Vol. 21, No.
8 August 1999
CE Refereed Peer Review
FOCAL POINT
★ Feline colonic disease presents
either as large bowel diarrhea or
constipation; the key to proper
management is to identify the
inciting cause if possible and
choose the appropriate dietary
and/or pharmacologic
intervention program.
KEY FACTS
■ Dietary fibers are divided into
soluble and insoluble groups,
which have complex and entirely
different effects in the colonic
lumen and on colonocytes.
■ Dietary intolerance is a form of
diet-induced diarrheal disease
caused by nonimmunologic
reactions to a food or food
substance, whereas true dietary
allergy is an immunologic reaction
to a specific component of food.
■ Inflammatory bowel disease,
which is a diagnosis of exclusion,
requires histopathology for
diagnosis.
■ Constipation is a common,
reversible problem in cats that
has many causes; however,
untreated or chronic constipation
will lead to irreversible colon
damage resulting in obstipation
or megacolon.
20TH ANNIVERSARY
Diet and Drugs:
The Keys to Managing
Feline Colonic Disease
Texas A&M University
Debra L. Zoran, DVM, PhD
ABSTRACT: Feline colonic diseases are less common than diseases of the small bowel but are
nevertheless diagnostic and therapeutic challenges. One aspect of developing a rational ap-
proach to diagnosing and treating colonic disease is to understand the colon’s unique physio-
logic and functional differences. Large bowel diarrhea can be acute (present for less than 3
weeks) or chronic. Acute diarrhea is often associated with dietary disturbances (e.g., dietary
indiscretion, food intolerance) or infectious/inflammatory diseases, including parasitic or pro-
tozoal infestations. Empiric therapy with antibiotics or anthelmintics or dietary changes often
correct the problem. However, many chronic colonic diseases (e.g., inflammatory bowel dis-
ease, neoplasia) require lifelong pharmacologic and/or dietary intervention.
G
astrointestinal (GI) tract diseases are common causes of anorexia, vomit-
ing, diarrhea, and weight loss in cats. Diseases affecting the colon are less
common than those affecting the remainder of the GI tract and general-
ly cause fewer signs. Because of the less demanding presentation, however,
chronic disorders of the large bowel often pose diagnostic and therapeutic chal-
lenges for practitioners. Disturbances of large intestinal function are typically
categorized into two groups: disorders causing diarrhea and those resulting in
constipation. These categories can be further defined as acute disorders, which
are often responsive to dietary and/or empiric treatment approaches, and chron-
ic and/or recurrent disorders, which require an aggressive, systematic diagnostic
and therapeutic approach. This article reviews common causes of feline large
bowel diarrhea and constipation and discusses the approach to diagnosing and
managing colonic disease, with special emphasis on the appropriate use of di-
etary therapy.
UNDERSTANDING COLON PHYSIOLOGY
The physiology and function of the feline colon are unique compared with
the remainder of the GI tract.1 Although the colon’s storage function and role in
water and electrolyte balance are well known, its importance in other aspects of
normal physiology are not. Much has been learned about certain aspects of nor-
mal and abnormal feline colonic function, such as the importance of different
Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

cell populations in inflammatory bowel

Soluble Fibers Insoluble Fibers
disease (IBD), normal colonic motility,
and role of cisapride in the management Decreased gastric emptying
Stomach Increased gastric
of megacolon. However, information is emptying
still lacking in other areas, such as the ef-
fects of different diets, especially dietary Slowed SI transit Increased SI
fiber; the role of the intestinal microbial Small transit
population in the development of IBD intestine
and colitis and its effect on dietary com-
ponents; the connection between IBD and Increased LI transit
lymphosarcoma; and the effect of dietary Decreased SCFAs compared
sensitivity in IBD. Diseases of the colon with soluble fiber
have often been considered as extensions Slowed LI transit Colon Increased dilution of
Increased SCFAs luminal contents
of diseases affecting the small intestine, Increased absorption of
Reduced luminal pH
and thus many are treated with small Increased mucosal growth luminal toxins
bowel disease in mind. However, man- Decreased pathogen growth Increased fecal weight
agement of colonic disease is most effec- Reduced dilution potential
tive if treatment is implemented with nor- Reduced fecal weight
mal colon physiology in mind.
One of the unique functions of the
colon is the further digestion of unab- Figure 1—The effects of soluble (highly fermentable) and insoluble (less ferment-
sorbed carbohydrates, proteins, and dietary able) dietary fibers on the gastrointestinal tract. (LI = large intestine; SCFAs =
fiber by the luminal bacterial flora. The short-chain fatty acids; SI = small intestine)
degradation of this undigested material in
the colonic lumen results in the formation
of short-chain fatty acids (SCFAs; e.g., acetate, propi- normal mammalian intestine but are fermented (de-
onate, and butyrate) as well as carbon dioxide, water, graded) by enzymes produced by colonic (and small in-
methane, and hydrogen gas.2 Luminal SCFAs acidify testinal) bacteria. Soluble (highly fermentable) fibers,
the luminal microenvironment, which may keep poten- such as oat bran, pectin, beet pulp, or vegetable gums,
tially toxic or mutagenic compounds in an un-ionized are readily digested by colonic bacteria and produce the
form3; are precursors for lipid synthetic (cholesterol, fat- largest quantities of SCFAs (Figure 1).9 However, be-
4
ty acids) and gluconeogenic pathways in the liver ; and cause soluble fibers are so completely degraded, they re-
help maintain normal colonic fluid and electrolyte bal- tain less ability to increase fecal bulk or dilute luminal
ance.5 SCFAs also help maintain a healthy bacterial pop- toxins.10 Insoluble (poorly fermentable) fibers, such as
ulation, which reduces the intrusion of pathogenic or cellulose, methylcellulose, coarse wheat bran, or the
opportunistic bacteria. hulls of oats/peas, are degraded by colonic bacteria more
In rats, pigs, and humans, butyrate is rapidly ab- slowly and thus retain a greater dilution potential and
sorbed by colonic epithelial cells and is used preferen- fecal bulking capacity.9 Fibers that increase fecal bulk are
tially for metabolic energy over glucose, glutamine, and important for several reasons: They improve or normal-
the other SCFAs.6,7 Studies of colonocyte fuel utiliza- ize colonic motility by distending colonic lumen, dilute
tion in cats have not been conducted. Because colono- luminal toxins (e.g., secondary bile acids, ammonia, in-
cytes have a short life span (approximately 4 to 7 days), gested toxins), and increase the rate of passage of ingest-
a readily available source of metabolic energy is needed ed material to reduce the exposure of colonic epithelial
to sustain their ability to proliferate. The presence of cells to luminal toxins.11
butyrate in the lumen serves this purpose, much like
glutamine does for small intestinal cells. In humans and CAUSES OF LARGE BOWEL DIARRHEA
rodent models, a lack of butyrate has been associated The characteristics of large bowel diarrhea include
with the development of colitis and “starved colon” hematochezia, increased mucus in and on the feces, in-
syndrome.8 creased frequency and urgency of defecation, increased
The most important dietary source of butyrate is tenesmus associated with defecation, and generally soft-
fiber. Dietary fiber is a catch-all term for a heteroge- formed to loose stools. Vomiting, dehydration, and
neous group of complex carbohydrates that are not weight loss are not commonly associated with colonic
readily broken down by the digestive enzymes of the disease but may occur in cats with chronic constipa-

