Hello and thank you so much for choosing to watch this webinar. My name's Sarah Caney. I'm a UK based specialist in feline medicine.

And this webinar is all about constipation in cats. What I'm gonna do is briefly start by reminding you of some important definitions related to this condition, and then we'll talk about the causes of constipation, what are the most important ones, what do we need to consider as differential diagnoses before moving on to talk a little bit about investigations, when they're helpful and what investigations might be worth considering. And then how we manage, firstly, the really severe cases, what's a sensible plan of action, and that's where I will share some innovations in more recent years that you might find helpful.

And then we'll also talk about importantly how we treat the milder cases and how we prevent recurrence of constipation. And throughout this, I will aim to be sharing my tips and tricks for practical management of these patients in your clinics. So let's start just with some important definitions.

So many of these you will be very familiar with, so constipation, of course, is defined as infrequent or difficult passing of hard, dry faeces from the colon or rectum. Obstipation is a more severe form of constipation, where typically the faeces are very impacted and hard and dry and present in the colon and rectum. Tinesmus is straining to pass faeces, which is often in this condition, of course, ineffective.

Dyschesia is difficulty and or pain passing the faeces, so often associated with conditions that the er involve the anal, the sort of terminal rectal tissues as well, and the perianal area. And then lastly we have mega colon, which is often seen as a sort of chronic end stage situation where we have a dilated hypomotile colon that is just not functioning functioning anymore. It's accumulating faeces and they are sitting within it, becoming extremely impacted.

So what are the functions of the normal colon? Well, importantly, of course, the colon has a big role in absorption of water and electrolytes, and that allows the formation of the faeces, which are then stored within the colon and rectum prior to defecation. The colonic mucosal cells also produce mucus, which helps to lubricate the passage of those faeces.

Of course there is smooth muscle within that colon as well that is going to propel those faeces out and colonic flora aid in digestive processes also. The innovation of the colon is quite complex and I don't pretend to be an expert, so this is a rather simplistic summary of the nerves involved in supplying the colon and rectum and anal areas. So we have the pelvic nerve, which I've shown in purple here, which is senses intraluminal pressure within the colon, feeds that information back and that then is.

To stimulate defecation and emptying of the colon, the pudendal nerve has sensory fibres that detect changes in pressure, temperature, touch and pain related to the anus and the anal canal, but also has motor nerves, which supply the striated muscle of the external anal sphincter, so controlling, evacuation of faeces there. We then have the sympathetic nerves, the, the red box, which are generally inhibitory to defecation, so inhibit the the colonic and rectal smooth muscle tissue, and have a motor response on the internal anal sphincter, so holding faeces in, in contrast to the parasympathetic nerves that have a motor response to the rectal smooth muscle, and inhibit the internal anal sphincter, so helping with passage of faeces. Deecation can be a reflex or under conscious control, and our conscious control, of course, as we know in ourselves, can inhibit the reflex, so we might feel a need to go, but we're able to control it in the normal healthy individual.

So why is constipation a concern? Well, of course, ultimately we need our patients need to excrete that waste product that goes without saying, but the longer the faeces are retained within the colon, the more damage can be caused, because that can cause some trauma to the lining of the colon, resulting in some inflammation, excess secretion of mucus and fluid by those colonic cells. There's going to be some discomfort associated with that faecal retention and dilation of the colon, and there's going to be also a risk of absorption of some of the toxic waste products that are contained within the faeces, and both of these can contribute to the typical anorexia, lethargy, nausea that many of our patients with constipation exhibit.

And if that constipation is prolonged or repeated over a long period and the colon is chronically over distended, then that can damage the smooth muscle function in the future and that ultimately can lead to mega colon. So what are the common causes of chronic severe constipation in cats? Well, idiopathic megacolon is top of the list here, so megacolon arises for reasons that we don't understand, would be responsible for, it's thought about 60% of cases with chronic severe constipation.

