Exam 3 - Exocrine Pancreatic Insufficiency Flashcards
what is exocrine pancreatic insufficiency?
syndrome caused by an insufficient amount of pancreatic digestive enzymes in the small intestines
what are some mechanisms that result in EPI due to insufficient pancreatic enzymes?
decreased synthesis & secretion from the exocrine pancreas
blockage of pancreatic duct
due to decreased activation of enzymes
EPI is diagnosed more commonly in dogs than cats, but these numbers are misleading - why?
fTLI test is only available at the GI lab at TAMU
where as over 90% of cTLI tests are done outside of the TAMU gi lab
T/F: rate of occurrence of EPI in cats has increased in diagnosis over the last few years
true
what are the percentages of dogs affected by EPI by age range?
under 1 year of age - 3.4%
under 2 years of age - 30.3%
over 2 years of age - 66.4%
what dog breed is most commonly affected by EPI?
GSD - 42.1%
other breeds - 57.9%
what cat breeds are most commonly affected by EPI?
DSH & persian
why is it important to consider the functional reserve of the exocrine pancreas?
the exocrine pancreas has an exceptional functional reserve
so clinical signs do not develop until more than 90% of the exocrine function has been lost
what is the most common etiology of EPI in german shepherd dogs?
pancreatic acinar atrophy
is there a breed predilection for EPI in cats?
no - higher occurrence in DSH/DLH only because it is the most common cats we encounter
what is the most common cause of EPI in humans & cats?
sequelae to chronic pancreatitis
what was the initial suggested causes of pancreatic acinar atrophy?
autosomal recessive trait - HAS BEEN DISPROVEN
genetic marker hasn’t been identified - certain haplotypes of MHC class I & II are associated with pancreatic acinar atrophy - autoimmunity
what are the 4 suggested underlying etiologies of exocrine pancreatic insufficiency?
- pancreatic acinar atrophy
- sequela to chronic pancreatitis
- sequela to obstruction of the pancreatic duct by pancreatic adenocarcinoma
- pancreatic aplasia/hypoplasia
what enzyme appears to be the limiting factor of pancreatic function?
pancreatic lipase - rate limiting enzyme for pancreatic digestion
what is the pathogenesis of exocrine pancreatic insufficiency?
lack of digestive enzymes in the intestinal lumen causing maldigestion
malabsorption
malassimilation - steatorrhea, increased fecal volume, weight loss, hypovitaminosis
potentially concurrent diabetes mellitus
what is the typical history reported for a patient with EPI?
polyphagia - sometimes with corprophagia/pica
weight loss
soft pale voluminous stools
steatorrhea, borborygmus, & flatulence
greasy hair coat in some cats
what are some signs of EPI seen on physical exam?
weight loss, poor hair coat, greasy soiling of the hair coat in some cats
what is steatorrhea?
fat stays in the feces
what clinical pathology is seen on patients with EPI?
normal CBC, hyperglycemia sometimes, slight elevation of SAP in some cases, normal urinalysis
what do you expect serum cobalamin concentrations to be in a dog with EPI?
decreased!!!!
T/F: hypocobalaminemia when left untreated was shown to be associated with a shorter survival time
true
what do you expect serum cobalamin concentrations to be in a cat with EPI?
decreased in almost all cases
what do you expect for results on trypsin-like immunoreactivity in dogs & cats with EPI? what values?
severely decreased
dogs cTLI < 2.5ug/l, 100% sensitive & specific
cats fTLI < 8 ug/l, highly specific but unknown sensitivity
serum cTLI concentration is specific for what?
exocrine pancreatic function
what is the most common clinical sign of EPI across all companion animal species?
weight loss
when do dogs with subclinical EPI require treatment?
only when they develop clinical signs
what is occult EPI in dogs?
dogs that have a moderately decreased serum cTLI concentration (2.5-5.6 ug/l) but have clinical signs compatible with EPI
most of these dogs have small intestinal disease & need further diagnostics, but some of these dogs will have EPI & require therapy (trial therapy if no other diarrhea cause can be identified, & re-evaluate serum cTLI 1 month later)
when may a fecal elastase concentration test be useful in a patient with EPI?
diagnosing EPI due to an obstruction of the pancreatic duct because these patients would be expected to have normal/elevated serum cTLI concentrations
is fecal elastase concentration a better diagnostic test than cTLI for EPI in dogs?
no - less sensitive & specific than cTLI, only 60% PPV
what is fecal elastase concentration?
ELISA test available in united states/europe for measuring fecal elastase
what is the pathophysiology behind EPI?
in dogs with EPI, there is a lack of the acinar cells & a lack of the zymogen granules
so when CCK is released, very little of these granules are released (granules have the pre-form, which isn’t dangerous to the cells)
in turn, the intestines have a lack of enzymes leading to maldigestion & associated clinical signs
what is the mainstay of treatment for EPI?
pancreatic enzyme replacement therapy
how are pancreatic extracts used for treating EPI?
dried extracts from porcine/bovine - 1 tsp/10 kg with each meal, sprinkled over the food
how is raw porcine/bovine/other pancreas used to treat EPI?
can be stored or frozen for many months - 1-2 ounces per 10 kg with each meal
T/F: dose of pancreatic enzyme supplements can be gradually decreased after the patient has a complete response to treatment
true
what is an adverse effect that has been reported with pancreatic extract supplementation?
pancreatic enzyme supplements can cause ulcerations of the oral mucosa & cause oral bleeding - most cases respond quickly to a decrease in dose
what are the 2 ways that cobalamin can be administrated for supplementation?
oral or parenteral
oral is effacacious in both dogs/cats with cobalamin deficiency
what are the advantages of using micro-encapsulated enzymatic products for EPI? what about disadvantages?
you can protect pancreatic lipase from destruction by gastric acid
may not release pancreatic enzymes in an efficient manner
T/F: products containing microbial lipases are not commonly used & are acid-resistant
true
what kind of diet should be given to an animal with EPI?
premium pet food that is not fat restricted - assimilation of fat doesn’t normalize with enzyme supplementation & restricting fat can cause deficiencies in essential fatty acids & fat soluble vitamins
what kind of diet should be avoided for a dog with EPI?
high fiber diets - don’t feed
T/F: there is not one specific diet that is recommended for dogs with EPI because some patients may do better on whatever diet & not one optimal choice has been described
true
if you see an EPI patient with a suspected coagulopathy, what drug will you give them?
vitamin K
T/F: patients with EPI are often vitamin deficient
true
what vitamin may you need to supplement for patients with EPI?
vitamin E - 250-500mg daily per dog for one month
what is the prognosis of EPI?
most patients require lifelong therapy - few recover
diabetes mellitus may complicate treatment
most treated patients will have a normal life expectancy & quality of life
how do you approach patients that don’t respond to treatment for EPI?
work up for concurrent conditions
antacids/proton pump inhibitor - decrease gastric acid production, may decrease destruction of supplemented pancreatic lipase
fat restriction as a last resort
why do we commonly see small intestinal dysbiosis in patients with EPI?
lack of antimicrobial factors in pancreatic juice & maldigestion/malabsorption provides nutrients for small intestinal bacterial proliferation
how is small intestinal dysbiosis handled in patients with EPI?
usually resolves when patients receive pancreatic enzyme supplementation - if clinical signs don’t improve, put on abx
tylosin at 25mg/kg every 12 hours for 6 weeks