INFLAMMATORY BOWEL DISEASE ■ SHORT-CHAIN FATTY ACIDS ■ FIBER

Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE I
Causes of Large Bowel Diarrhea in Cats
Dietary Allergy,
Inflammatory or Infectious Intolerance, or Indiscretion Neoplastic Inflammatory Bowel Disease

Bacterial Allergy Malignant tumors Lymphoplasmacytic

Salmonella species,
Clostridium perfringens,
Clostridium difficile,
Campylobacter species,
Yersinia enterocolitica,
Escherichia coli,
Mycobacterium
Viral
FeLV (neoplasia), FIV,
FIP (rare), panleukopenia
(kittens)
Protein, glycoproteins Adenocarcinoma, Idiopathic; most common
lymphosarcoma,
Intolerance mast-cell tumor, Eosinophilic
Additives, preservatives, fibrosarcoma, May be associated with
flavors, colors, histamine, undifferentiated sarcoma dietary allergy
protein, carbohydrates
Benign tumors Neutrophilic
Indiscretion Plasmacytoma, leiomyoma, May be present secondary to
Overeating, change of diet, adenomatous polyps an infectious agent
new food, garbage intake,
prey, foreign body Granulomatous
Rare in cats

Parasitic/protozoal/fungal/
miscellaneous
Cryptosporidiosisa, coccidiaa,
giardiasisa, toxoplasmosisa,
pentatrichomonas,
histoplasmosis, pythiosis,
Balantidium coli, Entamoeba,
phycomycosis

aMore common in the small intestine.

FeLV = feline leukemia virus; FIP = feline infectious peritonitis; FIV = feline immunodeficiency virus.

tion, colonic neoplasia, or severe colonic IBD. Condi-
tions causing large bowel diarrhea in cats generally fit
into one of four categories: (1) infectious diseases, in-
cluding bacterial, viral, and fungal (and, for the purpos-
es of this article, parasitic and protozoal) diseases; (2)
dietary allergy, intolerance, or indiscretion; (3) IBD; or
(4) neoplasia (Table I). These diseases or disorders can
be further categorized as acute or chronic.
Acute large bowel diarrheal episodes are often appro-
priately managed by dietary changes and/or empiric
pharmacotherapy. Pharmacotherapy for acute large
bowel diarrhea may include antibiotics, anthelmintics,
or motility-modifying agents (e.g., loperamide; Table
II); however, the use of empiric therapy should be de-
termined after carefully evaluating the cat’s signalment,
history, and physical examination for other diseases that
require additional assessment. In cats with chronic (du-
ration of more than 3 to 4 weeks) or recurrent large
bowel diarrhea, a definitive diagnosis must be obtained
for effective treatment to be instituted (Figure 2). Many
cats with chronic colitis will require both dietary and
pharmacologic therapy to control the disease. However,
appropriate use of dietary therapy may reduce the need
for drug therapy and also may increase the duration of
clinical remission.
Acute Large Bowel Diarrhea
Dietary Aspects
Indiscretion. Cats are more fastidious eaters than are
dogs; nevertheless, dietary indiscretion is an important
cause of acute feline diarrhea, especially in young cats
or kittens. Dietary indiscretion in cats is often caused
by a change in diet (e.g., new diet, introduction of hu-
man food, or prey consumption) but may result from
consumption of foreign substances (e.g., hair, string,
rubber bands, plants). Longhaired cats may have inter-
mittent bouts of large bowel diarrhea associated with
the passage of a hair mass, which may alter colonic
motility or cause irritant colitis. The addition of dietary
fiber (a strategy used by a new commercial “hairball”
diet) or lubrication (e.g., hairball remedies) to soften a
fecal mass are the most common therapeutic methods
of combating this problem. Diets that contain in-
creased insoluble fiber are often successfully used to

CAUSES ■ DIET CHANGE ■ FOREIGN SUBSTANCES

Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

TABLE II
Drugs for Treating Feline Large Bowel Diseasesa
Dose Frequency
Drug (mg/kg) Route (hourly intervalb) Indications

