EPI or something else?

[Carrotcat]

Hi all,

First of all I'd like to note that I'm not a native English speaker, so if I've got anything wrong or something is confusing, please let me know.

My cat has been suffering with diarrhea for some time now. It started in march. She was diagnosed with diabetes in april after major weight loss (from 7,2kg (obese) to 5,3kg (still overweight but less so)) and testing: (BLOODWORK)(ULTRASOUND), and with insulin treatment the diarrhea subsided for a while and she gained weight back to 6,0kg. Since her diagnosis she's had a weird pot-bellied figure, with ribs easily felt on top but a big round hard belly hanging below.

Diarrhea started back up again in July, waxing and waning. Started giving her a B12+folic acid supplement in august due to diabetic neuropathy. Diabetes is hard to regulate as she's still producing insulin of her own. Getting frequent hypo's, seems like she's going towards remission. Meanwhile, diarrhea got worse and worse.

End of august, she crashed with a major bowel infection. Super super sick, no appetite, incredibly weak, high fever, high white count, liquid chunky diarrhea that just poured out of her. We got her through, but barely. Weight went down to 5,0kg. (BLOODWORK) Stool testing was done for parasites, bacterial overgrowth, etc but showed no abnormalities. Was on antibiotics for 2 weeks, painkillers, anti-fever meds, anti-nausea meds, appetite stimulant meds.

From then on, it feels like she's never fully recovered. She's lethargic, sleeps most of the time. Doesn't care much about things other than food (but even her appetite is less than before, when it was ravenous). Coat looks unkempt, she doesn't groom much. Still drinks extreme amounts of water even with her diabetes decently regulated according to vet. Her eyes are sad. Still walks with weakness, lays down often while walking. She farts constantly. You can hear her stomach making weird noises when you listen closely. Her weight went back up to 5,5kg and has stayed there ever since.

As for her stools... 3-5 times a day she'll produce a huge, fist-sized heap of soft, orange/clay colored, shapeless, incredibly disgusting smelling poop. Either she doesn't care or doesn't have the strength to stay standing while pooping, so she'll sit in it and cover her entire backside in this foul mess. Then she'll walk around my house getting shit on everything. She'll attempt to groom herself, but it so disgusting that she doesn't succeed in actually getting clean (it'll look super 'wet' and greasy and smells like death even after she's licked herself clean). So I have to bathe her, which she hates, and disinfect my entire house often.

Vet's suggestions the entire time has just been to use pre- and probiotics, which I've done but haven't helped at all. I came across EPI and thought it might fit, so I asked my vet to test for it. They drew blood and sent it off, but when the results came back a few days later I found out they didn't do the fTLI test at all, just a spec fPL for pancreatitis and a B12 and folic acid panel. fPL was low-ish, B12 too low and folic acid way too high (BLOODWORK). They then told me that the fTLI test had to be sent overseas, would take a month and was very costly. And based on these blood results, EPI is likely and I should just start enzymes and see how she responds. She also got a B12 shot, and I got B12 tablets to give to her daily for the deficiency.

She refused the powdered enzymes (the only kind we have here is Zymoral, which supposedly smells/tastes like vanilla but just smells like stale cat urine to me), so I bought and started her on Creon last tuesday the 28th. Creon 10, 1/4th a capsule each meal.

She pooped her regular diarrhea in the evening, and then went 20 hours before pooping (once again same diarrhea) on wednesday. I figured, progress in frequency even if the stool's not good yet. But she had diarrhea 3 times in a row thursday morning, way more liquid than normal. I upped her to 1/2 of a capsule each meal on friday to see if that'd help, but she's been feeling noticably worse since. Frequency of the stool is still down (2-3 times a day now) but consistency is worse than prior to starting the enzymes. On friday/saturday she was really lethargic, her stomach was rumbling like crazy, her appetite worsened, and she seemed to have stomach pain (for which I've given her painkillers with vet's approval). I went back down to 1/4th capsule again on saturday morning, slight reduction in these symptoms, but still present enough for her to continue needing the painkillers.

So here we are today: she's getting 1/4th of Creon 10 with each meal. Pooping less frequently but more liquid diarrhea, butt fur still super greasy after each bowel movement. Stomach pain and rumbling, lethargic, reduced appetite.