Pelvic narrowing and damage to nerves following trauma, so typically a road traffic accident, perhaps a tailpole injury can result in also constipation downstream either through pelvic narrowing, preventing passage of the faeces or damage to the nerve supply to the colon, inhibiting defecation and leading to chronic problems. There are many, many other causes of constipation that we can see as listed on this slide, and these can vary in severity, so they include things like our hunting cat that wants to eat a whole rabbit, or mice or rats, bones within the colon can make it difficult and painful for the passage of faeces and result in constipation. Hair sometimes can as well in our long-haired cats we're thinking of particularly.

A cat with chronic kidney disease, may run borderline dehydrated, and that can result in faecal retention, and, then these hard faeces become harder for the cat to pass, so that can become a bit of a vicious cycle there. Stress, dirty litter trays, so the the cat that is indoor only, or prefers to use a litter tray, may have let's say a little bit of a protest about using an unclean litter tray and then over the next few days, because those faeces have not been passed, they become harder to pass because they are harder and drier. And so on and so forth.

So you can see a range of problems here. We have, you know, a lot of problems that don't specifically relate to the bowel. So again, things like osteoarthritis, obesity, lack of exercise, but we also have things that do primarily affect the bowel such as colonic, neoplasia, strictures, polyps, and other issues that that might affect the colon itself.

So a number of things that we need to consider and therefore in our history taking are going to be important to understand for the individual cat what the cause of their constipation might be. This is a case series, quite a large case series in in the vet world terms, 46 cats with colonic neoplasia, just showing what sort of tissue types are commonly found, and you can see that adenocarcinomas and lymphoma are probably equally represented in this case series, but some other tumours also. Presents in a small number of cats, so mass cell tumours, neuroendocrine carcinoma in a small number of cats, but the majority are either carcinomas or lymphoma.

Sometimes it's possible to surgically successfully resect these and do via a subtotal colectomy, for example. A number of surgical techniques described for that, which are obviously outside my area of expertise as an internal medicine specialist. So what's a logical approach when presented with a cat with constipation?

Well, of course, the history is really important to start with, but physical exam, diagnostic tests are also going to be part of our assessment, and then of course we need to find a solution for that cat, both in the short and the long term. So from a history perspective, we, we do need to confirm first of all, if the cat is brought in with a history of tinesmus or straining, that it does relate to the bowel and not the bladder. So that is usually fairly straightforward to work out on our examination, palpation.

It may be also partly evident or, or certainly suspicious based on the owner description of the cat's posture when they're straining, because of course, cats with when they pass urine, typically. Will adopt a more seated posture compared to passing faeces, but it's not always that straightforward. For example, cats with urethral disease tend to stand more upright straining to pass their urine, so that can be mistaken for straining to pass bowel motion.

Other common clinical signs were obviously pain, dyschesia on passing faeces, the cat generally, if it's severe, being depressed, off colour, some nausea or vomiting, loss of appetite, all very common as well. And of course the more severe cases there may be dehydration or other concerning findings on clinical examination. So our history aims to also detect whether there are important clues or previous insight really that can help understand well why is this cat constipated, so is there some known orthopaedic issue, or recent injury which has impacted on the cat, are there systemic diseases like chronic kidney disease, for example, or perhaps, you know, with this cat that's had a few bouts more recently, well, looking back further in time, has there been Pelvic trauma, for example, and often these cases, the constipation following trauma, it takes several months to emerge, and it's not usually an instant impact of that, so the cats may be all right for 6 to 12 months and then start to develop problems associated or more obviously clinically apparent problems with their defecation at a later stage.

Palpation, dilated, distended, colon with faeces obviously is generally quite straightforward for us, but we should also be mindful on our physical examination to look for other changes. So are there other clues of orthopaedic problems if this is an older cat in particular, can we see matted fur over the hip areas? Perhaps this cat is painful in that area, and that is a clue that there may orthopaedic or pain reasons as as difficulty passing the faeces.

