Canine Pancreatitis
The Normal Pancreas and What it Does
We eat food, chew it up into slurry, and swallow it. It travels down the esophagus to the stomach where it is ground up further and enzymes are added to begin the breakdown of dietary nutrients (digestion). When the food particles are small enough, they are propelled into the small intestine for further digestive treatment and ultimately nutrient absorption.
The small intestine has three portions: the duodenum that connects to the stomach and the jejunum and ileum below. The jejunum and ileum are mostly involved in absorption but the duodenum, being so close to the stomach, is the site of further digestion.
There are two ducts that enter the duodenum near where the stomach contents enter. One duct is for bile, squirted in directly from the liver’s gall bladder. The bile serves to neutralize the acid that the stomach had added to emulsify (or dissolve) dietary fats for absorption later in the tract, and also to excrete some toxins. The other duct is the pancreatic duct, which squirts in more digestive enzymes so as to break down starches and continue the breakdown of protein.
The pancreas is a pale pink glandular organ that nestles cozily just under the stomach and along the duodenum. As a glandular organ, the pancreas is all about secretion and it has two main jobs: the first job is the secretion of digestive enzymes to help us break down the food we eat, the second job is the secretion of insulin and glucagon (to regulate sugar metabolism). The digestive enzymes are the part of the story that concerns us in pancreatitis.
Pancreatitis is Inflammation of the Pancreas
In pancreatitis, inflammation disrupts the normal integrity of the pancreas. Digestive enzymes that are normally safely stored in granules are released prematurely where they digest the body itself. The result can be a metabolic catastrophe. The living tissue becomes further inflamed and the tissue damage quickly involves the adjacent liver. Toxins released from this orgy of tissue destruction are released into the circulation and can cause a body-wide inflammatory response. If the pancreas is affected so as to disrupt its ability to produce insulin, diabetes mellitus can result; this can be either temporary or permanent.
Specific Pancreatitis Disasters
Specific disasters include the disruption of surfactants in the lung tissue that normally keep the tiny air-filled alveoli from collapsing after each exhaled breath. Without surfactants, the alveoli close up and respiratory failure results.
Also, there is a syndrome called Weber-Christian syndrome where fats throughout the body are destroyed, which has painful and disastrous results.
Pancreatitis is one of the chief risk factors for the development of what is called disseminated intravascular coagulation, or DIC, which is basically a massive uncoupling of normal blood clotting and clot dissolving mechanisms. This uncoupling leads to abnormal simultaneous bleeding and clotting of blood throughout the body.
Pancreatic encephalopathy (brain damage) can occur if the fats protecting the central nervous system become digested.
The good news is that most commonly the inflammation is confined to the area of the liver and pancreas, but even with this limitation pancreatitis can be painful and life-threatening.
Pancreatitis can be acute or chronic, mild or severe.
What Causes Pancreatitis
In most cases we never find out what causes it but we do know some events that can cause pancreatitis:
Reflux of duodenal contents into the pancreatic duct. The pancreas has numerous safety mechanisms to prevent self-digestion. One mechanism is storing the enzymes it creates in an inactive form. They are harmless until they are mixed with activating enzymes. The strongest activating enzymes are made by duodenal cells; the digestive enzymes do not activate until they are out of the pancreas and mixing with food in the duodenum. If duodenal fluids backwash up the pancreatic duct and into the pancreas, enzymes are prematurely activated and pancreatitis results. This is apparently the most common pancreatitis mechanism in humans, though it is not common in veterinary patients.
Concurrent hormonal imbalance predisposes a dog to pancreatitis. Such conditions include: diabetes mellitus, hypothyroidism, and hypercalcemia. The first two conditions are associated with altered fat metabolism, which predisposes to pancreatitis, and the second condition involves elevated blood calcium that activates stored digestive enzymes.
