Cholangiohepatitis in cats is a disease that involves the liver and gall bladder whose cause is multifactorial in nature that can be very complex from a diagnostic and treatment perspective. Before getting into the crux of the disease, please bear with me for a brief lesson on a few unique aspects of feline anatomy that adds to the complexity to feline cholangiohepatitis and its management.
Like people and dogs, cats have a liver and gall bladder system that operates in close proximity and in concert with one another. The gall bladder is an organ that is slightly smaller than the size of a golf ball in cats that stores bile that is synthesized by the liver and sent to the gall bladder via little vessels called bile canaliculi.
Green in color, bile is an important component of digestion since it breaks down fats for absorption from ingested food. Following a meal, the gall bladder contracts and sends bile to the upper small intestine out the common bile duct to play its role in an initial stage of digestion.
Studies have consistently shown that 80% of cats that present with cholangiohepatitis also have inflammatory bowel disease (IBD) and 50% have pancreatitis. Here is why this brief anatomy lesson is important. While dogs and people have a separate pancreatic duct, the pancreatic duct of cats (which delivers digestive enzymes into the upper gut) shares the same opening as the common bile duct.
Let’s first start with the IBD connection. IBD is an autoimmune inflammatory condition of the feline gut that commonly causes chronic vomiting of undigested or only partly digested food. The inflammation caused by IBD changes the bacterial flora (normal bacteria present in the gut that aid indigestion) that can enable the proliferation of harmful bacteria to colonize, ascend up the common bile duct, and infect the liver and gall bladder. Since the pancreatic ducts of cats share the same opening as the common bile duct, pancreatic disease often ensues by virtue of anatomical proximity. Thus, this disease is often called by veterinarians “triaditis” referring to the triad of gall bladder, liver, and pancreatic disease presenting all at once.
Since cats commonly affected by cholangiohepatitis usually present very sick and dehydrated, natural management of disease disease will not help to stabilize them. Diagnostics and treatments must be administered aggressively and quickly. Diagnosis of cholangiohepatitis includes hallmark physical exam findings, such as jaundice (yellow pallor of the skin, whites of the eyes , and gums), dehydration, fever, depression, and painful abdomen. Laboratory findings include high white blood cell count, elevated liver enzymes, elevated bilirubin, and in cases where the pancreas is involved, elevated pancreas enzymes and positive testing on an assay called feline pancreatic lipase immunoreactivity (FPLI). Ultrasound guided biopsy of the liver is also commonly done to confirm diagnosis to rule out other liver diseases that can mimic cholangiohepatitis.
Treatment for cholangiohepatitis consists of aggressive IV fluids, IV antibiotics, and anti-nausea injections if vomiting. Once vomiting is controlled, cats should be offered food as soon as possible, preferably a low residue, highly absorbable diet or hypoallergenic diet. It is important to get anorexic cats eating as soon as possible to prevent a complication known as hepatic lipidosis (aka, fatty liver syndrome). If they will not eat voluntarily, appetite stimulants such as mirtazipine can be attempted, and if that does not work, an esophageal feeding tube is commonly placed that food slurry and oral medications can be directly syringed into (esophageal feeding tubes are easy to place and may remain in place for feeding and medicating for 2 weeks).
Another helpful (and from my perspective, essential) treatment for cats with cholangiohepatitis is treating with a compound known as a choleretic, a compound that loosens bile secretions stored in the gall bladder and bile ducts and facilitates their removal into the intestine to relieve sludging of the gall bladder and bile ducts. This also helps to release stored toxins that accumulate in the sludge within the liver and gall bladder of patients afflicted with cholangiohepatitis. The most commonly prescribed choleretic used in veterinary medicine is ursodiol.
Although it may sound counter-intuitive given infection playing a significant role in cholangiohepatitis, many feline patients require immune suppressive therapy with a steroid or cyclosporine due to the high prevalence of inflammatory bowel disease that would otherwise prevent recovery.
In some cases of cholangiohepatitis in cats, long term or even indefinite therapy with ursodiol and an immune suppressive medication is necessary to prevent relapse. This is where the holistic side of managing this disease comes in so that we may decrease the feline patient’s dependence on long time medication that has the potential for negative side effects.
1.) Hypoallergenic Diet
Feeding a hypoallergenic diet reduces the potential for reactivity in the hyper-reactive gut of the 80% of cholangiohepatitis patients whose disease was triggered by in large by IBD. My hypoallergenic diet of choice is Royal Canin Feline Ultamino. This innovative diet cleaves large chain animal source proteins into minimally reactive segments called amino acids. The feline patient readily absorbs these protein units with the least possible reaction yet absorbs ample protein for the feline to integrate into metabolic and tissue building processes.
2.) SAMe
This nutritional supplement provides invaluable therapy for all liver diseases. SAMe, or S-adenosylmethionine, has several desirable functions but primarily it is an antioxidant that protects sick liver cells from the toxins they have absorbed and normally would be excreting in bile.
3.) Silymarin
This is the active ingredient within the herbal medication commonly known as milk thistle. It has consistently been shown to be protective to the liver in cases of direct liver poisoning and infectious diseases such as leptospirosis that directly attack liver cells.
4.) Daily Probiotics
Probiotics provide the gut a steady inoculation of healthy bacteria that aid in digestion. They help to maintain a healthy bacterial flora (now referred to as the microbiome) to prevent maximize optimal digestion while preventing proliferation of harmful bacteria.
5.) Stem Cell Therapy
Although stem cell therapy has just begun to scratch the surface with its known benefit for treatment of this and other autoimmune diseases, preliminary case studies have proven promising. However, still lacking a larger body of cases to draw true conclusions, stem cell therapy would seem more experimental at this stage (stay tuned on this).
If your veterinarian is integrative in nature and is open to attempting wean off of immune suppressant, ursodiol, or both in conjunction with these holistic management strategies for cholangiohepatitis after a significant period of time of stability, only attempt the wean under the direct supervision of your veterinarian.
Many patients will relapse quickly if not weaned off medication correctly, while others may only enjoy the benefit of dose reduction but cannot realistically be fully weaned. The consequences of weaning from medication in the case of cholangiohepatitis can lead to devastating relapse.
Dr. Roger Welton is a practicing veterinarian and highly regarded media personality through a number of topics and platforms. In addition to being passionate about integrative veterinary medicine for which he is a nationally renowned expert, Dr. Welton was also an accomplished college lacrosse player and remains to this day very involved in the sport. He is president of Maybeck Animal Hospital , runs the successful veterinary/animal health blogs Web-DVM and Dr. Roger’s Holistic Veterinary Care, and fulfills his passion for lacrosse through his lacrosse and sport blog, The Creator’s Game.