Ukkk, ukkk, ukkk.
Every cat owner knows that sound. When it wakes you up from a dead sleep at 3 a.m., you know you’re about to find one or more piles of cat vomit somewhere close by.
Hopefully, for most cat owners this is at most a once or twice a year occurrence due to an occasional hairball or gastrointestinal irritation, but for some unfortunate cats (and their owners), this is a daily occurrence.
What always shocks me as a veterinarian is the number of cat owners who come in and report that their cat vomits or regurges on a weekly or more-frequent basis. They usually attribute it to “hairballs” or “eating too fast” and assume this is normal feline behavior. I always point out to these owners that if they themselves were vomiting two or three times a week, they would not consider it “normal behavior.”
Another common misconception is that their cats suffer from acid reflux, also known as gastroesophageal reflux disease (GERD). In contrast to humans, where an estimated 7 million people in the United States have some symptoms of GERD, primary GERD is a rare cause of vomiting in cats and is almost always secondary to another problem. So even though cats show the signs of acid reflux, there is almost always an underlying reason… not just because they ate another meal of spicy fast food.
What Is Acid Reflux
Acid reflux or GERD occurs when there is an uncontrolled backflow of gastric or intestinal fluids into the esophagus, which is the tube that connects the throat to the stomach. The acid in the gastrointestinal fluids – which include stomach acid, pepsin, bile and other components – can damage the mucosal lining of the esophagus and cause inflammation, a condition called esophagitis.
Symptoms Of Acid Reflux
Typically symptoms of GERD are a history of frequent vomiting, salivation secondary to esophageal irritation and a poor appetite. Due to the esophageal irritation, cats may act pained when swallowing and will often avoid food. Motility may be affected, and the cats can regurgitate food, fluids and mucous.
Underlying Causes Of Acid Reflux
The first step in determining the cause of your cat’s acid reflux is to determine if your cat is vomiting or regurging.
Regurge is a passive process and is actually quite rare in cats. With regurgitation, food or water will spontaneously be brought up from the stomach — food will be undigested and there will be no bile (yellow tinged fluid). The cat may gag after the event, but will show no signs of distress prior to the regurge.
Most causes of regurgitation in cats are due to esophageal motility disorders, which are rare. In kittens, rare congenital abnormalities, such as hiatal hernias, lead to chronic regurgitation and gastroesophgeal reflux of stomach acid. Regurgitation is also uncommon in older cats, with rare conditions such as feline dysautonomia or chronic esophagitis causing motility disorders of the esophagus.
Vomiting in cats is much more common. This is an active process — the typical “ukkk, ukk, ukkk” sound and body positioning with abdominal contraction as the stomach expels its contents. Cats will usually show signs of nausea: lip licking, frequent swallowing or salivation. Food may be present in various levels of digestion and bile (yellow tinged digestive fluid) is present.
There are multiple reasons for vomiting in cats. And yes, it may be a simple hairball, but hair is meant to pass through the GI tract. For cats that vomit hairballs more frequently than once or twice a year, there is typically an underlying gastrointestinal problem.
In younger cats, foreign bodies (pieces of cat toys, string, dental floss, plastic bags/wrappers) are a frequent cause of vomiting and may require surgery to put an end to the vomiting. Cats of any age can get a foreign body obstruction but most are younger (more playful) cats, though I once saw a 14-year-old cat that developed an intestinal obstruction from swallowing a whole almond. For tips on kitten-proofing your house to avoid such incidents, click here.
Food allergies, intolerances and IBD (inflammatory bowel disease) are frequent causes of vomiting in middle age cats (4 to 9 years old) and probably the number one reason for those “chronic hairball” vomiters. Unfortunately, as their underlying food intolerances are left untreated, the complications of inflammatory bowel disease will become obvious – constant vomiting and acid reflux (GERD), diarrhea and weight loss.
Chronic pancreatitis is often related to food sensitivities and presents with a similar history and clinical signs as chronic esophagitis and reflux, except there is no regurge.
