The term ‘triaditis’ refers to concurrent inflammation of three separate organs that occur in the same patient. In cats with ‘triaditis’ the affected organs are the intestines, the pancreas and the biliary tract.
When these organs are inflamed, they are called inflammatory bowel disease, pancreatitis and cholangitis respectively.
The biliary tract is comprised of the liver, gall bladder and the bile ducts. This system is involved in producing, storing and secreting a substance called bile.
The pancreas is an organ that produces enzymes that are used to digest food in the intestines to produce nutrients that the body can utilise.
Bile and digestive enzymes are secreted into the first part of the small intestines via the ducts (pipes) of the biliary tract and pancreas respectively.
The reason as to why these diseases are often linked together in cats is because of their unique anatomy where the pancreatic and bile ducts join together to form a single common duct before emptying their contents into the small intestine. Therefore, there is a greater risk of any infection ascending from the intestine via this common duct to cause infection of both the liver and the pancreas as well.
It is important to recognise that not all cases have involvement of all 3 organs and each disease in the ‘complex’ can occur on its own. To complicate matters further, cholangitis in the UK is recognised to have 2 different forms that can only be distinguished on surgical liver biopsy samples. There is an infectious form which is associated with the ‘triaditis’ complex and an immune-mediated form (see section on types of cholangitis below).
Cats with triaditis are also considered at high risk of developing another condition known as hepatic lipidosis (fatty liver disease).
What are the symptoms of Feline Triaditis?
Listlessness and loss of appetite are common.
Vomiting or feelings of nausea demonstrated as lip smacking, excessive drooling of saliva and yawning are also common.
Although the clinical signs can be dramatic and severe, they are unfortunately non-specific for most diseases. Disease in any of the organs involved in the triaditis complex either individually or in combination can show similar symptoms.
Jaundice is also a common symptom. Jaundice is identified by a yellow/orange discolouration of the mucous membranes like the gums. Unfortunately, jaundice is also not a specific symptom for this disease and can have various causes.
Therefore, the diagnosis can be challenging, and all 3 conditions need to be investigated even if there is a higher suspicion of one over the others based on physical examination.
How is triaditis diagnosed?
We will want to collect an extensive history which, will inform us about what you feel the problems are; how long they have been going on for; how severe they are; etc. The vet will then perform a full physical examination. In particular the colour of the gums will be noted. These will tell us if there is overt evidence of jaundice and whether the cat is suffering from dehydration.
The abdomen will be palpated for the size of the liver, any pain over the region of the pancreas or elsewhere and any swellings or masses within the abdomen. The body temperature will be measured. The history and physical examination are very important in leading to the diagnosis, but unfortunately further investigation will be required.
Bloods tests are performed for various problems like damage to the liver, pancreatic inflammation, protein levels and electrolyte (salt) levels. Jaundice can be detected in the blood by measuring levels of a pigment called bilirubin before clinical symptoms of jaundice (orange skin and gums) are obvious.
Urine is also tested for the presence of bilirubin as well as other things like its concentration.
Ultrasound examination of the abdomen will be performed. This allows us to visualise the architecture of the liver, gall bladder, bile ducts, intestines and pancreas to assess for structural changes to these organs. Ultrasound examination is non-invasive, non-painful and can be performed conscious. It only requires the fur to be clipped in the area of interest.
The examination, however, does not provide an actual diagnosis as the various disease processes causing cholangitis for instance will appear very similar on the ultrasound scan. Other disease processes including tumours may also have a similar appearance. Uncommonly an ultrasound scan may appear normal. In these instances, further diagnostics are still recommended if there is high suspicion of the disease.
The diagnosis of triaditis and to fully characterise the disease requires the collection of surgical biopsy samples. These samples are evaluated by a veterinary pathologist to provide the final diagnosis.
Other tests may be recommended based on the individual case and clinical signs. For instance, liver disease can affect the body’s ability to form clots and tests may be performed to assess for this function especially before procedures likely to cause bleeding such as surgical biopsies are performed.
How is triaditis treated?
A lot of the treatment is focused on managing the symptoms. The severity of disease can be variable but unfortunately many cats are very sick by the time they are presented to the veterinary clinic. In the majority of cases the patient requires admission to our emergency out of hour vets with 24-hour care provided even whilst diagnostics are being performed.
An intravenous drip will be administered. The condition is painful and therefore strong pain killer medications will be administered. Vomiting and nausea are prevalent and therefore anti-sickness medications are given alongside medication that protects the gut from further damage and inflammation. Liver protective medications will also be administered on a case by case basis.
It is very important that cats do not undergo a prolonged period of starvation or anorexia of more than 2-3 days. Early feeding is therefore instituted once any vomiting has been controlled. Unfortunately, affected cats will often not eat on their own and therefore, may require the placement and use of a feeding tube.
Specific therapy for cholangitis depends on the results of the biopsy samples. The forms of cholangitis are distinguished by the type of inflammatory cell that is found to be pre-dominant in the liver tissue samples.
What are the 2 forms of cholangitis and how are they treated?
This form is associated with the ‘triaditis’ complex and is caused by an infection. The mainstay of therapy is antibiotics. In some cases, surgical intervention may be required.
This form is caused by an exaggerated immune response and the mainstay of therapy is steroids. A condition known as ascites (free fluid in the abdomen) may be identified with this form.
In some cases, a mixed type may also be found. In these cases, early treatment is focused on controlling any infection with antibiotics. Steroids are then often added in later to control the exaggerated immune response.
What is the prognosis for my cat with ‘Triaditis’?
This can be variable, however, if treatment is instituted early in the course of the disease, the prognosis is often good and a full and complete recovery can be achieved.
The prognosis for cats with lymphocytic cholangitis is more difficult to define as the symptoms from this disease tend to wax and wane on their own. It is currently believed that cats with ascites may have a comparatively worse prognosis.