If you have a cat who is vomiting a hairball more than two times per month, there is a problem. In this episode, Dr. Chris Byers, veterinary internal medicine specialist and critical care specialist, join us to explain:
- How much puke is too much?
- Is your cat vomiting or coughing too hard?
- When should you take your cat to the vet?
- What tests are recommended for vomiting and why?
- What treatments are available?
Welcome, Dr. Christopher Byers
Dr. Lancellotti: Welcome, everyone, to the Your Vet Wants You To Know podcast. I am joined today by Dr. Christopher Byers, who is going to talk to us about chronic vomiting in cats- which is something that I think is a little bit misunderstood by pet owners. I’m excited to get to the reasons why cats might vomit and dispel that misconception that it’s okay for cats to vomit. Welcome to the show, today, Dr. Byers.
[00:01:28] Dr. Byers: Thank you for having me. I’m excited to chat with you about this very important topic in feline medicine.
[00:01:35] Dr. Lancellotti: So tell me a little bit about yourself. What’s your background, your experience, and your focus in veterinary medicine?
[00:01:41] Dr. Byers: Well, I am certainly a veterinarian, but like yourself, I’m a specialist. I am board certified in two areas- emergency and critical care medicine, as well as small animal internal medicine. Sometimes, in that latter specialty, we get called internists, which is not to be confused with first-year doctors that are called interns. It’s very confusing for some people. But as an internist, I deal with a lot of the problems affecting the internal organs of my patients. Currently, my professional time is spent primarily consulting with family veterinarians. I don’t work full-time in a hospital environment, although I do perform shifts now and then. But I’ve found that I like teaching, coaching, and mentoring my colleagues, particularly those that practice family medicine and primary care medicine. My clients, who are veterinarians, are all around the globe, and it is absolutely a true privilege to collaborate with them about they’re challenging patients. And then also, like you, I spend time on the road and in planes, traveling to various conferences to teach our colleagues in primary care.
[00:03:19] Dr. Lancellotti: Yeah. I think that’s one of the aspects of my job that I really enjoy too- getting the opportunity to teach family veterinarians about my specialty, why I love dermatology, and how they can have more success with their patients in their practices as well. So we definitely need people like you, who have this expertise in both emergency and critical care medicine, as well as internal medicine, to help those family veterinarians with their patients. So you’re an excellent resource for people. And I appreciate you coming on and sharing your expertise about this particular topic.
Do Cats Just Puke?
Dr. Lancellotti: I want to dispel this myth. What do you hear a lot of pet owners say about vomiting in cats?
[00:04:02] Dr. Byers: Unequivocally, regardless of what part of the country I’m practicing, I hear cat owners say some variation of, “It’s a cat. They just puke.”
[00:04:17] Dr. Lancellotti: Mm-hmm.
[00:04:19] Dr. Byers: And to be honest, I even hear this sentiment from some of our colleagues. When you reached out to me about recording a podcast, I was really excited and I certainly appreciate the opportunity to say, “Cats don’t just puke.”
[00:04:44] Dr. Lancellotti: Yep! I think that’s a really common misconception- that it’s normal for cats to puke or to have hairballs on a fairly regular basis. Some people think there’s this acceptable frequency of vomiting.
Is My Cat Vomiting Too Much?
Dr. Lancellotti: I want to talk a little bit about what chronic vomiting means, in terms of frequency and duration. So how would you define chronic vomiting?
[00:05:12] Dr. Byers: There’s two ways that I want to answer that question. The first, quite succinctly, is that if you have a cat who is vomiting a hairball more than two times per month, there’s a problem. The vomiting is not just a hairball issue. There’s something else going on. But let’s address that question a little bit more scientifically with true accepted definitions. Currently, in veterinary medicine, we will consider a cat to be a chronic vomiter when it has been going on for at least two weeks. But we have to take a step back from that seemingly simplistic definition because cats are cats. And what I mean by that is that they can be very challenging to figure out what’s going on with them, not just with vomiting, but for any medical issue.
[00:06:20] Dr. Lancellotti: You could not be more right about that. In dermatology, as well, they can be really difficult to figure out.
