Pancreatitis (Inflammation) in Dogs 애견 췌장염

[머쨍이호두]

The pancreas is a V-shaped organ located behind the stomach and the first section of the small intestine, the duodenum. It has two main functions: it aids in metabolism of sugar in the body through the production of insulin, and is necessary for the digestion of nutrients by producing pancreatic enzymes. These enzymes help the body promote the digestion and absorption of nutrients from food. Acute pancreatitis is a sudden onset of pancreatic inflammation. Chronic pancreatitis can also occur.

What are the causes of pancreatitis?

Multiple factors can contribute to the development of pancreatitis in dogs:

• Certain medications, especially potassium bromide, as well as some anti-cancer drugs and some antibiotics
• Metabolic disorders including hyperlipidemia (high amounts of lipid in the blood) and hypercalcemia (high amounts of calcium in the blood)
• Hormonal diseases such as Cushings disease (hyperadrenocorticism), hypothyroidism, and diabetes mellitus
• Obese and overweight dogs appear to be more at risk
• Genetics may play a role, with Schnauzers and Yorkshire terriers appearing to be more prone to pancreatitis
• Nutrition: Dogs with diets high in fat, dogs who have recently gotten into the trash or have been fed table scraps, or dogs who 'steal' or are fed greasy 'people food' seem to have a higher incidence of the disease
• Abdominal surgery, trauma to the abdomen (e.g., hit by a car), shock, or other conditions that could affect blood flow to the pancreas
• Previous pancreatitis

What are the symptoms of pancreatitis?

Symptoms of acute pancreatitis may range from mild to very severe. The symptoms are similar to those of other diseases and may include a very painful abdomen, abdominal distention, lack of appetite, depression, dehydration, a 'hunched up' posture, vomiting, and perhaps diarrhea. Fever often accompanies these symptoms.

Animals with more severe disease can develop heart arrhythmias, sepsis (body-wide infection), difficulty breathing, and a life-threatening condition called disseminated intravascular coagulation (DIC), which results in multiple hemorrhages. If the inflammation is severe, organs surrounding the pancreas could be 'autodigested' by pancreatic enzymes released from the damaged pancreas and become permanently damaged.

Dogs with chronic pancreatitis may show signs similar to those in acute pancreatitis, but they are often milder, and severe complications are less likely.

How is pancreatitis diagnosed?

To diagnose pancreatitis, other causes of the symptoms must be ruled out. A complete history is taken and a thorough physical exam, a complete blood count, chemistry panel and urinalysis are performed. Blood levels of two pancreatic enzymes, amylase and lipase, may be obtained. The cPLI (canine pancreatic lipase immunoreactivity) test is another diagnostic tool. In addition, radiography (x-rays) and ultrasound can also help in making the diagnosis. A biopsy can result in a conclusive diagnosis, but is not commonly performed.

How is pancreatitis treated?

The goals of treatment are to:

• Correct dehydration
• Provide pain relief
• Control vomiting
• Provide nutritional support
• Prevent complications

Dehydration and electrolyte imbalances are common in dogs with acute pancreatitis, so supplemental fluids are given either by the subcutaneous or intravenous route; depending upon the severity of the condition.

Dogs who are experiencing pain can be treated with pain relievers such as meperidine or butorphanol.

Medications are often given to decrease the amount of vomiting. If vomiting is severe, food, water, and oral medications are withheld for at least 24 hours. Depending upon the dog's response, food intake can be started again after a day or more. The dog is generally fed small meals of a bland, easily digestible, high-carbohydrate, low-fat food. In some cases, it may be necessary to use tube feeding to provide proper nutrition.

If the pancreatitis was caused by a medication, the medication should be stopped. If it was caused by a toxin, infection, or other condition, the appropriate therapy for the underlying condition should be started.

In rare instances where there are intestinal complications or the development of a pancreatic abscess, surgery may be necessary.

What is the prognosis for dogs with pancreatitis?

Pancreatitis can be a very unpredictable disease. In most cases, if the pancreatitis was mild and the pet only had one episode, chances of recovery are good and keeping the dog on a low-fat diet may be all that is necessary to prevent recurrence or complications. In other cases, what appears to be a mild case may progress, or may be treated successfully only to have recurrences, sometimes severe.