Dysautonomia is not something we see very commonly in cats, but constipation would be one clinical, clue of that and other clinical clues of more generalised dysautonomia I've listed on the slide here. So things like protrusion of the third eyelid, dilated pupils, slow heart rate, dry mucous membranes. And of course if we're thinking of more spinal disease, impacting on the nerves supplying the colon, then there may be other clues of spinal disease, such as proprioceptive deficits to the hind limbs.

So further diagnostics are the next stage to spend a little bit of time on and probably the number one thing, of course, to say, as you will know, is that, you know, these are not always needed in every constipated cat that comes in, particularly on the first time we see the cat, particularly if we can work out from our history already what might be important. Exacerbating factors for this cat, for example, is it a cat with chronic kidney disease that really just needs better support of hydration, to help it and perhaps, you know, a microlaxant enema is going to be enough to smooth things along. So further diagnostics may, may not be required in every case, but I would certainly say that if you are Certain as to what the cause of the constipation might be and if the patient is systemically unwell, then this is certainly something worth considering and also those repeat cases as well.

So really looking for further clues like evidence of chronic kidney disease or evidence of dehydration, electrolyte disturbances as well. And it's going to inform our treatment, of course, with all of these things as well as to how we might need to manage that patient. So the sort of tests that can be helpful of course include our blood tests and where possible, I would say if you're going to the trouble of collecting a blood sample and running some blood tests, I would in this sort of case not only do a mini profile but include electrolytes, include haematology as well.

I've put a question mark with the thyroid function there, because you may have spotted on an earlier slide that hypothyroidism would be, a potential cause of, constipation, and the situations in which hypothyroidism tends to be seen in our feline patients, you'll appreciate it's much less common in cats than in dogs, but would be occasionally as a congenital problem. So if you have a stunted, constipated kitten, think of hypothyroidism, congenital hypothyroidism. In an adult cat, hypothyroidism can arise following treatment of hyperthyroidism, so iatrogenic hypothyroidism, and constipation can be a feature of that as well.

Rectal examination, which I would not attempt, conscious, in a cat, but, under sedation or GA can be very helpful as well in these sort of cases, particularly those repeat cases to try and assess whether there are any masses within. That, pelvic canal or any narrowing from previous traumas, you can feel the prostate. Occasionally cats do get prostatic disease.

It's, you know, it's not impossible prostatic tumours in particular, so they can impact on, and lead to constipation in some cases as well. And of course you can examine other things too, anal glands being one. Imaging can be of some help.

We'll talk about radiography in just a moment. If you have access to advanced imaging, then in certain cases also, that also can be helpful. And of course if you're suspicious of disease that involves the colonic or rectal mucosa, then endoscopy also can be very helpful as per the colonic tumour cases that you saw some endoscopic pictures from that paper I mentioned earlier on.

So radiography, everyone will have access to and this this does have some utility. Again, you know, not every case you're going to feel really needs to have a radiograph, but it can be helpful to determine the severity of the constipation. Diagnostically, mega colon is, is defined on radiographic features, which I'll show in just a moment.

You may see foreign bodies, you may see spinal abnormalities, fracture. Dislocations, for example, you may see narrowing of the pelvic canal, you may see extraluminal obstructions, things like the prostatic mass that I mentioned earlier on, evidence of perineal hernia, and you potentially can, if you don't have access to an endoscope, following enemas, you can get some information that may be suspicious of, for example, a neoplasm by doing a barium enema study. So some examples here, so needles obviously show up beautifully on on a radiograph.

So this, this was a cat that had a needle in its colon did manage to pass it. So these cases don't always need, you know, any surgical treatment can be tracked as as the needle passes down and out into the litter tray. Some traumatic examples, so tailpo and RTA's resulting in fracture, dislocation, separation of that damage the nerves and lead on to, you can see in that left hand image we've got urinary retention as well as faecal retention.

The bladder is really very large. And then a smashed up pelvis, resulting in in constipation here, you can see this sort of very collapsed, narrowed pelvis there. And lastly, I think, or maybe not quite lastly of the radiographs mega colon, so you can see instantly this very distended colon.

