Feline Exocrine Pancreatic Insufficiency ~ Pawprints and Purrs, Inc.

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Feline Exocrine Pancreatic Insufficiency

Both cats and dogs can be affected by Exocrine Pancreatic Insufficiency, although it is more common in dogs. Older cats affected by Exocrine Pancreatic Insufficiency will usually develop the disease as a consequence of end-stage chronic pancreatitis.

What is Feline EPI and how is it diagnosed?

Feline Exocrine Pancreatic Insufficiency (EPI), refers to failure of the pancreas to secrete digestive enzymes normally in the small intestine. This results in a syndrome characterized by diarrhea and weight loss, often despite the presence of a normal or increased appetite. In cats it is most commonly due to end-stage pancreatitis. Chronic pancreatitis is more commonly a cause of EPI in cats and older dogs. Animals with EPI due to chronic pancreatitis often have diabetes mellitus, since the endocrine portion of the pancreas may also be affected. Additional symptoms like intermittent vomiting and decreased appetite due to pancreatitis, or increased thirst and urination associated with diabetes mellitus, are present as well. Eurytrema procyonis flukes attached in the pancreatic ducts have been reported as a cause of EPI in some cats.

The pancreas serves two major functions. One of these, the endocrine function, is to secrete hormones, particularly insulin. The second major function of the pancreas is to secrete digestive enzymes; this is known as its exocrine function. As the name implies, Exocrine Pancreatic Insufficiency involves abnormalities in the secretion of digestive enzymes. Since enzymes are not available to help digest nutrients, the nutrients cannot be used normally by the body. In addition to the lack of proper digestion of nutrients, Exocrine Pancreatic Insufficiency is accompanied by structural and functional changes in the tissue lining of the small intestine that further impair nutrient absorption.

Diets high in fat can predispose cats to pancreatitis. Feed your cat a diet low or moderate in fat content and avoid feeding high fat table scraps.

A fecal examination checks for the presence of fat and starch which indicates maldigestion or malabsorption. A fecal flotation and direct smear also will be performed to evaluate for parasites. A complete blood count (CBC or hemogram) evaluates for anemia, inflammation, infection, or low platelet count. A serum biochemistry profile evaluates the general health of your cat and determines the effect of EPI on other organ systems. A urinalysis evaluates kidney function and checks for the presence of urinary tract infection. Abdominal xrays evaluates organs such as liver, spleen, and kidneys and checks for masses. A serum trypsin-like immunoreactivity (TLI) evaluates for the presence of the pancreatic enzyme trypsin. Animals with EPI have extremely low concentrations of this enzyme in their serum.

The key diagnostic test for EPI is the measurement of trypsin-like immunoreactivity, or TLI, on a blood sample drawn after a 12-hour fast. Once the diagnosis is confirmed, the main treatment is pancreatic enzyme replacements, which usually result in improvement of the symptoms. However, if EPI is due to chronic pancreatitis, and is accompanied by diabetes mellitus or other conditions, it can be more difficult to treat successfully.

A low value on the TLI, accompanied by symptoms consistent with EPI, virtually confirms the diagnosis. Values of less than 8 µg/L are suggestive of EPI.

Routine bloodwork and other laboratory tests may help establish the diagnosis of concurrent diseases, but are generally not helpful in diagnosing Exocrine Pancreatic Insufficiency per se. Mild liver enzyme changes, and low serum cholesterol levels may be seen with EPI, but other significant test findings indicate clinical processes other than, or in addition to, EPI.

What are the clinical signs of EPI?

Clinical signs associated with Exocrine Pancreatic Insufficiency is characterized by loss of the majority of the functional reserve capacity of the exocrine pancreas. A decrease of intraduodenal concentration of pancreatic enzymes, bicarbonate, antibacterial and enteric mucosal trophic factors, as well as pancreatic and GI regulatory peptides are observed. Finally, malassimilation of nutrients (fats, carbohydrates, proteins, vitamins, trace elements), small intestinal bacterial overgrowth, morphologic and functional changes of the small intestine are produced as a result of EPI.

What are the symptoms of EPI?

Cats with Exocrine Pancreatic Insufficiency often show weight loss despite having a normal or increased appetite. They often have excessive appetites and diarrhea, but will vary in consistency and frequency. Voluminous, semiformed, malodorous, pale colored (yellow or gray), oily appearing stools are the classic finding for EPI. Increased rumbling sounds are often heard from the abdomen, and many affected cats will pass increased amounts of gas. Occasionally, a long history of intermittent gastrointestinal signs like vomiting, diarrhea, and reduced appetite will be present if EPI is due to recurrent bouts of pancreatitis.

