Abstract
Objectives
The aim of this study was to evaluate and describe 13 cases in which a pet piller broke during the administration of medication, and the tip was accidentally ingested by the cat.
Methods
A total of 15 presentations to the clinic were identified in a private practice database involving 13 cats in which the silicone tip broke. Two of these cats ingested foreign bodies on two separate occasions. Routine radiographic examination enabled the identification of silicone tips in all animals. On 2/15 occasions, the cats did not receive an emetic drug. Intramuscular xylazine (0.2 mg/kg) and dexmedetomidine (6 μg/kg) were administered to 12/15 and 1/15 cats, respectively.
Results
The cats were aged 3–17 years (mean age 11.00 ± 4.35 years). Vomiting occurred in 13 cats that received alpha-2 adrenoceptor agonists, although the silicone tip was recovered in only five occurrences. In 9/15 occurrences, endoscopy was performed under general inhalation anesthesia, and the silicone tip was successfully removed. Natural elimination occurred in only one case.
Conclusions and relevance
The use of pet pillers with detachable silicone tips increases the risk of accidental foreign body ingestion by animals. Therefore, guidelines regarding safety standards for manufacturing would be beneficial. No cat in this series developed clinical signs related to the ingestion of the piller tip, probably because of the quick presentation by the owners and early intervention, including endoscopic retrieval. Surgical intervention was not required in any case, including one in which the foreign body was lodged within the small intestine before being passed naturally by the cat.
Introduction
The accidental ingestion of foreign bodies by animals is routinely encountered in clinical practice. Cats ingest yarn, wool, paper, rubber bands, plant materials, plastics, hair and small toys. 1 Animals with gastric foreign bodies usually do not present with clinical signs unless the foreign bodies cause mucosal irritation, gastric distension or gastric outflow obstruction. However, intestinal foreign bodies result in clinical signs ranging from acute regurgitation and vomiting to chronic depression and inappetence, depending on the type, location, duration and severity of the obstruction. 2
Different types of small animal products can be purchased online and in bricks-and-mortar stores. Four types of pet pillers are available. The first is a syringe-type with no detachable parts and a unique applicator with an end shaped like two claws (Kruuse Buster Pet Pill/Tablet Syringe with Classic Tip; Jørgen KRUUSE A/S) (Figure 1a). The second is a pill gun with a single body, no detachable parts and a cylindrical shape with a cut at the end (Butler Sales Bullseye Pillgun Pet Pill Popper for Dogs and Cats; Patterson Veterinary) (Figure 1b). The third is a pet medicine syringe with two silicone tips (one for dispensing pills and the other for liquids) that project from the body of the applicator (QIYADIN Cat Pill Shooter Pet Piller Gun Dog Pill Shooter Cat Tablet Soft Tip Syringe; PetHouzz Store) (Figure 1c). The fourth type has a syringe-like applicator with a silicone tip that is glued on, and thus does not detach from the applicator; this is used for up to 10–15 days for a single treatment cycle in each animal (Buster Tablet Introducer Safety Soft Tip; Jørgen KRUUSE A/S) (Figure 1d).
Different types of pet pillers. (a) The syringe type has finger rings for better control during administration of a tablet or capsule. It has a transparent barrel, a reinforced tablet holder and a piston with a plunger. It does not have detachable pieces and is strong enough to withstand chewing (Kruuse Buster Pet Pill/Tablet Syringe with Classic Tip; Jørgen KRUUSE A/S). (b) The pill gun with a single body does not have detachable pieces and is durable. It is designed for repetitive use and can administer multiple pills (Butler Sales Bullseye Pillgun Pet Pill Popper for Dogs and Cats; Patterson Veterinary). (c) The pet medicine syringe piller has two detachable silicone soft tips: an open tip for small pills and a closed tip for liquids (QIYADIN Cat Pill Shooter Pet Piller Gun Dog Pill Shooter Cat Tablet Soft Tip Syringe; PetHouzz store). (d) The tablet introducer has a soft tip (1.3 inches) and silicone jaws glued to the syringe. It can be used a total of 10–15 times for a single treatment cycle per animal (Buster Tablet Introducer Safety Soft Tip; Jørgen KRUUSE A/S)
To the best of our knowledge, there have been no published cases of foreign bodies ingested by cats owing to detachment of pet piller tips. In this study, we evaluated and described 15 occasions in which a pet piller broke while pilling a cat, and the tip was accidentally ingested by the cat.
