Chronic (Long-Term) Vomiting in Cats

Chronic vomiting (emesis) is vomiting that lasts for longer than a duration of three weeks. Vomiting is one of the most common presenting symptoms in veterinary practices and has many possible causes. It is easy for pet owners to rationalise vomiting as just normal because the cat eats too fast or has hairballs. The occasional vomit might not mean you need to rush your cat to a veterinarian, but, if the cat vomits more than once a week, over 2-3 weeks, a check-up is important to find out why the cat is vomiting.

Pet owners may confuse regurgitation with vomiting, but there are differences. Vomiting is an active process, and you will see the cat’s sides heave when the cat vomits. Regurgitation is a passive process that takes no effort. Regurgitated food looks much the same as it was before the cat ate it.

Accompanying symptoms

Symptoms can vary depending on the underlying cause, which can give the veterinarian a clue as to the possible cause. These may include:

• Diarrhea
• Weight loss
• Increased or decreased appetite
• Increased thirst and urination
• Hair loss
• Abdominal swelling
• Itching

Causes of chronic vomiting in cats:

Causes can be split into gastrointestinal, systemic, dietary and parasitic.

Gastrointestinal

One study titled Diagnosis of chronic small bowel disease in cats: 100 cases (2008-2012) found that 99 out of 100 cats had either lymphoma or chronic enteritis (inflammation of the small intestine).

Lymphoma:

Cancer of the lymphoid tissue caused by the abnormal growth of lymphocytes (a type of white blood cell). It can develop in many parts of the body, but it affects the gastrointestinal tract most often.

Symptoms:

Can vary depending on the location, but may include:

• Vomiting
• Diarrhea
• Loss of appetite
• Lethargy
• Weight loss
• A palpable abdominal mass (high grade) may be present or thickening of the intestine

Treatment:

Chemotherapy: The treatment of choice for lymphoma. Surgery may be necessary to remove a lymphoma that is causing a gastrointestinal obstruction.

Inflammatory bowel disease:

A group of immune-mediated disorders affecting different parts of the intestines can be divided into the following:

• Colitis – Inflammation of the large intestine.
• Enteritis – Inflammation of the small intestine.
• Enterocolitis – Inflammation of the large and small intestine.
• Gastritis – Inflammation of the large and small intestine as well as the stomach.

In most cases, the cause of IBD is unknown; some possible causes include genetics, hypersensitivity to bacteria, and food allergies. There is an increasing belief that a highly-processed diet is a significant factor in the development of IBD.

Symptoms:

• Diarrhea
• Vomiting
• Lethargy
• Weight loss
• Anorexia (loss of appetite)

Treatment:

Where possible, find and treat the underlying cause. This may include:

• Dietary changes: Switch to low fat, high fibre diet or a hypoallergenic diet.
• Medications: Corticosteroids such as budesonide or prednisolone to suppress the immune system and control inflammation.
• Antibiotics: Can help control symptoms by reducing intestinal bacteria and suppressing the intestine’s immune system.
• Fecal transplant: This treatment is still very new and not readily available yet. It shows great promise for helping cats with digestive issues such as inflammatory bowel disease. A healthy donor with a healthy and diverse microbiome provides a stool sample which is introduced to the host cat in several ways including colonoscopy, endoscopy, enema or in pill form to restore a diverse microbiome.

Dietary

Food intolerance:

Food intolerance is an adverse reaction to a food or when the body is unable to break the food down (such as milk intolerance where the cat beyond kittenhood lacks the necessary enzymes to break down the sugars). It differs from a food allergy in that the immune system is not involved.

Symptoms:

• Vomiting
• Diarrhea
• Bloating
• Flatulence
• Non-seasonal itching
• Swollen and inflamed face and ears
• Hair loss

Treatment:

Avoidance: Where possible, avoid the food which caused the intolerances. This may either be a homemade diet or a commercial one. If you are feeding a homemade diet, it is crucial to ensure that your cat is receiving the correct nutrients in the diet.

