followup on Erik's ultrasound
Last month Erik had an ultrasound (prompted by an accumulation of suspicious bloodwork), which showed some "streaking" (deposits?) in the bile ducts and a possible gallstone. My vet referred me to a specialist, who we saw today.
(Aside: 7 pounds even, again. Sigh.)
The vet is skeptical about the gallstone -- skeptical that it could be causing the problems we're seeing in the absence of other problems we're not, and also a little dubious about whether it's really even there. The surgery Erik had in late 2005 was "game-changing", he said; some internal bits got moved around, and that makes it much much harder to read an ultrasound. (He's not dissing the guys who did the ultrasound; he's saying their job is hard.) He speculated that the "stone" might be an accoustic shadow. The only way to know is to go in and look, but he sees no reason to do that unless we're going in for some other reason.
The streaking is something of a puzzler, and he didn't talk much about it. He said there are four possible causes of the issues we're seeing in Erik: the hepatitis we already know he has (which we should continue to treat), IBD (irritable bowel disorder), diffuse lymphoma (which wouldn't produce ultrasound-visible tumors), and a tumor in the pancreas. Of these, the hepatitis is treated with drugs, the IBD would be treated with predinzone, the pancreas tumor could not be treated, and lymphoma is treated with chemo. So none of the treatments are surgical, but surgery would be required to figure out which of those is going on. (Surgery to "look around" and collect samples for biopsy.)
I asked what are the risks of doing that surgery and what are the risks of not doing it. (I got the impression from his reaction that most people don't ask about both, while I think it's essential.) If we don't do the exploratory surgery, we should take a shotgun approach, treat the symptoms, and see what happens. (I didn't get the impression that chemo was part of the ammo in that shotgun.) If we do the surgery, there are risks from the stress. While Erik is an older cat, the vet said he is otherwise healthy so he wouldn't rule out surgery. But, he said, he would judge that there's a 10-20% chance that we would look back on it and say "we shouldn't have done that". He said he is on the fence about whether the surgery is a good idea; he thinks the risks are comparable either way. (Oh, great...)
I asked about the lymphoma scenario -- is this something that moves quickly and would kill him in months, or is it something that would take a few years (he's 15.5 now)? Also a good question, he said, but he was dodgy about answering so I will follow up with my vet. I wrote down "a year w/prednizone", but I'm now not sure what predinoze has to do with lymphoma so I probably misunderstood. As an aside, his WBC has been high for a while (2-3 years, I think, but need to ask my vet), so at a gut level I don't think he has cancer. I should have asked the vet to comment on that given Erik's WBC history. My vet will be speaking with him, so maybe she can pursue that.
I asked about followup issues from surgery, since that took me by surprise last time. He said the best case is that Erik stays in the hospital a couple days, goes home, and we're pretty much done (one followup visit, I think). If they can't get him to eat after the surgery, they would use a feeding tube and things get more complicated (as we saw before). Last time the feeding tube caused an absess; this is very unusual, he said, but of course there's always a risk at any incision site (my read on this was "CYA").
He's on the fence and doesn't feel a sense of urgency, so I won't be acting before Pennsic. I need to talk with my vet more and think about things. There's no "quick fix" -- it's not like there's a tumor to be removed or the like -- but there could be a lot to be learned that would let us do more-effective drug treatments, maybe. Or, this might just be the way Erik is, and what we would learn is "the drugs you're using are good".
When I was giving him an overview of Erik's history at the beginning, consulting my own notes, he asked if I'm in the medical field. I guess most people don't use words like "icteric" in conversation. No, I said, just detail-oriented. :-) (I actually only started keeping my own notebook last winter, in an effort to track appetite changes, drug changes, behavior changes, etc more finely. Still no patterns there that I can see, but I might try using the data-visualization software my company makes to look for patterns.)
Edit: My vet called to ask how it went, so I gave her a rundown. While we were talking I asked what the treatment would be like if it did turn out to be lymphoma, and she described something that sounded like "cure worse than the disease" to me, though of course that's only a casual reaction to a cursory description. But, as I suspected, chemo does have the potential to be pretty invasive too. So we'll see. She also suggested that aspirating the liver would tell us if it's lymphoma; since the specialist didn't mention that, I asked her to discuss it with him and tell me what happens. (This is much less invasive than surgery -- basically just a needle stick, guided by ultarasound.) A problem with prednizone, she said, is that it can interfere with future biopsies, so she doesn't want to just put him on it unless we're sure we aren't going to do the surgery. She agreed that we do not need to do anything immediately, unless of course his condition changes, so there is time to think and study.