[00:06:28] Dr. Byers: And that’s why I love them. I jokingly say, “I don’t know when cats came to this planet, but I’m so happy that they did. They are my favorite species. I love them to death.” But when it comes to this issue of chronic vomiting, we all know a cat that may be vomiting once a day or once a week. But what about the cat that vomits once a month? That’s still technically going on for at least two weeks, so it technically meets the definition for chronic vomiting. But as a clinician, when I have that type of history shared by a pet owner, two thoughts go through my mind.
- Is this actually chronic vomiting?
- Are these two distinct episodes of acute (all of a sudden) vomiting? For example, the cat is getting into something that’s causing a tummy ache with vomiting as a result of it.
And that can be really hard to figure out just on physical exam, history, and clinical signs that a cat shows us in a physical examination. It’s not always straightforward, so that’s one complicating factor when we’re evaluating and assessing a patient with chronic vomiting.
Is My Cat Vomiting or Coughing?
The other is the potential of vomiting as a result of a really severe or harsh coughing episode. The classic example would be the asthmatic cat who has a coughing spell. If any of your listeners are asthmatic pet owners, they know that these kiddos can have a coughing spell where they cough multiple times. But sometimes, at the end of those coughing spells, a cat will retch. And as a result of that retch, they bring up some stomach contents. We call that post-tussive retching. And to somebody who is not medically trained, that post-tussive retching can look like vomiting. So when a pet owner who is concerned reaches out to their primary care doctor to schedule the appointment, and they’re asked by the client service representative, “Why are you bringing Fluffy in?” they’ll say, “Oh. Well, Fluffy’s vomiting. In reality, fluffy has an airway problem like asthma, and that post-tussive retch is an expected or common clinical sign of an airway problem. It’s not true vomiting. Pet owners can easily go to video-sharing sites like YouTube and simply look for videos on vomiting or asthmatic cats, for example. Parents have shared videos of cats coughing with this post-tussive retching behavior at the end of a coughing episode.
[00:10:15] Dr. Byers: Yeah. We always say “a picture is worth a thousand words.” If we apply that to video, then a video is absolutely invaluable. I would encourage any pet owner to record their pet doing the behavior that is of concern to them. Not just vomiting. Not just coughing. Whatever is a red flag. If there is a physical manifestation of that, record it. Take a video of it and share it with your veterinarian because it can be quite helpful for us to see what your concerns are. And it helps us, as clinicians, develop logical next-step recommendations for both diagnostic testing and therapies that will hopefully be beneficial.
[00:11:17] Dr. Lancellotti: Absolutely. I think that’s great advice. I love when my pet owners bring me pictures and videos of what’s going on at home, so that I can get a better idea of what my next steps are. Sometimes, when they come into the clinic, the animals are looking totally normal or very different from what the pet owner has seen at home. So use your smartphone and take advantage of what a helpful tool that is.
What are common gastrointestinal causes of vomiting in cats?
Dr. Lancellotti: Vomiting is a really complex process in the body. And when we’re in vet school, we’re taught to think about the reasons for vomiting as either problems that happen within the gastrointestinal tract or outside of it, causing the pet to get nauseous and leading to that vomiting. Can you talk to pet owners a little bit about some of those gastrointestinal diseases and some diseases that are outside the gastrointestinal tract that can potentially lead to vomiting?
[00:12:12] Dr. Byers: Absolutely. And you hit the nail right on the proverbial head. The way we think about chronic vomiting in the hospital, when I’m teaching colleagues or interns and residents- think of the gastrointestinal tract or everything else. I actually say this to pet owners when I’m counseling them in the room. I say it with a little bit of humor. I hope to emphasize how many causes there are. When we talk about the gastrointestinal tract as the reason for a cat’s chronic vomiting, we have issues like cancers. Unfortunately, cancer is always gonna be on the list. Some of the most common cancers to affect the gastrointestinal tracts of cats are lymphoma, adenocarcinoma, and something called a mast cell tumor. Cats can also get ulcerations within their gastrointestinal tract, just like you and I can. Sometimes, the area of transition between the stomach and the small intestine can get thickened, so much so that stomach contents are challenged to move from the stomach into the small intestine. Sometimes, the intestinal tract can telescope on itself. I think we’re all familiar with telescopes that can shrink and extend. Sometimes, intestinal segments can do that very same movement. We use the term telescoping on itself. The medical term when that happens is called an intussusception. And then, cats also eat things that they shouldn’t. They eat foreign objects, and sometimes, those objects don’t cause a complete obstruction where there’s an immediate surgical emergency. Sometimes, they’re small objects and they only partially obstruct the intestinal tract. Those partial obstructions can be associated with chronic, intermittent vomiting.
