Liver And Gall Bladder Disease In Your Cat – Cholangiohepatitis Triaditis
Aka Cholangitis –Triad Disease (CCHS)
Ron Hines DVM PhD
A recent study found that a little over half the mature cats brought to veterinarians because of chronic vomiting, weight loss, and diarrhea, had inflammatory bowel disease (IBD) – alone or as a part of triaditis. In a bit less than half, the problem had progressed to lymphoma. Only intestinal biopsies examined by a veterinary pathologist can tell the difference between the two.
What is Cholangiohepatitis?
Cholangiohepatitis is a form of chronic liver disease that is common in pampered cats in North America and Europe. It is rare for only the liver to be involved. Next to hepatic lipidosis, it is the most common ailment that our middle-aged cats suffer. (ref) This form of hepatitis centers on structures that convey bile , produced in the liver, into your cat’s gall bladder and on out into its small intestine. That group of structures are the liver’s triad region, hence the names Triaditis or Triad disease. Words that begin with “chole” all relate to bile. When the normal flow of bile is blocked by inflammation of these structures, severe consequences ensue.
Is All Liver Disease In Cats Cholangiohepatitis?
Feline infectious peritonitis (FIP), hepatic lipidosis (The fatty liver disease of fasting cats), liver damage due to medications and chemicals, lymphoma , toxoplasmosis, polycystic liver disease and gallstones all cause liver disease in cats. But cholangiohepatitis and hepatic lipidosis account for the majority of liver issues that cats face.
Is There More Than One Form of Cholangiohepatitis in Cats?
This disease occurs in three distinct forms and cases that combine the abnormal processes of all three.
The Sudden (acute) Form:
The sudden form of cholangiohepatitis is not a common problem. When it does occur, it is often in younger male cats. These cats suddenly stop eating and become depressed. They vomit and often run fevers . Their tummies may be painful and, due to their disinterest in food and water, they quickly become dehydrated and unkempt. After the initial attack, it is common for these cats to develop a yellowish hue to their eyes and gums (jaundice). It is also referred to as the “suppurative” or “neutrophilic” form of cholangiohepatitis/Triaditis because blood
cells generally present to fight bacterial infection flock to the cat’s liver triads. Blood work performed on these cats usually shows elevated liver enzymes, bilirubin and white blood cell count. There is no evidence, that I know of, that these sudden attacks cause the much more common chronic forms of cholangiohepatitis.
The Much More Common Chronic Debilitating Forms That Cats Suffer:
Cats with this form of cholangiohepatitis tend to be older than those with the acute form.
In these cats, the symptoms tend to wax and wane, with relatively good periods interspersed by periods of illness often associated with stress.
This form of cholangiohepatitis can have many names, all dependent on what cells and changes veterinary pathologists see in microscopic samples of your cat’s liver. If defense cells called lymphocytes predominate, they call it Lymphocytic Cholangiohepatitis. If neutrophils predominate, the term is Chronic Neutrophilic Cholangiohepatitis. When other defensive cell, macrophages and plasma cells, predominate, it is called Granulomatous Cholangiohepatitis. The terms used are limited only by the creativity of the pathologists that create them – most cases contain elements of them all.
All forms of Cholangiohepatitis can eventually lead to a non-functional, scarred liver. That state is called cirrhosis.
You can read a detailed description of the many forms of chronic cholangiohepatitis that occur in cats here.
Do Veterinarians Know Why These Liver Health Problems Occur So Commonly In Cats?
No, not really.
The acute form that occurs suddenly and most commonly in younger cats is often attributed to an infection of bacterial that followed the ducts that link the liver and gall bladder to the cat’s intestines. But there is probably more to this problem than a simple quirk of nature. In humans, acute cholangiohepatitis is known to be related to diet – particularly one that is too high in carbohydrates and too low in proteins and fat. You can read a bit about that here.
It is true that bacteria are occasionally found in the bile and livers of cats with cholangiohepatitis (ref) – but bacteria tend to grow in any
previously-damaged or distended (enlarged) organ whose circulation has been impaired (damaged) or whose secretion-flow has been halted . In a carefully designed study, bacterial infections were not identified as a cause of chronic cholangiohepatitis in cats. You can read that article here.