Materials and methods
A review of medical records in a private practice identified 13 cases with 15 separate veterinary visits involving the administration of a silicone tip to cats owing to detachment of the applicator tip between October 2017 and February 2023. For all cats, plain abdominal radiographs in the right, left and ventrodorsal positions were obtained within the first hour of admission, regardless of the time of ingestion. Endoscopy using a flexible video endoscope (Fujinon EG-250WR5, outer diameter 9.3 mm; inner diameter 2.8 mm; working length 1100 mm; total length 1400 mm) was performed for cats that did not expel the silicone tip by other methods. For general anesthesia, a catheter was placed in the right cephalic antebrachial vein, and all animals were premedicated with butorphanol 0.2 mg/kg IM. Anesthesia was induced with propofol (5 mg/kg IV) and was maintained with isoflurane in oxygen.
The heart rate, respiratory rate and rectal temperature were recorded before premedication and monitored immediately after induction of the anesthesia. Monitoring, which included lead II electrocardiography, was used to derive the heart rate, pulse oximetry, capnography, non-invasive mean arterial pressure measurement and rectal temperature measurements (LifeWindow Lite LW8Vet; Digicare). During anesthesia, 0.9% sodium chloride solution was administered at a rate of 3 ml/kg/h IV.
Results
Fifteen instances were identified from the medical database of the veterinary clinic, wherein 13 cats aged 3–17 years (mean age 11.00 ± 4.35 years) ingested the silicone tip of a pet piller (Table 1). The breeds included domestic shorthair (n = 10), Persian (n = 2) and Birman (n = 1). There were eight spayed female cats and five castrated male cats. Two cats ingested foreign bodies on two separate occasions, with intervals of 11 days and 4 months between the first and second ingestions, respectively. The owners reported that the pillers had detachable soft silicone tips and had been recently purchased.
Characteristics of the 13 cats that swallowed the silicone tip of a pet piller (n = 13 cases)
CKD = chronic kidney disease; CM = castrated male; DS = domestic shorthair; FeLV = feline leukemia virus; FIV = feline immunodeficiency virus; IBD = inflammatory bowel disease; SF = spayed female
None of the cats presented with vomiting, abdominal pain, discomfort, hematemesis or other clinical signs. On 9/15 occasions, the cats arrived at the hospital within 1 h of ingestion, whereas on 3/15 occasions, the cats arrived at the hospital after 3–5 h and 9–10 h.
The radiographic opacity, size and shape of the ingested foreign material enabled a definitive radiographic diagnosis in all cats. Foreign bodies were detected in the stomach and small intestine on 14/15 occasions (Figure 2a) and 1/15 occasions, respectively.
Silicone tips (white arrows) ingested by cats due to detachment from pet pillers. (a) Lateral abdominal radiograph showing a radiopaque cylindrical foreign body in the stomach. (b) After xylazine administration, the cat was able to expel the silicone tip through vomiting. (c) Endoscopic removal of the foreign body from the stomach. (d) Spontaneous elimination of the foreign body in fecal matter
On 2/15 occasions, the cats did not receive emetic drugs; these included one case involving chronic valvular disease and one in which the foreign body was in the small intestine. To induce emesis, xylazine 0.2 mg/kg IM was administered in 12/15 cases (Figure 2b), while dexmedetomidine 6 μg/kg IM was administered in 1/15 cases. Thus, alpha-2 adrenoceptor agonists were administered to 13 cats, and vomiting occurred in all cases. However, the silicone tip was recovered using this method in only five cases. One cat received two doses of xylazine during the same visit, while the other received two doses of dexmedetomidine; neither cat expelled its silicone tip. The cat that received dexmedetomidine was excessively sedated and received the reversal agent atipamezole, whereas the cat that received xylazine showed low sedation levels and did not necessitate the use of a reversal agent.