Some animals develop chronic pancreatitis, which can lead to diabetes mellitus and/or pancreatic insufficiency, also called 'maldigestion syndrome.' In pancreatic insufficiency, the nutrients in food are passed out in the feces undigested. A dog with this disease often has a ravenous appetite, diarrhea, and weight loss. Even though he is eating, he could literally starve to death. Treatment for pancreatic insufficiency is lifelong and expensive, but is possible. The dog's digestive enzymes are replaced through a product processed from pancreases of hogs and cattle which contain large quantities of the digestive enzymes. A change in diet with added nutritional supplements may also be necessary.

Exocrine Pancreatic Insufficiency (Maldigestion Disorder) in Dogs  ( 췌장 장애 )

We are asked many, many questions about the diagnosis and treatment of pancreatic diseases in the dog, specifically, those dealing with the digestion and absorption of nutrients. Such diseases are termed pancreatic insufficiency, exocrine pancreatic insufficiency, and maldigestion syndrome.

The pancreas has many glandular functions, some obvious and well known and others that are obscure and not understood at all. We classically think of the pancreas as the producer of insulin, and an insufficient production of that hormone leading to diabetes mellitus. For many dog owners, diabetes is easy to understand since they can think of it in terms of the disease seen in our fellow humans. Many people, however, have difficulty understanding diseases that affect the ability of the organ to produce the various enzymes that allow humans, dogs, and cats to digest their food.

Function of the pancreas

Certain cells of the pancreas called 'acinar' cells produce the important digestive enzymes utilized by the dog's body. The function of the enzymes is to break down food in the intestine into smaller molecules. The major digestive enzymes are protein molecules that are produced and stored in the pancreas. They include trypsin, chymotrypsin, amylase, and lipase. The trypsin and chymotrypsin break down protein molecules, the amylase breaks down starches, and lipase does the same to fats and triglycerides.

Breaking down the molecules of food into smaller sizes is an important part of the overall digestive process and allows nutrients to be absorbed by the cells that line the intestine. The nutrients are then passed from those cells into the bloodstream. There they can be transported throughout the body for use by the various tissues. When a dog eats a meal it stimulates the release of these enzymes. They flow from the pancreas into the anterior small intestine through a small tube called the pancreatic duct. Only after they reach the lumen or center of the intestine does their functional existence begin.

What is pancreatic insufficiency?

The disease characterized by a decrease or absence of these enzymes in the dog is referred to as 'exocrine pancreatic insufficiency' or 'maldigestion syndrome.' When dogs have this disorder, the proteins, starches, and fats found in their diet cannot be broken down into small enough pieces that allow them to be absorbed through the intestinal wall. The value and substance of the food, therefore, stays in the gastrointestinal tract and is passed out in the feces undigested. The affected dog, without treatment, literally starves to death even though it may be constantly eating. It is estimated that 90% of the pancreas must be destroyed before we see symptoms of insufficiency.

What causes pancreatic insufficiency?

There are several potential causes of pancreatic insufficiency. Chronic pancreatitis (inflammation of the pancreas) is a common cause of pancreatic insufficiency. In some young animals (usually less than two years of age), the cells of the pancreas just start decreasing in number and functioning. The cause for this is unknown, but it may be an inherited condition. Many different dog breeds can be affected, however, it is more common in large breeds, especially German Shepherds.

Signs of pancreatic insufficiency

Regardless of its cause, the signs associated with exocrine pancreatic insufficiency are usually obvious and fit a distinct pattern. The disorder may come on gradually over a long period of time or it may develop rapidly over a period of a week or two. The animals with the condition show rapid weight loss caused by loss of body fat, and muscle atrophy. The hair coat has poor quality. There is usually diarrhea with the stools being light yellow or clay-colored, with the consistency of mashed potatoes. In some cases, it may even be watery, without any form at all. Depending on the diet, there may be large quantities of undigested fat present in the stool. The animal will seem constantly hungry and eat as much food as it can ingest at one time. It will often eat abnormal things such as plants, dirt, or its own feces (though pancreatic insufficiency is a rare cause of stool eating in dogs). The animal, in its appearance and behavior, typifies one that is starving to death, and in reality, he is.

