Exocrine pancreatic insufficiency

Question 1

what is EPI?
what causes of EPI in dogs and cats?

Answer 1

Exocrine pancreatic hormone deficiency
* DOGS: Most commonly pancreatic acinar atrophy (PAA) in young animals
◦ Believed to be auto-immune
◦ Complex heritability
* CATS: Most commonly chronic pancreatitis
◦ May be underdiagnosed

• Other causes possible in both species – pancreatic aplasia or hypoplasia, pancreatic duct obstruction (neoplasia)

Question 2

what is thre history and clinical signs of EPI?

Answer 2

• Weight loss/stunted growth despite normal appetite or polyphagia
  ◦ Dogs may show coprophagia or pica
  ◦ Cats may be anorexic
• Voluminous, frequent, fatty diarrhoea (steatorrhea)
• Flatulence, borborygmi
• Vomiting
• Polydipsia
• Greasy hair coat

Question 3

what is the aetiopathogenesis of exocrine pancreatic insufficiency?

Answer 3

• Acinar cell loss – pancreatic acinar atrophy (PAA) in most dogs
  ◦ Can be associated with chronic pancreatitis
  ◦ Possible preceding AI lymphocytic pancreatitis
  ‣ Can see some cases where they remain in subclinical disease
  ◦ No clear evidence for congenital disease

Question 4

what is the signalment and predisposition of EPI?

Answer 4

• More common in dogs than cats
• Usually young – 1-4yo
• Breed predispositions
  ◦ GSD, Rough Collies, Chows, CKCSp

Question 5

what is the pathophysiology of EPI?

Answer 5

Nutrient maldigestion,…..plus
* Abnormal activities/function of mucosal enzymes
* Mucosal abnormalities due to absence of trophic activity of pancreatic enzymes
* Microbial dysbiosis
* Undernutrition – poor mucosal integrity

Question 6

How is EPI diagnosed?
what is the highly sensitive and specific test?
what can be used as a prognostic indicator?

Answer 6

• Low TLI diagnostic highly sensitive and specific - Trypsin-like immunoreactivity
  ◦ Enables determination between primary maldigestion due to EPI and SI disease
  ◦ Subnormal results in susceptible breed may suggest partial PAA – which may progress to EPI

* Low cobalamin – prognostic indicator if severe
◦ Low intrinsic factor from pancreas
◦ Bacterial overgrowth and binding of B12
◦ Concomitant SRE

Question 7

how is EPI managed?
what are theissues that are faced, how are thes overcome?
what is the prognosis?

Answer 7

• Pancreatic enzyme supplementation (capsule vs. powder) - taper dose to effect
• Freeze chopped pig/cow pancreas
• Never 100% effective
  ◦ Gastric degradation - It can help to co-administer H2 antagonist to reduce the gastric degradation
  ◦ Other GI consequences of EPI – dysbiosis
  ◦ Concurrent GI disease - IBD

Continue with normal food
* Can use specific diet if response is considered suboptimal and suspect additional pathology
◦ Moderate fat, highly digestible, low-fibre diet can help
◦ Altered diet mainly where concomitant dietary sensitivity is suspected
* Vitamin supplementation - Parenteral cobalamin – weekly, monitor blood levels
* Probiotics
◦ Help with normalisation of the microbiome.
◦ As per CE.

Prognosis
* Good with treatment
* Most dogs that will do well do so within first couple of weeks
◦ Weight gain, cessation of D+ and reduced faecal volume
* 20% of dogs respond poorly to treatment

Question 8

what biochemistry can you see in cases of EPI?

Answer 8

• Liver enzymes may be increased
  ◦ Alanine aminotransferase (ALT)
  ◦ Aspartate aminotransferase (AST)
  ◦ Alkaline phosphatase (ALP)
• Hypocholesterolaemia
• Concurrent diabetes mellitus: Hyperglycaemia
  Folate and cobalamin (vitamin B12)
• Folate: May be increased
• Cobalamin: Low in >80% of cases