One cat that did not receive alpha-2 adrenoceptor agonists vomited and did not expel the silicone tip. Subsequently, hydrogen peroxide (3%, 3 ml) was administered through a nasogastric tube to induce emesis. The animal vomited again, and the tip was expelled.
On 9/15 occasions, the cats underwent endoscopy under general inhalation anesthesia, and the silicone tip was successfully removed (Figure 2c). The interval between the suspected ingestion of the foreign body and endoscopy was in the range of 2–30 h. After presentation at the hospital, endoscopy was performed within 3 h in 5/9 cases, at 10–20 h in 3/9 cases and within 30 h in 1/9 cases. Natural elimination 36 h after ingestion of the silicone tip was observed in only one case (Figure 2d).
After the removal of the silicone tip, the cats were hospitalized for 4–24 h. During hospitalization, the cats received an oral gastric protectant (omeprazole, 1.1–1.3 mg/kg q12h) and an oral antiemetic (ondansetron, 0.5 mg/kg q12h) as part of supportive care to prevent esophagitis and gastritis.
Discussion
Foreign body ingestion by cats is generally accidental. 1 Based on this study, when diagnosing and treating foreign body ingestion, veterinarians should consider the cat’s age, comorbidities and clinical signs, the type and location of the ingested object, the time of ingestion and access to digestive endoscopy. In addition to radiographic evaluations, a detailed clinical history and physical examination are essential for diagnosis. 3 In the present study, we describe 15 occasions wherein 13 cats accidentally ingested the silicone tip of a pet piller during the administration of medications by the owners. To the best of our knowledge, this is the first report of this type of event.
Medicating cats is not an easy task, and owners are not always capable of doing it themselves. 4 Therefore, a pet piller is used as an aid to dispense pills. This has become increasingly popular among our clinic’s clients. In our experience-based approach, owners often choose products based on immaterial features (eg, color) and cost. In the present study, older cats with pre-existing diseases were the most affected, which is reasonable because they were likely to receive one or more medications daily. Veterinarians must be clear when explaining the prescription and types of pet pillers used. Moreover, they should teach owners an appropriate method for medicating their cats. Such measures can prevent the purchase of applicators with detachable parts, such as silicone tips, which may become easily detached and ingested by the cats. If owners do not receive essential information on the safe administration of oral medications using pet pillers, they may inadvertently purchase unsafe pet pillers with attractive packaging or marketing gimmicks.
The induction of emesis is a convenient method for gastric decontamination after toxicant ingestion and a potentially definitive treatment that can preclude endoscopy. Alpha-2 adrenergic agonists are the preferred emetic agents for cats, with xylazine and dexmedetomidine being the most frequently used. 5 Alpha-2 adrenergic agonists rapidly induce sedation and analgesia and produce a vasoconstrictor effect, which is followed by a period of hypotension and bradycardia due to their negative effect on cardiac contractility and cardiac output; therefore, they should be used with caution. 6 However, they have been shown to improve cardiac performance in a small study of cats with hypertrophic cardiomyopathy. 7 Reversal agents, such as yohimbine and atipamezole, can minimize the adverse effects of alpha-2 adrenergic agonists. 8
Although the recommended dose of xylazine to induce emesis in cats is 0.4–0.5 mg/kg, our individual preference was to administer 0.2 mg/kg IM. 9 Retching and productive emesis occurred in all 13 cats that received xylazine or dexmedetomidine, although the silicone tip was recovered in only five cases where the cat had a full stomach (both food and liquid), which facilitated recovery. Vomiting was not induced in one cat with chronic valvular disease, and one cat underwent endoscopy directly. The remaining cat naturally expelled the tip, which had already moved into the small intestine, via defecation.