Polyphagia (excessive hunger and abnormally large intake of solids), extreme weight loss, intestinal borborygmus (rumbling in the stomach caused by intestinal gas), and dental and dermatological problems, such as tooth decay and poor coat and seborrhea sicca (dandruff), may be present. Anorexia has also been observed in some cats.

Although the symptoms of EPI are typical, they are not pathognomonic. Diagnosis in cats includes intestinal parasites, inflammatory bowel disease, hyperthyroidism, chronic renal failure and triaditis (chronic pancreatitis-cholangiohepatitis-inflammatory bowel disease) and intestinal lymphoma.

End-stage inflammation of the pancreas, or pancreatitis, may also result in EPI. When this is the case, diabetes mellitus may also be seen due to damage to the endocrine portion of the pancreas. Pancreatitis is more commonly the cause of EPI in cats and older dogs.

What is the prognosis of EPI in cats?

Treatment of exocrine pancreatic insufficiency is usually necessary for life. Cats requiring additional medications to boost the effectiveness of enzyme therapy generally do well.

The management of EPI is based on the dietary modification and pancreatic enzyme supplementation. A highly digestible, lowfat, low-fiber diet has been shown to ameliorate clinical signs of EPI. On the contrary, some small animal gastroenterologists insist that feeding a low-fat diet does not significantly improve clinical symptoms. Dietary supplementation of medium-chain triglyceride oil (2 ml per meal every other day) may further improve the patient situation.

Exogenous pancreatic enzyme supplementation is the cornerstone of treatment of EPI. Powdered pancreatic extracts (1 teaspoon per meal for cats) are usually adequate. The powdered form of pancreatic extracts is more suitable compared to the enteric-coated tablets, capsules or raw-chopped pancreas. Cats with EPI require parenteral cobalamin, vitamin K and oral vitamin E supplementation.

Inadequate enzyme supplementation may be a cause of treatment EPI failure. In these cases reevaluation of dosage is indicated. Lipase is acid-sensitive enzyme.

In cats with EPI due to chronic pancreatitis, the outcome is much less predictable. If other conditions are present, particularly diabetes mellitus, then the prognosis may depend more on the ability to treat these complicating factors successfully.

EPI results from an irreversible loss of pancreatic acinar tissue in most cases, and recovery is rare. However, with appropriate management and monitoring, these animals usually gain weight quickly, pass normal stools, and can live a normal life for a normal life span.

How can Feline EPI be treated?

The main treatment for exocrine pancreatic insufficiency is the administration of enzyme replacements that are given with each meal. If the diagnosis of EPI is correct, and if sufficient enzyme supplement is provided, diarrhea will begin to resolve in a few days, followed by gradual weight gain in most cats. It is very important to establish the diagnosis of EPI before starting pancreatic enzyme replacement therapy. Enzyme replacement can be expensive, and usually must be given for the rest of the patient's life. Some cats with diarrhea and a provisional diagnosis of EPI are treated with pancreatic enzyme replacements even when the diagnosis of EPI has not been confirmed. These animals may have resolution of their diarrhea for reasons other than enzyme replacement. If their response to treatment is incorrectly interpreted as confirming the existence of pancreatic insufficiency, they may be kept on an expensive and potentially unnecessary treatment for a long time.

Once an appropriate dose is found that controls the symptoms, the enzyme dose can be reduced until the lowest dose that maintains control is identified. The powder form of enzymes is generally more effective than tablets, although the latter are easier to administer.

Some cats do not respond appropriately to enzyme replacement alone. These patients may benefit from medications that augment enzyme replacement therapy. Certain drugs that block H-2 receptors in the stomach may increase enzyme replacement effectiveness by preventing breakdown of the enzymes in the stomach.

Some cats seem to do better when they are fed a low fat, low fiber, highly digestible diet. Serum vitamin K is decreased in some cats. Supplementation or intramuscular injections of vitamin B-12 may be administered to restore serum concentrations of these substances in cats with EPI. Although such deficiencies have been documented in EPI, it is not known if they are significant. Rarely, cats with these vitamin deficiencies that do not respond to enzyme replacement alone will do better when these deficiencies are corrected. Antibiotics may be helpful in some cats if excessive bacterial growth in the intestines has occurred.

How is EPI prevented?

There is no known means of prevention of Exocrine Pancreatic Insufficiency. Affected cats should not be bred since EPI may be inherited.

Page URL: http://www.sniksnak.com/cathealth/epi.html

Resource References:
Drs. Steve and Brad Everson, DVM
Southern Hills Animal Hospital
Shreveport, Louisiana