Antibiotics
Ampicillin 11–22 PO, IM, IV 8 Anaerobic and gram-positive bacterial
infections
Cephalosporins 11–33 PO, IM, IV 6–12 Anaerobic and aerobic bacterial infections
Clindamycin 5–11 PO, IM 12 Toxoplasmosis, anaerobic infections
Doxycycline 2.5–5 PO 12 Aerobic, anaerobic, and intracellular
bacterial infections
Enrofloxacin 1–2 PO, SC 12 Gram-positive and -negative infections
Furazolidone 4 PO 12 Resistant giardiasis
Metronidazole 10–25 PO 12–24 Colitis, IBD, giardiasis
Tylosin 5–10 PO 12 Bacterial infections
Tetracycline 10–20 PO 8 Aerobic, anaerobic, and intracellular
bacterial infections
Trimethoprim sulfa 30 PO 12–24 Gram-positive and -negative bacterial
infection, toxoplasmosis
Anthelmintics
Fenbendazole 25–50 PO 24 for 3–6 days Ascarids, flukes, Giardia
Pyrantel pamoate 5–10 PO 24 Acarids
Antiinflammatories
Azathioprine 0.2–0.3 PO 24–48 IBD
Chlorambucil 0.25–0.33 PO 3 days IBD
Prednisolone 1–4 PO, IM 12–24 IBD
Sulfasalazine 10–20 PO 8–24 IBD
Miscellaneous
Cisapride 0.3–0.5 PO 8–12 Colonic motility disorders, megacolon
Cyproheptadine 1–2 PO 12–24 Stimulate appetite
Diphenhydramine 2.2 PO 12–24 Decrease histamine
Diphenoxylate HCl 0.063–0.6 PO 8 Antidiarrheal
Loperamide 0.04 PO 12–24 Antidiarrheal
a
Dosages are recommendations only and must be tailored to the needs of the patient.
b
Unless otherwise specified.
IBD = inflammatory bowel disease; IM = intramuscularly; IV = intravenously; PO = orally; SC = subcutaneously.

manage acute colitis due to dietary indiscretion; the in-
creased fecal bulk and fecal water content normalize
colonic motor activity and protect colonocytes from lu-
minal toxins or irritants11 (Tables III and IV).
Fructooligosaccharides. Fructooligosaccharides
(FOS) are complex carbohydrates with a glucose at-
tached to two or more fructose units. FOS are digested
by the microbes of the colon (rather than in the small
intestine by mammalian enzymes) to produce SCFAs
much like soluble dietary fiber.12 There is increasing ev-
idence in humans that adding FOS to the diet increases
the number of bifidobacteria, the normal beneficial flo-
ra, in the large intestine.13 FOS have also been helpful
in treating secretory diarrhea in humans and pigs, pre-
sumably by increasing the number of beneficial bacteria
while slowing the growth of pathogenic bacterial
species.14 In dogs and cats, FOS are readily fermented
in the colon to produce SCFAs.15
In a recent study examining the effects of FOS on
small intestinal bacterial overgrowth in dogs, FOS sup-
plementation did not reduce or alter the growth of
pathogenic species.16 However, the normal small intes-
tine of dogs does not have a large population of bacte-
ria that utilizes FOS. Alternatively, there is strong evi-
dence that cats have a significant population of normal
bacteria in the small intestine.17 A preliminary study of
the effects of FOS on small intestinal bacterial popula-
tions in cats found no effect on bacterial numbers or
species in the duodenum.17 Conversely, FOS supple-
mentation did alter the fecal microflora of healthy cats
by increasing the numbers of lactobacilli and Bacteroides
species while significantly decreasing the numbers of

BIFIDOBACTERIA ■ SECRETORY DIARRHEA ■ BACTERIAL OVERGROWTH

Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

Diagnosing Large Bowel Diarrhea

Large bowel diarrhea

Acute (<1 mo) Chronic or recurrrent (>1 mo)

Fecal flotation Minimum database

Fecal examinations (as per acute)
Viral testing (FeLV, FIV, FPL)
Positive Negative Toxoplasma titers, TLI assay

Treat Repeat fecal flotation three Positive Negative

to five times over 48 hr
Do direct smears
Zinc, sugar, or other Treat
special flotations
Do fecal cytology from Imaging studies
fecal or rectal scraping (radiology, ultrasonography)
Endoscopy (biopsy)

Positive Negative
Positive Negative

Treat Perform dietary and/or

Treat
therapeutic trial

Repeat diagnostics
Hypoallergenic versus Consider elimination diet
Antibiotic or
highly digestible
anthelmintic trial
versus high fiber

Figure 2—Algorithm of a suggested diagnostic pathway for evaluating cats with acute or chronic large bowel diarrhea. (FeLV = fe-
line leukemia virus; FIV = feline immunodeficiency virus; FPL = feline panleukopenia, TLI = trypsinlike immunoreactivity)

clostridia and Escherichia coli.18 Although dietary FOS
supplementation may alter the fecal flora of healthy
cats, whether it effectively alters the microflora of cats
with colonic disease is unknown. Nevertheless, several
commercial diets have added FOS to their diet formu-
lations (Table III).
Intolerance. Dietary intolerance is a diet-induced di-
arrheal condition initiated by a nonimmunologic re-
sponse to a substance that may or may not be food.19
One example of food intolerance is lactose intolerance,
in which diarrhea results from intestinal lactase deficien-
cy. However, food intolerance can be caused by food
components, such as coloring, flavoring, preservatives,
or vasoactive substances (e.g., histamine, spermine).19
Finally, nonimmunologic adverse responses to protein,
carbohydrate, or lipid sources in a diet also occur (e.g.,
gluten intolerance), but these are not well documented
in cats.19 There is no definitive diagnostic test for dietary
intolerance other than elimination of the offending sub-
stance by food trial. Cats with dietary intolerance will
respond to any diet that does not contain the offending
substance, and diets that are highly digestible and hy-
poallergenic will often be effective (Table III).
Allergy/Hypersensitivity. In contrast, dietary allergy or
hypersensitivity is an adverse reaction to a food or food
additive that has a proven immunologic basis.19 Almost

LACTOSE INTOLERANCE ■ FOOD COMPONENTS ■ FOOD TRIAL

 TABLE III
Diets for Managing Gastrointestinal Disease in Catsa,b
Reduced-Antigen, Highly Digestible Diets
Small Animal/Exotics

Hypoallergenic Diets (low fiber, % fiber High-Fiber Diets

Diet Line (protein/carbohydrates) on an as-fed basis) (% fiber on an as-fed basis)
(manufacturer) Canned Dry Canned Dry Canned Dry

Hill’s Prescription® Diets d/d — i/d i/d w/d, r/d w/d, r/d
(Hill’s Pet Nutrition, (Lamb & Rice) (soluble, 0.4) (soluble, 1.2) (insoluble, (insoluble,
Topeka, KS) 3.1, 7.0, 8.1, 15.2,
respectively) respectively)