Some veterinarians feel that the fact that the tubes linking the cat’s pancreas (pancreatic duct) and the tubes ( common bile duct) linking the cats gall bladder to its small intestine are so intimately entwined predisposes cats to these problems.
Others find increased levels of antibody (gamma globulins) in many cats with chronic cholangiohepatitis and a positive response to corticosteroids evidence that the disease is an autoimmune (immune-mediated) phenomenon. There is some evidence that things like that might occasional occur in dogs (ref) and monkeys (ref) but no solid evidence that it occurs in cats.
Could My Cat’s Diet Be A Factor?
Yes, it could.
Your cat’s liver is the first stop (portal circulation) for all compounds absorbed from its intestine. By virtue of its position astride the digestive system, it is more subject to injury from any undesirable things your cat eats.
The cat food industry has traditionally used ingredients in their diets that were rejected as not fit for human consumption. You can read a bit about that here.
These diets, when fed dry, also contain large amounts of preservative with unknown health affects for your cat. You can read about some of those preservatives here.
Recently, a link between high-iodine in cat foods and hyperthyroidism was discovered. You can read about that here. The source of iodine in cat foods is often from products containing fish parts (but occasional other spoiled ingredients too). (ref) Not only are those parts often high in iodine – they are often high in histamine as well – particularly the head and entrails that often end up in pet foods along with the toxins concentrated in fish livers. You can read an FAO publication on the problem here and a quainter one on how histamine-rich fish sicken Polynesian fishermen here. The first stop for all these compounds is your cat’s liver.
Canned fish-flavor cat foods are not immune to this problem. Histamine is not deactivated by the heat of the canning process. (ref)
Histamine works on the H1 and H2 receptors in your cat’s body. Its consumption is known to cause changes in stomach acids, the liver, gall bladder, pancreas and intestine as well as localized inflammation. (ref ) and altered liver enzymes. (ref) How and if histamine consumption is a factor in cholangiohepatitis of cats is unknown. No veterinarians or pet food companies I know of have explored it. But here are some publications that point to the need for that: ref1, ref2, ref3, ref4, ref5
There is absolutely nothing wrong with occasionally including cooked fish in your cat’s diet. But it must be supermarket fish fillets, put to the “smell” test, that you yourself would be willing to eat. All fish is rich in the amino acid histidine which is only converted to potentially damaging histamines as the fish carcass becomes stale.
What Are The Signs I Might See If My Cat Had Cholangiohepatitis?
The acute, suppurative form of cholangiohepatitis is something you will not miss – a happy cat one day, a sick vomiting kitty the next.
But the early signs of chronic cholangiohepatitis are easy to miss or brush off. It might be no more than a picky eater – a cat that has periods where it just sniffs it food and takes a few tentative bites. Perhaps some days of lethargy and a disinterest in interacting with its owner. Those signs and weight loss come on very gradually and they can come and go.
Occasional cats with this problem actually eat more. That is because they no longer absorb sufficient nutrients from their food and compensate through additional eating. But that extra eating does not result in weight gain.
There is usually no fever in the chronic forms of cholangiohepatitis.
Since cholangiohepatitis often coexists with pancreatitis and inflammatory bowel disease, signs of those conditions may be what initially cause you to set an appointment with your veterinarian.
Possible Complications That Might Occur
Cats do not tolerate periods of inappetence (not eating) well. When they stop eating for any reason, their livers often accumulate destructive fat (lipidosis, fatty liver). So cats that have little interest in food due to cholangiohepatitis are at greater risk. You can read about that problem in detail by following this hepatic lipidosis link.
A much rarer problem that occasionally occurs in destructive liver diseases of all kinds is hepatic encephalopathy in which elevated levels of blood ammonia and other undesirable compounds cause mental confusion and alter the cat’s personality. Read more about hepatic encephalopathy through this link.
Cats with that degree of advanced liver disease can also develop portal hypertension and free fluid in their abdomens (abdominal effusion, ascites).
Chronic inflammations sometimes progresses to overt cancer. Although it has not been proven in cats, the link between chronic lymphocytic stimulation and lymphoma cancer has been proven in humans. (ref) So it is plausible that there is a link between chronic lymphocytic cholangiohepatitis and later lymphoma – a more advance, cancerous lymphocytic abnormality.