According to Thies et al, 5 repeated use of xylazine may result in emesis in cats that do not vomit during the first attempt. In the present study, one cat received a second dose of xylazine after the first dose was ineffective; however, the second dose was also ineffective. In 2015, Thawley and Drobatz 9 demonstrated that compared with xylazine, dexmedetomidine more frequently induced vomiting in a population of cats treated for the ingestion of toxic substances or foreign bodies. In the present study, one cat received two doses of dexmedetomidine (6 µg/kg). However, both attempts were unsuccessful, with a predominantly sedative effect necessitating reversal with atipamezole.
The induction of emesis in cats is challenging. Apomorphine is a non-selective dopamine agonist commonly used in veterinary medicine to induce emesis in dogs as part of the emergency management of toxicosis. 10 Use of apomorphine in cats is controversial; it appears to be ineffective and has been shown to cause behavioral changes (anxiety, repetitive pacing, limb flicking and increased movement), hallucinations and hypermania in experimental studies involving cats. 11 Hydromorphone is advocated as a perioperative analgesic agent for cats and intramuscular or subcutaneous administration is preferred because it facilitates quicker emesis or salivation. 12 One cat in our study received 3 ml of 3% hydrogen peroxide without adverse effects. However, the administration of hydrogen peroxide is unsafe and its use as an emesis-inducing agent in cats is contraindicated. Veterinarians should be aware of the possibility of hemorrhagic necroulcerative gastritis after administration of this agent. 13
Endoscopy is an effective tool for the removal of objects from the gastrointestinal tract of cats and showed high success and low complication rates in the present study as a first-line treatment modality. 2 The cats in our paper were mostly older, and many had pre-existing medical conditions; therefore, avoiding a longer duration of anesthesia and surgical procedures may be beneficial.
The silicone tip of the pet pillers was approximately 3 cm (1.3 inches) in length, and we believe that it could cause acute gastrointestinal obstruction. Therefore, it is extremely important to inform owners about the risks of using pillers and dispensers and emphasize that the removal of objects from the gastrointestinal tract is not free of complications, even in healthy animals. Late presentation for the management of an ingested foreign body can result in complications. Therefore, owners need to understand the importance of immediate veterinary assessment if cats accidentally ingest the tips of pet pillers. 2 Most brands do not indicate the product use period, and the risks associated with the use of a piller with a detachable tip are high. The application of certain minimum standards for quality assurance, such as those applied to children’s toys, may be helpful in ensuring that pet pillers are manufactured with a design that prevents accidental ingestion of their parts during use with domestic animals.
In the present study, all the cats were discharged in good condition. In one case (where a foreign body was located in the small intestine), the owner was educated about potential clinical signs indicating intestinal obstruction and asked to inspect the cat’s stool daily. In this case, spontaneous elimination of the silicone tip via defecation occurred 36 h after ingestion.
The main limitation of this study is that it was a descriptive, retrospective study of data from a single specialty hospital. Data were collected retrospectively rather than according to a prospective plan, meaning that the same information was not consistently recorded and, in some instances, information was missing.
Conclusions
The use of pet pillers with a detachable silicone tip may cause accidental foreign body ingestion by the animal during use; therefore, guidelines regarding safe standards for manufacturing would be beneficial. No cat in this study developed clinical signs related to ingestion of the pet piller tip, probably because of the quick presentation by the owners and early intervention, including endoscopic retrieval. Surgical intervention was not required in any case, including one in which a foreign body was lodged within the small intestine and passed naturally by the cat.
Footnotes
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
The work described in this manuscript involved the use of non-experimental (owned or owned) animals. Established internationally recognized high standards (‘best practice’) of veterinary clinical care for the individual patient were always followed and/or this work involved the use of cadavers. Ethical approval from a committee was therefore not specifically required for publication in JFMS. Although not required, where ethical approval was still obtained, it is stated in the manuscript.
Informed consent
Informed consent (verbal or written) was obtained from the owner or legal custodian of all animal(s) described in this work (experimental or non-experimental animals, including cadavers) for all procedure(s) undertaken (prospective or retrospective studies). No animals or people are identifiable within this publication, and therefore additional informed consent for publication was not required.