17 Exocrine pancreatic insufficiency

The pancreas can totally fade out in some species. This can be due to a genetic disorder leading to acinar atropy, immune causes or due to  chronic pancreatitis. The result is called exocrine pancreatic insufficiency  (EPI) and primarily affects dogs.

German shepherds, rough coated collies and beagles are prone to acinar atrophy. EPI develops at about 18 mo of age.

Chronic pancreatitis most affects King Charles spaniels and cats.

As a reminder, the pancreas serves 4 main functions:

1. Enzymatic digestion of food

2. Production of antibacterial proteins

3. Neutralization of gastric acid

4. Production of intrinsic factor

The pancreas has impressive reserve capacity but when 90% is destroyed, these functions are all lost. This is not reversible.

  1. Enzymatic digestion of food
  • without these enzymes, food cannot be digested and absorbed. Animals quickly lose weight but maintain a strong appetite. They may even eat inappropriate objects (pica). The unabsorbed food leads to osmotic diarrhea. Fatty stool is seen due to limited digestion. Hair coats are often dull due to lack of absorption of vitamins.

2. Production of antibacterial proteins

  • without this secretion, animals can develop bacterial overgrowth or dysbiosis. This can also add to the maldigestion and flatulence issues.

3. Neutralization of gastric acid

  • without bicarbonate the acid from the stomach can irritate the duodenum and change the bacterial flora

4. Production of intrinsic factor

  • without intrinsic factor, cobalamin is released and cannot be absorbed. Cobalamin is required for DNA synthesis and is crucial for red blood cell production (erythropoiesis). Pernicious or macroocytic anemia is the formation of excessively large red blood cells in the face of cobalamin deficiency

Clinical signs

  • weight loss (cachexia)
  • polyphagia (eating lots), coprophagia and pica (eating weird stuff)
  • small bowel diarrhea with pale greasy feces
  • flatulence
  • anemia
  • lethargy
  • diabetes mellitus

Diagnosis

Affected animals are most readily diagnosed by measuring TLI – trypsin-like immunoreactivity and/or response to enzyme treatment.

TLI is preferred as the baseline levels of trypsin are moderate. It is possible to see a decline. Baseline levels of lipase are low so it can be difficult to determine if the pancreas is functional but not currently releasing lipase or dysfunctional and not able to release lipase.  Amylase is just not a good enzyme to measure due to other complexity.

Treatment

  1. Provide enzymes for digestion
    • the powder form is considered most effective
    • avoid enteric coated versions because they require bicarbonate to be dissolved.
    • it may take awhile to find the right level for the patient
  2. Provide acid control
    • minimize duodenitis and digestion of the enzymes by lowering acid levels
  3. Provide B vitamins and fat soluble vitamins
    • folate, cobalamin, A, D, E, and K (and most times they don’t need folate since the bacteria produce it)
  4. Feed an easily digestible diet
    • moderate fat, low fiber
  5. Antibiotics
    • some animals may need control of flora (short term treatment)

Prognosis

Prognosis is good but treatment is lifelong

Key Takeaways

Exocrine pancreatic insufficiency means the pancreas can no longer produce the enzymes and products it usually produces for digestion and gut health.

PANCREATIC FUNCTION DYSFUNCTION TREATMENT
Enzyme production Limited digestion-> flatulence, weight loss, ravenous, poor hair coat, greasy stool Enzyme supplementation

Vitamin A,D, E and K supplementation

Highly digestible diet

Antibacterial proteins Dysbiosis (bacterial overgrowth) Antibiotics
BIcarbonate secretion Duodenitis (ulcers) Antiulcer agents
Intrinsic factor secretion Cobalamin deficiency, macrocytic anemia Vitamin B12 supplementation

 

Resources

Pancreatic acinar atrophy in German Shepherds– review article

Chronic pancreatitis in dogs and cats -review article

Exocrine pancreatic insufficiency – client focused article

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