Diagnosis of pancreatic insufficiency

In most cases, a presumptive diagnosis can be made from clinical signs alone and it is then proven by one of several available tests used to accurately diagnose pancreatic insufficiency. These include:

• determining the levels of certain digestive enzymes in the blood (serum trypsin-like immunoreactivity), which is the most reliable
• measuring the level of chymotrypsin activity
• determining the levels of digestive enzymes in the stool (fecal proteolytic activity)
• examining the stool under the microscope (least reliable)

Treatment of pancreatic insufficiency

In its appearance and behavior, a dog with pancreatic insufficiency looks like one who is starving to death - and in reality, he is.

Fortunately, treatment can easily be accomplished. Unfortunately, it is an expensive and lifelong proposition. Treatment involves replacing the dog's pancreatic enzymes with enzymes from other sources. Our only source of medications for these cases is products made through an expensive process, using freeze-dried and ground-up extracts of hog and cattle pancreases. These glands are harvested in meat packing plants and then processed solely for this purpose. They are formulated either into tablets or powder and go under such trade names as Viokase or Pancrezyme. They contain large quantities of the same naturally occurring digestive enzymes that are deficient in the affected pet. The tablets are given prior to a meal while the powder is usually mixed with food and allowed to set 30 minutes before feeding. Response to therapy is immediate and the animal will usually return to near normal health. Unfortunately, cost becomes the major hurdle in treating pancreatic insufficiency. An affected dog, for instance, will need $60-100 worth of medication every month. Research is underway to develop synthetic digestive enzymes, and hopefully, will lower the price of treating these patients.

In some instances, raw pig pancreas can be used. The pancreas needs to come from animals certified as healthy by an approved meat inspector. Accurate dosing is more difficult with the raw pancreas, but in general, a 45-pound dog would need to receive 3 to 4 ounces of the chopped pancreas. The raw pancreas can be frozen at -4ºF for up to 3 months and still retain its enzyme activity.

If the dog does not respond well to the addition of the digestive enzymes in Viokase or Pancrezyme, the diet may sometimes need to be altered. A highly digestible diet is fed, medium chain triglycerides may be added as fat sources since they do not require breakdown by pancreatic enzymes, and multiple vitamin supplements are given (especially Vitamin B12 (cobalamin) and the fat-soluble vitamins A, D, E, and K.

Since the deficiency is one of enzymes and is cured by the addition of the same enzymes back into the diet, many dog owners regretfully try other cures. There are many products, nutritional and otherwise, that advertise they contain natural enzymes which aid in digestion. Examples of these are K-ZYME, ProBalance, Prozyme, and so on. These really do contain real and natural enzymes and in normal dogs can be very useful nutritional supplements. However, they are not the enzymes associated with Pancreatic Insufficiency. This is a very specific disorder with specific enzymes needed to correct it. The general nutritional supplement will do no harm, but regretfully, they will do no good either.

We occasionally see patients in which the pancreatic insufficiency is only temporary and somehow resolves itself in 6 to 8 months, but these are rare exceptions. In these cases, it is thought that the cells responsible for the production of the enzymes have been irritated in some way but not permanently damaged. When they recover from the incident, whatever it was, their ability to produce these enzymes returns.

Pancreas: Anatomy & Digestive & Endocrine Functions in the Dog  췌장 해부학

Anatomy

The pancreas is a small structure located near the stomach and attached to the wall of the small intestine. The pancreas has two major functions. It produces hormones to aid in the maintenance of a proper blood sugar (glucose) level. The hormones are secreted into the bloodstream. It also produces important enzymes to aid in the digestion of protein and fats (lipids). These enzymes travel from the pancreas to the small intestine through a small tube called the pancreatic duct.

