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68 Cards in this Set

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Is exocrine pancreatic insufficiency a disease?
No, it's a syndrome
What are the 6 primary clinical signs of EPI?
1) Malabsorption
2) Malassimilation
3) Diarrhea (severe)
4) Steathorrea
5) Weight loss
6) Failure to thrive*
-most common except cats
What dog is most commonly affected by EPI?
German shepherd
Why do we see decline in growth rates and potentially weight loss in animals with EPI?
Pancreatic acinar atrophy starts manifesting at about 6-9 months of age and a peak diagnosis at about 12 mo of age= still growing at this time so see decline in growth
What age of dogs usually develop EPI?
Adults
Exocrine pancreatic insufficiency is the end result of________.
Pancreatic Acinar atrophy
= selective loss of enzyme secreting acinar cells
Are the cells of the endocrine pancreas or pancreatic duct cells affected by EPI?
NO= NOT associated with diabetes mellitus, bicarbonate excretion is normal
What dogs have evidence of an inherited link to pancreatic acinar atrophy?
German shepherds and rough coated collies
If pancreas' with pancreatic acinar atrophy are biopsied and pathologists try to identify those who will develop EPI, what are they looking for?
Early histology shows chronic lymphocytic/ plasmacytic pancreatitis correlates
-autoimmune?- but don't benefit from glucocorticoids
What is most likely the main cause of EPI in cats?
Chronic pancreatitis
-also common in humans
What are 5 other potential causes of EPI other than pancreatic acinar atrophy?
1) Chronic pancreatitis
2) Congenital pancreatic hypoplasia
-pancreas didn't develop in first place
3) Pancreatectomy surgery
-remove part of pancreas it's going to be insufficient
4) Pancreatic cancer
5) Pancreatic duct abnormalities
-aberrant duct entering the LI
instead of the SI (need enzymes to get to right place to work)
What is the only possible other cause of EPI (not pancreatic acinar atrophy) that does not decrease serum TLI? Why?
Pancreatic duct abnormalities: normal bc normal size pancreas delivering enzymes to wrong place whereas everything else has a loss of pancreatic mass; may need enzyme replacement therapy
Why do animals with pancreatitis have maldigestion and malabsorption?
Lack of digestive enzymes
What type of diarrhea do animals with EPI get? What do the feces look like?
Small intestinal
-loose poorly formed "pulpy" feces
Describe the defecation frequency and fecal volume of an animal with EPI.
Large volume but normal number of defecations
How can you tell when an animal has fat malabsorption (like with EPI)?
Steatorrhea: Light tan to grey feces
What's the major cause of diarrhea in animals with EPI?
fat malabsorption
What causes the osmotic pull of water into the small intestine in animals with EPI?
Oxidation and degradation of fat by intestinal bacteria produces toxic fatty acids, stimulates additional water secretion by small intestine
Why do dogs with EPI show signs of copraphagy?
Because they're hungry
-occasionally seen in cats
At what age do dogs with pancreatic acinar atrophy tend to show signs of EPI?
18 months to 2 years of age
-normal growth, then weight loss, failure to continue to grow
Why do animals with EPI get lots of gurgling noises and flatulence?
Because lots of bacterial fermentation producing gases
What is a common sign of EPI in cats?
Poor hair coat
Are clinical signs for EPI pathognomonic?
Nope, similar signs to small intestinal disease bc pathology is essentially due to decreased SI absorption so it makes sense
What are the 3 primary differential diagnoses for EPI?
1) Small intestinal disease
2) Hyperthyroidism**
-cats w/ diarrhea & wt. loss
-same signs
3) Diabetes mellitus
-polyphagia & wt loss
What are 7 types of small intestinal disease that are a differential diagnosis for EPI?
1) IBD
2) Ecological disorders
-small intestinal bowel disease
3) Chronic salmonellosis, campylobacteriosis
4) Helminths: hookworm, whipworm
5) Protozoal diseases: giardia
5) Dietary intolerance or allergy
-very rare to have true allergy
5) Lymphangectasia
-lymph is a main route of absorbing fat
Though there are rarely significant changes in routine chemistry in animals with EPI, what are 3 changes you may see on a CBC/chem & UA?
1) Mild elevation in liver enzyme activities
2) Hypoproteinemia / hypoalbuminmia if secondary
3) Hypocholesterolemia
Are amylase/lipase levels relevant to EPI diagnosis?
NO
What is the purpose of doing a fecal float or smear in a dog that you suspect has EPI?
Looking for parasites such as giardia that cause small intestinal disease
-for giardia use ZnSO4
What are some specialty tests that you can request when you suspect EPI?
TLI
Cobalamin
Folate
Why would we want to measure cobalamin in an animal that you suspect has EPI?
Cobalamin deficiency is common in patients with EPI and if they do have this it makes it harder to manage them and makes them feel unwell in general
What is the test of choice for EPI and pancreatic acinar atrophy in dogs and EPI in cats?
Serum trypsin-like immunoreactivity (TLI)
****In a dog when are TLI levels diagnostic for EPI?
Serum [TLI] <2 ug/L
*****In a cat when are TLI levels highly suggestive of EPI?
Serum [TLI] <8 ug/L
How do you test fecal proteolytic activity?
