What to do when they won't eat at all: Pina & The E-tube
Pina’s people came into the Orleans Vet Hospital one day, searching for some answers for their cat. She was 16 going on 17. Her pancreas and liver became inflamed, and she became jaundiced (a yellow tinge to the skin, eyes, and gums). She refused to eat, and syringe feeding or appetite stimulants were not working very well - It was a struggle. When they brought her to the clinic, they didn't know if this was going to be their last day with Pina. Whether it was all over. So we talked.
Now, a cat will eat less, or flat out refuse to eat for many reasons. They will refuse food due to illnesses, due to the fact that you went on vacation and then they got stressed, or any combination of things that make them nauseous or even painful. Regardless of what the underlying reason is, by the time they are 3 to 4 days without food, their body senses that they are beginning to starve. Stored body fat rushes towards the liver in order to give them energy. This backfires, and the liver becomes overwhelmed. This is called hepatic lipidosis, or “fatty liver” disease.
For these cats, the chance of success increases by taking them out of starvation and supplying them with the nutrition their body requires to heal. And there lies the problem. Force feeding the quantity of food required to heal the liver becomes a miserable process. Because it is not one, two or six syringes of food they need every day:
It is often 200 to 400 calories per day they need. That is this many syringes down the hatch per day:
It is rare that I meet the cat or person who responds well to this. Because with all the work that it takes, you are always playing catch up to what their bodies actually need. And even if your cat accepts it, when you add in the combination of medications that likely have to be given at the same time, many people are forced to give up. You will hear stories of people who tried to syringe feed, along with medications, and it all worked out. Which is great! But realize that just as many will be euthanized because it didn't work out.
I installed an esophageal feeding tube (e-tube) for Pina. An e-tube allows you to avoid syringing food, water, medications or supplements by mouth. Instead, everything they need is passed into their body with an installed tube that goes directly to their esophagus. The body then naturally passes it down towards the stomach. The tube can stay in place for several months.
As a vet, I'm very used to the look, feel and expectations with these little red rubber tubes surgically installed and poking out the side of their neck. I know the comfort level and acceptance by cats is very high. But how do normal people faced with these decisions think about a tube sticking out of their cat? Something that can be perceived as downright scary, drastic or invasive?
I asked Pina’s people. And here are their experiences in their own words:
How did you feel before the e-tube went in?
We had a bit of a trepidation about it, but we knew that she needed it. She needed some intervention. She was losing weight, was lethargic, and wasn’t moving around as much as she used to. She wasn't purring. She was hiding in the closet all the time. She wasn't eating. So, we knew we had to do something. Although we were a bit nervous about a tube going down, we knew that it was for the best. We thought that we'll do whatever it takes. And, if at the end of the day it doesn't work, that we could rest knowing that we've done everything we could in order to save her. So, we had no qualms about doing it.
What was it like bringing her home the first day after the e-tube placement?
It's almost like when you bring your first baby home. It is because you're there, oh my gosh, I have to take care of this living being. Well, here we have a cat that's for all intents and purposes was sick. And we're there, "Okay. We have to make sure we get food in her and we have to make sure the food stays down."
Intimidating is a very good word with that tube. We didn't know if it was hurting her. It was, "How are we going to do the first feeding?" And I remember us doing the first feeding and I was trying to take out the top. I was doing it the wrong way, and I panicked, and I thought, "Oh my gosh, I can't feed her." And I called [the Orleans Vet Hospital] and they were so kind. They just said, "Bring her in." And I was just doing it wrong. They showed me how to do it and it was ok!”
At first, I must say that she was nervous because we were trying to force feed her [previously] and she didn’t like that at all. She was choking, and gagging, and it was not pleasant. So, every time I went to feed her, she would run from us. And we said "This is not quality of life." That's why we were thinking like, "If this is going to be her life from now on, she's going to be afraid and scared and running from us, then I'm sorry. I'm not going to go through it. But, now that she has the tube, it made it so much easier for us because it wasn't so hard on her. We weren't gagging her to death through her throat. We were just slowly giving her some nourishment through this tube and no problems at all. No sneezing, no gagging, no nothing. So, it was so much more pleasant for us and for her. So, it was a lifesaver for that”.
About knowing how much food to give her:
There was a bit of trial and error because she was getting sick. She was throwing up. We were giving her food too often. Instead of waiting 60 seconds, we were doing it after 30 seconds. And we were giving her quite a bit and I think it was an adjustment. We had to slow down. And, once we got comfortable with giving it to her, I mean now she comes down in the morning, prances around looking for food. And, so, before she never came out of her room.
