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Fatty Liver

Fatty liver, also called hepatic lipidosis, is a relatively common liver disease in cats. Why cats get fatty liver syndrome is unknown. It appears to be a fat metabolism disorder that results in large quantities of fat accumulating in the liver. In some cases, it appears that the disease can be triggered when a cat doesn't eat for a few days to a few weeks. For example, sometimes a cat with lipidosis will have a history of a stressful situation such as a new pet in the household or moving to a new home, which has caused the cat not to eat. These cats are considered to have secondary hepatic lipidosis.

However, many cats with fatty liver have no apparent inciting cause. In these cats, the disease is termed "idiopathic," which means that no known cause can be identified. Cats with fatty liver usually are presented to their veterinarian because of loss of appetite and weight loss. Cats that are overweight may be at greater risk. Sometimes, an owner will note that the cat is jaundiced, having yellow skin or a change in the color of the eyes. On examination, the veterinarian may note that the liver is enlarged. The diagnosis of fatty liver should be considered in any jaundiced cats with weight loss and poor appetite. However, the diagnosis can only be confirmed definitively by a liver biopsy. Laboratory tests are usually done, which will show elevated levels of bilirubin in the blood and urine. Also, the liver enzymes will be elevated, especially an enzyme called alkaline phosphatase. It is important to remember that other diseases can cause these exact same signs. Thus, it is important to determine that the cat does indeed have lipidosis.

Liver cancer, toxicity and pancreatic disease are just a few of the other conditions that might present with anorexia, weight loss, and jaundice. Fatty liver is diagnosed by liver biopsy, which is usually done via a large needle gun through the skin while the liver is being imaged with ultrasound. Surgery is not required. An ultrasound-guided liver biopsy does require a brief anesthesia. But the procedure is quite short and relatively safe unless the patient has a blood clotting disorder, which can be seen in severe, advanced cases of fatty liver. In these patients, biopsy must be avoided and the disease is usually treated initially without proof of the diagnosis. Often, when the cat is under anesthesia for a liver biopsy, a feeding tube is placed in the stomach or esophagus because feeding cats with lipidosis is the cornerstone of treatment. Fatty liver is a reversible condition when it is detected early and treated appropriately.

Adequate nutrition is the single most important treatment. Feeding the cat can reverse the metabolic defect that led to the fat accumulation in the liver. Occasionally in mild cases, this can be done by force feeding. However, because the key to successful treatment is getting enough calories into the cat, most will require a feeding tube. Cats with severe or advanced fatty liver need additional treatment. They require hospitalization for intravenous fluids. When liver failure is present and there is toxin build up in the blood (a condition called hepatic encephalopathy) treatment with lactulose may be required to lower the level of ammonia in the blood. Some cats will have blood clotting disorders that also require treatment. Untreated, fatty liver is generally fatal with the cat dying of liver failure. So, any cat with a loss of appetite and weight loss should receive prompt veterinary attention.

Most cases of feline hepatic lipidosis are associated with obesity.

What is Fatty Liver Syndrome, and how does a cat get it?

Feline Fatty Liver Syndrome (FLS) is also known as feline hepatic lipidosis. This disease is unique in cats and is one of the most common liver diseases seen in cats.

The typical cat with FLS has recently gone through a period of anorexia (not eating). The chances of FLS occurring are greater if the cat was obese before the anorexia began. As fat is broken down to supply nutrients for the anorectic cat, the fat is deposited so rapidly in the liver that it cannot be processed. It becomes stored in and around the liver cells, resulting in liver failure. The cat usually becomes icteric or jaundiced, as evidenced by a yellow color in the whites of the eyes or in the skin. At this point, the disease will be fatal if not treated rapidly and aggressively.

What causes feline hepatic lipidosis?

Feline hepatic lipidosis can occur because of nutritional, metabolic or toxic injury to the liver. Feline hepatic lipidosis has been associated with diabetes mellitus, hyperthyroidism, heart disease, kidney disease, chronic feline lower urinary tract disease (FLUTD) (now called FUS), chronic upper respiratory disease, cancer, and pancreatitis. Approximately 50% of cases, however, are called 'idiopathic,' meaning we do not know what has caused the condition, although almost all cases are associated with obesity. I become very concerned when I see an overweight cat because of the potential for that cat to develop this disease. Stress seems to 'trigger' the disease. Stresses can include a change in diet, a concurrent disease such as a bacterial infection, a change in the environment (new home, new baby, new pet, etc.), or a prolonged decrease in appetite for other reasons.

What are the signs of hepatic lipidosis?

Most cats with feline hepatic lipidosis are older, overweight, and have gone through some stress which has caused a decrease or lack of appetite. Most cats with hepatic lipidosis become depressed and the decreased appetite continues over the course of days to weeks. Many cats, then, will have lost a considerable amount of weight before they are seen by a veterinarian. Many cats lose a large amount of muscle mass. Sporadic vomiting is common, as is jaundice.

Some cats may develop hepatic encephalopathy, an abnormality of the brain function due to liver disease. These cats may appear to be more depressed and lethargic.

How is it diagnosed?

