Canine Exocrine Pancreatic Insufficiency: A Challenging Condition

Natalie Dennis - St. Matthew's University

Cases/Abstracts - Winner

Introduction

Exocrine pancreatic insufficiency (EPI) is a particularly concerning digestive condition that leads to nutrient deficiencies, weight loss, and death if left untreated (Foster and Smith, 2012). EPI4dogs Foundation defines EPI as “the inability of the pancreas to secrete digestive enzymes: amylase to digest starches, lipases to digest fats, and proteases to digest protein. Without a steady supply of these enzymes to help break down and absorb nutrients, the body starves. When EPI is undiagnosed and left untreated, the entire body is deprived of the nutrients needed for growth, renewal, and maintenance. In time, the body becomes so compromised that the dog either starves to death or dies of organ failure. The Merck Veterinary Manual defines EPI as “a syndrome caused by insufficient synthesis and secretion of digestive enzymes by the exocrine portion of the pancreas”. “Lack of pancreatic digestive enzymes leads to maldigestion and malabsorption” (2011). This condition is certainly nothing to overlook. Many pet owners and veterinarians are unfamiliar with the detrimental condition and the purpose of this case study is to enhance the veterinarian’s and pet owner’s knowledge and awareness of EPI.

Like other canine medical conditions, EPI requires proper diagnosis and management. However, the condition is unique because it also requires a responsible and financially stable dog owner with patience and willingness to learn as much as he or she can about EPI and nutrition. Clinical signs can be misleading, as they are comparable to those of many other conditions. While diagnosis can be simplified when differentials get ruled out, medical bills can add up to an outrageously high expense. Overall management of EPI is best described as nutritionally variable, effective, expensive, and lifelong. The following case report outlines signs, diagnosis, dietary management, and financial aspects of a canine EPI patient. Its purpose is to emphasize requirements of the veterinarian and client in nutritional support for the condition, as well as to highlight the significance of financial requirements. As such, this case can be of interest to a broad readership of veterinary professionals, veterinary science students, and pet owners.

Clinical Report

“Molly”, a ten-year-old spayed female German shepherd was diagnosed with Exocrine Pancreatic Insufficiency at the age of fourteen months in May 2005. Her owner was concerned with Molly’s watery diarrhea, failure to gain weight, coprophagia, and a ravenous appetite for 6 months’ duration with low exercise activity in her life. Her owner struggled to maintain her weight on 2 1/2 cups of dry Kibbles ‘n Bits ‘Beefy Bits’ twice daily with treats high in carbohydrates, providing Molly more than 2000 kcal/day. Despite her high caloric diet, Molly presented to her regular veterinarian for physical examination at 64 pounds (29 kg) with a thin body condition score of 2.5/5, a delayed skin tent of 2.5 seconds, and a greasy, poor hair coat. There were no other significant findings upon examination.  The abnormal findings and clinical signs perplexed multiple clinicians into a tedious process of diagnostics and elimination of differentials that eventually led to Molly’s initial diagnosis of EPI. According to Merck Veterinary Manual, dogs with EPI often display clinical signs of  “…polyphagia (excessive hunger), weight loss, and diarrhea. Vomiting and anorexia are observed in some animals with EPI and may be a sign of concurrent conditions. The feces are most commonly pale, loose, and voluminous and may be malodorous. In rare cases watery diarrhea may be seen. The high fat content of the feces can lead to a greasy appearance of the hair coat”.  

