By Dr Daisy A. May, MRCVS BVSc, Veterinary Surgeon
It’s no fun receiving an IBD diagnosis, and this is just as true when it’s your feline family member curled up on the consult table.
If your cat has been diagnosed with IBD (whether this was recently or some time ago), you might be wondering at what point it is correct to consider euthanasia.
It’s a difficult – some would even consider taboo – topic.
But frankly, it’s also a very important one.
So, in today’s blog post, we’re going to take a deep breath; exhale; and talk openly and honestly about feline IBD, including treatment options; links with lymphoma; and at what point euthanasia unfortunately has to become a consideration.
What Is Feline IBD?
Key point, to get us started: IBD in cats is not the same as human IBD. So, please bear in mind that this blog post is entirely feline specific!
IBD stands for inflammatory bowel disease.
If your cat suffers from IBD, it means that their intestines are chronically inflamed and irritated (angry). Sometimes the stomach is also involved.
IBD in cats doesn’t have a single known cause that we can pinpoint. However, our current understanding of the syndrome suggests that it likely occurs in individual cats as a result of a complex interplay of factors.
These may include the presence of certain bacteria or parasites within the gastrointestinal tract; immune system dysregulation or over-reactivity; food allergies and intolerances to specific proteins found in the cat’s diet; and possibly other environmental factors.
Pretty complicated, right?
The TLDR is we aren’t really sure why your cat has IBD…but we do at least have a fairly good understanding of what’s probably going on at gut-level, and (the good news) we can often do quite a bit to treat things and get your pet feeling well (and hopefully pooping normally) again.
So: what we do know for certain is that when a cat develops IBD, white blood cells (the ‘invader fighting’ cell of the immune system) congregate in large numbers within the walls of their intestines.
The presence of these white blood cells (which really aren’t supposed to be in the intestinal wall in such high numbers) causes the wall of the guts to become thickened, because now there are far more cells packed in there.
Of course, this in turn interferes with the gut’s ability to do it’s job properly: passage of food through the gastrointestinal tract can become difficult due to the wall thickening, digestion is affected and the absorption of nutrients from food within the gut can be severely compromised, leading to diarrhea and weight loss.
In some cases, the stomach lining can also be affected. We call this ‘gastritis’ (which is a Latin term that vaguely translates as ‘inflamed stomach’). In these cases vomiting may also be seen.
The small intestines are the most common part of the gastrointestinal (GI) tract to be involved in cases of feline IBD, though. And just when you thought we were done with the impromptu Latin lesson, I’ve got another term for you: enteritis. It means inflamed small intestines.
Finally, you may have heard your vet throw around the word ‘colitis’ already, especially if your kitty has been having diarrhea. Well, colitis is also Latin, and basically translates as inflamed colon (the colon is the large intestine, and is the very last part of the GI tract before the rectum).
Basically, stick “itis” on the end of a body part, and you can be reasonably confident that it’s medical terminology for “inflamed”.
So: if your cat has IBD, they are suffering from some combination of enteritis and/or gastritis and/or colitis, due to abnormally high numbers of white blood cells within the walls of the small intestine/stomach/colon.
I hope that makes sense!
A final thing to be aware of is that when cats get IBD, unfortunately the effects aren’t always confined to the gastrointestinal tract. Due to the unique anatomic setup within the feline abdomen (because of course, cats always have to be different, don’t they?), the pancreas and liver are also intimately tied in with gut function.
So unfortunately, where the guts are angry, pancreatitis (angry pancreas) and/or hepatitis (angry liver) can also occur in combination with the IBD.
What Are The Signs Of IBD In Cats?
IBD tends to develop in middle-aged to older cats, of any sex and breed.
If your cat is suffering from IBD, you may notice one or more of the following signs:
- Chronic vomiting (if the stomach is involved, ie, your cat has a gastritis component to their IBD)
- Chronic diarrhea
- Blood and/or mucus in the stools
- Weight loss
- Reduced appetite (sometimes)
- Ravenous appetite (sometimes…just to confuse things)
- Lethargy/reduced activity levels
Of course, most cats will very occasionally vomit or bring up hairballs…but as a rough rule, if your cat is throwing up (whether that’s vomit, bile, grass or even hair) more than once a month, this is abnormal and warrants veterinary attention.
How Is IBD In Cats Diagnosed?
When you first present your cat at the vets with some combination of the above signs, your vet is going to need to rule out some other possible causes first, before a diagnosis of IBD is considered.