Gastrointestinal lymphoma, unfortunately a common cancer in cats, can cause signs identical to IBD, GERD and pancreatitis. The sooner the diagnosis is obtained, the quicker specific treatment can be initiated.
Diagnosing Acid Reflux
Diagnostic testing can vary in its scope and cost for cats with chronic vomiting. The first step for many of these cats is not a laboratory test, but a simple diet change.
In a vomiting cat that is otherwise healthy, veterinarians often start with a trial of a limited ingredient diet (a single source diet combining one protein and one carbohydrate fiber that the cat has never eaten before, such as venison and pea) or a commercial hydrolyzed diet (a diet manufactured in a laboratory to break proteins down to a level the cat’s immune system can’t recognize as antigenic while still remaining nutritionally complete). If no improvement is seen within 1-2 months of a strict diet trial, then food allergy is considered a less likely cause of vomiting and additional diagnostics are required.
Simple radiographs (X-rays) and a barium study (a radiopaque liquid that highlights the GI tract) can help delineate congenital abnormalities and foreign bodies. Ultrasound is a fantastic diagnostic tool for visualizing the feline gastrointestinal tract, pancreas and lymph nodes, but is still limited in its ability to provide a definitive diagnosis.
Definitive diagnostic samples of the feline esophagus and gastrointestinal tract can only be obtained by endoscopy and endoscopic biopsy or surgical biopsy. Both procedures require the cat to be under general anesthesia.
In endoscopy, a camera is placed down the cat’s throat into the esophagus, then into the stomach and then intestines. Special grasping forceps can be used to take biopsy specimens to send to a pathologist to definitively diagnose the cause of the vomiting. The way to visualize the esophagus for a true diagnosis of GERD can only be done with endoscopy (esophagoscopy). Most specialty practices offer endoscopic or laparoscopic biopsy, but this procedure is rarely available at most private practitioners due to the cost of the equipment.
Surgical biopsies of the stomach or intestines can be done by a general practitioner or surgeon, often as part of an abdominal exploratory surgery. One must always balance the risk of more invasive procedures (reaction to general anesthesia, poor wound healing, and infection) with the benefits of the information obtained (biopsy samples to develop a specific treatment plan),
Treatment for any cat is always a challenge, as any cat owner can attest to. For cats that suffer from severe reflux and esophagitis, advanced IBD, lymphoma or pancreatitis, often times a feeding tube is placed temporarily to provide nutrition and medications which will bypass the oral cavity as these cats are often not eating well on their own.
Cats with GERD or esophagitis will benefit from esophageal and stomach protectants such as sucralfate – a tablet that dissolves in water and, given by mouth, will coat esophageal and stomach erosions.
Famotidine, known most commonly as Pepcid, is used to lower the stomach acid in cats to promote healing of ulcers and erosions. Famotidine is an inexpensive OTC tablet, but can be prescribed as a suspension by your veterinarian for owner’s struggling to give their cats a tablet.
Appetite stimulants, such as cyproheptadine or mirtazapine, can be prescribed by your veterinarian to encourage your cat to eat.
For chronic regurgitation or vomiting, metoclopramide, or Reglan, is often prescribed to help increase intestinal motility, fight nausea, and close the lower esophageal sphincter to reduce reflux and vomiting. This medication is by prescription and comes as either a liquid suspension or small tablet and is only used when gastrointestinal obstruction and congenital conditions have been ruled out.
Steroids are often used to decrease inflammation in the gastrointestinal tract of cats suffering from IBD or to induce remission in cats with lymphoma. This medication comes as a prescription tablet or cherry-flavored liquid, but can be compounded into a more-palatable flavored liquid or even a chew tablet treat for cats that are a challenge to medicate.
Metronidazole, or Flagyl, is an antibiotic that is frequently used to decrease intestinal inflammation and has the added benefit of controlling bacterial overgrowth in the intestines and Helicobacter in the stomach.
If all these medications sound overwhelming, you are right! An owner’s insightful history, combined with your veterinarian’s specific diagnostics, are the best tools to pinpoint the cause of your cat’s vomiting or regurgitation, and minimize the amount of treatments needed to help your feline friend.