Ralston Purina Clinical — — — EN-Formula — OM-Formula

Nutrition Management® (soluble, 0.67) (soluble and
Diets (Ralston Purina Co., n-6:n-3 insoluble, 10.6)
St. Louis, MO) ratio = 5:1c

Innovative Veterinary Diets IVD Lamb, IVD Lamb, — Neutral Formula Hifactor Formula Hifactor Formula
Select Care™ and Limited Rabbit, Venison, Rabbit, Venison, (soluble, 2.9) (soluble, insoluble, (soluble, insoluble,
Ingredient™ Diets Duck & Potato Duck & Potato n-6:n-3 ratio = 2:0 and FOS, 1.6) and FOS, 4.5)
(Innovative Veterinary Diets, n-6:n-3 ratio = n-6:n-3 ratio =
20TH ANNIVERSARY

division of Nature’s Recipe 2.4–6.1:1 2.4–6.1:1

Pet Foods, Corona, CA)

IAMS Eukanuba® Veterinary Response LB/Feline — Low Residue Low Residue — —

Diets (The IAMS Co., (Lamb & Barley) Feline (soluble, Feline (soluble,
Dayton, OH) n-6:n-3 ratio = 5:1 FOS, 0.52) FOS, 2.08)
n-6:n-3 n-6:n-3
ratio = 5:1 ratio = 5:1

Waltham Veterinary Diets Selected Protein Selected Protein — — — —

(Waltham, Vernon, CA) (Venison (Duck
& Rice) & Rice)
aBased on information on canned and dry (if available) diets in the current product information guides published by the respective manufacturers.
b Thistable provides a representative listing of products and is not exhaustive; new products are continually becoming available, and existing formulas are often changed.
cPackaged as boxes containing eight 1.5-oz pouches.

FOS = fructooligosaccharides; n-3 = omega-3 fatty acids; n-6 = omega-6 fatty acids.
Compendium August 1999
Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE IV
Soluble and Insoluble Sources of Dietary Fiber 24,a,b
Soluble Insoluble Combination

Vegetable gums Cellulose Metamucil® (Procter & Gamble, Cincinnati, OH)

Carrageenans Wheat bran/germ Oat/rice bran (including oatmeal)

Mucilages Hemicelluloses Pea fiber (whole or soup)

Pectins Lignins Beans (whole, pinto, kidney)

Oligosaccharides Methylcellulose (Citrucel®; Potatoes (with skin)

(e.g., lactulose or FOS) SmithKline Beecham,
Pittsburgh, PA)

Potatoes (no skin) Pumpkin (canned)

Fibercon® (Lederle, Philadelphia, PA)

a Soluble (highly fermentable) and insoluble (less fermentable) fiber sources do not contain exclusively one fiber type but rather a
majority of one type and minimal amounts of the other.
b This table provides a representative listing of products and is not exhaustive.

FOS = fructooligosaccharides.

all food allergens in cats are proteins or glycoproteins
from beef, fish, eggs, chicken, pork, rabbit, or dairy prod-
ucts, but sensitivity to lamb has also been reported.20,21
The clinical signs associated with an allergic reaction to
food can be cutaneous (e.g., facial pruritus, miliary der-
matitis, endocrine alopecia, eosinophilic granuloma, gen-
eralized pruritus) or gastrointestinal (e.g., acute or chronic
vomiting or diarrhea). Although cutaneous signs report-
edly occur in up to 30% of cats with food hypersensitivi-
ty, prevalence of GI signs is unknown.20
Diagnosing dietary allergy is difficult, primarily be-
cause a 6- to 12-week food-elimination trial is required.
Measurement of allergen-specific IgE via skin testing or
serum-based immunoassays (e.g., radioallergosorbent
test [RAST], ELISA, monoclonal antibody–based
ELISA) and gastroscopic food-sensitivity testing have
been proposed as alternative diagnostic approaches to
elimination diets; however, these tests have been incon-
sistent and unreliable (false-positive and -negative re-
sults are common) and are thus not recommend-
ed.20,22,23 Both intradermal skin testing and ELISA or
RAST tests have a high incidence of false-positive val-
ues (40% to 60%), which may be caused by food anti-
gen alteration during processing, digestion, or me-
tabolism.23 Gastroscopic food testing is a good test for
ruling out food sensitivity (i.e., it has a very high nega-
tive predictive value), but false-positive reactions are
relatively common.23 In addition, skin and gastroscopic
tests will not positively identify animals that have a de-
layed hypersensitivity response (not mediated by IgE)
as having an allergic response.23
The best diets for identifying and treating food aller-
gies are homemade elimination diets that contain novel
protein sources that have highly digestible, modified
proteins smaller than 18,000 D.24 Several recent reviews
have addressed this subject and provided recipes and
commercial dietary information concerning hypoaller-
genic diets.23 A food-elimination trial is initiated by en-
suring that all food sources other than the prescribed
diet are removed from the diet, including flavor-coated
antibiotic or preventative preparations and nonhypoal-
lergenic treats. It is important that owners realize that
cats can also acquire a sensitivity to the protein in the
therapeutic diet, and thus a recurrence of signs may oc-
cur.
Although homemade diets are good for diagnostic
purposes, they may fail for long-term management of
food hypersensitivities because many clients are unwill-
ing or unable to prepare consistent, balanced diets for
their cats. A recent study showed that a large percentage
(80%) of homemade diets were nutritionally inadequate
for the maintenance of adult cats.19 An imbalanced diet
may not be too detrimental during the course of a di-
etary trial but over several months will create protein de-
ficiency, deficiency of specific amino acids or essential
fatty acids (e.g., taurine, arachidonic acid), or vitamin
and mineral imbalances.19 Several commercial “hypoal-
lergenic” or limited-antigen diets have been developed