Use of certain drugs can predispose to pancreatitis (sulfa-containing antibiotics such as trimethoprim sulfa, chemotherapy agents such as azathioprine or L-asparaginase, and the anti-seizure medication potassium bromide). Exposure to organophosphate insecticides has also been implicated as a cause of pancreatitis. Exposure to steroid hormones have traditionally been thought to be involved as a potential cause of pancreatitis but this appears not to be true, though steroids are able to cause an increase in lipase blood tests.
Trauma to the pancreas that occurs from a car accident or even surgical manipulation can cause inflammation and thus pancreatitis.
A tumor in the pancreas can lead to inflammation in the adjacent pancreatic tissue.
Miniature Schnauzers are predisposed to pancreatitis as they commonly have altered fat metabolism.
Signs of Pancreatitis
The classical signs in dogs are appetite loss, vomiting, diarrhea, painful abdomen, and fever.
Making the Diagnosis
A reliable blood test has been lacking for this disease until recently. Traditionally, blood levels of amylase and lipase (two pancreatic digestive enzymes) have been used. When their levels are particularly high, it is a reasonable sign that these enzymes have leaked out of the pancreas and pancreatitis is present; still, these tests are not as sensitive or specific as we would prefer. Amylase and lipase can elevate dramatically with corticosteroid use, with intestinal perforation, kidney disease, or even dehydration. Some experts advocate measuring lipase and amylase on fluid from the belly rather than on blood but this has not been fully investigated and is somewhat invasive.
A newer test called the PLI or pancreatic lipase immunoreactivity test has come to be important. As mentioned, lipase is one of the pancreatic digestive enzymes and only small traces are normally in circulation. These levels jump dramatically in pancreatitis and the diagnosis can be confirmed with a less expensive and non-invasive test. A regular lipase level measures all forms of lipase, not just those of a pancreatic source; this is test is specific for pancreatic lipase. The problem is that the technology needed to run this test is unique and the test can only be run in certain facilities on certain days. Results are not necessarily available rapidly enough to help a very sick patient.
More recently a new test called the SPEC cPL (specific canine pancreatic lipase) test has come to be the test of choice. This test is a newer generation immunological test for canine pancreatic lipase and can be run overnight by a reference lab. This test is able to detect 83% of pancreatitis cases (the test is 83% sensitive) and excludes other possible diseases in 98% of cases (i.e. the test is 98% specific for pancreatitis). There is no comparable test for cats at this time.
Radiographs can show a widening of the angle of the duodenum against the stomach, which indicates a swelling of the pancreas. Most veterinary hospitals have the ability to take radiographs but this type of imaging is not very sensitive in detecting pancreatitis and only is able to find 24% of cases.
Ultrasound, on the other hand, detects 68% of cases and provides the opportunity to image other organs and even easily collect fluid from the belly. Since pancreatitis can be accompanied by a tumor near the pancreas, ultrasound provides the opportunity to catch such complicating factors.
In some cases, surgical exploration is the only way to make the correct diagnosis.
Treatment
The passage of food through the duodenum is a strong stimulus to the pancreas. In the treatment of canine pancreatitis we do not want any stimulation of the pancreas; we want the pancreas to rest. This means no food and no water for 2 to 3 days (IV fluid support prevents dehydration).
Fluid support will generally require potassium supplementation because potassium depletes in pancreatitis. Blood pH must be tracked as well. A critical patient with pancreatitis may need 24 hour care and blood test monitoring several times a day. A plasma transfusion represents a specific type of fluid therapy and helps provide certain proteins that inhibit pancreatic enzymes. Whether or not the protection afforded by plasma is real or theoretical is still being worked out, but since it is difficult to go wrong with a plasma transfusion, do not be surprised if your veterinarian uses this approach.
Pancreatitis is a painful condition and pain management is not only humane but important in recovery. Untreated pain affects the immune system and increases mortality. Injectable pain medications, fentanyl patches, and even continuous drips can be used effectively to control pain. Additional medication to control nausea is also commonly used. Antibiotics are often used because even though pancreatitis is not a bacterial disease, bacterial invasion from the diseased intestine is a common occurrence.
