5/15 Ruby Internist report

[Katherine&Ruby]

Yesterday's epic saga.

Good morning everyone.

I received a phone call from an internist at AMC. Overall the call was really good. Ruby is doing well, being very purry and sweet with everyone. She seems happy and ate quite a bit last night (they are giving her DM kibble, not my preference but Ruby LOVES it). The vet was supportive of my management of Ruby's diabetes even though she thinks she doesn't need to be on insulin anymore and thinks it might be contributing to her inappetence (newsflash: it's not). She was also supportive of raw feeding and took note of the fact that I rotate her proteins so regularly and therefore ruled out the possibility of her being allergic to a particular kind of meat.

Even though Ruby has been tested a lot for pancreatitis, she did not want to completely rule that out. She also said that it could just be an IBD flare as opposed to a pancreatitis flare, and that Ruby might just be prone to them. Basically her take was that I needed to learn how to manage the symptoms, which of course I am fully prepared and educated to do. The question is: do I do the biopsy? She seemed to think it was not necessary at this moment, but then when will I know that I need to do it? I'm very confused.

Help?

 

[tiffmaxee]

That is a good report! The being in limbo is always hard for me to handle. While she is doing so well I think I would want the biopsy if it would give me clarification. The rotten part is that it doesn’t always give clarity by endoscopy so to know for sure you need the surgery. Once you know you either treat or learn to manage depending on results. JMHO. What’s your gut telling you? Trust your gut.

 

[Suzanne & Darcy]

Ruby is enjoying her JUNK FOOD! At least she is eating!
That is very confusing. At least you now that the internist is conservative and not jumping directly to the most aggressive thing. I don't know what I would do at this point if I were you.
(1) I would be thinking -- do I go ahead and get tissue samples (endoscopically only) and see where we are ... since Ruby is already there and since we've already been through this scary episode... and since I've already spent all this money (just telling you what would be going through my mind); or
(2) Do I take her home and see how she does? But does she need treatment now to bring that inflammation down? Or do I take her home and, if she does not do well back at home, start her on budesonide (which will create some BG challenges but not insurmountable ones.)

This is a tough one. You did say, Katherine, that her TAMU GI panel was normal? If so, maybe you should let them do the panc test (which my vet says is also not always accurate, but at least it is something) before taking her home if you decide to just take her home with a wait and see approach.

What caused that high AMPS yesterday? Just being uncomfortable/sick feeling (I'm wondering if that's been driving Darcy up as well?) What have her BG readings been since being at AMC? Have they told you?

If you decide not to do any biopsy, then every time she stops eating for a while or seems inappetant, you will be wondering... what's going on? Oh no, does she need treatment? I don't know.

Hmmm... I'm sure I will have more thoughts on this as I think about it during the day. I'm just putting myself in your shoes (and I've been in those shoes more often than I would like to admit ... being a crazy cat lady.)

But... do you at least feel better about Ruby now... I do... I feel like there are some things to be treated possibly but that she is not critical and she's got a LOT of great years ahead of her I just made myself smile while I typed that!

 

[carfurby (GA)]

I'm glad you got a good report and Ruby is eating. Sending prayers.

 

[Suzanne & Darcy]

Yes... already... one more thought... if you do the endoscopy and don't get much info, you'll be kicking yourself... if you don't do the endoscopy and later you need one (and maybe Ruby isn't doing as well clinically) you will be kicking yourself.

I will go look for my Crystal Ball... I lost it years ago and I'm useless without it.

 

[tiffmaxee]

Endoscopy is great when it works. That’s how Tiffany was diagnosed. My vet was 100% sure based upon the location that he could get a firm diagnosis. If the vets can tell you that endoscopy is great.

 

[Our Dolly Girl (GA)]

Yesterday's epic saga.

Good morning everyone.

I received a phone call from an internist at AMC. Overall the call was really good. Ruby is doing well, being very purry and sweet with everyone. She seems happy and ate quite a bit last night (they are giving her DM kibble, not my preference but Ruby LOVES it). The vet was supportive of my management of Ruby's diabetes even though she thinks she doesn't need to be on insulin anymore and thinks it might be contributing to her inappetence (newsflash: it's not). She was also supportive of raw feeding and took note of the fact that I rotate her proteins so regularly and therefore ruled out the possibility of her being allergic to a particular kind of meat.

Even though Ruby has been tested a lot for pancreatitis, she did not want to completely rule that out. She also said that it could just be an IBD flare as opposed to a pancreatitis flare, and that Ruby might just be prone to them. Basically her take was that I needed to learn how to manage the symptoms, which of course I am fully prepared and educated to do. The question is: do I do the biopsy? She seemed to think it was not necessary at this moment, but then when will I know that I need to do it? I'm very confused.