SKIN TESTING ■ GASTROSCOPIC FOOD TESTING ■ HOMEMADE DIETS

Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

for treating dietary allergy specific media and transport

(Table III). These diets are
formulated with unique pro-
tein and carbohydrate
sources; some have other ad-
ditives (e.g., added omega-3
[n-3] fatty acids), however,
and thus a lack of response
to one commercial reduced-
antigen diet does not neces-
sarily rule out dietary allergy.
Keys to successful manage-
ment of cats with food hy-
persensitivity include persis- Figure 3—Photomicrograph of a fecal smear stained with antibiotic therapy that alters
tence and flexibility because Diff-Quik showing clostridial spores (“safety-pin” structures) the normal bacterial flora,
multiple food trials may be surrounded by epithelial cells and bacteria. The examination clostridia will overgrow,
required to find the best diet was performed with the 100× objective under oil immersion. sporulate, and produce en-
for the patient.
Infectious Causes
Infectious diseases, including parasitic or protozoal
infections, are a frequent cause of acute large bowel di-
arrhea in cats (Table I). Evaluation of a cat with acute
colitis should begin with obtaining a good history, es-
pecially a complete dietary history. All cats with large
intestinal diarrhea should have multiple fecal flotations
(three to five over several days), using salt and sugar
flotation media and zinc sulfate centrifugation tech-
niques. Microscopic examination of feces using saline-
mounted direct smears and stained specimens (fecal cy-
tology using Diff-Quik or Wright stains) are also
excellent diagnostic tests. Fecal cytology is used to iden-
tify clostridial spores, Histoplasma organisms, Giardia, or
other protozoal agents as well as to characterize the type
and degree of inflammation. Special sedimentation
techniques (e.g., Baerman) should be considered after
other avenues of evaluating the fecal specimen have
been explored. It is rarely necessary to culture feces in
cats with acute colonic disease; however, in some cats
with chronic colitis, a fecal culture may be indicated.
The key to obtaining diagnostic fecal cultures is col-
lecting and transporting samples in media appropriate
for each organism. For example, microaerophilic trans-
port and culture conditions are required to culture
Campylobacter from fecal samples, and thus special
transport tubes and media (Campy BAP) are necessary.
Culturing obligate anaerobes from feces requires spe-
cialized transport tubes and sample handling and is a
very difficult, time-consuming laboratory process;
therefore, culture of fecal anaerobes may not be rou-
tinely available at some commercial microbiology labo-
ratories. It is essential to find a laboratory that is capa-
ble of handling such requests and then obtain the
tubes needed.
Clostridium species are nor-
mal inhabitants of the feline
small intestine and colon.
Under the normal, acidic
conditions of the colonic lu-
men (with the presence of
normal anaerobic flora),
these potential pathogens do
not cause problems. Howev-
er, after a change in diet,
stressful event or illness, or
terotoxin. The enterotoxin
is believed to be responsible
for the development of diarrhea in affected animals.25
Clostridial enterocolitis is well recognized in dogs but
is a less common cause of diarrhea in cats. In addition,
there is little information regarding cats on the compar-
ative usefulness of identification of spores versus detec-
tion of enterotoxin by commercial assays. In dogs, diag-
nosis of clostridial colitis has previously been based on
the identification of safety-pin–shaped spores on stained
fecal smears (Figure 3). However, the presence of spores
does not necessarily indicate the presence of enterotox-
in; thus assays for detection of enterotoxin have been
used to guide treatment.
The reverse passive latex antigen (RPLA) kit was re-
cently compared with fecal spore counts for diagnosis
of clostridial enterocolitis in dogs. A poor correlation
among fecal spore counts, clinical signs, and the
RPLA assay was found.25 The other commercial kit,
an ELISA, has not been evaluated in dogs or cats, so
its effectiveness is unknown. Thus, until assays for de-
tection of enterotoxin in feces are validated, diagnosis
of clostridial enterocolitis in cats should be based on
finding large numbers of spores on a stained fecal
smear as well as on the response to treatment. Treat-
ment with antibiotics with an anaerobic spectrum
(e.g., ampicillin/amoxicillin, metronidazole, clin-
damycin, tylosin) for 5 to 7 days is effective in most
cases. In addition to antibiotic therapy, adding soluble
fiber or FOS to the diet may enhance the recovery of
the normal bacterial flora and acidify the colonic lu-
men, which may inhibit further clostridial sporulation
(Table III).
Other specific infectious causes of enterocolitis in
cats include E. coli; Clostridium difficile; and Salmonella,
Campylobacter, Giardia, and Entamoeba species. (Table