It’s very likely that your vet will request a fecal sample and send this to the lab as a first step to check for bacterial and/or parasitic infections, such as worms or giardiasis. We check for these first because they can be cured with medication, whereas IBD is a lifelong syndrome which cannot be cured and therefore must be managed for the rest of your pet’s life.
If your pet’s fecal sample is negative, the next recommended step is likely to be an abdominal ultrasound scan. An experienced scanning vet will be able to identify whether the stomach and intestinal walls are thickened by measuring these on the ultrasound images.
The vet will also use the ultrasound machine to check for masses and to examine the lymph nodes around the intestines; basically, they are checking for any signs that a cancer might be to blame for your cat’s symptoms.
If the walls of the intestines and/or stomach appear thickened, IBD can be suspected, and in some cases treatment may be started at this point…but note that a diagnosis of IBD cannot be confirmed without tissue biopsies.
Using my very limited graphic design skills, I have produced a flow chart of the above:
Do be aware though, that it is possible for your cat to have IBD and a bacterial or parasitic infection (positive fecal sample). So, sometimes it will be necessary to treat the infection, and consider IBD as a diagnosis if the signs still persist once the infection is treated.
At the point where an ultrasound has been undertaken and thickened gut walls are found, a decision then needs to be made as to whether or not you want tissue biopsies to be taken.
The purpose of biopsies is to confirm and characterize the IBD and rule out alimentary lymphoma (a common type of gut cancer in cats, which can masquerade as IBD on ultrasound; see ‘IBD versus alimentary lymphoma’).
Obtaining a biopsy to confirm a diagnosis of IBD requires a full general anesthetic. Tissue samples are then collected, either via endoscopy or by surgically entering the abdomen to collect biopsies directly. The site from which the biopsies are collected (and so the way in which they are collected) depends on what part (or parts) of your cat’s gastrointestinal tract are affected.
The complication rate (that is, the chance of something going wrong during or after the procedure) can be relatively high with some types of biopsy. It’s also a fairly costly procedure. For these reasons, sometimes owners prefer to start treatment based on the presumed diagnosis of IBD following ultrasound.
Finally, if IBD is suspected, your vet may also suggest a blood test to check your cat’s levels of vitamin B12 (cobalamin). If your cat has low B12, this is likely to reflect the fact that they are unable to properly absorb nutrients due to intestinal wall thickening.
In this case, B12 will need to be supplemented by regular injections. Supplementing B12 orally (with tablets) won’t work well because – as we know – absorption from the guts is compromised.
How Is IBD Treated In Cats?
IBD in cats is treated through some combination of the following methods.
Typically, there is a degree of trial and error involved, and it may take several weeks (and several changes to the management plan) before your cat is symptom free.
Be patient and follow your vet’s advice as strictly as possible, for the best and quickest outcome.
Some cases of feline IBD are responsive to treatment with a hypoallergenic or novel protein diet. For the sake of ease (and because it’s what I always recommend for my patients), we’ll be focus in on hypoallergenic diets, here.
Remember how we said earlier that one possible cause of IBD is food allergies and intolerances to proteins in the diet? Well, a hypoallergenic diet is basically a diet which does not contain any proteins to which a pet’s immune system is able to react.
Typically, hypoallergenic diets contain proteins which have been hydrolyzed (broken down into much smaller ‘protein pieces’). These smaller protein fragments are too teeny tiny for the immune system to recognize as foreign, and so the immune system doesn’t react to them.
As a vet, I recommend either Purina Pro Plan Hypoallergenic or Royal Canin Hypoallergenic cat food; not because I have any sponsorship deals with Purina or RC, but because I trust these foods and they work.
If you can’t get hold of these where you live – for example, if you’re USA-based – then a limited ingredient diet using a protein source that is novel for your pet, would be an alternative approach.
It takes 8-12 weeks of feeding your cat the hypoallergenic food and absolutely nothing else before you can expect to see a full result. No treats, no dreamies, creamies, crunchies or munchies.
And no catching mice, so if you’ve got a garden hunter on your hands, you may need to consider keeping them indoors.
Metronidazole is an antibiotic and anti-protozoal medication which also has calming, anti-inflammatory effects on the guts. As we touched upon earlier, one possible cause of IBD in cats is an immune system which is overreacting to normal gut bacterial populations.
Of course, the presence of “bad” gut bacteria can also exacerbate IBD, because the immune system will react to these, too.
For these reasons as well as it’s anti-inflammatory effects, metronidazole can be useful in treating feline IBD in some cases.
Immunosuppressive medications are drugs which suppress or dampen down the immune system, so that it’s not functioning as strongly.
But wait, surely a strong immune system is a good thing, right?
