to get stool out. On the other, if there is a blockage somewhere and it is not resolving, continually pushing on that blockage could cause a serious problem like a colon rupture. It is really really tough to know which is happening because we can't see what is going on inside of the colon.

3. Will Linus need Cisapride for life? That's a tough call. Our first issue is to get this current crisis cleared up (and I'll give you more advice on that at the end of this answer.) Once he is doing well, a good plan may be to keep him on the Cisapride for a few weeks (or even months) and then try to very gradually reduce the dose. If you start noticing a decrease in frequency of stools when you reduce the dose then you know that he needs to stay on it.

I do have a few patients that go on Cisapride as necessary. They do well for several months off of the drug and then if the owner is noticing that the stools are coming less frequently, they start it up again. You have to be very observant to do that because if you wait too long and he gets too constipated then Cisapride on its own is not going to work.

You may want to talk to your vet about trying a food called Medi-Cal Gastro Response. This food was new on the market about a year or so ago. It contains psyllium and a number of other things that are supposed to really help the health of the bowel and to help intestines move. I have many patients in my practice that were formerly on regular Cisapride that we have been able to take off of all medications as long as the cat stays on this food. It's a prescription food so you need to get it through your vet.

4. Is this likely to be a chronic problem? From past experience, it is very uncommon for a cat to have a couple of bouts of constipation like this and then be fine for the rest of their lives. Unfortunately it sounds like this very well could be a chronic problem for Linus.

So, here is the part that you really want to know...what do you do now? My answer is probably not one that you want to hear. When I have a case like this where a cat is having problems like this that are lasting more than 24 hours, what I usually want to do is keep the cat in the hospital for 2-4 days. During this time I give intravenous fluids. The fluids really help to sort of "lubricate his insides" and help things to get moving. I also give repeated warm water enemas to continue to flush out what is inside. These enemas are more intensive than what you gave at home. We usually use a long tube that goes up fairly far into the colon and helps to add moisture to what is there. Most cats handle this relatively well.

If the cat is continuing to have problems I usually take more xrays. The reason for this is to look for evidence of some type of foreign object obstruction. These are not always easy to find and sometimes repeated xrays are needed. My guess is that this is not an obstruction but if it was then it needs to be dealt with ASAP.

I do not take constipation lightly! I know it seems like he is not constipated because he is making repeated trips and having some soft stool, but I really think the soft stool is because he is straining to get out something that is higher up. I can't tell you how many cases I have had like this where the owners have been reluctant to come in (and really, I don't blame them!), and have waited too long. The longer we wait the harder this gets to fix.

So, hopefully that answers your question. That was a much longer response than I usually give but I felt it was necessary. As inconvenient as it is, I really would advise that you have Linus seen again. It sounds like your vet is doing all of the same things that I would do. Rest assured that you can trust your vet....they really do have Linus' best interests in mind.

I hope he feels better soon!

Dr. Marie.


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Dr. Marie replied:

I am concerned by the fact that Linus didn't want to eat today. This means that he is not feeling well. :( This makes me even more certain that he needs to go back to see the doctor.

The vet will know what to check for. I can't see that any blood tests would give us more answers.

I really feel for people who live in remote areas. It's easy for me to tell my clients (in the city of Ottawa) to just pop in, but when you've got to drive for an hour or more that makes things harder!

Praying for good news for you and Linus!

Dr. Marie.

Dr. Marie replied:

Hi Mia...I've added your second reply here (just to keep things all on the same page):

Now The added info ( I think this is important):
- the very first time Linus was constipated, on the drive up to the vet's, he pooped in his carrying cage. Just before and as he pooped, he cried out in pain. Right after the poop passed he seemed calmer, and was not in pain.
-His litter box ( 3 of them) are in the basement; the only times I have actually observed him pass a stool; it has been with pain/discomfort. Last time he had enemas and did not pass stool at the vets, and we brought him home; he exhibited a lot of discomfort just before passing the stool ( he was with me and I saw this, then he promptly went and pooed downstairs. This happened again with the 2nd passing of stool that same day). Then no stools for a couple of days (if you recall).When I think its uneventful; I haven't actually seen him; just found the stool in the litter.( however, it is only through these last months that I've seen signs of discomfort; never before).
- He has never passed stool with the enemas at the vet's; because of this, 2x he had a 'manual' clean out; and the last time we brought him home after the enemas when he did not pass it.
- these last 2 times;we were told when the 2 different vets palpated him that he was NOT constipaited.
- Now this: We have Linus because we saw him hit by a car as a stray kitten on a highway. We picked him up and took him to the vet; and ended up keeping him. He had had a broken pelvis ( in the 'growth plate). Thinking about the narrow pelvis; I called the vet last evening; I left a message on his machine; he called me back; here is what he said: Linus has a small growth spur from the accident ; he feels that it, like the slightly narrow pelvis, are not significant enough to cause a problem.

Here are my thoughts and questions:
- what is causing the pain and discomfort as stools pass or try to pass?
-Is he always doing this?
-Is this related to his accident ( even though our vet feels the bone spur and narrowed pelvis are so slight)?
- Could the constipaition that did happen relate to his 'holding it' because it hurts to go?( and therefore after the enemas and clean outs the delays again before there are more stools?)
-Should we pursue this thinking in some way?

Once again; thank you so much for your input Dr. Marie.

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Here's my answer:

First of all, I am thrilled that Linus has had some normal stools since we have talked. You're right, this makes the idea of an obstruction an awful lot less likely.

Regarding the psyllium, I do feel that psyllium helps cats. I'm not a fan of pumpkin and high fibre diets. In the past we used to think that high fibre would help move stools along, but newer research suggests that the bigger bulkier stools can be a problem. However, psyllium does more than just bulk up stools. It does a lot of stuff for intestinal health.

Did you ask your vet about the Medi-Cal Gastro Response food? The company that makes this food has put an awful lot of research into getting the exact right amount of psyllium and other ingredients to help the most with intestinal health.

I'm not sure what to tell you about the narrow pelvis. My gut instinct is that if the pelvis was too small for stool to pass then we would be seeing very small stools...plus this wouldn't be an issue that comes and goes. It's hard to comment on the bone spur as I can't see the xrays and examine Linus. I suppose it is in theory possible that he has some off and on pain in his pelvis. If this is the case that when he is having some pain he may be reluctant to get into the position to posture for defecation and as such he holds his stool for too long and it gets harder for him to pass. If this is the case, then the anti-inflammatory may help. The problem will be in knowing whether he needs it long term or not.

The problem with cases like this is that we rarely know exactly what the cause of the problem is.

Hopefully that answers your questions. So glad to hear that things are "flowing" better now!

Dr. Marie.

Dr. Marie replied:

Thanks so much for the bonus and the kind words in your feedback!

Dr. Marie.