[00:14:46] Dr. Lancellotti: What do you think are some of the most common foreign bodies that we see in cats?
[00:14:53] Dr. Byers: Pieces of baby toys, pieces of cloth, and in my experience, to be honest, earplugs are very common. I don’t know why, but I have had surgeons have to remove multiple earplugs over the past 20 years. So, keep them in a drawer in your nightstand, not on top. That would be my advice to a pet owner.
[00:15:28] Dr. Lancellotti: I’ve also heard a lot of hair ties and strings, as well.
[00:15:32] Dr. Byers: Yeah. With hair ties, I haven’t had to take them into the operating room very often. What I more commonly need to do is a procedure called Gastroscopy, where we use this little fiber optic camera to go down through the mouth, through the esophagus (food pipe), into the stomach and grab them. It’s still something that’s done under anesthesia, but we consider it minimally invasive because we don’t have to make any incisions.
What are other causes of chronic vomiting in cats?
[00:16:04] Dr. Lancellotti: How about some of those other diseases in internal organs outside of the gastrointestinal tract? What might you see causing vomiting from those organs?
[00:16:15] Dr. Byers: Outside of the gastrointestinal tract, the most common disorders associated with chronic vomiting in cats would be hyperthyroidism (elevated thyroid hormone level) which is very common in our senior and geriatric aged cats. We can have inflammation of the pancreas, which is called pancreatitis. Cats get various inflammatory and infectious conditions that affect their liver and gallbladder. Sometimes, they can be quite ill with those diseases- chiefly something called cholangiohepatitis. And then of course, we have chronic kidney disease, which is a progressive deterioration in kidney function of cats. Chronic kidney disease is not something that we would expect to encounter in a one or two year old kiddo, but rather in a cat who is senior or geriatric aged.
What are the most common causes of vomiting in cats?
Dr. Byers: With all that said about all of the major gastrointestinal causes, as well as causes of chronic vomiting that have nothing to do with the gastrointestinal tract, if we all take a step back with the intent of not losing sight of the forest for the trees, statistically based on the published data, the two most common causes of chronic vomiting in cats are cancers of the intestinal tract or something we now call chronic enteropathy. Your listeners may be more familiar with the previous term we used that is inflammatory bowel disease (IBD).
Why is my cat vomiting?
[00:18:21] Dr. Lancellotti: So if a veterinarian is concerned about chronic vomiting in a cat, what tests might the veterinarian recommend to the pet owner to figure out why the vomiting is occurring?
[00:18:33] Dr. Byers: So when I’m having this conversation with pet owners, I tell them that, in general, I like to work logically from a non-invasive to potentially invasive tests. What do I mean by that? Well, I want to start with blood, urine, and feces (stool) testing. Those types of tests can help me screen for hyperthyroidism, chronic kidney disease, evidence of liver abnormalities. Sometimes, we do diagnostic imaging like abdominal radiographs or x-rays, or we perform something called ultrasonography. Those are all very non-invasive tests. But ultimately, one may need to talk about obtaining biopsies of the liver or the gastrointestinal tract. And understandably, that is more invasive then taking x-rays or running a blood test. I always want to run the blood tests or perform the imaging studies first because hyperthyroidism doesn’t require biopsies to make a diagnosis. It’s something that we diagnose based on history, clinical signs and blood work. We don’t need to get a chunk of tissue, but (frustratingly) when we’re talking about chronic enteropathies (the former inflammatory bowel disease) or intestinal cancers, to date, despite many studies attempting to find such a test- there is no blood test. There is no urine test. There is no poop test. There is no diagnostic imaging test that can reliably and accurately differentiate a chronic enteropathy or inflammatory bowel disease from intestinal cancer. So, one may need to consider performing biopsies to make that type of diagnosis definitively.