Food allergy:

Food allergies are the third most common type of allergy in cats (behind flea allergy and inhalant allergy). The most common causes of food allergies are fish, beef, chicken, eggs, and wheat. Cats become allergic to foods they have eaten for an extended period (usually two years or more). There is no breed, sex or age predilection. Cats with other allergies (such as inhalant) may be at greater risk of developing food allergies. There appears to be a genetic component.

Symptoms:

• Vomiting
• Diarrhea
• Nonseasonal itching
• Otitis externa (ear infection) due to scratching
• Excessive grooming
• Hair loss (due to excessive licking and scratching)
• Feline acne

Treatment:

• Dietary changes: Avoid the food which caused the allergies is the best method of treatment, which may either be a homemade diet using novel ingredients (such as kangaroo) or the use of a commercial hypoallergenic one. If you are feeding a homemade diet, it is important to ensure that your cat is receiving the correct nutrients in the diet.
• Corticosteroids or antihistamines: To control itching.
• Antibiotics: If a skin infection has occurred due to trauma from scratching

Parasitic

Intestinal worms:

The most obvious culprits are tapeworm and roundworm, which are both common intestinal worms. Tapeworms are transmitted by fleas, or infected prey (rats and mice). Cats become infected with roundworm by ingesting infective eggs in the environment or food, water, prey such as rats, mice, beetles, and earthworms or trans-mammary infection via the mother’s milk.

Symptoms:

• Vomiting (which may contain worms in cats with a heavy roundworm burden)
• Stunted growth in kittens
• Pot-bellied appearance
• Anal scooting (tapeworms)
• Tapeworm segments around the anus or in feces

Treatment:

• Worming medication: Treatment of worms is straightforward, with several chews, tablets and topical products available to kill the parasites. As fleas spread tapeworm, diligent flea control is also essential.

Systemic disease

Hyperthyroidism:

A hormone-secreting benign tumour of the thyroid gland. It is the most common endocrine disorder in cats and occurs most often in cats over ten years of age.

Symptoms:

• Vomiting
• Weight loss
• Increased appetite
• Diarrhea
• Rapid heart rate
• Jittery behaviour
• Poor coat condition

Treatment:

There are several ways to treat hyperthyroidism which you can discuss with your veterinarian. Some treatments cure the disease while others manage it. Some cats may also have chronic kidney disease, which hyperthyroidism keeps in check. Once hyperthyroidism is treated, chronic kidney disease can become worse. In this situation, veterinarians may recommend managing the disease instead of curing it.

• Radioactive iodine: This is the preferred treatment as it completely cures the disease. Radioactive iodine kills the tumour while leaving the thyroid gland intact.
• Surgery: Removal of the enlarged thyroid lobe(s), known as a thyroidectomy. The pros of this option are that it is a permanent cure. Cons include increased anesthetic and surgical risks due to the effect the disease may have had on the cat’s heart and kidneys.
• Diet: Hills y/d is low in iodine, which is required by the thyroid gland to produce its hormones, low iodene=reduced hormone production. It can take a few weeks for this food to take effect.
• Medication: The use of medication (Methimazole/Tapazole) doesn’t cure hyperthyroidism, only controls it. Medication is administered daily for the rest of your cat’s life. Methimazole can be given either in oral or transdermal (applied to the skin inside the ear) form.

The advantages of medication are that treatment is reversible if side effects occur (see precaution at the end of this article).

Chronic kidney disease:

A slow and progressive decline in kidney function with several causes which include infection, hereditary, kidney tumours, nephritis and nephrosis, polycystic kidney disease, aging and idiopathic (no known cause). Up to 70% of kidney function can be lost before symptoms of kidney disease become apparent.