(Aside: 7 pounds even, again. Sigh.)
The vet is skeptical about the gallstone -- skeptical that it could be causing the problems we're seeing in the absence of other problems we're not, and also a little dubious about whether it's really even there. The surgery Erik had in late 2005 was "game-changing", he said; some internal bits got moved around, and that makes it much much harder to read an ultrasound. (He's not dissing the guys who did the ultrasound; he's saying their job is hard.) He speculated that the "stone" might be an accoustic shadow. The only way to know is to go in and look, but he sees no reason to do that unless we're going in for some other reason.
The streaking is something of a puzzler, and he didn't talk much about it. He said there are four possible causes of the issues we're seeing in Erik: the hepatitis we already know he has (which we should continue to treat), IBD (irritable bowel disorder), diffuse lymphoma (which wouldn't produce ultrasound-visible tumors), and a tumor in the pancreas. Of these, the hepatitis is treated with drugs, the IBD would be treated with predinzone, the pancreas tumor could not be treated, and lymphoma is treated with chemo. So none of the treatments are surgical, but surgery would be required to figure out which of those is going on. (Surgery to "look around" and collect samples for biopsy.)
I asked what are the risks of doing that surgery and what are the risks of not doing it. (I got the impression from his reaction that most people don't ask about both, while I think it's essential.) If we don't do the exploratory surgery, we should take a shotgun approach, treat the symptoms, and see what happens. (I didn't get the impression that chemo was part of the ammo in that shotgun.) If we do the surgery, there are risks from the stress. While Erik is an older cat, the vet said he is otherwise healthy so he wouldn't rule out surgery. But, he said, he would judge that there's a 10-20% chance that we would look back on it and say "we shouldn't have done that". He said he is on the fence about whether the surgery is a good idea; he thinks the risks are comparable either way. (Oh, great...)
I asked about the lymphoma scenario -- is this something that moves quickly and would kill him in months, or is it something that would take a few years (he's 15.5 now)? Also a good question, he said, but he was dodgy about answering so I will follow up with my vet. I wrote down "a year w/prednizone", but I'm now not sure what predinoze has to do with lymphoma so I probably misunderstood. As an aside, his WBC has been high for a while (2-3 years, I think, but need to ask my vet), so at a gut level I don't think he has cancer. I should have asked the vet to comment on that given Erik's WBC history. My vet will be speaking with him, so maybe she can pursue that.
I asked about followup issues from surgery, since that took me by surprise last time. He said the best case is that Erik stays in the hospital a couple days, goes home, and we're pretty much done (one followup visit, I think). If they can't get him to eat after the surgery, they would use a feeding tube and things get more complicated (as we saw before). Last time the feeding tube caused an absess; this is very unusual, he said, but of course there's always a risk at any incision site (my read on this was "CYA").
He's on the fence and doesn't feel a sense of urgency, so I won't be acting before Pennsic. I need to talk with my vet more and think about things. There's no "quick fix" -- it's not like there's a tumor to be removed or the like -- but there could be a lot to be learned that would let us do more-effective drug treatments, maybe. Or, this might just be the way Erik is, and what we would learn is "the drugs you're using are good".
When I was giving him an overview of Erik's history at the beginning, consulting my own notes, he asked if I'm in the medical field. I guess most people don't use words like "icteric" in conversation. No, I said, just detail-oriented. :-) (I actually only started keeping my own notebook last winter, in an effort to track appetite changes, drug changes, behavior changes, etc more finely. Still no patterns there that I can see, but I might try using the data-visualization software my company makes to look for patterns.)
Edit: My vet called to ask how it went, so I gave her a rundown. While we were talking I asked what the treatment would be like if it did turn out to be lymphoma, and she described something that sounded like "cure worse than the disease" to me, though of course that's only a casual reaction to a cursory description. But, as I suspected, chemo does have the potential to be pretty invasive too. So we'll see. She also suggested that aspirating the liver would tell us if it's lymphoma; since the specialist didn't mention that, I asked her to discuss it with him and tell me what happens. (This is much less invasive than surgery -- basically just a needle stick, guided by ultarasound.) A problem with prednizone, she said, is that it can interfere with future biopsies, so she doesn't want to just put him on it unless we're sure we aren't going to do the surgery. She agreed that we do not need to do anything immediately, unless of course his condition changes, so there is time to think and study.