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Exocrine Pancreatic Insufficiency 317

Exocrine Pancreatic Insufficiency Client Education
Sheet
VetBooks.ir Diseases and Disorders

German shepherds, rough-coated collies,
BASIC INFORMATION
and should not be used for the diagnosis of
and Eurasians. • Other diagnostic tests are much less reliable
Definition • In the vast majority of the remainder of dogs EPI in dogs or cats:
A syndrome caused by insufficient secretion of and in almost all cats, EPI is due to chronic ○ Fecal proteolytic activity is recommended
pancreatic digestive enzymes by the exocrine pancreatitis. only for species for which a TLI assay is
pancreas • Other potential but rare causes of EPI include not available (e.g., ferrets).
obstruction of the pancreatic duct by a ○ Measurement of fecal elastase concentra-
Epidemiology pancreatic adenocarcinoma or abdominal tion is available only for dogs and only
SPECIES, AGE, SEX surgery, pancreatic aplasia, or pancreatic in Europe. A positive test result is not
Occurs more commonly in dogs than in cats. hypoplasia. specific for EPI and must be confirmed
In dogs belonging to breeds that are affected • Decreased secretion of pancreatic digestive with a decreased cTLI concentration.
by pancreatic acinar atrophy (PAA), exocrine enzymes leads to lack of these enzymes in the • Serum cobalamin concentration should
pancreatic insufficiency (EPI) is most commonly small intestine, which leads to maldigestion be assayed because > 80% of dogs and
diagnosed in young adults. In other dog breeds and associated clinical signs. virtually all cats will be cobalamin deficient
and cats, EPI can occur at any age. • Secondary cobalamin deficiency is very and therefore require oral or parenteral
common in dogs and occurs in almost all supplementation.
GENETICS, BREED PREDISPOSITION cats with EPI.
In some dog breeds (i.e., German shepherds, • In patients with EPI due to chronic pan- TREATMENT
rough-coated collies, and Eurasians), EPI is creatitis, pancreatic inflammation may also
considered to be hereditary. A simple autosomal- lead to destruction of islets of Langerhans Treatment Overview
recessive inheritance, until recently suspected and cause concurrent diabetes mellitus. • Pancreatic enzyme replacement is crucial.
to be the mode of inheritance in the German • Cobalamin can be supplemented parenterally
shepherd dog, has now been disproven. There DIAGNOSIS or orally if cobalamin deficiency is present.
is no known breed predisposition in cats. See
Etiology below regarding PAA. Diagnostic Overview Acute General Treatment
The most reliable diagnostic test for EPI for • Oral enzyme replacement therapy
RISK FACTORS dogs and cats is serum trypsin-like immunore- ○ Starting dose: 1 tsp/10 kg body weight
• Chronic pancreatitis can lead to destruction activity (TLI) concentration, which is measured with each meal
of exocrine pancreatic tissue and EPI. by species-specific assays. ○ Tablets and capsules are not as effective
• Rarely, pancreatic adenocarcinoma or as powder.
abdominal surgery can lead to obstruction of Differential Diagnosis ○ Premixing the pancreatic enzymes with
the pancreatic duct, causing lack of pancreatic • Primary small-intestinal disease (e.g., inflam- the diet is not necessary.
enzyme secretion into the small intestines. matory or infiltrative bowel disease) • Oral or parenteral cobalamin supplementa-
• Other secondary causes of chronic diarrhea tion if the patient is cobalamin deficient
ASSOCIATED DISORDERS and weight loss (e.g., hepatic failure, chronic ○ Oral supplementation: 250 mcg (cats and
Many canine and feline patients with EPI have kidney disease, hypoadrenocorticism, hypo- small dogs) to 1500 mcg (giant-breed
other gastrointestinal disorders. Dogs with EPI thyroidism [dogs], hyperthyroidism [cats], dogs) daily for 90 days, then re-evaluate
commonly have secondary small-intestinal other less common causes) 2 weeks after last dose
dysbiosis (formerly known as small-intestinal ○ Parenteral supplementation: 250 mcg (cats
bacterial overgrowth or antibiotic-responsive Initial Database and small dogs) to 1500 mcg (giant-breed
diarrhea [p. 260]); other dogs and cats can • CBC, serum chemistry profile, and urinalysis dogs) weekly for 6 weeks with one more
have concurrent idiopathic inflammatory bowel results are usually within normal limits. dose a month later and re-evaluation a
disease (p. 543). • Imaging studies are usually unremarkable. month after that
Clinical Presentation Advanced or Confirmatory Testing Chronic Treatment
HISTORY, CHIEF COMPLAINT • Serum TLI is the test of choice for a diagnosis • Oral enzyme replacement therapy
• Weight loss is the most common clinical of EPI in dogs and cats. ○ After patients have fully responded and
sign in dogs and cats. ○ A severely decreased serum TLI concentra- returned to their ideal body weight, the
• Loose stools and less commonly diarrhea tion is diagnostic of EPI. amount of enzyme supplement can be
• Ravenous appetite ■ In dogs: ≤ 2.5 mcg/L (cTLI; reference decreased to the lowest effective dose,
○ Unlike dogs, approximately 40% of cats interval, 5.7-45.2 mcg/L) titrated based on stool quality and body
with EPI can have decreased appetite. ■ In cats: ≤ 8.0 mcg/L (fTLI; reference condition score or weight.
interval, 12-82 mcg/L) • Oral antibiotic therapy (e.g., tylosin 25 mg/
PHYSICAL EXAM FINDINGS ○ Some patients may have a serum TLI kg PO q 12h for 6 weeks) and cobalamin
• Poor body condition (NOTE: due to timely concentration in the questionable range supplementation in patients that do not
diagnosis in dogs, emaciated patients are rare.) (>2.5 but <5.7 mcg/L [dog]; >8.0 but respond to enzyme replacement therapy alone.
• Poor haircoat and sometimes in cats, greasy <12.0 mcg/L [cat]). • Insulin therapy if patient has concurrent
soiling of the haircoat, especially in the ■ These patients most likely have chronic diabetes mellitus (p. 251)
perianal area small-intestinal disease and should be
evaluated accordingly and then retested Nutrition/Diet
Etiology and Pathophysiology 4-6 weeks later. • Dietary fat restriction is not recommended.
• Approximately 50% of dogs with EPI have • If no other disease process can be identified, • Several studies in dogs have failed to show
PAA, a condition that is mostly seen in trial therapy may be helpful. any impact of diet on therapeutic response.

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