What Are The Tests My Veterinarian Will Perform To See If Triad Disease Is the Underlying Cause Of My Cat’s Digestive Problems?
A Physical Exam
Your veterinarian will want to perform a thorough physical examination of your cat.
The vet might notice a steady or sporadic drop in your pet’s weight over previous office visits. In advanced cases , your vet might discover abnormal skin pigmentation (icterus) or a swollen or painful tummy. But in most cases of cholangiohepatitis; on your initial visit to the vet’s office, your vet’s physical examination of the cat will be normal. That , in itself, will help your veterinarian work his or her way to the final diagnosis.
A CBC and Blood Chemistry
Complete blood cell counts (CBC/WBC) and blood chemistry value determinations are generally a vet’s next step in diagnosing illnesses with vague signs. They are often combined with an examination of your pet’s urine for abnormalities. I prefer that samples be sent to a national laboratory. Their equipment tends to be the most accurate and reliable than test run at animal hospitals. You can read a study that contrasts that accuracy here , view normal values for many tests here and a typical value report here.
Test results that might indicate a cholangiohepatitis problem or the chronic pancreatic and intestinal inflammatory conditions often linked to it are a high GGT activity , elevated ALT and alkaline phosphatase (AP) in the presence of normal thyroid hormone levels. Increased bilirubin level increased fTLI test, increased globulin levels, reduced cobalamin and folate levels and abnormal bile acids tolerance studies (ref). No blood value elevations, in themselves, are diagnostic for cholangiohepatitis – but they can be quite suggestive of the disease to your veterinarian.
Standard x-rays can give your veterinarian an indication of the size and shape of your cat’s liver, the presence of liver tumors, etc. They cannot rule out or rule in cholangiohepatitis.
An Abdominal ultrasound Examination
An ultrasound examination, when performed by an expert in its interpretation, can be of considerable help in diagnosing cholangiohepatitis or bile duct obstruction. It is also one of the least traumatic ways to guide a needle through the pet’s abdominal wall and into its liver to obtain a biopsy specimen for pathological examination.
A Liver Biopsy
The best way to diagnose cholangiohepatitis with certainty is for a veterinary pathologist to microscopically examine small snippets of your pet’s liver. There are two ways to obtain those samples. The cat’s abdomen can be opened surgically (exploratory laparotomy) or samples can be obtained using a long biopsy punch or needle aspirate that is guided through use of a real-time ultrasound image. The surgical method has the advantage of allowing the veterinarian to visually inspect the entire contents of the pet’s abdomen for abnormalities. The ultrasound-guided method has the advantage of being considerably less traumatic. A second advantage of the surgical approach is that it allows the veterinarian to take full-thickness biopsy samples of your pet’s intestines when concurrent IBD/lymphoma is suspected. (ref)
Early (small cell/low grade ) intestinal lymphoma cancer and IBD can be quite hard to tell apart. ( read here ) Both procedures are not without risk and must be done with the utmost care in cats that are seriously ill because inflamed organs are more likely to leak when punctured and ill kitties pose greater anesthesia risk.
Bacterial Culture of Your Cat’s Liver And Bile
If liver or bile samples are to be obtained for pathological study, they should probably also be checked for the presence of bacteria. Bacteria are rarely if ever the primary cause of chronic cholangiohepatitis. But if they are present, they need to be addressed with antibiotics.
What Treatments Might Help My Cat?
Stabilization In Life-Threatening Emergencies
If your cat’s cholangiohepatitis has progressed to life-threatening liver failure, the pet will require hospitalization. These seriously ill cats need customized intravenous fluid therapy since they are often dehydrated with electrolyte imbalances , and they need nutritional support – things like feeding tubes, liquid diets and, perhaps, parenteral nutrition.
Cats may need medications to control vomiting as well as the good nursing care and attentiveness that veterinary technicians are trained to provide.
Veterinarians place many cats with both sudden and chronic cholangiohepatitis on antibiotics.