Diagnosis of FLS is made from blood tests for liver function and from a liver biopsy or aspirate. The former may be performed during surgery or with a needle inserted through the skin. The tissue sample is sent to a pathologist for interpretation. The latter involves inserting a very tiny needle through the skin and into the liver, removing a small number of liver cells, and examining those cells under the microscope. The FLS cat will have a large amount of fat in and among the liver cells. Generally, other tests are then performed to determine why the cat stopped eating. If the cause for anorexia is treatable or resolved, the prognosis is reasonably good.

History: The history of an overweight cat losing his appetite and losing weight would give the veterinarian the suspicion that the symptoms could be indicative of hepatic lipidosis (among other things).

Physical Exam: On a physical exam, the liver may or may not feel enlarged. Again, the veterinarian would note an overweight cat that has lost muscle mass. Jaundice may be present which would be highly suggestive of a liver disease.

Laboratory Findings: The diagnosis of hepatic lipidosis is supported by blood tests included in a chemistry panel, which indicate the liver is damaged. The liver enzyme SAP is usually markedly elevated. Other liver enzymes such as ALT (SGPT) and AST (SGOT) are usually increased. The bilirubin (a breakdown product of red blood cells, which is normally eliminated by the liver) can be increased above normal as well. High cholesterol and ammonia levels are common. The results of a bile acid test would be abnormal.

Some cats may be anemic, and have decreased clotting ability in their blood.

Radiographs (X-rays): The liver may appear normal in size or enlarged.

Ultrasound: Typical changes can be seen in the liver and the ultrasound can rule out some other causes of the symptoms and laboratory abnormalities.

Biopsy: The way to definitively diagnose hepatic lipidosis is through a liver biopsy or fine needle aspirate.

Is this a treatable disease?

This disease is very treatable, but treatment of FLS requires that the cat receive nutritional support until the appetite returns. A consistently high quality diet will allow the liver to resume functioning so it may remove the fat. This does not occur quickly; it takes an average of 6-7 weeks. Therefore, a method of force-feeding must be used to allow you to feed your cat at home.

What is the treatment of feline hepatic lipidosis?

The keys to successful management of cats with lipidosis are early diagnosis and intensive nutritional support.

Change in Diet: Cats will need to have nutritional support for 3-6 weeks. The cat is fed a high-protein, calorie-dense food. Because these cats are already very ill and stressed, extreme care must be taken to not stress the cats further by force feeding.

Feeding Tubes: In almost all cases, a feeding tube needs to be placed. This tube can be inserted through the side of the cat into the stomach, through the nose and into the stomach, or into the esophagus and down to the stomach. The type of tube used depends on the size of the cat, the seriousness of the illness (can the cat be anesthetized?), and the preference of the veterinarian and owner.

Appetite Stimulants: Appetite stimulants such as diazepam are usually NOT effective because they are best used in cats who still have some appetite and interest in food.

Fluids and Electrolytes: Many cats with hepatic lipidosis are dehydrated. If the cat has had significant vomiting, the potassium level in the blood is often low and needs to be supplemented.

Vitamin Supplementation: The liver is responsible for making the factors that help blood to clot. It needs vitamin K to do this. Normally, the liver stores vitamin K so it is readily available. Cats with hepatic lipidosis may need supplemental vitamin K to correct a coagulation (clotting) problem.

A multiple vitamin supplement is recommended. Thiamine deficiency can occur as a result of long periods of anorexia, so thiamine supplementation is of particular importance.

Gastrointestinal Medications: Drugs such as cimetidine (Tagamet) or ranitidine (Zantac) are often used to prevent ulceration of the stomach or intestine. Medications such as metoclopramide are often given to decrease vomiting and stimulate the movement of food through the stomach and intestine.

Treatment of Hepatic Encephalopathy: In those cats with hepatic encephalopathy, drugs such as neomycin and metronidazole can be used.

Antibiotics: Because these cats are very stressed, their immune system may not function adequately. As a preventive measure, antibiotics such as amoxicillin are sometimes given.

How to provide the necessary nutritional support?

A feeding tube is surgically implanted into your cat so you can syringe special food through it into the stomach. There are several types of feeding tubes available. The best one for your cat will be determined based on several factors.

A special food mixture, is syringed through the tube three to five times per day. This food is formulated to meet the cat's nutritional needs; it should not cause vomiting or diarrhea.

When is the tube removed?

Persistence is essential. The average cat requires 6-7 weeks of feeding before it begins to eat. At least once weekly, offer your cat a small amount of its favorite food so that you will know when its appetite returns. The feeding tube will not hinder eating in any way. After your cat has been eating well for 3-4 days, it should be returned to the hospital for tube removal. Removal of the tube is simple and does not require anesthesia; however, you should not attempt to remove the tube yourself.

What is the prognosis for cats with hepatic lipidosis?

Even with intensive care, approximately 35% of cats with hepatic lipidosis die from the disease. Cats who do recover generally do so in 3-6 weeks, however, some may need continued nutritional support for months.

Generally, the damage to the liver is reversible, and the condition rarely recurs.

How is hepatic lipidosis prevented?

Owners play an important role in preventing hepatic lipidosis. By keeping your cat in a healthy body condition, you can greatly reduce his risk of developing this disease.

Care must be taken in developing weight reduction programs for obese cats. Greatly restricting intake or using a food the obese cat will not eat could incite the development of hepatic lipidosis.

Obese cats who lose their appetite for any reason should be considered candidates for developing hepatic lipidosis and nutritional support should be given.