Right, that’s true…except when the immune system is overreacting, like in cases of feline IBD, causing gut wall thickening, inflamed guts and an inability to properly digest food and absorb nutrients.
So clearly, in these cases we might want to reach for a little something’something to quiet that overreactive immune system down. Most commonly for IBD in cats, this means treatment with corticosteroids (what we commonly just call ‘steroids’). Oral prednisolone is usually used, for preference.
If your cat’s IBD does not respond to first line treatments, your vet may need to prescribe a stronger immunosuppressive medication such as chlorambucil or azathioprine.
Unfortunately these stronger drugs are more likely to cause unpleasant or even dangerous side effects, such as anaemia or a severely suppressed immune system. Your vet is going to want to monitor your pet closely, if they are taking chlorambucil or azathioprine.
Vitamin B12 (cobalamin)
As we mentioned earlier, some cats with IBD are unable to properly absorb vitamin B12 from their guts due to the thickened, poorly functioning gut walls. These cats will have low blood levels of this vital micronutrient.
If your vet has identified that your cat has a low B12 level, they will start a course of B12 injections (usually one injection every 2 weeks until the level has normalized).
Not every cat with IBD will need treatment with B12 injections, but every cat with IBD should definitely have their blood B12 level checked.
The presence of parasitic worms within the gastrointestinal tract can be a cause or an exacerbating factor for IBD.
So if you have a cat who suffers from IBD you need to be extra careful to keep on top of worming them on a monthly or three-monthly basis (depending on the product you are using, and how long it’s protective effects last).
Prebiotics, Probiotics And Fibre
Gut bacterial populations play a complicated part in causing or exacerbating IBD. It therefore stands to reason that prebiotics and probiotics might be helpful in the treatment of the syndrome.
Basically, by using prebiotics and probiotics to support “normal”, healthy bacterial populations within the gut, we are making it less easy for bad bacteria to thrive.
Many of the vet practices where I work as a locus veterinary surgeon stock either Fortiflora or Protexin Pro-Kolin brand probiotic, but you can buy it cheaper online without a prescription via the links (you’re welcome). I find that it’s both effective and taken quite readily by the vast majority of cats, who – as we all know – can be rather fussy.
Less bad bacteria means a lower likelihood of the guts reacting, setting an IBD flare up in motion.
It’s also been noted that increasing the level of fiber in the diet can be helpful in the management of IBD in some cats. Adding a source of soluble fiber such as psyllium to the diet can help. So, if Pro-Kolin isn’t helping, as a next step I’d recommend trying Protexin’s Pro-Fibre, which contains psyllium husk and pectin in addition to a probiotic.
IBD Versus Alimentary Lymphoma
It would be impossible for me to write a blog post on feline IBD (especially one that discusses euthanasia) without mentioning lymphoma.
This is because alimentary lymphoma (ie, lymphoma affecting the stomach or intestines) is one of the most common types of cancer a cat can get.
And the signs (vomiting, diarrhea, weight loss, appetite changes) are practically identical to feline IBD.
And, like IBD, this particular cancer tends to develop in middle-aged to older cats, of any sex and breed.
What’s more, on ultrasound, a low-grade alimentary lymphoma (LGAL) spread throughout the stomach and/or intestinal walls can appear practically identical to a gut which is thickened as a result of IBD.
Remember I said you can’t diagnose IBD 100% without surgical biopsies?
This is why.
IBD and LGAL are basically impossible to tell apart, even with ultrasound images, and even when a highly skilled and experienced veterinary specialist is doing the scanning.
To complicate matters further, we have strong evidence to suggest that in some cases IBD can become alimentary lymphoma. Simplifying things a little, this happens because the abnormal accumulation of white blood cells (lymphocytes) within the gut walls can become cancerous, over time.
The main benefit of having gut biopsies done in suspected IBD cases, is that sometimes these cases turn out to be LGAL (and NOT IBD at all!), and (once identified) the LGAL can be treated with a targeted course of chemotherapy.
With appropriate treatment, the majority of cats with LGAL can be expected to enjoy a good quality of life for 12-18 months following diagnosis.
Interestingly, protocols for LGAL often make use of drugs we’ve already mentioned: prednisolone and chlorambucil. This does mean that many cats with unidentified LGAL, will have a partial response/improvement on treatment for IBD.
As a final point, unfortunately as well as low-grade alimentary lymphoma, cats can also get high-grade alimentary lymphoma (HGAL). This is a far more aggressive type of gut cancer than can also masquerade as IBD.
Thankfully, HGAL is decidedly less common than both IBD and LGAL…but if your cat has received a suspected IBD diagnosis yet is not responding as expected to treatment, or is going downhill quickly, you (and your vet) do need to consider whether you could in fact have a HGAL case on your hands.