I know I told you that bacteria are seldom if ever the underlying cause of this form of liver disease, but the down side of giving antibiotics is minimal – at least when they are provided for a limited time. Antibiotics also reduce the general bacterial population of the cat’s digestive system, which might lessen the workload on the pet’s liver. Some, like metronidazole often decrease diarrhea through an – as yet – unknown mechanism. (ref)
Although antibiotics may help by reducing overgrowth of unwanted bacteria in digestive tract or specific ones in the liver and bile, they also kill off important intestinal flora that your cat requires for good health. In humans fecal transplants are sometimes used to replace these “good” bacteria. ( read here & here ) It is generally understood these days that a great variety of intestinal organisms are critical for the good health of you and your cat ( read here ). I will send you the full article (Borody2012) if you ask me.
Probiotic pastes you see advertised, that contain, perhaps, four of the 40+ organisms that naturally dwell in your pet’s intestines are a very meager substitute. Besides, most of the organisms they contain are destroyed in their passage through the hostile environment of your pet’s stomach.
S-adenosylmethionine SAMe (Denosyl)
S-adenosylmethionine is a product officially defined as a “nutraceutical” or food supplement – not a medication. The company that markets it, Nutramax, reports its aid in the repair and protection of damaged livers in glowing terms . Articles and testimonials to that are generally provided by the Company’s employees themselves or at Company-sponsored events. (ref)
Independent research on the benefits of SAMe in treating liver damage are less definitive. Some found it no better than a placebo. ( ref 1, ref 2, ref 3, ref 4) some possibly helpful (ref) and a few swore by it. Those that produced questionable results on its effectiveness were what we call “double blind” studies in which neither the researchers nor the recipients knew which received SAMe and which received a placebo (sugar pill) and the ones not sponsored by the manufacturers.
I do not know if S-adenosylmethionine will be helpful to your cat or not. But there are few proven option in slowing the progression of liver disease and I see no harm in giving it to cats with cholangiohepatitis.
Choleretics and hydrocholeretics are compounds that facilitate (aid) the passage of bile from its points of production in the liver to its point of action in the intestine. Since bile stasis (lack of movement) appears to be a major part of cholangiohepatitis in cats, anything that encourages bile movement should be helpful. Frequent small meals stimulate the muscles of bile-containing system (biliary system), but so do certain compounds. One is ursodiol (ursodeoxycholic acid) , a medication developed to help dissolve human gall stones by making bile less viscous (flows easier). It is a form of natural bile acid produced in the liver.
Your veterinarian may decide that your cat would benefit from this medication indefinitely.
Silymarin (milk thistle)
Like Denosyl® , this is another Nutramax supplement marketed for liver disease in pets. (ref) In the Asian market, the Company suggests pet owners take the product as well as their pet. (ref). An NIH study found Silymarin to be of no values in in human chronic liver disease. ( read here ) as did a second study (ref); while another found beneficial affects. (ref) I wish I could give you better information than that, but I really can’t tell you more. But like other products marketed by this Company, there is no harm in giving it.
Medications that interrupt the inflammatory process
Chronic inflammation is the root of the liver damage seen in long-term cholangiohepatitis in cats. There are medications, steroids and immune-modulators, that act to decrease all forms of chronic inflammation. A side effect of all these medications is a lessening of the animal’s ability to fight infection or destroy tumors in their early stages. Some cats with cholangiohepatitis, inflammatory bowel disease and pancreatitis improve when given these medication.
When they are given, they are best given only intermittently and for relatively short periods of time during which the cat’s blood work and general condition are closely monitored by your veterinarian for unwanted side effects.
These medications include corticosteroids like prednisolone and drugs developed to fight cancer such as chlorambucil, cyclosporin. and methotrexate.
Because the effects of these medications is non-selective in which portions of your cat’s immune response they suppress, none can be given without risk. (ref) But then, no truly effective medication can be given without the risk of side effects. Being watchful for them is one of the important jobs of your veterinarian.
Vitamin And Nutrient Support
Cat that aren’t eating aren’t receiving important vitamins. So supplying them, independent of diet is a good idea. The nutrient-absorbing ability of cats with cholangiohepatitis and its associated diseases cripple the cat’s ability to absorb these compounds through their intestines. So, at least initially, these compounds are best given by injection when that is an option.