Help?

Katherine this is such a great report overall. You must be feeling some relief. I wish I had the expertise to help with deciding when, if at all, to do a biopsy. I am also the wrong person to answer because I have procrastinated having a biopsy of Dolly’s nasal passages for far too long. I think you have to go with your gut or trust the doctor and wait and see how Ruby is doing. Making decisions for our precious cats is so hard at times and I know you don’t want to leave there with regrets, feeling you are making the wrong decision. I’m sure you will get some better answers from others. I am just so happy to hear she is eating well and happy. I hope either way she can go home soon. Sending healing prayers with a special request to the decision making Gods

 

[Suzanne & Darcy]

What does Frank say?

 

[Wendy&Neko]

That is a good report! And I like that the internist is on board with the raw feeding. Neko too was doing the 4+ raw protein rotation at the time of her SCL diagnosis, or rather her non diagnosis but internist best guess. It was too late for her to do either endoscopy or biopsy because of her heart condition. I always wondered whether I really needed to give her the chlorambucil which made her feel so rotten for a couple days after getting it. So my Canadian $.02 would say, get a sample now, while Ruby is healthy enough to do so. And for Neko, budesonide did not impact her blood sugar at all. So if you need to go there at some point, the same may be true for Ruby. ECID of course.

Remind me again, has Ruby had her B12 and folate levels tested? If so, what were the results.

Funnily enough, Neko's internist also thought her "low" numbers might be contributing to inappetance. It wasn't of course.

 

[Katherine&Ruby]

Thank you for understanding my quandary and my emotional state!

I am very happy that Ruby is eating. I think the only thing the hospital did that I did not do was give her antacid and subQ. Will remember next time this happens. I forgot to ask her about Ruby's BGs, although if she's eating DM kibble it's probably high. I called and left a message to get the numbers.

I guess in my head I conflated the endoscopy with the biopsy, and now am realizing they are two different things: the endoscopy comes first, and then if necessary they go for the biopsy? You're right @Suzanne & Darcy, Ruby is at the hospital, and I've actually paid for the endoscopy to happen already, just need to pull the trigger. If as you say @tiffmaxee that Tiffany was diagnosed with endoscopy alone, then it might be worth it but I'd have to have more information on her ultrasound to know if there is enough inflammation in her upper GI to warrant it.

Another important point: This is the second time IMs have NOT pushed for scoping or biopsy for Ruby, advice that I should probably to listen to. The IMs at Blue Pearl said in February after ultrasound and TAMU GI panel to go with diet change, and this IM at AMC is saying to manage the symptoms. Oy vey. You'd think that crystall ball repair shops would be in abundance since COVID 19, right, Suzanne?

What does Frank say?

Frank says I should listen to the doctors. He said that about Ruby's diabetes treatment too, but he might be right about listening to them this time. I dunno.

my Canadian $.02 would say, get a sample now, while Ruby is healthy enough to do so. And for Neko, budesonide did not impact her blood sugar at all. So if you need to go there at some point, the same may be true for Ruby. ECID of course..

Hmmm, you make a very good point about her being healthy enough for a biopsy now. I am really heartened to hear that budesonide did not affect Neko's BGs. That makes me feel a lot better.

OK, my head is about to explode. I think what I am going to do is ask for further details on the US report to see if an endoscopy would be worth it.

 

[Katherine&Ruby]

Remind me again, has Ruby had her B12 and folate levels tested? If so, what were the results.

Sorry, didn't answer this question. I've attached the report from TAMU.

 

[Suzanne & Darcy]

Looks good. If you just had the pli checked that recently 2/21 I would maybe skip the panc test unless the vet says it can really change in a few months (I guess it can)... but at the time that was done, things were looking good (not two months ago).

 

[Katherine&Ruby]

Looks good. If you just had the pli checked that recently 2/21 I would maybe skip the panc test unless the vet says it can really change in a few months (I guess it can)... but at the time that was done, things were looking good (not two months ago).

She did say it could have changed. Maybe I should have that done again but it will take time for the results to come back and Ruby will be out of the hospital by then.

 

[Summer and Susie (GA)]

Prayers for you making all the right decisions and that Ruby heals!

 

[JaxBenji]

Yay for Ruby eating that's a great sign You will make the best decision for Ruby with the information you have - just know that (and, if like me, just keep repeating it to yourself ).

 

[Hercule's mum]

I am glad it is a good report!