Because clinical signs of EPI share similarities with a variety of other medical conditions and it is rarely encountered, the veterinarian must rule out all possibilities when presented with a dog displaying these symptoms. Parasites, allergies, bowel inflammation, and systemic disease must be ruled out, as these conditions can cause dogs to display similar symptoms to those with EPI. For example, clinical signs of food hypersensitivity similarly include “…vomiting, diarrhea, abdominal pain or an increased fecal frequency” (Verlinden, Hesta, Millet, Janssens, 2006).  Though clinical signs can be misleading, diagnosis of EPI through laboratory testing is straightforward when it comes to determining enzyme levels in the blood. “The diagnosis of EPI is based on history, clinical signs, and low levels of serum canine trypsin-like immunoreactivity (TLI)” (Biourge, Fontaine, 2004). The TLI test determines the level of trypsin-like enzymes in the bloodstream, particularly trypsinogen (Merck, 2011). A mild to significant decrease in serum TLI is consistent with EPI. Pancreatic Lipase Immunoreactivity (PLI) is also highly specific for exocrine pancreatic function and could be used to diagnose EPI (Merck, 2011). However, there is a small degree of overlap in serum PLI concentrations between normal dogs and dogs with EPI, making the measurement of PLI slightly inferior to TLI for accurate diagnosis. Once a dog tests positive for EPI with the TLI, he or she must be tested again following treatment to confirm the efficacy of treatment once it is established. A variety of diagnostic tests done prior to the TLI, such as a fecal evaluation, urinalysis, and blood chemistry panel, are useful towards ruling out differential diagnoses.

Molly’s diagnosis occurred through a comprehensive fecal analysis that was negative in multiple aspects, ruling out parasites and bacteria. Her veterinarian ran a serum trypsin-like immunoreactivity (TLI) on Molly and obtained a positive result. Bloodwork was not included in this medical visit as it was done recently for ovariohysterectomy. Blood chemistry panel results were within normal parameters, according to her veterinarian. This diagnostic visit was a costly venture for the owner. According to her veterinarian, the price of the fecal analysis was $79.50, while the serum TLI was $120.00, costing the owner a total sum of $199.50. Other important aspects of this medical visit involved discussion of options for Molly’s owner and finding an appropriate diet plan to improve and maintain good health for Molly.

At minimum, “…the management of EPI includes supplementing each meal with the most important key nutritional factor, pancreatic enzyme extracts, to replace the enzyme deficiency of the pancreas. It is almost equally essential to feed a highly digestible diet, and giving, at least initially, an antibiotic treatment to control small intestinal bacterial overgrowth” (Biourge, Fontaine, 2004). A highly digestible diet is low in fat. Options for enzyme replacement include powdered enzyme formulas, enzyme tablets, and raw beef, pork, or lamb pancreas. Supplements as these “…contain amylases, lipases, proteases, and other pancreatic enzymes to replace the naturally occurring digestive enzymes depleted by EPI” (Clark, Steiner, Williams, 2012).  The risk of parasitic and bacterial contamination is always a concern with the use of raw pancreas. Cooking can eliminate these risks but also inactivates the enzymatic activity to an extent (Brooks, 2012). Enzymatic powder and tablets are equally effective and can be easily mixed into the dog’s food. Beyond minimal treatment methods, antibiotic treatment and vitamin B-12 supplementation are necessary for EPI patients that develop intestinal bacterial overgrowth, which often accompanies EPI (GlobalSpan, 2011). Bacterial overgrowth causes malabsorption, vitamin B-12 (cobalamin) deficiency. Some patients respond best when an H2 blocker-type antacid is given concurrently with the enzymes” (Brooks, 2012). According to Wendy Brooks, “Treatment is for life; without enzyme supplementation, all of the unpleasant symptoms will recur. Response can be excellent but approximately one dog in five will simply not respond well. Many do not ever regain a normal amount of weight.” Although cures and preventatives do not exist for EPI dogs, lifelong enzymatic and diet therapy have the potential to keep these dogs alive by enabling them to live a normal, healthy lifespan. Molly’s response to enzyme replacement powder and a low residue diet became evident within two to three weeks of starting treatment. This was noted through body condition score, improvement in hair coat, and stool bulk.