So, now, she has an appetite. So, we know it was a success. And, yes, the first couple of days were a little nerve wracking, but we were getting food in her. That's all we wanted was to make sure she got food in her. So, we were just happy doing that. And you were saying [Dr. Kris], "Okay. I want you to increase it up to two cans." I went, "Oh my gosh.” He wants two cans. There's no way. So, for the first few weeks, I mean a couple of weeks, she was getting a can, maybe a bit more. And we were saying, "How are we going to increase this?" But, slowly by the third, fourth week, we made two cans. And we spread it out enough. We were lucky because we had the time. I can get up in the morning and feed her at 7:00 and 11:00 and we give her at 4:00 and then at 9:00. So, it worked out very well.
When did things look like they were working?
You said, "Well, you can introduce a little bit of treats and all that...we were nervous because she'd never eaten with her mouth [since the illness began]. And so, when she took to it and she started eating a few - thank goodness".
She knows how to use her mouth still because that's what you're worried about…you have to open your mouth, you have to chew it, and you have to have a smell, you have to want it. And she wanted it. So, I think that was a turning point right there is that she could actually take it orally as well as she was comfortable with getting the tube feeding. And she started to make sounds again, and sit by the fire, and come and see us and follow us around, and rub herself on our legs, and started to be our cat again, which we had lost. And, so, we were really, really happy that we did this.
So, I know it was a lot of money and we kind of struggled. Like people were saying, "You spent what?" But, we were like, "This is our It's our baby, this is our cat.” You’d do it for your kids. Why wouldn't you do it for your cat, at least as much as you can? And we know she's had a good life and everything. We've always taken care of her and all that stuff. And we feel that there's no reason why she can't live another three years relatively happy and everything else. If we can give her three more years, I think we've done our job.
Do you regret putting in the tube?
No. Never. She's got three additional months so far. She gained weight. She's happy. The jaundice is gone. We'll go to bed saying, "We've done absolutely everything we could to help her. We never gave up on her." And I think that's the way you have to look at it. If you can do it, do it because she's not suffering. That's for sure. She's much better.
Dr. Kris comments:
Within the next few weeks, we plan to remove her feeding tube. And here is my message today: the feeding tubes work for cats like Pina, because it reveals their true health potential.
So if you have a cat with some sort of illness (not just liver disease) that is causing them to lose weight because the willingness to eat or ability to hold onto the nutrition is not there, this is a worthwhile technique to talk to your vet about. If their appetite is just “meh” due to an illness and they are losing weight, this can help them. It’s not about sustaining them artificially to drag things out. It's not about "putting them through something". It is about giving them the help they need to reveal the truth about their health potential. The e-tube is a test of what life is there to bring back. And it can be accomplish in a way that enhances the bond between people and their cats instead of promoting a struggle. Because it’s like bringing home a baby from the hospital for the first time - challenging but worthwhile. There is a greater good as Pina’s people so rightly pointed out.
Technical notes: I used a plain, red rubber french tube available at most clinics, and there is no advanced equipment required to do this. All medications and water easily went through the tube as well. Since they don't taste the medications it’s a completely different experience for them as compared to getting all these thing by mouth. I often use or suggest a baby bullet blender. For Pina, we used a higher protein, low carb Rayne GI canned food than blends very well.
Of course, this technique does require anesthesia, and there are some risks of the tube clogging. You know what can be put into the tube if it clogs? Coca Cola! What does that tell you of the make up of America’s #1 soft drink?! What about that anesthesia? Shouldn't that be a last resort in a sick cat? Modern anesthesia is a small risk compared to the high chance these patients succumbing to malnutrition, progressive deterioration and euthanasia.
What about Nasoesophageal tubes? Tiny tubes that go in through the nasal passage and require no anesthesia? Yes, those are great…and are suited for feeding special drip diets in intensive care units. They are not going to work over months while at home.
Is having an e-tube painful? Usually they have pain medication for 3 days, then they seem really comfortable. I’ve not seen anything unmanageable. They usually seem comfortable right after waking up from the anesthesia (we will be talking about balanced pain control in a future post). You can touch an manipulate the tube within hours, with no adverse responses.
Does the e-tube stop them from moving their head or neck? Nope. They have good mobility and show normal behaviour. They also don't typically try and scratch it out. It is a theoretical possibility though. It can get itchy if they develop an infection where the tube goes into the body.
Is this for everyone? No. You need to be hands on and gung ho! You need some time. Just like taking care of a baby or toddler.
Will it make them better for sure? Guaranteed? The words “guarantee” and “medicine” never belong in the same sentence. When people use the term "guarantee" in discussions about diagnosing or treating their pet, it is usually a coded statement that means "I am not willing or interested in treating this issue". Which is fine. I don't know what their life is like, what values they hold, and what other monkeys they have on their back.
By opting for any intervention, medicine or treatment, your are giving them a requirement for health. Then you see what they can do with it!
Have you ever fed your cat through a feeding tube before? Would you ever install an e-tube into your cat? Leave a note in the comments!
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