Unfortunately, in cases of HGAL, euthanasia quickly becomes a very real consideration.
As a general rule, where HGAL is to blame, the onset of signs (vomiting, diarrhea, weight loss) is usually more sudden and less gradual compared to in cases of IBD or LGAL. It is also generally easier to identify HGAL on ultrasound, as often lymph nodes will be enlarged, masses will be present and/or other organs will be affected.
In most cases of HGAL, palliative treatment is the best option, although in a few select cases surgical intervention may be possible or chemotherapy may be considered.
Personally, I have never recommended chemotherapy for a cat with HGAL though, because only about 1 in 3 cats will respond to the chemo, and for those who do respond their survival time is only expected to be 2-3 months.
Yeah. HGAL f*cking sucks.
I’m going to be brutally honest and straight up say that my first recommendation in all feline HGAL cases is euthanasia, as soon as noticeable signs have developed. It’s by far the kindest treatment option.
When To Euthanize A Cat With IBD
I want to start with an obvious (if understandably painful) truth: if your cat’s IBD is not responding to treatment, and all treatment options have been exhausted (i.e., have not worked), then you do need to consider that euthanasia might be the kindest option.
Unfortunately in some severe cases, feline IBD simply does not respond to treatment.
In these cases, the patient’s quality of life (QOL) can become very poor. When quality of life is no longer good, euthanasia is definitely preferable to allowing your cat to suffer.
If your cat isn’t responding to IBD treatment as expected, or is deteriorating quickly, then you also need to consider that they could have alimentary lymphoma rather than IBD (see ‘IBD Versus Alimentary Lymphoma’).
Consider having biopsies taken, if you haven’t already. If HGAL is confirmed, then euthanasia is undoubtedly the kindest option for your cat.
Of course, because this is the real world, there are a variety of other, less obvious factors that need to be considered when discussing euthanasia of a pet following the diagnosis of a lifelong condition such as IBD.
To this end, if you come into my consult room I might also raise the option of euthanasia in the following circumstances:
- You have financial restraints which mean you’re not able to afford appropriate treatment for your cat’s condition.
- You have other commitments which mean you practically cannot manage to treat your cat’s condition.
- Your cat has other diseases (in combination with IBD) and there are difficulties with treating these.
- Your cat is finding treatment very stressful (eg, being forced to take tablets on a daily basis), or refuses to take medication altogether.
- You report to me that your cat’s chronic diarrhea (due to IBD) is making it impossible for you to maintain a hygienic living environment for yourself/your family/your cat…and (for whatever reason; I’m not here to judge) you aren’t able to give things any more time to see if they improve on treatment.
- You have otherwise implied that you are unable to cope (practically, financially or emotionally) with the IBD diagnosis.
- Your cat is very elderly and you have decided that you don’t wish to pursue treatment for the IBD and/or other health conditions they may have.
If you are in one of the above situations, I feel for you.
It’s a shitty position to be in and please know that you are not doing anything wrong by considering whether euthanasia might be the right call.
Don’t be afraid to be honest and open with your vet about any concerns you have regarding the IBD diagnosis, whether these relate to the disease itself; treatment options; finances or practical issues.
We aren’t here to judge you – that’s not our job. We’re here to help.
It may be that your vet can suggest a solution, or alternative treatment plan.
Or, if you have a cat whose IBD is responding to treatment, but you are experiencing practical, emotional or financial issues that are making you consider euthanasia, it may be possible for you to consider rehoming.
Or it might be that, all factors considered, you and your vet agree that euthanasia is the kindest option for your cat. And that’s fine too. As any good vet will be happy to remind you, euthanasia is not cruel. It’s simply an end to suffering.
In some cases, it’s the right decision.
Assessing Your Cat’s Quality Of Life
If you’re concerned that your cat might have a poor quality of life (QOL) as a result of their IBD, then you may find it helpful to conduct a QOL assessment...like a sort of guidance quiz, if you like.
You can use one of the following two tools, or a combination of both, to help you decide whether euthanasia might be the right call at this point for your cat.
Quick 2-minute at home QOL quiz: https://www.goodbyegoodboy.com.au/free-quality-of-life-assessment
More in-depth questionnaire to print, complete and take to discuss with your vet: https://vet.osu.edu/vmc/sites/default/files/import/assets/pdf/hospital/companionAnimals/HonoringtheBond/HowDoIKnowWhen.pdf
I hope you found the contents of this post helpful.
Vet Love, to you and your feline family member,
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