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Exocrine Pancreatic Insufficiency (view source)

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{{OpenPagesTop}}Also known as: '''''EPI — Pancreatic Exocrine Insufficiency'''''
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==Introduction==  
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'''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.
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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| Exocrine Pancreatic Atrophy]] or [[Pancreatic Atrophy, Exocrine|Pancreatic Acinar Atrophy (PAA)]]. In the cat EPI is usually associated with [[Pancreatitis|chronic pancreatitis]].
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==Description==
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'''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.
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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 [[Pancreatitis, Chronic Interstitial|chronic pancreatitis]].  
      
==Signalment==
 
==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 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.  
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EPI can occur in cats as a result of [[Pancreatitis, Chronic Interstitial|chronic pancreatitis]] and also occasionally in calves with [[Pancreatic Hypoplasia|pancreatic hypoplasia]]. In contrast, '''horses''' with very little pancreatic tissue develop '''hypoinsulinism''' but rarely EPI.
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EPI can occur in cats as a result of [[Pancreatitis|chronic pancreatitis]] and also occasionally in calves with [[Pancreatic Hypoplasia|pancreatic hypoplasia]]. In contrast, '''horses''' with very little pancreatic tissue develop '''hypoinsulinism''' but rarely EPI.
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For EPI in the dog see [[Exocrine Pancreatic Insufficiency - Dog| here]]
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<big>'''[[Exocrine Pancreatic Insufficiency - Dog|Exocrine Pancreatic Insufficiency in the dog]]
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For EPI in the cat see [[Exocrine Pancreatic Insufficiency - Cat| here]]
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'''[[Exocrine Pancreatic Insufficiency - Cat|Exocrine Pancreatic Insufficiency in the cat]]</big>
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==Diagnosis==
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===History===
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*Weight loss with or without polyphagia (usually ravenous with scavenging)
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*Coprophagia and pica
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*Polyuria and polydipsia due to Diabetes Mellitus
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*Varible diarrhoea (large volumes of semi-formed faeces)
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*Vomiting
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*Borborygmus and flatulance
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===Clinical Signs===
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*Steatorrhoea
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*Diarrhoea
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*Mild to marked weight loss
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*Muscle wastage
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*Polyphagia
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*Poor haircoat
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*Flatulance
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===Laboratory Tests===
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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.
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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.
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Other tests are available but are often inconvenient and expensive.
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===Other===
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Atrophy of the pancreas seen via exploratory laparotomy or laparoscopy
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==Treatment==
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===Enzyme replacement===
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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.
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===Dietary modification===
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*Diets containing high volumes of non-fermentable fibre should be avoided
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*Low fat diets should not be fed
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*Certain studies show that:
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**animals may do better with a highly digestible diet
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**the animals may also benefit from readily hydrolysed and absorbed medium chain triglycerides within the diet
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===Vitamin supplementation===
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Levels of vitamin B12 (cobalamin) and vitamin E (tocopherol) are often found to be low.
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*Tocopherol should be supplemented for 1 month
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*Cobalamin weekly for several weeks. Long term monitoring should be carried out in cats.
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===Antibiotic therapy===
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{{Learning
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Dogs with EPI often have Small Intestinal Bacterial Overgrowth (SIBO). This can be treated with oral oxytetracycline, tylosin or metronidazole.
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|Vetstream = [https://www.vetstream.com/felis/search?s=exocrine Exocrine pancreatic insufficiency (EPI)]
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|literature search = [http://www.cabdirect.org/search.html?rowId=1&options1=AND&q1=%22Exocrine+Pancreatic+Insufficiency%22&occuring1=title&rowId=2&options2=AND&q2=&occuring2=freetext&rowId=3&options3=AND&q3=&occuring3=freetext&x=37&y=15&publishedstart=yyyy&publishedend=yyyy&calendarInput=yyyy-mm-dd&la=any&it=any&show=all Exocrine pancreatic insufficiency publications]
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===Glucocorticoid therapy===
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}}
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This is a last line treatment.
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*Oral prednisolone. Long term treatment is usually not needed
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==Prognosis==
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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==
 
==References==
    
Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) '''BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition)''' ''BSAVA''
 
Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) '''BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition)''' ''BSAVA''
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Ettinger, S.J, Feldman, E.C. (2005) '''Textbook of Veterinary Internal Medicine''' (6th edition, volume 2)
 
Ettinger, S.J, Feldman, E.C. (2005) '''Textbook of Veterinary Internal Medicine''' (6th edition, volume 2)
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[[Category:Pancreas_-_Pathology]][[Category:To_Do_-_Clinical]]
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[[Category:To Do - Caz]]
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Sturgess, K. (2003) '''Notes on Feline Internal Medicine''' Blackwell Publishing.
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[[Category:Cat]][[Category:Cattle]][[Category:Dog]]
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Tams, T.R. (2003) '''Handbook of Small Animal Gastroenterology''' (2nd edition) Saunders.
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{{review}}
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{{OpenPages}}
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[[Category:Pancreas_-_Pathology]]
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[[Category:Pancreatic Diseases - Cattle]]
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[[Category:Expert_Review]]
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