FECAL FLOTATIONS ■ CLOSTRIDIAL ENTEROCOLITIS ■ RPLA ASSAY

Small Animal/Exotics 20TH ANNIVERSARY
I). These infectious agents rarely cause clinical disease
in cats (most cases are asymptomatic), with the excep-
tion of giardiasis26; however, Giardia species usually
cause small bowel diarrhea instead of colitis. Cats that
develop enterocolitis caused by these agents are often
purebred, cattery-raised, young, or immunocompro-
mised (feline leukemia virus [FeLV]– or feline immuno-
deficiency virus–positive).27 Cats may shed these organ-
isms for many weeks following clinical or subclinical
infections.26 This is especially important because most
of these agents are zoonotic, making client communica-
tion and awareness essential.
Chronic Large Bowel Diarrhea
As in any chronic disease process, it is very important
in chronic large bowel diarrhea to obtain a definitive
diagnosis for the best chance at treatment success. The
first, and possibly most important, step is to obtain a
complete history, including onset, frequency of signs,
character of fecal mass, presence or absence of blood or
mucus, presence of vomiting or weight loss, and any ef-
fective treatments as well as a complete dietary history.
A dietary history should include any changes in diet; all
components of the diet, including table foods; how
long the current diet has been fed; and how much is
fed. The diagnostic approach to chronic diarrhea
should follow the algorithm for evaluating a cat with
acute diarrhea (e.g., multiple fecal examinations and
empiric or dietary therapy as indicated). However, in
many cats, a minimum database (including thyroxine if
indicated), survey or contrast radiographs, and ultra-
sonography may be necessary. Ultimately, other diag-
nostics, such as fecal culture, intestinal permeability as-
says (e.g., hydrogen breath tests, fecal α-1 protease),
specialized tests of motility (e.g., scintigraphy), or en-
doscopy (to obtain biopsies, aspirates, or cytology of
the GI tract), may be indicated (Figure 2).
Inflammatory Bowel Disease
The diagnosis and medical management of feline
IBD has changed very little in the past several years.
This is primarily because the disease continues to be a
diagnosis of exclusion for which the pathogenesis re-
mains largely unknown, despite considerable research
into the immunologic mechanisms and histologic pat-
terns of IBD. Therefore, IBD remains an idiopathic
disease for which a definitive cause is unknown.28,29 The
most common histologic classification of colonic IBD
in cats is lymphoplasmacytic colitis. 28–31 However,
eosinophilic, neutrophilic, and granulomatous infil-
trates occur with variable frequency. Any of these in-
flammatory conditions may occur as a primary colonic
disease but may also be associated with disease of the
LYMPHOPLASMACYTIC COLITIS ■ PREDNISOLONE ■ METRONIDAZOLE
Compendium August 1999
small bowel or stomach. Thus, it is reasonable to per-
form gastric and duodenal biopsies on cats that appear
to have only large bowel diarrhea. In addition, the en-
doscopic appearance of the region should be noted be-
cause mucosal friability, erythema, and ulceration may
occur with IBD.30 Despite mucosal appearance, it is ex-
tremely important to obtain multiple (e.g., six to eight)
high-quality (presence of submucosa, not just mucosal
tissue) biopsies from each location (including normal-
appearing mucosa).
The treatment of feline IBD continues to be pred-
nisolone and metronidazole in combination or sepa-
rately30–32 (Table II). The reasons for the effectiveness of
metronidazole in feline IBD may be multifactorial and
include its anaerobic antibacterial spectrum, effective-
ness against Giardia, and proposed immunomodulating
effects on the gut. Antibacterial therapy (e.g., tylosin,
metronidazole, amoxicillin, tetracycline) may be indi-
cated in cats with a neutrophilic inflammatory compo-
nent, whereas cats with eosinophilic enterocolitis will
often require aggressive therapy with prednisolone or
other immunosuppressive agents.33 Azathioprine, cy-
closporine, chlorambucil, and sulfasalazine/olsalazine
are used to reduce the dose of prednisolone required for
long-term maintenance or in those cats that are intoler-
ant of, or poorly responsive to, prednisolone therapy.33
Although it is unusual to need 5-aminosalicylate–
containing drugs (e.g., sulfasalazine, olsalazine/me-
salamine) to manage feline colonic IBD, sulfasalazine
has been recommended for cats with IBD unresponsive
to other therapies.30,33 Olsalazine and the other mesal-
amine-containing, antileukotriene drugs used in human
and canine colitis have not been evaluated in cats. The
risk of salicylate toxicity must be considered but ap-
pears to be minimized if a low dose is used.33 Omega-3
fatty acids have also been included in diets used for
treating feline IBD because of their antiinflammatory
properties.34 Omega-3 fatty acids reduce inflammation
by altering the fatty acid profile of lipid membranes so
that cyclooxygenase and lipoxygenase action on the fat-
ty acid releases the 3-series prostaglandins and
leukotrienes, which are antiinflammatory compared
with the normal 2-series prostaglandins.34 However,
there have been no controlled studies of the effective-
ness of these agents for treating feline IBD. As newer
therapeutic approaches are being developed for use in
human IBD (e.g., biologic therapy [tumor necrosis fac-
tor-α]) and specific nitric oxide synthase or cyclooxyge-
nase-2 inhibitors are identified, the therapeutic options
for cats with IBD will expand.
In addition to the pharmacologic management of fe-
line IBD, there is keen interest in the role of diet.
There are a few cats for which dietary therapy alone
Compendium August 1999 20TH ANNIVERSARY
will be sufficient to control IBD. These cats usually
have either fiber-responsive colitis or dietary intoler-
ance/sensitivity as the cause of the diarrhea. However,
the goal of dietary therapy in those cats that do not
have diet-responsive colitis is to reduce disease severity,
frequency of relapses, and drugs needed to control the
disease. One of the reasons dietary intervention is advo-
cated in treating IBD is the hypothesis that dietary al-
lergy may have an important role in the disease. One
key is that multiple hypoallergenic diets may have to be
tried before an effective diet is discovered. This is a tri-
al-and-error process that, until better methods for iden-
tifying food hypersensitivity are developed, is the only
accurate means of diagnosing this disease.
In human colonic IBD, increasing the amount of bu-
tyrate available to the colonic epithelium reduces the
incidence and severity of disease recurrences.35 Whether
this effect is important in feline colonic IBD is un-
known. Because there have been few studies in cats on
the effects of soluble or insoluble dietary fiber on nor-
mal colonic function, it is difficult to make specific rec-
ommendations concerning dietary fiber for cats with
IBD. In addition, because of the presence of a signifi-
cant population of bacteria in the small intestine of
cats, fiber may be metabolized quite differently by this
species.17 However, adding modest amounts of soluble
and/or insoluble fiber to the diet to increase fecal bulk
and motility while providing a source of butyrate as a
colonic fuel source seems reasonable as part of the man-
agement of feline IBD. There are several high-fiber di-
ets available commercially, but each has different types
and amounts of fiber (Table III). There have been no
studies performed to determine the beneficial or ad-
verse effects of these different fiber sources in cats with
IBD. Finally, some cats with colonic IBD may respond
best to a diet that is highly digestible, which will leave
less residue for the diseased colon or the abnormal mi-
croflora to act upon. Until a better understanding of fe-
line IBD is achieved, the role of diet in the develop-
ment or treatment of feline colonic disease will remain
uncertain.
Neoplasia
Neoplasia of the intestinal tract in cats, representing
less than 1% of all tumors, is uncommon compared
with tumors in other sites.36,37 Tumors of the colon are
rare, but adenocarcinoma, lymphoma, and mast-cell tu-
mors are the most frequently reported feline colonic tu-
mors; leiomyosarcoma, plasmacytoma, and fibrosarco-
ma are also reported, but infrequently.36,37 The most
common nonhematopoietic neoplasm of the colon in
cats is adenocarcinoma.36,38 Unlike most other diseases
of the large bowel, weight loss is often the most com-
BUTYRATE ■ ADENOCARCINOMA ■ LYMPHOMA
Small Animal/Exotics
mon presenting complaint for cats with colonic neopla-
sia; anorexia and hematochezia are also common pre-
senting complaints. Most colonic neoplasia is not dis-
covered until the tumor has metastasized. Nevertheless,
examination of cats with a palpable or suspected ab-
dominal tumor should include routine hematologic
and biochemical assays, radiographs (abdominal, con-
trast, thoracic metastasis check), and ultrasonography
with fine-needle aspiration of lymph nodes or the mass
as indicated.
The incidence of intestinal adenocarcinoma metasta-
sizing to regional lymph nodes, mesentery, omentum,
and other abdominal organs is nearly 50%.37–39 Adeno-
carcinomas and mast-cell tumors tend to create ob-
structive lesions, whereas lymphomas are often infiltra-
tive throughout large regions of the GI tract. 36,37
Diagnosis can be obtained via endoscopic biopsy in
many cats; however, an exploratory laparotomy is also a
reasonable approach because intestinal resection is the
treatment of choice for both adenocarcinomas and
mast-cell tumors.36,39 Despite the fact that adenocarci-
nomas metastasize early, cats can have long survival
times (e.g., average of 6 to 15 months, sometimes as
long as 4 years) after intestinal resection of the tu-
mor.37,39 Cats with intestinal mast-cell tumors rarely live
longer than 4 to 6 months because of the aggressive na-
ture of this neoplasm and lack of effective chemothera-
py.37 Palliative therapy for intestinal mast-cell tumors
includes histamine blockers and corticosteroids to re-
duce release of vasoactive amines; however, the effec-
tiveness of these treatments is unknown.37
Lymphoma is the most common hematopoietic tu-
mor of the GI tract in cats and can be part of multicen-
tric disease or alimentary lymphosarcoma.37 Most cats
with alimentary lymphoma are FeLV-antigen negative,37
whereas most with multicentric lymphoma are FeLV-
antigen positive. The presence or absence of FeLV anti-
genemia may influence the long-term prognosis (i.e.,
FeLV-positive cats often have shorter survival times as a
result of FeLV-associated disease rather than reduced re-
sponsiveness to chemotherapy).37,40 Lymphosarcoma and
IBD can be quite difficult to distinguish by histo-
pathology alone, especially in the early stages of the dis-
ease; in cats with lymphoplasmacytic IBD that is unre-
sponsive to conventional therapy, or when suspicion of
lymphoma is high, immunocytochemistry for cell sur-
face markers can be used to differentiate the two (lym-
phomas are usually monoclonal [i.e., their origin is a
single cell clone that has identical cell surface markers]).
These assays are not universally available and are quite
expensive but may be invaluable for differentiating
lymphoma and IBD. Staging and treatment protocols
for lymphoma are available in the literature.37
Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