Also how absolutely concreted these the faeces are. You can just, I dread to imagine how many days of faeces have built up in there, but they've severely compacted, impacted, severe, severe obstruction, obstipation rather, and, the textbook definition of mega colon is that the diameter of the colon should be. Less than 1.5 times L5 or L7, so you can see it's about double, in this example, so, diagnostic of, of megacolon.

And yes, this is the last one I think this is a a cat that where endoscopy not available, but a barium enema was useful in showing filling defects and this cat had a colonic tumour. So let's now move on to talk about management. So severely constipated cats often need rehydration.

In the longer term, we want to encourage, as optimal as possible hydration, as part of our strategies to prevent future recurrence, future repeat constipation episodes. But when they're presented acutely unwell and severely constipated, they may also need. Electrolyte abnormalities to be corrected, often analgesia because this is a really uncomfortable condition, but as the faeces are passed or extracted, that is actually going to be quite traumatic to the colonic mucosa.

So very painful. Don't forget, analgesia. If there are other underlying known causes that are correctable, then of course, you know, correcting them.

So I guess one example might be that iatrogenic hypothyroid cat. Supplementing that cat with thyroid hormone may in the long term help to minimise repeat episodes of, of constipation as well. We want to remove anything impacted, or help the cat to pass those impacted faeces, a number of strategies which I'll talk about next, and then of course prevent future episodes.

So with those really severe obstipated cats that have severe faecal impactions, we've got a number of, of options of things that we we can do. The enema in itself is, is. Often not fully effective, but it is the least invasive option, the most invasive option which you probably had the misfortune to have needed to do on occasion is to anaesthetize the cat, to do a combination of enemas and manual evacuation where you're sort of milking out the faeces or extracting the faeces yourself with the cat under anaesthesia.

And in the middle we've got the oral laxatives and in particular polyethylene glycol 3350, which is often called PEG, PEG or PEG 3350, which is contained in many laxatives used in people, and which I'll talk about specifically because that has, we've found to be incredibly helpful in cats as well. We want to avoid phosphate enemas, which are often used in people because in cats, they can cause hypophosphatemia and hypocalcemia, which can be fatal, so we definitely want to avoid those. But there are a number of different enemas that we can use that the humble microlax can be helpful.

Really for pretty mild constipation if there is, you know, a sort of stubborn faecal nugget that needs removing, then fair enough. But generally for the really severe cat we can feel really compacted faeces on your abdominal palpation. I wouldn't bother with a microlax.

I think it's just not going to be anywhere near enough. Enema options are generally going to be with that severely impacted cats not tolerated very well consciously, but, often require the cats to be sedated or anaesthetized to to be performed and. So I don't do these actually anymore pretty much anymore because of better options which I'll share with you on the next slide.

But you would need a soft lubricated tube, and you can use either warm water or warm saline. To which you can add things and I would typically add lactulose, just it's something that's there and on the shelf and often helpful, but you can use mineral oil or docusate is another stool softener, or KY gel as well. People have used as just a really intense lubricant to help pass the faeces out.

What I like to use, and I think is a much better option all round is the oral laxatives. So the PEG 3350 that I already mentioned. And although I've put the top of this slide, a slight contradiction there, a newer, and better approach, the contradiction is not the better bit, but newer, and then putting 2010 next to it makes me sound really, really old, but, this is an abstract from 2010, by car and colleagues and.

They reported it in 2010, but it was never written into a full paper. And so I think it's never really filtered out into the vet world very widely. It's relied on CPD and constipation CPD is probably not the most popular CPD shall we say.

So there are still a lot of clinicians that I meet that are not aware of this study. But, in this study, and colleagues, what they did in these severely severely impacted cats that that previously would have all needed general anaesthetic and this, you know, manual evacuation of the faeces. Instead of that, what they did is they placed a nasal esophageal tube.