The question I always ask myself before an invasive exam is: Would the results of biopsy change the way you manage her on a daily basis, or long-term prognosis? if no, I wouldn't do it.

I always find anasthesis scary, so would avoid them if something is not clearly necessary.

Also, completely independent of the particular issues that Ruby have, I find vets always seem to want do more than necessary, so if they do not think is necessary I wouldn't push.

 

[Katherine&Ruby]

I find vets always seem to want do more than necessary, so if they do not think is necessary I wouldn't push.

Thank you, Karen, this is a good point.

 

[Pamela & Amethyst]

 

[Wendy&Neko]

I guess in my head I conflated the endoscopy with the biopsy, and now am realizing they are two different things: the endoscopy comes first, and then if necessary they go for the biopsy?

No. If inflammation is in a location that the endoscopy can take an example, you get an endoscopy done and send the sample out for pathology and that's it. Sometimes the pathology report isn't clear (personal experience talking here ), so we got a second more experienced pathologist to read the data. Same result, leaning to SCL but not 100% certain. So we got a PARR test, which is a clonality test. If there are symptoms (there were), the PARR can confirm cancer. It's not great a test to say "no cancer", hence the LymphoPro test Amy posted about yesterday as a coming new test that might help there. If the inflammation is in the place that endoscopy cannot reach, or you need a sample of the muscularis, you have to go to surgical biopsy or that laparoscopy if there is a vet who can perform that one. Endoscopy is much less invasive, still needs anaesthesia (does in humans too), but in and out in a day. Key is to get a skilled endoscopy vet.

If two vet specialists are telling you that you don't need this yet, I might listen to them, but also ask them what would trigger them to suggest it was time to get an endoscopy or biopsy.

 

[Tomlin]

Do you know if you are talking with an intern vs one of the staff doctors? Dr. Doug Palma is listed as on staff at AMC and his focus is both gastro and interventional endoscopy. Here is the link to his info:
https://www.amcny.org/find_doctor/doug-palma/

One option would be to ask to speak with him directly or for them to consult with him on the case. I always prefer speaking with them directly so I know exactly what they are saying and am able to ask questions if I have any.

Also, just an FYI, Dr Elizabeth Appleman is the IM with a special interest in DM & endo at AMC
https://www.amcny.org/find_doctor/elizabeth-appleman/

 

[Katherine&Ruby]

If two vet specialists are telling you that you don't need this yet, I might listen to them, but also ask them what would trigger them to suggest it was time to get an endoscopy or biopsy.

Thank you for letting me know about the difference between endoscopy and biopsy. So many new things I am learning!
Spoke with the IM again. She said how nice it was to have such a calm and friendly cat like Ruby in the hospital. She’s eating well and she’s going to touch base again tomorrow morning about discharge. Her BGs have been in the mid-100s (despite eating kibble!) so she has not gotten any insulin and vet thinks she had a spike because she was in distress. This makes me happy. I asked her your question, Wendy, and she said that if Ruby has another one of these flares when she comes home or even in two weeks time that they would schedule a procedure for her in a day. If she doesn’t have another one for another three months, I should try to manage the flare at home and see how she does. This seems like a sensible solution right now. Thank you for helping me to concisely phrase that question to her, Wendy!

@Tomlin I’ve been speaking with a resident who has been conferring with the IM team. I know of Doug Palma and tried to make an appointment with him directly before but was told he didn’t have availability for a month. I am happy with the dialogue I’ve had with her so don’t feel the need to go over her right now, but Palma and Applebaum have been mentioned to me as the go to doctors there.

 

[Tomlin]

I’ve been speaking with a resident who has been conferring with the IM team. I know of Doug Palma and tried to make an appointment with him directly before but was told he didn’t have availability for a month. I am happy with the dialogue I’ve had with her so don’t feel the need to go over her right now, but Palma and Applebaum have been mentioned to me as the go to doctors there.

That’s great . I wasn’t thinking in terms of going over the interns head because they aren’t providing good care, but to potentially have a dialogue with them regarding Wendy’s suggestion to ask about what would or when would they recommend it is time to move forward with biopsies.

I am happy you have a great plan and that all is going well!! Such great news!!

 

[Diane Tyler's Mom GA]

Hi Katherine, sounds like Ruby is being well taken care and she's being such a good girl there. I'm happy she's coming home tomorrow and you are holding off for further procedures for now. I'm so happy that they told you if you needed to bring her in again that they would schedule a procedure for her in a day.
So happy she's eating well. Prayers for sweet Ruby . Get a good sleep tonight Katherine .♥