Chronic Vomiting in Cats isn’t Normal After All

Chronic vomiting is so common that many vets and cat owners have made excuses for it.

A study of 100 cats with a history of chronic vomiting, weight loss, chronic diarrhea or a combination was recently accepted for publication by the Journal of the American Veterinary Medical Association.1 The authors, whom I led, concluded that chronic small bowel disease likely is the cause of these clinical signs in hundreds of thousands of cats.

Chronic vomiting, present in 73 percent of the cases, is so common that many veterinarians and cat owners have made excuses for it.

The top four reported to me over the years are:
* He eats too fast;
* She has a sensitive stomach;
* It’s just hairballs; and
* “He’s just a puker,” to quote one of my clients.

Consequently, the typical approach has been the use of diets for “sensitive stomachs,” diets for hairballs, hypoallergenic diets, medications for hairballs and antiemetics (metoclopramide, ondansetron, maropitant, famotidine, etc.).

Often there is improvement in clinical signs, but rarely are they completely relieved. In addition, the improvement often diminishes over time.

My two clinical associates and two pathologists teamed with me to better understand the cause of chronic small bowel disease in cats.

One hundred cats with the aforementioned clinical signs were examined by abdominal ultrasound. The small bowel wall thickness was measured in several places; if one or more measurements were 0.28 cm or greater, surgery was performed. At surgery, at least three full-thickness biopsies were collected from the small bowel using a 6 mm biopsy punch so all layers of the bowel wall could be examined. 

In addition, the liver (wedge) and pancreas (4 mm biopsy punch) were biopsied. Histopathology and immunohistochemical staining were performed on all samples, and PCR for Antigen Receptor Rearrangement (PARR) was performed on samples deemed to be “ambiguous.” “Ambiguous” was defined as a cellular composition that had characteristics of both inflammatory disease and small cell lymphoma, the two most common diagnoses.

Can it be IBD?

In the paper, we use the term “chronic enteritis” instead of “inflammatory bowel disease.”

IBD is one of several causes of chronic enteritis and requires more testing to rule out other known causes before the term IBD is justified. However, ultimately IBD, as a diagnosis of exclusion, is correct in a high percentage of cases.

The final diagnoses of the 100 cats are shown in Table 1. It is notable that the incidences of chronic enteritis and neoplasia are almost equal. It also is notable that the cats with lymphoma were slightly older than those with enteritis.

There is growing evidence that some cats with chronic enteritis transition into lymphoma. This should motivate the practitioner to be aggressive in getting biopsies of these cats so the disease can be diagnosed at the more treatable stage.

Symposium set at WVC
Gary Norsworthy, DVM, Dipl. ABVP, and J. Scot Estep, DVM, Dipl. ACVP, will present a symposium on small bowel disease at the 2014 Western Veterinary Conference in Las Vegas in February. The emphasis will be on diagnosis, but therapy also will be included.
Pathologists will be especially interested in Dr. Estep’s findings and how they affect appropriate diagnostics.

The presence of vomiting alone and vomiting with weight loss are the basis for my theory that small bowel thickening causes hypomotility. Hair and food move through the bowel at subnormal speed. When more hair or food is ingested, the full bowel results in reflux vomiting. As the bowel wall thickens further, nutrients are not absorbed properly, resulting in weight loss and compensatory polyphagia, well recognized clinical signs of cats with intestinal lymphoma.

Maybe Not Hairballs …

Another notable finding in this study is that vomiting of hairballs is really not as normal as we have thought. The vomitus of many of the cats contained hair or hairballs more than 50 percent of the time.

I hypothesize that formation and vomiting of hairballs are due primarily to hypomotility of the small bowel. Instead of moving aborally at the normal speed, hair moves slowly, resulting in hairball formation.

I am convinced that the vomiting of hairballs is a sign of chronic small bowel disease if it occurs twice a month or more in any cat; or if it occurs once every two months or more in shorthaired cats; or if it occurs in cats that are not fastidious groomers, i.e., presented with many mats in their hair coats or with heavy dandruff.

About 25 percent of the cats in the study were presented for an annual examination. I begin my annual examinations with the client completing a history form that asks about several clinical signs. Vomiting is the most commonly reported clinical sign and is often accepted by the client as insignificant based on one or more of the excuses listed above.

Thus, one of the best ways to find chronic small bowel disease, and many other diseases, is to perform an annual examination that includes proper history taking. This must include proactively asking about chronic vomiting; otherwise, clients will often not report it.

Some veterinarians use endoscopy to obtain gastric and small bowel biopsy samples. However, surgical biopsy has two distinct advantages. First, 76 percent of the cats in the study had segmental disease as evidenced by both normal and abnormal ultrasound findings and proved by visual evaluation of the tissues at the time of surgery. Many cats had disease that was limited to areas not accessible to the endoscopic biopsy forceps.