And they actually used infusion pumps to trickle in this polyethylene glycol solution, and there are a number of different preparations, ones that are used prior to endoscopy that in people that have preparations like clean prep, so explains it all, but also are used for management of long-term constipation in people, so things like Movicol are very much they all contain the same PEG 3350. But in this protocol, car and colleagues trickled in this peg solution and at a rate of 6 to 10 mL per kg per hour, and what they found was all the cats basically pooed within 24 hours. The median was 8 hours, and so it prevented the need for general anaesthetic and this manual evacuation.

The cats basically were able to pass the faeces themselves. And as long as there's no obstruction of the the colon or rectum, this is safe to do and appears, you know, safe from an electrolyte perspective as well. So it is something that I would really encourage you to to do the next time you have one of these really tricky cases.

So this is just one case example of a patient of mine, a cat called Hobbs, who sadly had had recurrent episodes of constipation, obstipation, where every few months he would need to come in, be cleared out, and typically he would present as he had done to me with poor appetite, lethargy, depression, some vomiting. It's all. And he was very, very constipated.

So, we placed the nasal esophageal tube actually, rather than attaching him to a pump, we bolused peg. So I gave 20 to 30 mL per kilo every few hours. I think it was probably about every 4 hours or 3 hours, sorry.

Written on the slide, and, you can see he's giving me the death stare in this photo. He wasn't well impressed at having a tube and a collar. However, this does, does work very, very well, and so he did defecate after 4 administrations and avoided the need for a clear out.

And actually with Hobbs, I used Moviol because I happened to have some Moviol from one of my children, but, and it was before we had the the sort of easily available vet options, which now exist, the Bova and Summit, both, for example, produce a peg, preparation, but, Hobbs had the Mova call and, so if you are tuning into this from a country outside the UK. Then it, it is essentially the same product as as is used in human preparations. So in the long term, how are we going to manage these cases as well so that we prevent recurrence.

Some of these cases can be very challenging to manage, and ultimately colectomy, it is an end stage surgery for some of these really refractory cases. I'm not a surgeon, but I guess that pelvic canal surgery may be something that's indicated in some cases as well, hence including on this slide. What general advice also can we offer to our owners?

Well, we definitely want to always offer a clean litter tray, encourage the cat to be active, manage their weight where appropriate, if they've had fur balls, then grooming the cat can be helpful. We want to definitely encourage drinking, maintain. Any and all tactics at all that we can think of there.

So things like cats tend to prefer drinking out of metal, glass or ceramic dishes. They like them full to the brim rather than plastic dishes. Some cats do like water fountains, of course.

All these sort of tips can be helpful. Also for those cats that have had really severe episodes. Training the owners in feeling the cat's abdomen so that they know what, you know, perhaps if a build up that needs veterinary attention has occurred, particularly for those cats that don't use a litter box and go outside.

If the cat's using the litter box, then I would say to the owner, we're really aiming for the cat to poo once a day. That would be the intention and preferably, you know, a soft but formed poo every day. So, I mentioned encouraging drinking.

Wet food is probably the most significant thing that has an impact on our cat's hydration. It's a natural way of taking in a lot of fluid, but we do have a lot of dry cat addicts out there. And also cats with kidney disease or constipation that just generally vulnerable, that may benefit from having more water than they would otherwise drink.

And I thought this was maybe thinking of the innovations, there's a relatively new product called Hydracare, which is made by Purina. And one of its indications is indeed the constipated cat. Hydrocare comes in sachets and it's it's called a nutrient enriched water.

It looks like a little bit of a sort of watery gravy as you can see, actually this is a video, so I'll click it on in Cassie is drinking Hydrocare in that left hand video. And this is, a, a, a sort of liquid that is palatable, but also it formulated in such a way that it is very well absorbed, and really supports hydration, and, is therefore. Helpful in cats with urinary disease, but also helpful in those constipated cats where you just want to really ensure they are as optimally hydrated as possible and that that is not a reason for absorption of fluid from the faeces whilst they're in the colon.