[00:21:10] Dr. Lancellotti: Boy, it’d be really nice if we had that tool to be able to easily do that. Huh?
[00:21:14] Dr. Byers: It would be wonderful. And I’m not gonna lie, if I were to be the one to figure out that test, I will then subsequently be retired in Fiji and nobody will ever see me again.
What is a biopsy for vomiting in cats?
[00:21:28] Dr. Lancellotti: You mentioned biopsies, but for pet owners who may not be quite as familiar with that term, can you just quickly overview what a biopsy would entail?
[00:21:38] Dr. Byers: Sure. There are two types of biopsies that one can perform for the gastrointestinal tract. The one that most parents think about is surgery, where there’s an incision made into the belly cavity and the surgeon takes a small piece ( smaller than the head of an eraser) to get biopsies of the intestines for a pathologist to review. That procedure is associated with an incision, so there is a 10 to 14-day recovery period at home with pain management and exercise reduction. The other way is through a procedure called endoscopy, where we use that special fiber optic camera to go down through the mouth, through the food pipe, into the stomach, and the first part of the small intestine. Or we can go the other way (colonoscopy) through the anus, into the colon, and potentially, even into the last part of the small intestine. That procedure is still performed under general anesthesia, but there is no incision, so it is less invasive than surgery. The less invasive nature of endoscopy is the major benefit to that procedure. With that being said, the intestinal tract has 4 layers. Ideally, we want the pathologist to look at all four of those layers. Only surgical biopsies allow us to do that. When we perform endoscopy, the minimally invasive procedure, we are only able to sample that first layer that comes into contact with food, for example. Those biopsies are good, but they’re not perfect. Sometimes, the major abnormality that would allow us to make a diagnosis is actually in the third (muscularis) layer. Endoscopy can’t sample that third layer. Only surgical biopsies can do this. So, when a pet owner is contemplating whether to pursue biopsies of the intestinal tract, they need to make sure that they understand the benefits, the limitations, and the potential risks of each of those procedures, so that they’re making the best informed decision.
Which specialist can help with chronic vomiting in cats?
[00:24:35] Dr. Lancellotti: Yeah. And that’s a really good conversation to have with their veterinarian regarding their specific pet, because each pet is different, and a lot of the decision is going to be based on what that animal’s individual risk is. So if your cat is vomiting, it is important to have that discussion with your family veterinarian about the different tests available, which tests would be recommended for your specific pet, and what the risks and benefits are from each one of those tests, in relation to what your animal is experiencing. A lot of these tests that you mentioned can be done with family veterinarians, in the general practice setting, but some of them are more advanced tests. Who would a pet owner go to see if they potentially wanted a specialist involved in this situation?
[00:25:30] Dr. Byers: You are absolutely correct, in that all of these tests may be able to be performed by a primary care doctor- including endoscopy or surgery. But sometimes, a primary care doctor is uncomfortable performing these tests, they don’t have the equipment to perform them, or they really would appreciate the insight and opinion of a specialist before performing additional testing. So for those scenarios, pet owners would be encouraged to collaborate and consult with a board certified internal medicine specialist. I’m a very big proponent of what has been termed “the triad of care,” which is a really amazing collaborative relationship between a pet owner, the family veterinarian or primary care clinician, and (when needed) a board certified veterinary specialist. In this case of chronic vomiting, traditionally the specialist to bring onto a pet’s healthcare team would be an internal medicine specialist.
[00:26:58] Dr. Lancellotti: And there is a link to find an internal medicine specialist near you under the resources tab, but it’s also important to ask your primary care veterinarian or family veterinarian if they have an internal medicine specialist that they like working with. Oftentimes, they may have a personal relationship with a local internal medicine specialist and they can make that recommendation for you.
[00:27:28] Dr. Byers: Some of your listeners may live in parts of the country or the world where traveling to an internal medicine specialist (of any type) is not feasible. Maybe the closest individual is six hours away. That may not be a reality for some pet owners. What’s really nice, in 2022, is that veterinary internal medicine specialists, veterinary dermatologists, and all the other specialists are available via teleconsulting, as well. We can’t teleconsult with pet owners because we need to examine patients. There’s profound importance of laying hands on a patient to examine them. But family veterinarians and primary care doctors can teleconsult with a specialist colleague, and that can be very helpful and impactful for a pet’s health, especially when traveling to be physically examined by a specialist isn’t possible.