I am wondering, (hopefully) having read all of that... do ya'll think this is EPI, or actually something else? Looking at the before/after pics of those emaciated dogs, it strikes me that she doesn't have the main symptom (weight loss). She's actually still overweight. That's weird right? But what else can explain her symptoms? Vets in my area are clueless at best and harmful at worst, so I feel obliged to seek out this info on my own.

Worth noting: I don't believe that she's ever had pancreatitis. I can count on 1 hand the number of times she's vomited *in her entire life*, and aside from the bowel infection she's never had anything other than a voracious appetite.

I'm also really worried about her going hypo with no food available to pull her out of it at night. She used to be freefed, now she's getting timed meals. Can't leave out food with Creon, she won't eat food with powdered enzymes. I also have other cats who aren't allowed to eat the food with enzymes.

Last night her glucose was 14.4 mmol/l at shot time, and 11.0 mmol/l 6 hours later (nadir, lowest point). I gave her a final big meal and then felt it was safe enough to go to bed. 6 hours later I woke up and went to test her for her next shot, and her glucose was at 4.5 mmol/l. This is due to her own pancreas "waking up" and giving her an extra dose of homemade insulin. You can't predict it, and because she has no food freely available now to eat and get her sugars up, she has no way to pull out of it. I'm terrified to sleep tbh.

[Olesia711]

Thanks for writing in... and i am so sorry your cat (and you) are going thru all of this. By the way, your English is excellent!!!!!!
SOOOoooo...after reading your post, the first thing that came to my mind is that your cat may be dealing with Cushings. Can you have your cat checked for Cushings?

The reason why i am wondering if your cat is struggling with Cushings is because she has Diabetes AND your description " she's had a weird pot-bellied figure, with ribs easily felt on top but a big round hard belly hanging below." this is very typical of Cushings..... along with "Coat looks unkempt".

I am not saying that this is not EPI... as it could be, but my first suspect would be Cushings. The reason why i am saying this is because i had a dog that had many of the same symptoms you are describing and the vet also thought it was EPI ... but the enzymes did not work and the Tylan antibiotic did not help.... so they guessed about a lot of other conditions.... and once they ran the ACTH test, they discovered he had Cushings. Once they figured out the correct dose of Lysodren... within 1 week, he dramatically improved.

Cushing is not very common in cats, but it can and does happen. I'd ask your vet to test for it.... and request the full test.

IN the meantime..... it could be EPI with dysbiosis as you are guessing.......as some of the symptoms fit... but then again, the same symptoms can be many other things..........

Obviously the pre+probiotics are not working.....or most likely will not work since whatever is going on is not just a messed up gut flora (dysbiosis)..... at this juncture, just in case this is EPI......i would ask the vet to prescribe Tylan (Tylosin tartrate antibiotic) and YES! cats can and do get dysbiosis and YES they can be prescribed this antibiotic. Years ago they didn't think cats got dysbiosis, but after more advanced research, they discovered they can and do get it.

Also, in case this is EPI.... go ahead and increase the CREON dose... see if that helps. Are you giving CREON 3000 or CREON 5000 ???? and how much does your cat weigh?

REgarding the testing..... let me look into fTLI testing in the Netherlands.... and i will get back to you.

[Tuckaboo Pam]

Hi Lisa. I'm Pam, from Florida, USA.

All your issues are way over my head, but from what I know from having treated Tucker (dog) for EPI, for over four years, I do wonder if your kitty has something called SID. If you mentioned it in your post, I didn't notice it.

The diabetes, etc, I know nothing about, but I saw your post, I knew you were worried, and I just want to say that this forum is an incredible resource. I have read about others who have the same health issues as your kitty, and they will help you.

You have come to the right place. The people here will hold your hand and help you, and remember that all questions are good questions. People who love their pets are special people, and this is a gathering place for good people.

Check back soon. Your English is great. ---Pam

[Carrotcat]

Thanks for writing in... and i am so sorry your cat (and you) are going thru all of this. By the way, your English is excellent!!!!!!
SOOOoooo...after reading your post, the first thing that came to my mind is that your cat may be dealing with Cushings. Can you have your cat checked for Cushings?

The reason why i am wondering if your cat is struggling with Cushings is because she has Diabetes AND your description " she's had a weird pot-bellied figure, with ribs easily felt on top but a big round hard belly hanging below." this is very typical of Cushings..... along with "Coat looks unkempt".