Exocrine pancreatic insufficiency is notorious for having profound physiologic effects on dogs, preventing them from living a normal, healthy lifestyle, when not treated properly or not treated at all. Physiologic effects that accompany EPI include small intestinal bacterial growth, as well as a decline in the condition of the intestinal mucosa, malabsorption of nutrients, a decline in the condition of the integumentary system, weight loss, and appetite increase (GlobalSpan, 2011). Thus, dogs with this condition are unhealthy overall. EPI patients can develop small intestinal bacterial overgrowth (SIBO), which damages the intestinal mucosa, which leads to diarrhea resulting in malabsorption of cobalamin, proteins, and carbohydrates (Batt, 2010). According to GlobalSpan, almost 50% of EPI dogs with SIBO of these patients lose the ability to absorb cobalamin because of this bacterial overgrowth. Cobalamin, also known as vitamin B12, is essential for digestion, weight gain, proper cognitive function, and a healthy coat (Steiner, 2012). EPI patients face an overall malaise and decline in health, despite a voracious appetite, in result of these many physiological effects brought on by the disease.

Exocrine pancreatic insufficiency holds challenging characteristics beyond physiological effects on the pet. Identifying and providing ongoing treatment to a pet affected with an enzyme deficiency can become a very costly venture for the pet's owners. In fact, “…while manageable, it places a steep financial and emotional burden on dog owners” (EPI Research Fund, 2010). “About twenty percent of dogs are euthanized as a direct result of their EPI, usually because of the cost of treatment or lack of clinical improvement” (Westermarck, 2009). Doctor Patty Khuly says, “…blood tests to diagnose the problem and other tests to rule out other major disease processes may well rack up significant bills ($300 to $1000 or more)” (2012). In July 2005, Molly visited the Veterinary Medical Center at the University of Minnesota for in-depth reevaluation of her condition at the age of one year and four months. This visit entailed blood work such as a urinalysis, a chemistry panel, and a serum trypsin-like immunoreactivity test. Her liver, kidney, and pancreatic functions were evaluated and there were no significant findings. The medical bill for this visit included the fees of a new medical record, examination, diagnostic tests, Metronidazole for the SIBO, and vitamin B12 injection to promote cobalamin absorption. The cost of this visit recommended by Molly’ regular veterinarian resulted in the sum of approximately $112.09 (Exhibit A & Exhibit B). In addition to medical visits, the complexity of feeding Molly during her lifespan presented an inevitable expense. Molly’s daily feeding consisted of one early morning meal and one late afternoon meal of 1 and ½ cups of dry Iams Intestinal Low Residue mixed with a ½ cup of Kibbles ‘n Bits along with two acid reducers (cimetidine) and with one teaspoon of Epizyme powder. A 30-pound bag of Iams Low Residue costs $89.13, while a 35-pound bag of Kibbles ‘n Bits costs $24.95, A 30-tablet box of acid reducers costs $4.59, and a 12-ounce bottle of Epizyme powder costs $123.23. Exhibit A

Exhibit B

        Low residue formulas are often necessary to support an EPI patient’s digestive sensitivity. This type of diet was key for maintaining normal stool habits in Molly. Using thirty days as an approximation for an average month’s time, the monthly consumption amount and yearly costs of consuming a low residue product, such as with Molly’s case, can be calculated. Molly’s consumption of three daily cups of Iams food for one month adds up to 90 cups per month. She went through 1,080 cups per year when consuming 90 cups per month. Four cups of dry dog food is approximately equal to one lb of dry dog food. 1,080 cups divided by 4 equals 270 lbs of Iams dry dog food consumed per year. 270 lbs divided by 30 lbs per bag sold equals 9 bags consumed at $89.13 per bag to equal a cost of $802.17 per year for the Iams Formula. Conclusively, $8,021.70 was spent over ten years feeding Molly the Iams Low Residue food. Molly also consumed one cup of Kibbles ‘n Bits daily to maintain a moderate fat and caloric intake. This product was also useful in enhancing the palatability of Molly’s daily feeding to make sure she receives all of the dietary nutrients and enzymes provided in each meal. Using thirty days as an approximation for an average month’s time results in the estimation of thirty cups consumed per month. This monthly consumption pattern over a twelve-month period results in the use of 360 cups of Kibbles ‘n Bits fed per year. Four cups of dry dog food are approximately equal to one pound of dry dog food. 360 cups divided by 4 equals 90 pounds of Kibbles ‘n Bits dry dog food consumed per year. 90 pounded divided by 35 pounds per bag sold equals about 2.57 bags consumed at $24.95 per bag to equal a cost of $64.12 per year for the Kibbles ‘n Bits food. Feeding Kibbles ‘n Bits to Molly over a ten-year period resulted in spending $641.20.