They include, vitamin K, E and B12. Some veterinarians also suggest taurine, folate and L-carnitine supplements. (Your vet may just administer a vitamin supplement – there is no harm in doing that – or confirm a B-12 deficiency by ordering a serum cobalamin assay.. Deficient cats often perk up when that vitamin is supplied.)
What About Giving My Cat Stuff I See Marketed On The Internet?
Be very cautious about giving you cat these products. Be even more cautious abut expecting them to work. At best, you will not harm your cat. But it is impossible to know what these preparations really contain or how they will affect the medications your veterinarian
prescribed. You can read an article about those dangers here.
Might Modifying My Cat’s Diet Help?
A low carbohydrate high protein, highly digestible diet, given in many small amounts during the day, is known to be beneficial in liver disease treatment. Diets that contain sucrose or corn syrup fructose,or large amounts of carbohydrates are undesirable. You can read one study about that effect here. It is also know that increased dietary protein levels reduce certain liver/bile related problems in humans (ref)
As important as what you feed is when you feed. Multiple, small feedings, given throughout the day, are more likely to encourage healthy bile flow than one or two larger ones.
The only caution in feeding a high protein diet is in cats with very advanced liver disease in which the liver has lost its ability to rid the body of ammonia. I mentioned this problem, hepatic encephalopathy, earlier in this article. In those situations, where the cat’s blood ammonia (hyperammonemia) levels are elevated above normal, your cat’s protein intake, the source of much of this ammonia, needs to be strictly regulated.
Is There Anything One Can Do To Prevent This Problem?
Feed you cat a diet less likely to contribute to the problem is the only thing I know of. Cats are true carnivores – something pet food companies find difficult to accept. The profits generated by including ingredients of less-than-first-quality are likely to have negative effects on your cat’s long-term health. So is adding ingredients that appeal to your tastes but are not normally eaten by cats. I believe that what we feed our cats is a significant factor in the increased frequency with which veterinarians see certain diseases like cholangiohepatitis, hyperthyroidism and lymphoma. Cholangiohepatitis often involves excess stimulation of your cat lymphocytes and their immune functions; other veterinarians have also theorized that diet and intestinal environment play an important role in excessive, destructive stimulation of that system. (ref)
You can read about some of the undesirable ingredients added to cat foods here.
You can read about the problems fish products have caused in cats here.
You can read about the potential negative effects of preservatives in pet food ingredients here .
You can read about preparing your cat’s diet at home here and about the general characteristics of a good diet for cats with digestive tract problems here.
What Is The Long Term Outlook For My Cat?
The liver is an organ that repairs itself well when faced with a sudden crisis that still leaves a portion of its cells (hepatocytes) intact. The liver is not nearly as efficient in recovering from sustained, long-term, damage (scaring) – even when the initial cause is corrected. So cats with the acute suppurative form of cholangiohepatitis are usually cured rapidly or lost to this World.
But the majority of the people that read this article are the owners of cats with the more common chronic form of cholangiohepatitis. Making modifications to those cat’s life style and diet, along with periodic veterinary attention, should allow your cat to continue a happy life in spite of chronic cholangiohepatitis. Never expect it to be fully cured, but expect its condition to markedly improve with periodic dips associated with stress.
The outlook for cats is less bright when the problems is only discovered in its advanced stages, when multiple systems are affected by chronic inflammation, or when the problem has advanced to the early stages of leukemia (lymphoma). We know that chronic stimulation of your cat’s lymphocyte populations can be the first step on a road to lymphocytic cancer (lymphoma). Sometimes, your vet must actually have the properties of these lymphocytes analyzed to decide how far along in that process things might have progressed. You can read about tests that do that here. But even then, not all cases of lymphoma progress rapidly. (ref)
What Is The Continuum Of Digestive Tract Inflammation? Is There A Connection Between Cholangiohepatitis, Inflammatory Bowel Disease and Pancreatitis in Cats?
I believe that there is.
It is quite common for cats with cholangiohepatitis to also suffer from inflammatory bowel disease and pancreatitis. (ref) Although that study found a significant link, other unpublished studies have found the link to be even higher.
Since all three conditions share similar elements of inflammation, occur in the same cat, and respond to similar treatments, I believe that they are likely to have the same cause and simply represent different expressions of the same underlying problem or continuum – no part of which can be meaningfully distinguished from the other except by arbitrary divisions.