I am not saying that this is not EPI... as it could be, but my first suspect would be Cushings. The reason why i am saying this is because i had a dog that had many of the same symptoms you are describing and the vet also thought it was EPI ... but the enzymes did not work and the Tylan antibiotic did not help.... so they guessed about a lot of other conditions.... and once they ran the ACTH test, they discovered he had Cushings. Once they figured out the correct dose of Lysodren... within 1 week, he dramatically improved.

Cushing is not very common in cats, but it can and does happen. I'd ask your vet to test for it.... and request the full test.

IN the meantime..... it could be EPI with dysbiosis as you are guessing.......as some of the symptoms fit... but then again, the same symptoms can be many other things..........

Obviously the pre+probiotics are not working.....or most likely will not work since whatever is going on is not just a messed up gut flora (dysbiosis)..... at this juncture, just in case this is EPI......i would ask the vet to prescribe Tylan (Tylosin tartrate antibiotic) and YES! cats can and do get dysbiosis and YES they can be prescribed this antibiotic. Years ago they didn't think cats got dysbiosis, but after more advanced research, they discovered they can and do get it.

Also, in case this is EPI.... go ahead and increase the CREON dose... see if that helps. Are you giving CREON 3000 or CREON 5000 ???? and how much does your cat weigh?

REgarding the testing..... let me look into fTLI testing in the Netherlands.... and i will get back to you.

Hi, thank you! She hasn't been tested for Cushings, no. I did bring it up, but vet said that the diabetes should be under control first as you can get a false positive otherwise. She's never been fully regulated :/ but I'll bring it up at our next appointment! Maybe she's regulated enough to test now... Did your dog also have diarrhea as a symptom of Cushings? And did that improve with that medication?

Vets here are really reluctant to prescribe antibiotics. Even when she had her bowel infection they waited a few days to see if she'd improve on her own before being willing to prescribe antibiotics. I don't think they'd prescribe tylan just like that, but I'll ask anyways. Worth mentioning that her diarrhea didn't resolve on the previous antibiotic either. It improved (from chunky liquid to soft shapeless heaps) but never normalised.

I'm giving 1/4th of creon 10.000. Cat weighs 12 pounds. I can increase to 1/2 again but I'm afraid that it will cause stomach pain again like before.

Edit: oh, forgot to mention that she does not have the fragile skin, patchy hair loss, frequent UTI's or ear curling symptoms of Cushings. Her blood pressure is also perfect. She's also on quite a low dose of insulin, only 1.5U (sometimes less when she's low at preshot time).

[Carrotcat]

Hi Lisa. I'm Pam, from Florida, USA.

All your issues are way over my head, but from what I know from having treated Tucker (dog) for EPI, for over four years, I do wonder if your kitty has something called SID. If you mentioned it in your post, I didn't notice it.

The diabetes, etc, I know nothing about, but I saw your post, I knew you were worried, and I just want to say that this forum is an incredible resource. I have read about others who have the same health issues as your kitty, and they will help you.

You have come to the right place. The people here will hold your hand and help you, and remember that all questions are good questions. People who love their pets are special people, and this is a gathering place for good people.

Check back soon. Your English is great. ---Pam

Hi Pam, it's definitely possible that she has SID. Thank you for commenting!

[Olesia711]

thanks for the additional details. Yes, please do ask the vet if the Diabetes is regulated enough to test her for Cushings.... just a little tidbit of info... if this is EPI with the Diabetes (and not Cushings)..... the diabetic blood sugar will be much more difficult to maintain in the acceptable diabetic blood sugar range. Usually when dealing with Diabetes and EPI.... the manageable diabetic blood sugar range is a wee bit higher than what is normally the rule.

And YES! my dog with Cushings had loose stools... and it looked just like EPI stools too..... but..... Once they tested him for Cushings and determined that that is what he had... as soon as they happened upon the right dosage of Lysodren (for Cushigns) his poo became normal within a week ...

Yes, a lot of vets don't want to prescribe antibiotics and they have good reason to recommend pre+probiotics instead.... BUT.... when the pre+probiotics don't work, then they need to resort to certain antibiotics. The reason why we strongly recommend Tylan is because Tylan is a macrolide antibiotic and does not kill ALL the bacteria in the gut but rather only inhibits reproduction. Many other antibiotics, such as Metronidazole, kills everything and that is bad. BUt for certain ailments, Metro is necessary.... however.... not for gut dysbiosis. With dysbiosis.... what they have recently discovered is that not only is there not enough bacteria, but there also is not enough of a variety of bacteria. in the gut..... this is why if you don't have to, don't prescribe many antibiotics. .... unless absolutely necessary... and also why Tylan is recommended over other antibiotics.