And the study data shown above the videos has two groups of cats, the cats receiving Hydracare at the top line, the darker blue, and it shows firstly, over the first period is the control period where before they started offering the Hydrocare, just looking at the total liquid drunk per day in grammes was up to about 150. For all of the cats, whichever group they were in, and then the study days they have a sort of one time dose of nutrient water offered, and you can see those cats in the nutrient water group, the top line are drinking more because they're taking in more fluid per day. And when the doses increased up to 2 times, you can see again a dose dependent increase in the amount of liquid drunk per day.

So in other words, the cats don't stop drinking the water. But they just end up drinking more. The bottom right bar chart shows the 48 hour pooled urine specific gravity of these cats over a period of time.

So again, we've got the baseline is the first set of columns, and just to keep you on your toes, they've reversed the colour schemes here. So the nutrient water group is now the paler blue. And you can see the cats are broadly all consuming broadly all producing urine with a specific gravity of around about 1050.

But then on the 1 times 1.5 times and 2 times nutrient water dose, you can see that the USG of the cats on that nutrient water, the cats that are being offered Hydrocare, comes down to 1020 to 1030. In a dose dependent fashion.

So this is a products worth trying. Some cats really do love it. Of course, not every cat does and some cat loves it for a bit and then goes off it.

But even for the few days that the constipation is really at its worst, this would be something that I routinely recommend to my clients that they use. I also mentioned having a clean optimum litter tray available to your cats, so I do believe any cat with urinary or defecation issues should be offered a litter box, and all older cats, by which I mean cats aged 11 years and over, should also be offered a litter box, even if they've always preferred to go outside and toilet outside, give them the option. And the ideal, the optimum litter tray is in a quiet, undisturbed location that's easy for the cat to access, and the litter tray needs to be large, so it ideally should be 1.5 times the cat's body length in length.

That's the cat's body length from the nose to the tail base as a minimum. So really the largest tray you can find generally. A low-sided or low entry point is especially important for older cats.

With your younger cats, it's perhaps less critical, but any mobility issue, and you want a low access point, not covered, not lined, and the cats, if they would, if they could choose what cat litter they wanted, they would generally tend to go for a fine. Sandy consistency clumping litter and that resembles sand, which is their typical preferred substrate, but if it's a clumping litter, the beauty of that is that you can easily scoop the waste, whether that's urine or faeces, and so the tray always appears from the cat's perspective, as long as you are scooping to be clean and inviting. We want to have plenty of litter trays, so ideally one per cat and one extra.

Don't put them all in a row, you want them in separate locations, so it's not possible for one cat to block access to the toilet facilities by another, and obviously we want to make sure that they are kept as clean as possible, even with your. Your scooped clumping litter periodically depending on the number of cats using the tray, you will need to empty that tray completely and give it a wash. But if you've only got one cat and it's not got, either polyuria or diarrhoea, you probably don't need to do that too frequently.

So what other strategies can be helpful just to review some of the things that are out there and some that are more helpful than others. Cadillacs and similar branded products are available as a sort of flavoured mineral oil for cats, and they're often marketed for passing hair balls, but also helpful for. Mild constipation.

They are very, very mild and benign. Some owners really swear by these, but for cats with significant problems, they're not really going to be, I think, part of the solution and generally not recommended for long term use as well in terms of inhibiting absorption of nutrients, for example. If you have mineral oil itself in a bottle, I would not dose a cat orally with that because if they do aspirate it, it can cause a lipid pneumonia, which can be really really unpleasant and actually I had cases where they needed lung lobes to be removed because the the pneumonia was so bad and an impact on the cat.

So I would definitely only use the palatable preparations and if the cat is obviously happy to to take them. Stool softeners, things like docusate, can be, can be helpful, but probably are not always easy to administer to a cat. I have used them occasionally in enemas, but I don't tend to use these very often.

