Page 668 - Small Animal Internal Medicine, 6th Edition

640 PART IV Hepatobiliary and Exocrine Pancreatic Disorders

OTHER DIAGNOSTIC TESTS As noted, dogs and cats with hypocobalaminemia require
It is also advisable to measure the serum cobalamin concen- vitamin B 12 supplementation. This may be by parenteral
VetBooks.ir tration in animals with EPI because it is often decreased injections (0.02 mg/kg IM every 2–4 weeks until the serum
concentration normalizes) or orally. Recent studies have
because of a deficiency of pancreatic IF, as noted earlier. If
the serum vitamin B 12 concentration is low, it should be
and cats with EPI and a lack of IF (Toresson et al., 2017;
supplemented either parenterally or enterally as detailed in demonstrated the efficacy of oral cobalamin even in dogs
the treatment section. 2018). Cyanocobalamin tablets are given at a dose of 0.25 mg
Serum folate concentrations are high in about one-third once a day for cats and dogs 1 to 10 kg; 0.5 mg once a day
of dogs with EPI. This may indicate dysbiosis or SIBO, for dogs of body weight of >10 to 20 kg; and 1 mg once a
although the sensitivity and specificity of high serum folate day for dogs body weight >20 kg. Efficacy of treatment is
concentration for the diagnosis of SIBO are poor. The def- monitored with regular measurement of serum cobalamin
inition and diagnosis of SIBO is problematic; if a newly concentration.
diagnosed dog with EPI fails to respond to enzyme and Dogs and cats with EPI failing to respond to standard
cobalamin supplementation and other comorbidities have therapy should also have a fecal culture as previously
been ruled out, a trial antibiotic therapy for putative SIBO described and any pathogens treated. Concurrent SIBO may
would be indicated. The importance of SIBO and the role of also be suspected in these cases and may respond to courses
antibiotic treatment in cats with EPI are unknown. Occa- of appropriate antibiotics (e.g., oxytetracycline, tylosin, met-
sionally, in dogs and cats with EPI, the serum folate con- ronidazole). It is advisable to administer antibiotics in
centration may be low; this can suggest dietary deficiency affected dogs only as necessary if they fail to respond to
or concurrent inflammatory or infiltrative disease in the enzyme and cobalamin therapy.
jejunum, or potentially metabolism by bacteria, which is It is relatively common for German Shepherd Dogs with
also reported. Unlike cobalamin, there is no clear evidence PAA to have concurrent inflammatory bowel disease, and
that folate should be supplemented in dogs when its level this must also be addressed. Animals with EPI as a result of
is low. chronic pancreatitis may require insulin therapy for concur-
Dogs with EPI have reduced gut immunity and are thus rent DM and other treatment for acute flare-ups, including
likely to be more susceptible to GI pathogens. A fecal culture analgesics (see earlier).
would be indicated in any dog failing to respond to standard
therapy, particularly if it had a history of being fed raw diet
or raw pancreas. DIET
Disruption of fat digestion is the most important feature of
Treatment EPI. A low-fat food has therefore been traditionally recom-
mended, but it may not contain enough calories to feed a
DRUGS large-breed dog (e.g., German Shepherd Dog) effectively. Fat
All dogs and cats with clinical EPI require enzyme supple- usually contributes a significant proportion of daily energy
mentation for the rest of their lives. In most cases, this is intake because it is more energy-dense than carbohydrates.
provided as a powder or in the form of a capsule, which is In large-breed dogs with EPI and cachexia, weight gain may
opened and then sprinkled on the food. A recent study con- be difficult to achieve with a low-fat diet. There is no con-
firmed the efficacy of one enteric-coated canine enzyme vincing evidence in the literature that long-term feeding of
preparation (Mas et al., 2012). Fresh raw pancreas, which a low-fat diet improves outcome in dogs with PAA, although
can be frozen in aliquots, may be used as an alternative and there is some evidence that it may result in faster resolution
can be effective, but there is also the potential for acquiring of clinical signs. However, high-fat diets, such as proprietary
gastrointestinal infections (e.g., Salmonella and Campylo- renal diets, should obviously be avoided. We therefore rec-
bacter spp.). The dose of enzymes is initially as recommended ommend that dogs with PAA be fed a normal to moderately
by the manufacturer and then titrated to the individual. A fat-restricted, highly digestible diet, with reasonable calorie
large proportion of enzyme activity is lost in the acid pH of density. The diet should also be low in fiber because fiber
the stomach (up to 83% of lipase activity and 65% of trypsin impairs the activity of pancreatic enzymes, and soluble fiber
activity). To overcome this, the dosage of enzymes given is may actually absorb pancreatic enzymes. Fiber may also
increased or an H 2 blocker is administered concurrently to reduce small intestinal absorption and activity of brush
increase the gastric pH. Preincubating enzymes with the border enzymes. The proprietary veterinary diets marketed
food is not indicated because they require the alkaline envi- for gastrointestinal disease in dogs (e.g., Hill’s i/d, Royal
ronment of the small intestine to work properly. Reports Canin Gastrointestinal diet, Eukanuba Intestinal or Derma-
suggest that the dosage of enzyme replacement may be tosis FP) fulfill these requirements and are recommended, at
reduced over the long term between 6% and 58% but not least for initial stabilization. In the long term, after the gut
stopped completely, perhaps because of resolution of the wall recovers, these dogs can be maintained on a normal fat
secondary bacterial overgrowth and the effects of chronic level in most cases and can often return to their normal diet.
malnutrition and cobalamin deficiency on enterocytes and In some individuals with PAA, extra calories can be added
brush border enzymes. to the diet between meals in the form of medium-chain