Ahh... so approx 5,000 CREON with a meal made your kitty not feel good??? so instead of increasing by another 1/4 of CREON 10,000... maybe just try increasing the CREON by 1/8... and see how that goes. You are opening up the capsule and sprinkling the little CREON pellets on top of damp food... correct?

[Eddiespaghetti]

Well, your english is probably better than mine.
I need to start by saying, I do not have experience with cats. I am super allergic to them. All of this information works on dogs, but I cannot see why some or all won't transfer over.
If it is EPI that being untreated with cause of a lot of problems with the diabetes and insulin. If they aren't getting the nutrients from the food the insulin will cause hypoglycemia. If increasing the CREON causes upset stomach you can try an acid reducer, or a PPI. I don't know what the options are in the Netherlands.
As for the possible Cushing's, This is not a long term solution, but it is a decent quick treatment. Melatonin can help with Cushing's depending on what is the actual cause. Melatonin is also non-harmful. This might be a thing to try.
You are already giving B12 and managing a lot of the other stuff. I was just trying in my two cents. Jill and Olesia have you pretty much covered.

[Eddiespaghetti]

It won't let me edit my post. I need to apologize the medications I am on cause me to ramble and sometimes become incoherent.
Olesia is insanely smarter than I am. She probably knows me about all this. However, I personally don't think it's Cushing's. It doesn't sound like those symptoms are Cushing's. I am leaning more towards liver issues. Either liver disease or possibly lesions of the liver. The ultrasound shows the liver is hyperechogenic. Something is going on with it's liver.
I sadly cannot say what exactly is going on.
There is a chance the relatively untreated EPI mixed with the diabetes is causing stress on the liver.
There is a couple things I would try that are easy. If you are worried about increasing the CREON, I would change to a lower fat food. The lower fat food will require less enzymes to break down the food. The lower fat food could also help relieve the stress on the liver. In America they sell diabetic care cat food. I really hope your country has something comparable.

Of course, I can be completely wrong. Luckily, there is some great people here who will correct me.

[Carrotcat]

thanks for the additional details. Yes, please do ask the vet if the Diabetes is regulated enough to test her for Cushings.... just a little tidbit of info... if this is EPI with the Diabetes (and not Cushings)..... the diabetic blood sugar will be much more difficult to maintain in the acceptable diabetic blood sugar range. Usually when dealing with Diabetes and EPI.... the manageable diabetic blood sugar range is a wee bit higher than what is normally the rule.

And YES! my dog with Cushings had loose stools... and it looked just like EPI stools too..... but..... Once they tested him for Cushings and determined that that is what he had... as soon as they happened upon the right dosage of Lysodren (for Cushigns) his poo became normal within a week ...

Yes, a lot of vets don't want to prescribe antibiotics and they have good reason to recommend pre+probiotics instead.... BUT.... when the pre+probiotics don't work, then they need to resort to certain antibiotics. The reason why we strongly recommend Tylan is because Tylan is a macrolide antibiotic and does not kill ALL the bacteria in the gut but rather only inhibits reproduction. Many other antibiotics, such as Metronidazole, kills everything and that is bad. BUt for certain ailments, Metro is necessary.... however.... not for gut dysbiosis. With dysbiosis.... what they have recently discovered is that not only is there not enough bacteria, but there also is not enough of a variety of bacteria. in the gut..... this is why if you don't have to, don't prescribe many antibiotics. .... unless absolutely necessary... and also why Tylan is recommended over other antibiotics.

Ahh... so approx 5,000 CREON with a meal made your kitty not feel good??? so instead of increasing by another 1/4 of CREON 10,000... maybe just try increasing the CREON by 1/8... and see how that goes. You are opening up the capsule and sprinkling the little CREON pellets on top of damp food... correct?