Symptoms:

• Vomiting especially on a morning due to having fasted for several hours overnight
• Increased thirst and urination
• Urinating outside the litter tray
• Decreased appetite
• Weight loss
• Drooling (due to nausea)
• Poor coat condition
• Lethargy
• Bad breath
• Anemia

Treatment:

There is no cure for chronic kidney disease, and the goal of treatment is to slow down the progression of the disease as well as relieve symptoms which may include:

• Fluid therapy: Damaged kidneys have a reduced ability to concentrate urine, which leads to excess fluid loss via the urine. Caregivers must monitor and manage the cat’s hydration status by encouraging water consumption, switching to a wet diet and where necessary providing fluids subcutaneously.
• High quality, low protein diet: Protein is the building block of the body, and is necessary for normal function. After the body uses the protein in the foods, a toxic waste product called urea is produced which the kidneys remove from the body via the urine. When kidney function declines, urea can build up in the blood. A low-protein diet can reduce the build-up of urea.
• Low phosphorous diet: Phosphorous is a mineral which combined with oxygen becomes phosphate (you may see the two words used interchangeably). Together, calcium and phosphate work closely to build and repair bones and teeth. It is also used as a building block for several important substances, which include those used by the cell for energy, cell membranes, and DNA. As with protein, as kidney function declines, they are less able to remove excess phosphate from the blood.
• Phosphorous binders: Your veterinarian may recommend phosphate binders in conjunction with a restricted phosphate diet to slow the progression of kidney failure. These medications are given with every meal and work by soaking up, or binding to phosphate and eliminating them via the GI tract.
• Other treatments can include anti-nausea medication, antacids and appetite stimulants.

Diabetes:

Diabetes is a common disease where the cells build up a resistance to insulin, a hormone necessary for glucose to enter the cells. As a result, glucose levels build up in the bloodstream as it is unable to enter the cells. The body can’t function properly if the cells don’t have enough glucose due to decreased insulin or increased resistance to it because it lacks the energy from the glucose.

Causes include obesity, acromegaly, genetic predisposition, pancreatitis, and Cushing’s syndrome.

Symptoms:

• Vomiting
• Increased thirst and urination
• Increased appetite (polyphagia)
• Weight loss
• Weakness in hind legs
• Fruity smelling breath
• Dehydration
• Poor coat condition

Treatment:

• Proper weight management under the supervision of a veterinarian for obese cats can reverse diabetes which may include dietary modification and exercise.
• Medical management: Oral hypoglycemic drugs (such as Glipizide) may be prescribed to lower blood glucose.
• Insulin: Administration of insulin under the skin at the back of the neck. Administer every day at the same time.
• GLP-1 analogues: A new way of treating diabetes in humans and will hopefully become available to cats in future. The gastrointestinal tract secretes the hormone Glucagon-like peptide (GLP-1) after eating which, triggers the secretion of insulin as blood sugar levels rise. These medications reduce the level of glucose in the blood by increasing the amount of insulin. The benefit of this medication is that it only works if blood sugar levels are high. Ohio State University has begun studying the effects of these drugs on cats. Another potential benefit is that administration may only be necessary once a month.

Liver disease:

Liver disease is defined as any condition which damages the liver, which leads to an inability to perform many of its vital functions. There are several causes including portosystemic shunt, tumours, toxoplasmosis, cholangitis.

Symptoms:

• Ascites (abdominal effusion)
• Polyuria (increased urination)/polydipsia (increased thirst).
• Hepatomegaly (enlargement of the liver) or microhepatica (small liver).
• Muscle wasting
• Drooling, due to nausea.
• Lethargy
• Diarrhea
• Vomiting
• Dark coloured but clear urine
• Bad breath
• Melena (dark tarry stools)
• Neurological
• Coma

Treatment:

Depends on the underlying cause and may include the following:

• Surgery: To correct a portosystemic shunt or remove tumours.
• Antibiotics and immunosuppressive drugs: For cats with cholangitis to reduce inflammation.
• Supportive care: Dietary changes, anti-nausea medications, fluids, vitamin K injections and blood transfusions for cats who have developed blood clotting disorders.

