CANINE PANCREATITIS PART I
Dr Hilary Lam BVSc, PgCert, MVS
Pancreatitis is defined as inflammation of the pancreas. It can be categorized into acute, chronic, or acute on chronic.
CLINICAL SIGNS
In mild cases, clinical signs include decreased appetite, occasional vomiting and diarrhoea. In life-threatening cases, clinical presentation may involve systemic inflammatory response syndrome and multiple-organ dysfunction syndrome or even death.
BREED PREDILECTION AND RISK FACTORS
Any breed can be affected. Schnauzer, Yorkshire Terrier, Spaniels, Boxers, Shetland Sheepdog, Collies are overrepresented.
Risk factor includes obesity (2.6x), endocrine diseases such as Diabetes, hypothyroidism, hyperadrenocorticism have been associated with pancreatitis. Other risk factors have been suggested: table scraps given in the preceding week or generally (2x); unusual food items consumed prior to presentation (4x-6x more likely); dietary indiscretion of items in the trash (13 x).
DIAGNOSTIC TEST
Blood test CBC should be performed to screen for underlying anaemia, dehydration, leukocytosis, thrombocytopenia.
Biochemistry profile may help to detect hepatic, renal changes and electrolytes loss secondary to inflammation and dehydration. Lipase and amylase have poor sensitivity and specificity for pancreatitis (Amylase 14-73%, Lipase 18%-69%). Canine pancreatic specific lipase by Idexx Snap cPL has a positive predictive value of 54% if the level is >200ug/L. For VetScan cPL Rapid Test there is a positive predictive value of 54% if its >200ug/L and 75% if its >400ug/L.
Imaging such as ultrasound may be used to identify changes (e.g. hypoechogenicity, mixed echogenicity with hyperechoic mesenteric tissue, any sign of biliary obstruction, free fluid, corrugation of duodenum, ileus).
CT scan may help to distinguish any further sign of abscessation or mass lesion including neoplasia, may also help in diagnosing necrotizing pancreatitis. Most of the time its use is prohibited by cost, assess to facility and owner's willingness to allow their sick pet to undergo general anesthesia.
Histopathology examination of the pancreas is the gold standard. However, most patients do not require surgery.
MEDICAL TREATMENT
Intravenous fluid should be used to correct dehydration, maintenance and losses.
Pain relief include opioids (Fentanyl, methadone, buprenorphine) may help to relief abdominal pain. Constant infusion with ketamine, lidocaine may be used. Steroids or non-steroidal anti-inflammatories may worsen compromised renal status, intestinal ulceration.
Anti-vomiting therapy include maropitant, ondansetron, dolasetron can be considered. Maropitant is shown to be more effective than metoclopramide.
Gastroprotectants such as pantoprazole, omeprazole, famotidine, sucralfate can be used to treat gastric ulceration secondary to pancreatitis.
Antibiotics therapy is rarely indicated Most pancreatitis are sterile, however in selected cases may be beneficial.
Fresh frozen plasma has shown little benefit and costly, and one article have suggested its use may increase mortality. Anecdotally some veterinarians think it will shorten hospital time.
Nutritional support is important for recovery. Early enteral nutrition is recommended to improve gut barrier function and decrease bacterial translocation. The idea of holding off water and food in pancreatitis patient has little evidence of support. Trickle feeding is recommended. Total parenteral nutrition may provide adequate calories via central venous catheter but does not prevent villi atrophy. Commonly low-fat diet with high digestibility is recommended.
Surgical intervention is rarely indicated except following condition: biliary tract obstruction, peritonitis, pancreatic abscess. Surgical lavage, debridement of necrotic tissue, jejunostomy tube placement maybe helpful in some severe clinical cases.
References
1. Hand M, Zicker SC, Novotny BJ. Acute and chronic pancreatitis In Hand M, Zicker SC, Novotny BJ: Small Animal Clinical Nutrition Quick Consult. Mark Morris Institute, 2011, pp 208-212.
2. Justin S. To feed or Knot to Feed? Controversies in the Nutritional Management of Pancreatitis. TVP. Nov/Dec, 2016, pp45-51
3. Sedlacek H.S., Ramsey, D.S., Boucher, J.F., et. al.. Comparative efficacy of maropitant and selected drugs in preventing emesis induced centrally or peripherally acting emetogens in dogs. J Vet Pharmachol Ther. 2008. 31:533-537.
4. Villaverde C. Nutritional management of exocrine pancreatic diseases. In Fascetti AJ, Delaney SJ: Applied Veterinary Clinical Nutrition. Somerset, NJ: John Wiley & Sons, 2012, pp 221-234.
5. Washabau R.J. In Washabau RJ, Day MJ. Canine and Feline Gastroenterology- Pancreas. St. Louis: Saudners Elsevier, 2013, pp799-848.
6. Xenoulis, P.G., Suchodolski, J.S., Steiner, J.M.. Chronic pancreatitis in dogs and cats. Compend Cont Ed Pract Vet. 2008; 30,3:pp166-180.
CANINE PANCREATITIS PART II
In part II, we will briefly discuss on feeding recommendations for canine pancreatitis patient.
HOW MUCH TO FEED?
In hospital canine patients with pancreatitis should be aimed to feed to the estimated resting energy expenditure by the following simple equation:
1. RER (kcal/day) = 70 × (BW kg)0.75 *
2. RER (kcal/day) = 30 × (BW kg) + 70
* Equation can be used as an approximation of RER for 5-25kg dogs
Commercial available low fat enteral diets can be recommended for discharge or for patients that are severely hyperlipidemic. Choices include:
|
Brand of low fat diet
|
Fat content of dried food
(g/1000kcal)
|
Fat content of canned food
(g/1000kcal)
|
|
Prescription Diet i/d Low Fat
(hillspet.com)
|
20
|
23
|
|
Veterinary Diet Gastrointestinal Low Fat
(royalcanine.com)
|
19
|
18
|
Most sick animals may require assistive feeding. Many veterinarians may consider syringe feeding but note that it has the risk of food aversion and aspiration, so care should be taken when performed. Some practitioners, nutritionist, internist may consider nasoesophageal or nasogastric tubes as an alternative way of managing canine pancreatitis. Esophagostomy tubes are generally reserved for severe chronic pancreatitis in dogs.
Hyperlipidaemia is associated higher risk of pancreatitis. Dogs with hyperlipidemia they should receive minimally 14g of fat per 1000 kcal. Fat free diets are not recommended as minimal intake of dietary fat is required for absorption of fat-soluble vitamins and as a source of essential fatty acids.
Dietary fat may be saturated or unsaturated and have different lengths of fatty acid chains. Omega 3 e.g. docosahexaenoic acid (DHA) , alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) may reduce pancreatic inflammation. Each omega 3 capsule add 1 g of fat to a dogs intake, thus omega 3 supplementation should be used judiciously. Furthermore extended administration is recommended thus patients with chronic pancreatitis is more likely to benefit compared to acute pancreatitis.
Proper storage of food is recommended as improper food storage may lead to oxidization or rancid of fat.
Long term nutritional recommendations
Patients with acute pancreatitis may make full recover and may consider slowly transition the animal in the previous diet or intended maintenance diet. And advise should be given to avoid risk factor such as abrupt food changes, tablet scraps, excessive amount of treats, obesity, trash bin scavenging)
Patients with chronic pancreatitis
The evidence for dietary fat restriction in chronic canine pancreatitis is based on clinical impression. There have been articles published the maximal dietary fat concentration is 24g-25g/ 1000kcal.