Thanks, I'll ask about the Cushings testing! I'm also planning to ask them to do another abdominal ultrasound, just to cover all bases, and maybe a standard bloodpanel again to check organ function and such. From what I'm reading about Cushings, one or both adrenal glands should be enlarged if she actually has it, so hopefully that'll provide some clues. I'll ask about the Tylan too, maybe they'll be willing to prescribe it if nothing else works and other stuff is ruled out. When she had her bowel infection they put her on Cylanic, which google says is Amoxicillin/Clavulanic acid.

If all fails, I guess I'll turn to prednisolone as a final gambit. One of my other cats has IBD and has been on pred for 6 years! She was really ill too, and nothing worked until we arrived at IBD as an exclusionary diagnosis (at the time, it was "she either has IBD or bowel cancer, either way pred will help"). At the back of my mind, I'm worried Angel does have cancer. She's almost 14 years old, pretty old for a purebred cat (Ragdoll), and I know with older kitties, cancer is common.

For now, I'm planning to just slowly increase the Creon yes... maybe her feeling bad on friday/saturday was unrelated to the increase, her tummy's not in a great state anyways now of course. Could be a coincidence, won't know until we repeat it and see how she feels once again with an increase. I am opening the capsule and sprinkling the pellets on top of wet food, yes. Luckily she has no problem eating them.

For the last 2 days she's held steady at only 1 poop per day. That seems like a good sign right? Still loose though, and very stinky and greasy. If all else fails and she starts to feel awful again, I think I'll stop giving the Creon for a bit and see if the stools start increasing in frequency again. That should point out whether it's actually helping her or not, is my thinking.

Maybe I'm being very silly, but could it still be something innocent like JUST the B12 deficiency causing this? I'd really love for this to all to turn out to have been a big fuss over nothing after all. My vet did say that once they become B12 deficient for any reason, stools won't normalise until the deficiency has been fixed. So maybe she became deficient because of her bowel infection and it's caused problems ever since... or maybe that's crazy, idk.

[Carrotcat]

Well, your english is probably better than mine.
I need to start by saying, I do not have experience with cats. I am super allergic to them. All of this information works on dogs, but I cannot see why some or all won't transfer over.
If it is EPI that being untreated with cause of a lot of problems with the diabetes and insulin. If they aren't getting the nutrients from the food the insulin will cause hypoglycemia. If increasing the CREON causes upset stomach you can try an acid reducer, or a PPI. I don't know what the options are in the Netherlands.
As for the possible Cushing's, This is not a long term solution, but it is a decent quick treatment. Melatonin can help with Cushing's depending on what is the actual cause. Melatonin is also non-harmful. This might be a thing to try.
You are already giving B12 and managing a lot of the other stuff. I was just trying in my two cents. Jill and Olesia have you pretty much covered.

It won't let me edit my post. I need to apologize the medications I am on cause me to ramble and sometimes become incoherent.
Olesia is insanely smarter than I am. She probably knows me about all this. However, I personally don't think it's Cushing's. It doesn't sound like those symptoms are Cushing's. I am leaning more towards liver issues. Either liver disease or possibly lesions of the liver. The ultrasound shows the liver is hyperechogenic. Something is going on with it's liver.
I sadly cannot say what exactly is going on.
There is a chance the relatively untreated EPI mixed with the diabetes is causing stress on the liver.
There is a couple things I would try that are easy. If you are worried about increasing the CREON, I would change to a lower fat food. The lower fat food will require less enzymes to break down the food. The lower fat food could also help relieve the stress on the liver. In America they sell diabetic care cat food. I really hope your country has something comparable.

Of course, I can be completely wrong. Luckily, there is some great people here who will correct me.

Hi, thanks for commenting! Don't worry, I ramble too (as you can see in my last post lol). I'll ask about getting her an acid reducer when I speak to the vet. My other cat was on Omeprazole for a while, I think that's an antiacid too. He had to take them twice a day, with food, 2 hours prior to his other meds, so I'm curious about how that works with stuff like Creon.

I'm concerned about her liver too yeah. Getting a repeat ultrasound soon since the last one was almost a year ago. They couldn't explain the hyperechogenic liver at the time but said it wasn't a concern since her bloodwork was okay. I'll see about getting her some low fat food. She's currently on mostly wet food of different brands and textures to keep it interesting for her. The other cats have dry food available but she doesn't care for it, THANKFULLY she loves wet food way more (makes giving her the creon much easier). We do have diabetic cat food but it's overpriced and often still high carb (not great for diabetes).