TABLE V
Laxatives for Treating Constipation in Catsa
Frequency
Laxative Dose Route (hourly interval) Trade Name

Bulk-forming
Psyllium 1–2 tsp PO 12–24 Metamucil® (Procter & Gamble,
Cincinnati, OH)
Methylcellulose 1–4 tsp PO 8–24 Citrucel® (SmithKline Beecham,
Pittsburgh, PA)

Emollients
Dioctyl sodium sulfosuccinate 25–50 mg PO, per rectum 12–24 Colace® (Mead Johnson,
Evansville, IN)
Dioctyl calcium sulfosuccinate 50–100 mg PO, per rectum 24 Surfak® (Hoechst Marion
Roussel, Kansas City, MO)

Lubricants
Petrolatum jelly 1–2 ml PO 24 Vaseline® (Chesebrough-Ponds’
USA Co., Greenwich, CT)
Petrolatum jelly–based 1–2 ml PO 12–24 Laxatone® (EVSCO
Pharmaceuticals, Buena, NJ),
Laxaine® (Pfizer Animal Health,
New York, NY)

Osmotics
Lactulose 1ml/cat PO, per rectum 8–12 Chronular® Cephulac® (both from
(Hoechst Marion Roussel)
Polyethylene glycol 25–40 ml/kg PO 4 Colyte®, GoLYTELY® (both
and electrolytes (for bowel preparation) from Carter Products,
Cranbury, NJ)

Saline
Magnesium hydroxide 5–10 ml (dogs) PO 12–24 Milk of Magnesia® (UDL Labs,
2–6 ml (cats) Rockford, IL)

Stimulant
Bisacodyl 5 mg PO 24 Dulcolax® (Novartis, East
Hanover, NJ)
a This
table provides a representative listing of products and is not exhaustive.
PO = orally.

Constipation, Obstipation, and Megacolon neous causes (e.g., hypokalemia, hyperparathyroidism,

Constipation is a common problem in cats. The con-
dition can be induced by changes in diet or environ-
ment (e.g., soiled litter, hospitalization, new cat), inges-
tion of foreign objects (e.g., hair, string, plants, bones,
feathers), intra- and extraluminal obstructions (e.g., tu-
mors, intussusception, pelvic fractures, anal stricture,
hair mats around anus), ileus (e.g., postoperative, in-
flammatory, metabolic), neurologic diseases (e.g.,
dysautonomia, paraplegia, Manx cats with sacral spinal
cord deformity), drug therapy (e.g., anticholinergics,
opioids, antacids, sucralfate), dehydration, or miscella-
physical disability).41 Obstipation is intractable constipa-
tion, and its presence implies loss of colonic function.
Feline megacolon can be acquired (chronic constipa-
tion or obstipation) or can result from idiopathic dila-
tion of the colon caused by a loss of neuromuscular
function.41
The key to effective management of feline constipa-
tion is identification and correction of the cause. Un-
complicated cases of constipation are resolved by restor-
ing hydration status or assisting the removal of the fecal
mass via administration of warm-water enemas and/or

OBSTIPATION ■ MEGACOLON ■ MANAGEMENT

 Small Animal/Exotics
stool softeners (e.g., dioctyl sulfosuccinate). Alterna-
tively, uncomplicated constipation may be corrected by
PENDIU
M
M’
20th