Once the patient has started to eat again, a low fat diet, such as one of the prescription high fiber diets, is important to minimize pancreatic stimulation. Since there is potential for the pancreas to always have a chronic smoldering bit of inflammation, long-term use of a low fat diet is likely to be recommended.
Beware of Diabetes Mellitus
When the inflammation subsides in the pancreas, some scarring is inevitable. When 80% of the pancreas is damaged, insulin cannot be produced, and diabetes mellitus results. This may or may not be permanent depending on the capacity for the pancreas’s tissue to recover. See more information on the management of diabetes mellitus.
Date Published: 1/2/2006 12:27:00 PM
Date Reviewed/Revised: 05/03/2011
Feline Pancreatitis:
Most of us have heard of the pancreas but aren’t really sure what it is.
The pancreas is a pale pink glandular organ nestled just under the stomach. It has two main functions: the production of metabolic hormones (insulin and glucagon, which regulate blood sugar) and the production of digestive enzymes, which are secreted through a duct into the intestine to digest food. In cats, the pancreatic duct frequently joins with the common bile duct from the liver. Both bile (a fluid used to excrete toxins as well as to prepare fat for absorption into our bodies) and pancreatic fluid, which is rich in digestive enzymes, enter the intestine from the same location. There are other hormonal products from the pancreas that assist in the regulation of digestion and movement of food but the above description is a basic picture of what the pancreas does.
Pancreatitis is potentially a metabolic disaster. Here’s why:
The normal pancreas has a number of safeguards in place to keep its digestive enzymes securely stored. If these enzymes escape, they will digest the body! This is exactly what happens when the pancreas gets inflamed: the enzymes escape and begin digesting the pancreas itself. The living tissue becomes further inflamed and the tissue damage quickly involves the adjacent liver. Toxins released from this orgy of tissue destruction are released into the circulation and can cause a body-wide inflammatory response. If the pancreas is affected enough so as to disrupt its ability to produce insulin, diabetes mellitus can result; this can be either temporary or permanent.
Certain disasters include the disruption of surfactants in the lung tissue, which normally keep the tiny air-filled alveoli from collapsing after each exhaled breath. Without surfactants, the alveoli close up and respiratory failure results.
Also, fats throughout the body are destroyed in an effect called the Weber-Christian syndrome.
Pancreatitis is one of the chief risk factors for the development of what is called “disseminated intravascular coagulation” or DIC, which is basically a massive uncoupling of normal blood clotting and clot dissolving mechanisms. This leads to abnormal simultaneous bleeding and clotting of blood throughout the body.
Pancreatic encephalopathy (brain damage) can occur if the fats protecting the central nervous system become digested.
Fortunately, total disasters such as the above are rare but be aware that the potential for such disasters exists should the pancreatic inflammation get out of hand.
Most of the time, pancreatitis is confined to the area of the liver and pancreas.
Pancreatitis can be acute or chronic (acute cases can reverse completely)
Pancreatitis can be mild or severe (acute cases tend to be more severe).
What Causes Pancreatitis in Cats?
Unfortunately, 90% of the time we never find out. We have some idea of possible risk factors, though.
Trauma (getting hit by a car or falling from a great height)
An active feline distemper infection
Toxoplasma (a parasite) infection can involve the pancreas, although it almost always involves other tissues as well
There may be an association with pancreatitis and inflammatory bowel disease. The theory is that the abnormal intestinal disease leads to an overgrowth of bacteria. These bacteria are able to crawl up the pancreatic duct and cause infection in the pancreas.
Organophosphate insecticide exposure. Organophosphates are not commonly used in flea control any more but they are readily available in hardware and garden stores. They are also in some flea collars.
Use of drugs; drugs have certainly caused pancreatitis in humans and dogs but have not been proven to have done so in cats. Still, with a cat with a history of pancreatitis, it is prudent to avoid drugs that have been associated with pancreatic inflammation. Such drugs include azathioprine (an immune suppressive agent); thiazide diuretics, (furosemide); tetracycline (an antibiotic); valproic acid (a seizure control agent); and procainamide (a heart medicine).