Hormonal or endocrine function (insulin and glucagon)

The glucose-regulating hormones produced by the pancreas are insulin and glucagon. When starches and carbohydrates are eaten, they are broken down into the sugar glucose. The glucose is absorbed through the wall of the digestive tract and passes into the bloodstream. Insulin allows glucose to leave the bloodstream and enter the body's tissues. Glucose can then be utilized as energy for the cells. When glucose levels are high, glucagon causes it to be stored in the liver and muscles as glycogen. If not enough insulin is produced, diabetes mellitus (sugar diabetes) can occur.

Digestive or exocrine function (trypsin, chymotrypsin, and lipases)

The pancreas produces the protein-digesting enzymes trypsin and chymotrypsin. Fat digestion is aided by enzymes called lipases, also produced by the pancreas. Without these enzymes, dogs would not be able to break down important dietary components. When the pancreas does not produce adequate amounts of these enzymes the condition is called pancreatic insufficiency.

Pancreatic Hypoplasia: A Cause of Pancreatic Insufficiency in Puppies

The pancreas is a small structure located near and attached to the wall of the small intestine. The pancreas has two major functions. It produces insulin to aid the blood in sugar absorption and it produces important enzymes to aid in the digestion of protein and fats (lipids). These enzymes travel from the pancreas to the small intestine through a small tube called the pancreatic duct.

The pancreas produces the protein-digesting enzymes trypsin and chymotrypsin. Fat digestion is aided by enzymes called lipases, also produced by the pancreas. Without these enzymes, dogs would not be able to break down important dietary components.

Hypoplasia is the term for an underdeveloped tissue or organ. One of the most common puppy abnormalities of the pancreas is congenital pancreatic hypoplasia, which refers to an underdevelopment of the pancreas. It is also called 'juvenile pancreatic acinar atrophy.' In puppies with this condition, the portion of the pancreas that produces the hormone insulin usually develops normally, while those cells that produce enzymes for digestion of food, especially fats, do not. When the pancreas does not produce these digestive enzymes, we call it 'pancreatic insufficiency.' Pancreatic hypoplasia, the most common cause of pancreatic insufficiency is genetic and is most noted in German Shepherds, Doberman Pinschers, Saint Bernards, Irish Setters, and Labrador Retrievers.

What are the symptoms?

The symptoms relate to the fact that food is improperly digested, preventing its absorption. The degree or severity of symptoms varies with the amount of loss of functional pancreatic tissue. A dog with pancreatic hypoplasia does not have a fully developed pancreas, but whether it is 50 percent or 90 percent developed alters the degree to which it functions. In other words, the pancreas may be capable of producing enzymes to digest a little, some, or most, but not all of its food.

Symptoms generally include a loose, greasy, foul-smelling stool. The hair coat is generally dry and brittle as a result of inadequate fat digestion and utilization. Most dogs have an increased, oftentimes voracious appetite, as they are functionally starved as a result of fecal loss of nutrients. Despite a great appetite, most dogs are thin - again due to nutrient loss. Coprophagy (stool eating) is common among affected individuals, although many normal puppies also engage in this habit.

What are the risks?

Mildly affected dogs, those with almost-normal enzyme production, are not at great risk. They may, however, experience loose stool and remain thin, with a dull hair coat. Dogs with moderate to severe pancreatic hypoplasia will be more severely affected. Left untreated, these dogs will experience severe signs of malnutrition, including death.

What is the management?

Management is aimed at improving the digestion of foods so that, nutritionally, the dog will not be severely compromised. Commercially prepared enzymes are available to replace or supplement what the pancreas is not producing. Pancreazyme and Viokase are the two most commonly prescribed enzyme formulations. Either one can be used. Basically, these supplements contain the enzymes needed for digestion. The enzyme supplement is mixed with the food prior to feeding. In addition to providing enzyme supplementation, it is beneficial to feed specially prepared diets, which are formulated for ease of digestion. The prescription diet i/d by Hill's is one such diet. From the authors' experience, it is important to discuss the costs associated with management with each owner. Enzyme supplements and prescription diets are costly and will need to be fed for the life of the animal. It is also possible the dog will be controlled with treatment, but may never return to perfect health. Symptoms to some degree may persist even with proper management.