CO
1 9 7
9 - 1
9 9 9
ANNIVERSARY
A LookBack
There have been many advances
in our understanding and
treatment of feline colonic
diseases. Specific examples
include the recognition of
clostridial enterocolitis and
giardiasis as important causes of
infectious diarrhea in cats,
increased understanding of and
interest in the importance of
diet in the management and
prevention of gastrointestinal
(GI) disease, and the role of
cisapride in the management of
feline idiopathic megacolon. We
are also gradually beginning to
understand the important
differences in the feline GI tract soluble fiber present in
(e.g., cats have a sizable enteric some diets may contribute
flora that may be important in
specific digestive processes or fecal mass becomes dehy-
development of inflammatory
bowel disease [IBD]). Although
there have been many advances
in our knowledge of the feline
large intestine, there is still
much we need to learn about its
function as well as the
development of diets that
prevent or reduce the incidence
of diet-associated colonic disease,
improved methods of diagnosing
and managing idiopathic
megacolon, and the
pathophysiology of colonic IBD.
20TH ANNIVERSARY
increasing fecal bulk either
via diet or pharmacologic
means (e.g., laxatives; Table
S

V). Cats with recurrent
constipation due to an ob-
structive lesion that causes
constipation that is not sur-
gically correctable may re-
quire lifelong dietary and/or
laxative therapy to control
their disease.
Adding insoluble fiber to
the diet, which increases fe-
cal bulk, can be very help-
ful in managing constipation
if cats are well hydrated. In-
creased fecal bulk creates a
larger, softer stool that is
easier to pass and stimulates
an increase in segmentation
and propulsion contractions
that move the stool distal-
ly.11 However, in cats that
are dehydrated or do not
drink adequate quantities of
water, large quantities of in-
to constipation because the
drated. Fibers that increase
fecal bulk are pea fiber, oat
fiber, coarse wheat bran,
cellulose, methylcellulose,
or pumpkin fiber.42 In cats
with colitis, increasing the
amount of soluble fiber (to
increase SCFAs and de-
crease fecal bulk) is pro-
posed to be beneficial.34
Commercial diets con-
taining increased fiber are
generally better for long-
term fiber therapy than are
diets to which fiber has
been added because they
are balanced and more
palatable (Table III). How-
ever, commercial diets dif-
fer in types and amounts of
dietary fiber, so diet selec-
FECAL BULK ■ COMMERCIAL DIETS ■ LAXATIVES
Compendium August 1999
tion is important. For example, Hill’s Prescription Diet
r/d® contains primarily insoluble fiber (cellulose or
peanut hulls), which is an excellent bulk-forming laxa-
tive. Alternatively, an example of a diet formulation
that contains both soluble and insoluble fiber is IVD’s
Feline Hifactor Formula®. Table IV illustrates a few
sources of soluble and insoluble fibers that are available
commercially (health food stores, pharmacies, grocery
stores) for managing fiber-responsive diseases by adding
fiber to the cat’s regular diet.42
Laxatives are used to prevent or alleviate constipa-
tion. The best general-purpose laxatives are bulk-form-
ing (e.g., psyllium, methylcellulose), osmotic (e.g., lac-
tulose), or emollient (e.g., docusate sodium/calcium)
(Table V).32,33 However, osmotic and emollient laxatives
can be irritating to the colonic mucosa and should not
be used before endoscopic procedures or in cats with
colitis or severe constipation that will likely have con-
current colonic irritation. 32 Magnesium-containing
cathartic laxatives and phosphate-containing enemas
should not be used in cats because they may cause fatal
hyperphosphatemia or hypermagnesemia. Stimulant
laxatives (e.g., bisacodyl) can be quite useful in cats
with chronic constipation, obstipation, or early-stage
megacolon. Bisacodyl stimulates inducible nitric oxide
synthetase,43 which increases colonic contractions but
may cause fatigue of the myenteric plexus if used con-
tinuously over a long period (days to weeks). Prokinetic
agents (e.g., cisapride) can be used to increase colonic
smooth muscle contractions44 and may be quite useful
for treating cats with postoperative ileus; constipation
due to such chronic, irreparable conditions as neopla-
sia; or idiopathic megacolon.41 Metoclopramide is an
effective prokinetic agent for the upper GI tract but is
ineffective in the colon. The cholinergic drugs (e.g.,
bethanechol) are difficult to administer to cats and have
numerous side effects and thus should be avoided.
Feline idiopathic megacolon is an uncommon syn-
drome for which pathogenesis is slowly beginning to be
understood. Recent studies suggest that colonic smooth
muscle function is impaired in cats with this disease
and that the use of cisapride is effective in improving
colonic function in cats with some remaining colonic
motor function.44 In its early stages (i.e., dilated colon
for typically less than 6 months), this disease is usually
managed with combination therapy that includes one
or all of the following: increased dietary fiber (bulk),
osmotic laxatives (lactulose), stimulant laxatives
(bisacodyl), and cisapride (up to 10 mg/kg every 12
hours) along with occasional warm-water enemas as
needed. The oral colonic lavage solutions (e.g., poly-
ethylene glycols) have not been shown to be effective in
cats with this condition and require administration of
Compendium August 1999 20TH ANNIVERSARY
large volumes, which is not practical for cats on a regu-
lar basis. If a cat’s colon is impacted with hard, dry fe-
ces, administering warm-water enemas or mechanically
removing fecal material is necessary before initiating
cisapride therapy. When megacolon has been present
for more than 6 months or pharmacologic and dietary
therapy is no longer effective, the best approach is sur-
gical palliation via a subtotal colectomy with or with-
out pelvic osteotomy.45,46 Following colectomy, cats will
have soft to liquid stools for several months but will
eventually produce soft to semi-formed feces with
proper management, including a low-residue diet;
small, frequent feedings; and time to adapt.
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About the Author
Dr. Zoran is affiliated with the Department of Small Animal
Medicine and Surgery, College of Veterinary Medicine,
Texas A&M University, College Station, Texas, and is a
Diplomate of the American College of Veterinary Internal
Medicine.