Exocrine Pancreatic Insufficiency

Description

Exocrine pancreatic insufficiency (EPI) is a syndrome characterised by insufficient secretion of digestive enzymes by the exocrine portion of the pancreas. Most commonly EPI occurs following the progressive reduction in pancreatic mass caused by pancreatic acinar atrophy or chronic pancreatitis. EPI may also occur secondary to excessive gastric acid secretion (excess acid affects the activity and production of the pancreatic enzymes)or severe protein malnutrition ( decreased synthesis of pancreatic enzymes). Concurrent diabetes mellitus and pancreatic hypoplasia have also been documented as causes in the dog.

The Pancreas has a considerable functional reserve and a large proportion needs to be non-functional to show signs of EPI. In the dog EPI is mostly caused by Pancreatic Atrophy, Exocrine or Pancreatic Acinar Atrophy (PAA). In the cat EPI is usually associated with chronic pancreatitis.

Signalment

EPI is most common in the dog, German Shepherd dogs and rough collies are over-represented. Many other breeds however can also be affected by EPI.

EPI can occur in cats as a result of chronic pancreatitis and also occasionally in calves with pancreatic hypoplasia. In contrast, horses with very little pancreatic tissue develop hypoinsulinism but rarely EPI.

For EPI in the dog see here

For EPI in the cat see here

Diagnosis

History

Weight loss with or without polyphagia (usually ravenous with scavenging)
Coprophagia and pica
Polyuria and polydipsia due to Diabetes Mellitus
Varible diarrhoea (large volumes of semi-formed faeces)
Vomiting
Borborygmus and flatulance

Clinical Signs

Steatorrhoea
Diarrhoea
Mild to marked weight loss
Muscle wastage
Polyphagia
Poor haircoat
Flatulance

Laboratory Tests

Routine tests are generally unhelpful. Serum alanine aminotransferase (ALT) can have mild to moderate elevations. Other biochemical results include reductions in total lipid, polyunsaturated fatty acid concentraions and cholesterol. The most sensitive and specific test for the diagnosis of EPI is the trypsin-like immunoreactivity assay(TLI). The values are greatly reduced as compared to normal animals. Values <2µg/l in dogs and <8µg/l in cats are considered diagnostic. This test must be carried out after withdrawing food for several hours. Serum fTLI is only available from specialist laboratories. Other tests are available but are often inconvenient and expensive.

Other

Atrophy of the pancreas seen via exploratory laparotomy or laparoscopy

Treatment

Enzyme replacement

EPI can be managed with the supplementation of pancreatic enzymes from dried pancreatic extracts. Meals should be fed twice a day to allow weight gain. Many clinical signs resolve within 5 days. Doses can then be lowered to a minimum effective dose which is different for each animal. Cheaper alternatives include chopped raw cow or pig pancreas.

Dietary modification

Diets containing high volumes of non-fermentable fibre should be avoided
Low fat diets should not be fed
Certain studies show that:
- animals may do better with a highly digestible diet
- the animals may also benefit from readily hydrolysed and absorbed medium chain triglycerides within the diet

Vitamin supplementation

Levels of vitamin B12 (cobalamin) and vitamin E (tocopherol) are often found to be low.

Tocopherol should be supplemented for 1 month
Cobalamin weekly for several weeks. Long term monitoring should be carried out in cats.

Antibiotic therapy

Dogs with EPI often have Small Intestinal Bacterial Overgrowth (SIBO). This can be treated with oral oxytetracycline, tylosin or metronidazole.

Glucocorticoid therapy

This is a last line treatment.

Oral prednisolone. Long term treatment is usually not needed

Prognosis

EPI is a life-long condition and so is the treatment. However recoveries have been reported. The prognosis is generally good so long as the owner understands the longevity of the disease and the cost involved with treating it.

References

Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition) BSAVA

Also known as:

EPI