Exocrine Pancreatic Insufficiency

Signalment

• Most common in dog:
  • German Shepherd Dogs
  • Rough Collie
• Occurs occasionally in other species including calves with pancreatic hypoplasia and in cats (chronic pancreatitis)
• In contrast, horses with very little pancreatic tissue develop hypoinsulinism but rarely EPI

Description

Exocrine pancreatic insufficiency (EPI) is a syndrome caused by insufficient synthesis and secretion of digestive enzymes by the exocrine portion of the pancreas

• Leading to insufficient activity of digestive enzymes in the lumen of the small intestine
• Pancreas has considerable functional reserve, large proportion needs to be non-functional to show signs of EPI
• In dog it is mostly caused by pancreatic atrophy or Pancreatic Acinar Atrophy (PAA)
• In the cat it is usually associated with chronic pancreatitis

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 TLI serum assay. 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. A starting dose of 2 teaspoons per 20Kg of bodyweight per meal is usually effective. 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 (100-150g/20Kg bodyweight).

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 (5-25IU/Kg bodyweight orally)
• Cobalamin weekly for several weeks (100-250µg i.m. or s.c.). 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 at 1-2mg/kg bid for 1-2 weeks. Long term treatment is usually not needed

References

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