Page 660 - Small Animal Internal Medicine, 6th Edition

632 PART IV Hepatobiliary and Exocrine Pancreatic Disorders

long period while awaiting the resolution of disease. Increas- feeding, if necessary, in a more stable patient. High-fat
ing evidence is accumulating in human medicine about the critical-care diets are potentially associated with increased
VetBooks.ir importance of early enteral nutrition in patients with pan- pain but are tolerated in hospitalized animals with adequate
analgesia. Once the animal is eating voluntarily, it can be
creatitis; the more severe the pancreatitis, the earlier nutri-
tion support should be instituted. Furthermore, recent
initial choice is baby rice mixed with water, followed by a
studies suggest that prepyloric (e.g., nasoesophageal or gas- transitioned on to a lower-fat diet for recovery. A good
trostomy tube) feeding may be as safe as jejunal feeding. low-fat proprietary veterinary diet (e.g., Eukanuba Intestinal
There is little evidence that immunomodulating nutrients are Formula, Mars Petcare; Hill’s i/d Low Fat, Hill’s Pet Nutri-
of benefit, and data on probiotics in pancreatitis are conflict- tion, Topeka, KN; Royal Canin Digestive Low Fat, Royal
ing, with one study showing increased mortality in humans Canin USA, St. Charles, MO; Purina EN Gastroenteric
(Besselink et al., 2008), so these are best avoided. There have Canine Formula, Nestlé SA, Vevey, Switzerland) (Fig. 37.6).
been no studies evaluating the efficacy of early or late enteral It may not even be necessary to use a low-fat diet. There is no
or parenteral nutrition in naturally occurring pancreatitis in evidence that standard diets increase the severity of disease
dogs or cats. Therefore the advice currently given is based on in patients with acute pancreatitis, so a liquid critical care
anecdotal evidence, extrapolation from humans, and experi- diet should also be tolerated if given in small amounts and
mental studies in dogs. However, a recent pilot study com- often. However, there is evidence in humans that higher-fat
paring early enteral nutrition via esophagostomy tube with diets increase pain and prolong hospitalization times for this
parenteral nutrition in 10 dogs with severe acute pancreatitis reason, which also appears to be anecdotally true in dogs.
found that prepyloric tube feeding of a low-fat canine diet, Addition of pancreatic enzymes to the diet is wise in the
with added pancreatic enzymes and medium-chain triglyc- very acute phases of the disease when the pancreas is not
erides, was well tolerated by dogs with acute pancreatitis. The secreting enzymes down the duct. Concurrent antiemetics
dogs receiving enteral nutrition did not show obvious post- are also essential to allow effective feeding in many cases
prandial pain, and a significantly greater number of dogs in (see next section). In patients for which enteral nutrition
the parenteral group showed vomiting and regurgitation is not possible or when only a small percentage of the daily
compared with those in the enteral group (Mansfield et al., caloric requirements can be given enterally, some form of
2011). supplemental parenteral nutrition should be considered.
Starvation is also contraindicated in cats with acute pan- This is administered most practically as peripheral paren-
creatitis because of the high risk of concurrent hepatic lipi- teral nutrition (Chandler et al., 2000). However, it is very
dosis. Current advice is therefore to institute some form of clear that recovery is improved if at least some of the daily
enteral feeding, whenever possible, within 48 hours in dogs calorie intake can be given enterally.
and cats. The more severe the disease, the more important
it is to feed early. In severe cases this is best achieved with Antiemetics
nasoesophageal tube feeding by slow continuous infusion of Antiemetics are often necessary to manage acute vomiting
a critical care diet, although frequent small-volume feeds are in dogs and cats with pancreatitis. The neurokinin (NK1)
also well tolerated by many patients. Anesthesia to place an receptor antagonist maropitant has central and peripheral
esophagostomy or gastrostomy tube is best avoided in the antiemetic effects, and seems to be the most effective anti-
acute stages of pancreatitis but is indicated for longer-term emetic in dogs and cats with pancreatitis. Maropitant is

A B

FIG 37.6
Baby rice is a good first choice for feeding dogs with moderate acute pancreatitis
because it contains no fat and protein. It comes as a finely ground rice powder (A) that
can then be mixed with water and, if desired, a gravy substitute such as Bovril (B) to
enhance the flavor for feeding. Dogs with severe acute pancreatitis should be tube fed a
critical-care diet (see text and Box 37.2).