[00:28:43] Dr. Lancellotti: Yeah. I think that’s a great resource for people to have as well, and certainly something you can ask your family veterinarian about if there’s not an internal medicine specialist in your area.
How can I stop my cat from vomiting?
Dr. Lancellotti: We talked a lot about the different tests that can be done to figure out why an animal is vomiting, and certainly the treatments are going to be recommended based on those test results. But what if there’s a situation where the pet owner is maybe not able to do all these tests or there’s a lot of risks associated with testing for a specific pet? What about for owners who just want to stop the vomiting? Let’s talk a little bit about treating the vomiting based on what our best guess is for the cause, or what veterinarians refer to as empiric treatment. What are some of the benefits and risks to empiric treatment of chronic vomiting?
[00:29:32] Dr. Byers: With that question, I think it’s important to state that true effective treatment of chronic vomiting requires figuring out what’s causing the chronic vomiting in the first place. It’s really important, whenever possible, to thoroughly investigate all of those potential causes so that we’re treating a pet as appropriately and as properly as possible. For example, something like chronic kidney disease is certainly treated very differently than hyperthyroidism, so successful management, in that regard, really does depend on making an accurate diagnosis. But we live in the real world. I don’t know anybody who has the money tree growing in their backyard or in their garden- which I don’t. So as clinicians, we understand that (for a wide variety of reasons) an owner or a family may not be able to pursue definitive diagnostic testing. That doesn’t mean that we don’t want the cats vomiting to not stop. Of course we do. In those situations, we will talk about empirical or “best guess” treatments. The awesome thing is that in many of these circumstances, empirical treatment will be successful, but there are times when it isn’t. And if I’m being completely honest with listeners, that’s when pet owners tend to become frustrated. Why? Because their pet isn’t getting better. So here’s what I want families to understand and accept about empirical therapy for chronic vomiting, in this case. Yes, it is an option. No, success cannot be guaranteed. And if empirical treatment isn’t successful, nobody is going to know why because we don’t have a definitive diagnosis. And pursuing definitive testing, after some of the potential empirical therapies, can actually make obtaining a definitive diagnosis much more challenging (and sometimes, near impossible) later. The summary of empirical therapy is; yes, it can be done, but it’s not always going to work. Please don’t yell at your veterinarian when it doesn’t work. We don’t have a definitive diagnosis in those scenarios and we’re just doing our best to help your cat feel better.
[00:32:52] Dr. Lancellotti: Yeah. That is a pretty good message there. There’s a risk and benefit to every decision that we make regarding the pet’s health. One of those risks with empiric treatment is that they’re not going to get better and we don’t know why. So if that’s a risk that you’re comfortable with, then certainly empiric treatment might be something that you’re considering, but just keep in mind that it’s a significant risk when you take that approach.
Cats don't just puke!
Dr. Lancellotti: We talked a lot about chronic vomiting and I think that there’s such good information here for pet owners. What are some of the big takeaway points that you’d like pet owners to remember about chronic vomiting in cats?
[00:33:27] Dr. Byers: The big takeaway is simply that cats don’t just vomit, with the exception of the rare hairball. Usually, it’s less than one hairball a month. If it’s more than two times a month, there’s another problem going on. But typically, with a chronic vomiter, there is an underlying disease that is causing the chronic and intermittent vomiting. So, we want cat owners to partner with their family veterinarian and (possibly) a board certified veterinary internal medicine specialist to get to the bottom of the problem.
[00:34:16] Dr. Lancellotti: Yeah. Absolutely. There are a lot of great resources out there for you to be able to work with your veterinarian and figure out exactly where that vomiting is coming from.
Connect with Dr. Byers and other pet owners
Dr. Lancellotti: Dr. Byers, this was really good information for pet owners and I know that you feel very strongly about educating (not only) pet owners, (but) primary care veterinarians and family veterinarians (as well). Tell us a little bit about some of the publishing and the teaching that you do. How can pet owners connect with you to learn more?