Final diagnoses of 100 cats with clinical signs of chronic small bowel disease.
(1) Normal
(49) Enteritis
(50) Neoplasia:
 • Lymphoma (46)
 • Small cell (39)
 • Lymphoblastic (7)
 • Mast cell disease (3)
 • Adenocarcinoma (1)

Second, endoscopic biopsies generally only contain mucosal tissue. Pathologists prefer to examine all of the layers, especially in ambiguous cases. The therapeutic significance of this will be shown in a subsequent paper in which we will show the difference in therapeutic response and prognosis in cats with villus and mucosal lymphoma vs. those with lymphoma that infiltrates deeper into the bowel wall.

The findings of this study should motivate the practitioner to be much more proactive in working up cats with signs of chronic vomiting, diarrhea and weight loss or a combination of these signs.

Chronic small bowel disease is very common and can cause all of these signs.

It is time to quit accepting our timeworn excuses and treating these cats symptomatically. Get a diagnosis so you can treat these cats appropriately and potentially prevent the transition from IBD to lymphoma.

Dr. Norsworthy, Dipl. ABVP, operates Alamo Feline Health Center in San Antonio. He is a member of the Veterinary Practice News editorial advisory board.


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5 thoughts on “Chronic Vomiting in Cats isn’t Normal After All

  1. Hello. My 9 year old Persian fits this description. She has a lifetime history or IBD symptoms. I treat her with homecooked food, and probiotics. That has corrected her chronic diarrhea. Recently she’s been vomiting ALOT of hairballs (about 20 in a month and a half). She fits the description above – chronic hairballs with no weight loss. She isn’t healthy enough to undergo surgery, so what do I do for her. Please help! I’m worried sick for her!

    1. Rachel – I have two adult cats that were diagnosed with IBD two years ago. One through a biopsy and the other through ultrasound. My conventional vet recommended Prednisolone as the “treatment”… I did my own education and discovered a world of natural, holistic health options. Switched to raw diet with supplements of Probiotics and have been working with a Homeopathic Vet to promote healing. I truly believe my cats would have passed if I didn’t do natural treatment to address the illness vs. suppress the symptoms through drugs. Weaned one of my cats off Prednisolone and the other one is almost there. Finding the right Probiotic is important too. Digestive Enzymes might help. I recommend looking into Homeopathy and working with an experienced Homeopathic Vet to address diet and remedy use to help your kitty achieve the best health possible. Homeopathic Vets will do phone consultations, so don’t worry about finding one near you: Another trusted site for information is (Dr. Becker). Best wishes for your furbaby.

      1. Hi!

        I’m on the hunt for a good probiotic. I’ve been told my girl is “a puker” but my mama instinct has always disagreed. Felt like a lazy answer.
        Do u have any good suggestions/ what worked for u? I’ve been looking at Natren’s Felinedophilus:

        But I’d love to hear your discoveries. She’s a super picky eater (while her brother will eat anything) so that makes it a little extra tricky.


  2. Lucy is 12.4 yrs old. From the time she got her shots at 3 months. Took her right back to the vet. Vet did 2 UGH studies. 1 was fine, but she still vomited.2nd series showed something, perhaps a foreign body in her stomach. Did surgery to remove substance as she did not pass it. Surgery showed a sore that the barium adhered to. Biopsied it was not malignant. Vet said she would probably be on Pepcid A.C. the rest of her days. Fast forward on to age 9. She had an episode of pain and vomiting. Took her to emergence vet. Blood test and stomach x ray showed nothing. Changed her food to Royal Canin Gastrointestinal. Fine. A few bouts of vomiting, but with Pepced was ok. Then a few months ago, the vomiting started again. I had moved, so I took her to a vet near me. Gave her a shot of steroids and antibiotics along with Cerenia for vomiting. Also did bloodwork and a stomach x ray. A little thickness in the stomach lining. Not helping, so I made the trip back to the original vet.Had her records sent to her. She saw nothing remarkable on the x ray. She also did a test for pancreatitis which was normal. She had lost a little weight. Put her on Cerenia, 4 days on two days off. Also Mirtazapine 3.75mg tablet for appetite. 1 tablet every 3 days. Pepcid morning and night. Did real well. Gained a pound and held it for a little over a month. Changed the dosage on Cerenia to 2 days on 2 off. Changed the appetite med to a longer time between doses. Vomited once. Not eating well, but not vomiting. Go back to vet on April 23rd. All her life she has had issues with her stomach. Never loose stools. At a loss as to what to do next. Very nervous cat, always has been. She had been abused and found in a garage. My vet nursed her to good health and I adopted her. Any advice?