EPI

Question 1

Compare the endocrine and exocrine pancreas

Answer 1

Endo - 2% - hormones in blood

Exo - 98% - into the duodenum

Question 2

What are the possible causes of EPI?

Answer 2

Most common in dogs - pancreatic acinar atrophy (PAA) just exocrine
Cats - chronic pancreatitis (can happen in dogs too) (endo and exocrine function)
Pancreatic hypoplasia (endo and exocrine function, puppies, v v v rare)
Chronic pancreatic duct obstruction (e.g. by neoplasia) - seen in humans, not documented in animals. Can cause pancreatitis or atrophy

Question 3

What is the likely signalment of PAA?

Answer 3

Mostly dogs
GSDs/ rough coated collies over represented, possibly also chows
Autosomal recessive

Question 4

What happens in PAA

Answer 4

Possibly auto-immune,
Marked inflammatory infiltrate with T lymphocytes, leading to loss of secretory ability
subclinical then clinical phases

Question 5

When do signs of EPI appear?

Answer 5

Maldigestion once 90% of secretory ability is lost

Question 6

What are the signs of EPI due to?

Answer 6

Loss of digestive ability
Low b12/ other vitamins
Changes in SI mucosa/ microflora

Question 7

How is the mucosa affected in EPI?

Answer 7

Decrease in intrinsic factors to maintain normal GI mucosa
Abnormal activities and impaired function of mucosal enzymes
Reduced degredation of exposed brush border enzymes

Question 8

Why are there changes in intestinal microflora in EPI?

Answer 8

Loss of the AB properties of pancreatic juice
Increased amount of substrates for bacteria in the SI lumen
Changes in intestinal motility and immune functions
Bacteria may impair absorption by competing for nutrients and changing intraluminal factors

Question 9

Outline the loss of B12 in EPI

Answer 9

Water soluble vitamin
Absorbed by specific factors in the ileum when bound to intrinsic factor (made by the pancreas)
V common to be low in b12 with EPI, cats seem to get it more frequently/ severely
There can also be a overgrowth of b12 binding bacteria

Question 10

What can low b12 lead to?

Answer 10

Anorexia/ lethargy/ weight loss
poor hair coat
anaemia
d+
neuro signs 
lack of response to other Tx

Question 11

Aside from b12, what other vitamins may be lacking in EPI?

Answer 11

Vitamin A (no associated clinical sings)
Vitamin E (Tochopherol)
Vit K (rare, more in cats)

Question 12

What are the clinical signs of EPI

Answer 12

Polyphagia/ possible coprophagia
Weight loss
Increase volume/ freq of f+
Flatulence/ borborigmus ++
sometimes v+
Loose yellowish f+
Normally less than 4yo at onset (older in CKCS)
Poor coat
Nervousness possible (expected due to abdo pain)

Question 13

What would you see on bloods?

Answer 13

Low TLI
Possibly low b12
low lipid/ cholesterol
Possible mild to moderate increase in ALT - may reflect hepatocyte damage due to increased absorption of hepatotoxic metabolites

Question 14

Outline the TLI test

Answer 14

Pancreatic specific
Not affected by intestinal disease/ oral pancreatic enzymes
Ideally do a fasted sample (as should increase after eating)
Renal dysfunction can cause a rise in TLI

Question 15

Outline subclinical EPI

Answer 15

No need for tx

Variable progression, some never get clinical signs

Question 16

How do you treat EPI

Answer 16

Supplementation of pancreatic enzymes (raw pancreas or dried pancreatic extract)
Pancreas - 500-100g per meal per 20-35kg dog
Give lots then find LED

Question 17

What may affect Tx of EPI?

Answer 17

Low cobalamin -supplement if low
Small intestinal bacterial overgrowth. many will respond to just the enzymes, but if not may need to give ABs
Some may have co-morbidities (DM or other SI dz). Tx as needed. DM v hard to control if present.
There is an arguement for giving antacids to reduce gastric pH and therefore reduce gastric degredation of enzymes but no definitive evidence to say this works

Question 18

Why do up to 75% of EPI dogs have SIBO?

Answer 18

Increased availability of nutrients in the intestine lumen
Lack of bacteriostactic factors from pancreatic secretions
Change in intestinal motility and immunity

Question 19

What diet should you provide for EPI?

Answer 19

Unclear evidence for anything
Fibre may impair pancreatic enzymes
Fat restriction questionable
Normally aim for a highly digestible, low firbre, low fat diet.

Question 20

What is the general outcome for EPI cases?

Answer 20

50% respond well to treatment
Approx 20-30 PTS in first year
Short relapses can occur
If good response, QoL and life expectancy are normal