[00:34:47] Dr. Byers: I publish a blog called criticalcaredvm.com, and at that site I share information about a variety of diseases that affect cats and dogs, including chronic vomiting. Pet owners can follow me on all of the major social media sites like Instagram, Facebook, and Twitter, by finding me @criticalcaredvm. If you have any veterinary colleagues that are listening, to share this with their own pet owner clients, I have published a textbook called Feline Emergency and Critical Care Medicine that’s available at all major sites, including Amazon. If you couldn’t tell, I love my cats.
[00:35:44] Dr. Lancellotti: That’s great. Publishing a textbook is a huge amount of work, so congratulations on that. That’s very exciting.
[00:35:52] Dr. Byers: Thank you. I’m excited because I really wanted to publish this textbook and I just found out, in the past couple of months, that the publisher is really happy with it- so much so that now they want me to write a canine version. So, that’s on its way, as well. The end of 2023 is when that one should be making an appearance. But like you said, textbook production is quite a process. I’m humble that anybody would want to read anything that I put out there and I just hope that it helps advance the care for these kiddos.
[00:36:38] Dr. Lancellotti: That’s awesome. We talked a lot about how many tests there are, as far as chronic vomiting with these animals, and many family veterinarians are comfortable evaluating chronic vomiting in cats, but for pet owners that want to consult with a veterinary internal medicine specialist, there is a link for you under the resources tab. You can find someone local to you or ask your family veterinarian about an internist nearby. You can also view the references for today’s show in the show notes, and I’ll have links for you to be able to connect with Dr. Byers on social media and his website. If you have a cat that’s gone through chronic vomiting, you’ve gone through this diagnostic workup, and you’re looking for a community of people to share your experience with (to know that you’re not alone), I would encourage you to join the Facebook group and tell us about your experience with your chronic vomiting cat. There are pet owners out there who are going through the same thing that you are. You are not isolated. You are not by yourself. There’s a community of support that’s out there for you.
Scratching the Itch - Not One More Vet
[00:37:46] Dr. Lancellotti: Dr. Byers, I like to end each episode with a segment that I call Scratching The Itch. This is a short segment that highlights something- either a human interest story, a product, or a website- just something that provides relief or makes you feel good. Hence, scratching the itch. Do you have a ‘scratching the itch’ for our listeners, today?
[00:38:06] Dr. Byers: I do. Thank you for asking about this. The itch that I want to scratch is promoting mental wellbeing, especially among veterinary professionals. Your listeners may not know that the veterinary profession has higher suicide rates than the general population. Male veterinarians by 1.6 times. Female veterinarians by 2.4 times. Male technicians and veterinary nurses by 5 times. And female technicians and veterinary nurses by 2.3 times. And overall, sadly, 1 in 6 veterinarians considers suicide at some point in their career. There is a common misperception that veterinary professionals simply play with animals all day, and you and I both know that reality is very far from this. So in an effort to raise awareness about this very important issue, I’d like to share with your listeners the efforts of a very impactful organization called Not One More Vet (NOMV). This organization helps veterinary professionals through peer to peer support, financial support grants, educational presentations, and by developing collaborative relationships with various agencies to extend services to the veterinary community.
[00:40:13] Dr. Lancellotti: Yeah. We’ll have that link posted in the show notes for people who are listening through Apple Podcasts or through Spotify. We will also have that link posted on the website within the transcript. That’s a great place for pet owners to go and learn more about the Not One More Vet initiative, what they’re doing to support veterinary wellness within our community. Also, it’s a place where you can go and donate if you would like to support the veterinary community and feel like giving. They’re really doing an amazing job of helping to support veterinary mental wellbeing and I appreciate you highlighting that. Dr. Byers, thank you very much.
[00:40:52] Dr. Byers: Thank you for giving me the opportunity.
[00:40:55] Dr. Lancellotti: Honestly, this has been such great information for pet owners who have a cat that may have chronic vomiting, and I hope that they use this information to work with their family veterinarian (or a veterinary internist) to figure out how to make their animal feel better. I really appreciate you taking the time to come on and talk, today. Thank you.
[00:41:13] Dr. Byers: Thank you very much.