            Though “…concurrent antacid therapy has been shown to have little effect on overall digestive ability in EPI patients” (Merck, 2011), some clients or veterinarians may be willing to give antacids a chance to optimize digestion and absorption potential. Molly’s veterinarians recommended antacid use and she remained on them for nearly ten years. Four daily acid reducer tablets consumed over a course of thirty days add up to about 120 tablets per month. Over 12 months, Molly’s total consumption of antacids equals 1,440 tablets per year. One $4.59 box of acid reducers contains 30 tablets. 1,440 tablets divided by 30 tablets per box equals 48 boxes used per year. 48 boxes of acid reducers at $4.59 a box costs $220.32 per year. Ten years of antacid consumption for a patient such as Molly cost $2,203.20.“Enzyme replacement is a large part of the treatment. Replacement products are available by veterinary prescription only and can be quite expensive” (Pet MD, 2012). Molly consumes two daily teaspoons of Epizyme powder. Over approximately 30 days, her consumption adds up to 60 teaspoons per month.  6 teaspoons equals 1 ounce (dry measure by volume). 60 teaspoons per month divided by 6 teaspoons equals 10 ounces of Epizyme powder consumed per month. 10 ounces multiplied by 12 months equals 120 ounces of Epizyme powder consumed per year. 120 ounces of Epizyme powder consumed by a 12-ounce bottle being sold results in 10 Epizyme bottles being consumed per year.  Purchasing ten of the 12-ounce bottles of Epizyme powder at a cost of $123.23 a bottle results in a yearly cost of $1,232.30.  Purchases made on this product over a course of ten years add up to $12,323.00.

Discussion

The total cost of the dry food, acid reducers, and Epizyme powder ($8,021.70 + $641.20 +$2,203.20 + 12,323.00) make up the total dietary cost of $23,189.10 required for Molly’s ten-year duration. The total amount of EPI expenses during Molly’s lifetime includes the dietary purchases and her diagnostic medical visits ($23,189.10 + $199.50 + $112.09), resulting in a total of $23,500.69. This is a rough estimate of the expense of keeping an enzyme-deficient dog like Molly alive and well for ten years. These costs disregard Molly’s other medical concerns such as her spay, vaccines, parasites, flea, tick, and heartworm preventative. Management of EPI expenses will vary slightly from that of Molly’s depending on the individual patient’s dietary needs and lifespan. “Research indicates that responses to different diets vary among individual dogs. Because responses to the diets are unpredictable, it is suggested that feeding regimens be individually formulated for dogs with EPI” (EPI4dogs). According to her owner and regular veterinary follow-up visits, Molly’s response to her supplemented diet indicated that the measures taken to manage her condition were adequate. Improvements in her stool and body condition were achieved. It became evident that her clinical signs were reflective of the malabsorptive effects of the disease and they were corrected. She achieved a constant health state, proving efforts and costs to be effective and crucial.

Conclusion

Exocrine pancreatic insufficiency requires more than just the help of a veterinarian. In order to fulfill a good prognosis as seen with Molly, the pet owner must be financially supportive and willing to learn as much as he or she can about EPI and nutrition. This will help the owner and his or her to dog avoid a decline in the dog’s health. Awareness of initial and lifetime expenses is crucial, as well as the many key nutritional factors in managing EPI as seen with Molly. These factors vary in cost, source, and amount for each patient. Health checks, bacterial growth control, and diet contribute to the complexity of management and should be communicated between the veterinarian and client. Molly’s EPI expenses of $23,500.69 dollars within ten years are additive to other expenses in her lifetime such as preventative medicine and spay, so expenses must be calculated realistically. Thus, canine exocrine pancreatic insufficiency is most certainly a challenging condition to manage during a dog’s lifetime.