X-ray degradation test, Gelatin degradation
Is fecal proteolytic activity measured very commonly when diagnosing EPI? Why or why not?
No, because false negatives and false positives are common
-but still useful in exotics
What are 4 diagnostic tests used to diagnose EPI?
1) Serum TLI
2) Fecal proteolytic activity
3) Fecal elastase
-in europe
4) Fecal fat determination
-steatorrhea is seen in lots of other diseases
What is the only advantage that fecal elastase has over TLI for diagnosing EPI?
TLI is a radioimmunoassay so have to use radioactive materials and fecal elastase doesn't use radiation
Do cats or dogs get EPI more commonly?
Much lower in cats
What most commonly causes the signs that are seen in animals with EPI in cats?
Small intestinal disease by far
What is a big difference in the vitamin levels of a dog with EPI compared to a cat with EPI?
Almost all cats with EPI have cobalamin deficiency
-in the dog it's less common
What does it mean if a dog's serum concentration of TLI <5 but >2?
may represent a subclinical state of EPI, PAA cases that have not yet reached full-blown EPI, or just normal for the dog
-Exocrine pancreas has sizable reserves, need to lose essentially all exocrine tissue to see clinical signs
How should you medically manage a dog that has signs of small intestinal disease with a serum concentration of TLI <5 but >2?
Most dogs respond well to dietary change (fat restriction) and don't need enzyme supplementation
-W/D, R/D
When do we use enzyme replacement therapy for animals with EPI?
If full blown loss of exocrine pancreas
What should you use for enzyme replacement therapy
Porcine Pancreatic enzyme extracts (Pancreazyme, Viokase)
what type of enzyme replacement therapy does NOT work?
Plant derived-products
How much enzyme replacement therapy should you give an animal with EPI?
Start w/ 1 tsp of powdered extract/ meal for typical german shepherd dog
What type of vitamin supplementation should be given to an animal with EPI?
-Fat solubles (A,D,E,K)
-Cobalamin in all cats and many dogs
What are 4 things to consider if there's no response to an animal whose been on treatment for EPI for 2-3 weeks?
1) Consider dose increase
-risk of gingivitis and periodontal bleeding (from increasing enzymes & mouth isn't meant to be exposed to active enzymes)
2) Consider antibiotic therapy
-Tylosin for secondary dysbiosis, metronidazole
-for secondary bacterial overgrowth
3) Consider antacid therapy
-enzymes may be damaged by gastric acid
4) Pred at 1 mg/kg SID for secondary inflammatory disease (abnormal GI function)
How long do you have to give enzyme replacement therapy to animals with EPI?
Lifelong
Why are ~20% of EPI cases euthanized within 1 year of diagnosis?
Cost of therapy
-poor response, food aversion in cats
What is the prognosis of EPI with treatment?
Adequate therapy and attention to diet, prognosis is good for a reasonable quality of life
Why is it so important to diagnose EPI in an animal?
Because they need enzyme replacement therapy
What is the most common pancreatic malignancy in dogs?
Adenocarcinoma, but not a common diagnosis
What is the prognosis of adenocarcinoma of the pancreas?
Prognosis is grave to hopeless
-usually present or are diagnosed at a late stage
What dogs do not uncommonly get nodular hyperplasia?
Older dogs
-benign process
Pancreatic ______ are also seen in dogs, diagnosed on histopathology.
Pancreatic adenomas
What is a pancreatic pseudocyst?
Fluid filled structure associated with or within the pancreatic parenchyma
-lack an epithelial lining= pseudocyst
How are pseudocysts related to pancreatitis?
Pseudocysts are a complication/ sequel of acute pancreatitis and often present w/ pancreatitis signs, but may be a benign or incidental finding
Are there any negative consequences of having a pancreatic pseudocyst?
Yes, often contain large amounts of digestive enzymes, so can rupture and cause acute severe peritonitis signs
Do pancreatic abscesses contain pancreatic enzymes?
Nope, a collection of inflammatory cells/ inspissated pus associated with the pancreas, but lacking significant quantities of pancreatic enzymes
-usually sterile, but if infection occurs can get severe disease.
What is the treatment of choice for a pancreatic abscess?
Surgical drainage is treatment of choice. but significant post-operative morbidity and mortality.
-if not clinical, monitor size and treat conservatively
What are 2 pancreatic parasites?
1) Eurytrema procyonis
2) Amphimerus pseudofelineus
q
What animals are infected by Eurytrema procyonis?
Pancreatic fluke of cats, also found in foxes and raccoons
What are the physical consequences Eurytrema procyonis?
Heavy infestation can lead to pancreatic duct fibrosis
How do diagnose Eurytrema procyonis? An how do you treat it?
-Diagnose from characteristic eggs in feces
-Treat with with fenbendazole for six days
What is Amphimerus pseudofelineus? What organ is it found in?
Hepatic fluke of cats, can also be found in the pancreas, causes signs of chronic pancreatitis
How do you diagnose Amphimerus pseudofelineus?
Eggs are destroyed in routine fecal float, need formalin-ethyl acetate sedimentation.
*Have to know your looking for the eggs since fragile
What is the treatment for Amphimerus pseudofelineus?
Treat with praziquantel for 3 days as well as routine approach for chronic pancreatitis