Chances are the cause for a given case will never be revealed.
If your Cat has Pancreatitis, what might you Observe at Home?
In dogs and humans, this condition is associated with a lot of nausea and abdominal pain. According to one recent study in cats, though, only 35% of cats with pancreatitis showed vomiting and only 25% appeared to have abdominal pain. Fever is a possible sign but often the temperature will drop instead. Lethargy and appetite loss are consistent signs. Nearly all cats with pancreatitis lose their appetites.
Approximately 40% of cats with hepatic lipidosis have pancreatitis as the underlying cause.
Hepatic lipidosis represents a specific type of liver failure that stems from appetite loss/inadequate calorie intake and complicates pancreatitis tremendously.
Pancreatitis is Hard to Diagnose
What Tests can be Run to Find out if a Cat has Pancreatitis?
One of the first steps in evaluating a sick cat is a metabolic database, which is a blood panel and urinalysis. Often this test will not turn up a good indicator of pancreatitis. There are two pancreatic enzymes commonly checked on this panel (amylase and lipase) but unfortunately elevations in these enzymes are not consistent even with obvious or severe pancreatitis. Changes in the liver usually are evident (remember, the pancreas is located near the liver and the liver very readily indicates when it has been damaged by releasing its own enzymes called ALT and AST). Radiographs are often included in this initial testing work up but the pancreas is difficult to visualize and radiographs may not reveal the problem.
If the cat does not respond to support, further evaluation is needed: either ultrasound or other advanced imaging, or surgical exploration. Ultrasound often reveals an enlarged pancreas surrounded by fluid and confirms the diagnosis. Surgical exploration offers the further advantage of allowing tissue sampling of other adjacent organs to rule out additional problems, such as inflammatory bowel disease. The pancreas can be biopsied but many veterinarians are reluctant to do so for fear that removing a piece of tissue could generate further inflammation. Some veterinarians also feel that flushing the belly with warmed sterile fluids helps remove some of the inflammatory toxins.
There are some blood tests of note that are accurate in the diagnosis of pancreatitis. The first is the PLI test. PLI stands for panreatic lipase immunoreactivity. Lipase is one of the pancreatic digestive enzymes, and small traces of it are normally in the circulation. These levels jump dramatically in pancreatitis, thus the diagnosis can be non-invasively confirmed without the expense of ultrasound or the invasiveness of a biopsy. The problem is that technology needed to run this test is unique and the test can only be run in certain facilities on certain days. Results are not necessarily available rapidly enough to help a very sick cat.
A newer test is the SPEC-FPL, which stands for specific feline pancreatic lipase. This test is similar to the PLI but can produce results within 48 hours. At the present time only one labratory is able to run this test.
How is the Cat Treated?
There are three parts to treatment: removing the cause of the pancreatitis (this is usually not possible since the cause is only rarely known); monitoring and instituting protection against the disastrous complications listed above; and general support and symptomatic relief through the inflammatory crisis. Fluid therapy is used to support the vasculature and combat any dehydration from vomiting or diarrhea. Medicines are used to control pain and nausea. Food is withheld if vomiting is a problem. In dogs, high fat diets are important predisposing factors for pancreatitis but this appears not to be true for cats. Pre-existing inflammatory bowel disease seems to bear more feline relevance so treatment in that direction seems more appropriate (steroids, antacids, low residue diets, vitamin B-12 supplementation). Plasma transfusions seem to be helpful as they replace the clotting factors needed to prevent DIC as well as natural blood factors to deactivate pancreatic enzymes. Anecdotally, digestive enzyme supplementations are felt to be helpful in some cases.
Prognosis
How the cat does in the long run depends on how severely ill he or she is. If the cat survives the episode of acute pancreatitis, there is a good chance that he or she will live a normal life thereafter. However, chronic cases of pancreatitis may wax and wane for years, requiring a permanent diet change and chronic medication administration.
Date Published: 1/1/2001
Date Reviewed/Revised: 03/27/2009
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