Other:

Vestibular disease:

Vestibular disease is a condition in which the cat develops incoordination due to several disorders affecting the vestibular apparatus in the inner ear or brain stem. The vestibular system is responsible for providing the brain with vital information about orientation and direction relative to gravity. This information means your cat is aware if he is turning, upside down, right side up, walking, running or falling.

There are several causes which may include polyps, cancer, congenital, and idiopathic (no known cause).

Symptoms:

• Alert but disoriented
• Involuntary rhythmic movement of the eyes (nystagmus)
• Head tilt on the affected side
• Circling in one direction
• Falling to one side
• Wobbly gait (ataxia)
• Vomiting
• Vocalisation

Treatment:

• Nutritional support: As most cats with vestibular disease have difficulty eating due to nausea and poor coordination.
• Anti-nausea medication such as meclizine.
• Surgery and/or radiotherapy for malignant tumours.
• Surgery or laser therapy to remove polyps.
• Corticosteroids to reduce brain swelling.

Diagnosis

The veterinarian will perform a complete physical examination of the cat and obtain a medical history from you. It will be necessary to perform several tests to find the cause. Not all cats will receive all tests obviously, baseline test results and presenting symptoms can give the veterinarian a starting point to determine which diagnostic tests are indicated.

• Baseline tests: Complete blood count, biochemical profile and urinalysis. These tests can reveal the overall health of the cat and assess kidney and liver function.
• Fecal analysis: To look for worm eggs or segments in the feces.
• T3 & T4 tests: This blood test measures T3 and T4 levels which are hormones are produced by the thyroid gland and are elevated in cats with hyperthyroidism.
• Fructosamine blood test: Fructosamine is formed when albumin (a blood serum protein) and glucose bond together. This measurement gives an idea of average blood glucose over the preceding two to three weeks. Reduced total protein and hyperthyroidism can cause a decrease in the result. Chronic stress can cause a small increase, but not usually in the same range as diabetes.
• Ultrasound: To evaluate the pancreas and liver and intestines, which may be thickened in cats with IBD or lymphoma.
• Endoscopy: A thin, flexible tube with a camera is used to visualise the gastrointestinal tract.
• Laparoscopy: A surgical procedure in which a small incision is made to insert a laparoscope into the abdomen to evaluate the organs and gastrointestinal tract. Biopsy samples can be taken during this procedure.
• Biopsy: The only definitive way to diagnose IBD or lymphoma is with a full-thickness biopsy of the intestines which will be evaluated by a veterinary pathologist. If abnormalities are found during a liver ultrasound, the veterinarian may take a biopsy to assess for tumours.
• Bile acids tolerance test: This involves taking a blood sample from your cat and then feeding him a fatty meal. Two hours later, a second blood sample is taken. When a cat eats, bile is released into the small intestine to assist with the digestion of fats (lipids). The bile is then absorbed by the intestine and returned to the liver where it is removed from the bloodstream. In a cat with liver disease, this process doesn’t occur as efficiently, and levels of bile remain high in the blood.
• ALT and AST tests: Changes to the liver enzymes ALT (alanine aminotransferase) and AST (aspartate aminotransferase). The ALT test determines the level of this enzyme in the blood, which increases when damage to the liver cells has occurred. AST is an enzyme in skeletal and cardiac muscle cells, the brain and red blood cells. Elevated AST in the blood is also an indicator of liver disease, although as it is present in other organs, it is not as specific for liver cell injury as elevations in ALT.
• Bilirubin: This is a major breakdown product of red blood cells. When red blood cells wear out, they are trapped in the spleen and destroyed, releasing bilirubin into the blood. This type of bilirubin is called unconjugated. This bilirubin is transported in the blood to the liver, where it is taken up and conjugated (joined with glucuronic acid). This conjugated form may either be stored in the liver cells or excreted into the bile. Bilirubin levels are increased in cats with liver disease, gallbladder disease or have excessive destruction of red blood cells (hemolysis).
• Serologic testing: Testing for diseases such as FeLV, FIV, FIP, and toxoplasmosis as these diseases are associated with some liver disorders in cats.