I'm really including for completeness, if this is something that's on your list and you would like sort of a bit more information about it. But it is certainly it can be helpful, when you use it. Stimulants also have a role to play, particularly the megacolon cats.

So Sisapride is probably the one that you're most familiar with there, and we are able to get that in reformulated, . Products, losing my words there, but you can see the tablets and the suspension available from Summit, for example, and certainly in combination typically with a softener, so something like lactulose or peg orally, these can be effective in some megacolon cats in treating their disease. There have been concerns expressed in people with long term use.

This is something that I guess we've not commonly recognised in cats, but just worth mentioning. And of course we don't want to use a stimulant if we are unsure or suspect any obstruction of the colon. Combinations of things are often used in more severe cases, and I've already mentioned that combination of lactulose or peg with cisapride, but there are some human preparations that are combinations, and Normax would be one of those, although I'm not certain that it's still available, having done a little bit of a Google.

It's something I've used extremely infrequently, but mentioning here just because in some refractory cases that have not responded toysaid and where surgery is not an option for that mega colon. I have had some success, using this combination of, Danron or Danthron, and, Docuzate. Diets are also important to look at, and there are a number of different approaches.

Canned definitely preferable to dry for most most conservative cats just because, again, we want to promote optimal hydration. But then we have the whole sort of fibre story really and in the past we used to really go to the two extremes of either a high fibre diet, a very sort of bulky diet, the likes of Hills Adi or WD to sort of increase the faecal water content and bulk, so you have these. Soft voluminous faeces, that certainly in some, some constipated cats could, could be a successful strategy, but I would very much avoid in a cat with mega colon because you just end up with a, you know, very distended dilated full colon quite easily.

The other extreme was the low residue diet. So a diet that just really highly digestible, very, very little faecal material produced, and that is, is a route that I would often take with a megacolon case because, you know, you just want as small a volume of of faeces produced as possible really in those cats because it's, it's gonna be less work for the colon, less to accumulate. But the world of fibre has definitely moved on from there.

And so there are now some diets that are very good, that are sort of moderate fibre. So they're not high fibre, they're not low fibre. They have a combination of, of digestible and undigestible fibres, that contribute to, I think, better sort of colonic health in terms of softening, but also potentially helping stimulate the colon to pass the faeces.

There are some studies, particularly with the Royal Canon moderate fibre diet, that showed the cats with refractory conservation could do very well. You know, some of these cats just with diet alone, but other cats, it allowed reduction of other therapies and a much better outcome compared to standard diet and cisapride lactulose, for example. I am a fan of looking at the diet and trying to explore what dietary options might be helpful for cats with chronic constipation where possible.

Obviously cats that have renal disease, the priority is still the therapeutic renal diet for those cats that certainly have significant renal disease. So we can't always choose the perfect diet. It does depend on the individual patient needs as well.

And then finally, as I've already emphasised, I'm not a surgeon, but surgery is an appropriate treatment for many cats with really intractable constipation in spite of our best efforts. So those really difficult megacolon cases that. Just don't respond to cisapride or potentially other stimulants where we're just having a vicious cycle of faeces accumulation and not being able to clear it out.

Actually a subtotal colectomy can be the answer. Similarly, excuse me, surgery can be, of course, helpful for some cats with colonic masses, not terribly commonly seen in cats, but, surgery can be curative for some of those as well. So don't forget to consider that as part of the potential strategy for your cat with constipation.

And this is actually a practise catheter clinic I worked at some years ago who'd had a had a various traumas, resulted in megacolon amongst other issues and and had lived very, very well, post colonic surgery. So thank you very, very much for choosing to listen to this webinar. I do hope that you've found it helpful, and I hope that there have been some tips that are useful with respect to future management of these cases.

And I would encourage you also to visit my website, where particularly under the Helpful info menu, you can see different pages where there are free to access resources. There are some webinars that are free to view for both vets. And nurses, but also for owners, there are some technical guides and resources there as there as well.

Thank you very, very much.