Exocrine Pancreatic Insufficiency in Dogs (EPI)

Overview of Canine Exocrine Pancreatic Insufficiency (EPI)

Exocrine pancreatic insufficiency, commonly abbreviated and referred to as EPI, is a disorder in which the pancreas does not produce an adequate amount of digestive enzymes. This deficiency results in maldigestion (poor digestion) and malabsorption (poor absorption). EPI is most commonly found in German shepherd dogs, but can be seen in any breed. It is rare in cats.

EPI is seen most commonly in young dogs secondary to pancreatic acinar atrophy (a decrease in the enzyme producing cells of the pancreas). EPI, however, can occur in older animals secondary to chronic pancreatitis (pancreatic inflammation).

General Causes of Exocrine Pancreatic Insufficiency in Dogs

• Pancreatic acinar atrophy (most common cause)
• Chronic pancreatitis
• Pancreatic cancer
• Congenital abnormality (an abnormality present since birth)

What to Watch For

• Chronic diarrhea
• Excessive food intake
• Weight loss
• Flatulence (gas)
• Coprophagia (eating feces)
• Pica (eating unusual things such as dirt)
• Borborygmus (a rumbling noise caused by gas passing through the intestines)

Diagnosis of Exocrine Pancreatic Insufficiency in Dogs

Veterinary care includes diagnostic tests and subsequent treatment recommendations. Diagnostic tests are needed to identify EPI and exclude other diseases. Your veterinarian will take a complete history and perform a thorough physical examination. A thorough knowledge of the history and clinical signs is very important in the diagnosis of EPI. Tests may include:

• Fecal examination to check for the presence of fat and starch which indicates maldigestion or malabsorption. A fecal flotation and direct smear also will be performed to evaluation for parasites.
• A complete blood count (CBC or hemogram) to evaluate for anemia, inflammation, infection or low platelet count.
• Serum biochemistry profile to evaluate the general health of your dog and to determine the effect of EPI on other organ systems.
• Urinalysis to evaluate kidney function and to check for the presence of urinary tract infection.
• Abdominal X-rays to evaluate organs such as liver, spleen, and kidneys and to check for masses.
• Serum trypsin-like immunoreactivity (TLI) to evaluate for the presence of the pancreatic enzyme trypsin. Animals with EPI have extremely low concentrations of this enzyme in their serum.

Treatment of Exocrine Pancreatic Insufficiency in Dogs

Dogs with EPI generally feel well and are otherwise healthy. Treatment often is administered on an outpatient basis and may include one or more of the following:

• Dietary modification
• Pancreatic enzyme replacement
• Concurrent antibiotic therapy

Home Care and Prevention of EPI

Administer any medications that your veterinarian has prescribed. Feed your dog as directed by your veterinarian. Watch your dog carefully for resolution of symptoms, especially resolution of diarrhea and gain in body weight. Contact your veterinarian if improvement is not observed over the first few weeks.

The cause of pancreatic acinar atrophy is unknown and this cause of EPI cannot be prevented. Diets high in fat can predispose pets to pancreatitis. Thus, feed your pet a diet low or moderate in fat content and avoid feeding high fat table scraps.

Information In-depth on Exocrine Pancreatic Insufficiency in Dogs

Exocrine pancreatic insufficiency (EPI) is most often caused by pancreatic acinar atrophy (a shrinking of the enzyme producing cells of the pancreas) the cause of which is unknown. It is seen most commonly in young dogs, especially German shepherd dogs.

EPI can have major impact on the animal because severe longstanding diarrhea and profound weight loss are commonly observed. Other medical problems can lead to symptoms similar to those encountered in EPI. These conditions should be excluded before establishing a definitive diagnosis of EPI:

• Bacterial infectious diseases, such as Salmonella, Clostridium and Campylobacter.
• Viruses, such as Coronavirus and Parvovirus.
• Fungal infections, such as Histoplasma, Mycobacteria and Phycomyces
• Parasitic disease, such as roundworms, hookworms and whipworms
• Protozoal infections, such as Coccidia, Giardia and Trichomonas
• Inflammatory Bowel Disease (IBD). The cause of IBD is unknown, but it is thought to be immune-mediated. Diarrhea and weight loss are commonly observed in dogs with IBD. An intestinal biopsy is the only way to diagnose IBD definitively.
• Dietary intolerance or dietary allergy usually occurs in response to a particular dietary protein, but can occur secondary to almost any component in the animal’s food. Diarrhea and abnormalities of the skin are most commonly seen with this disorder.
• Drugs and toxins are more often associated with acute diarrhea, but chronic exposure to certain medications or toxins can be associated with chronic diarrhea.
• Cancer of the gastrointestinal tract can cause diarrhea and weight loss.
• Obstruction (blockage) of the gastrointestinal tract due to cancer, foreign bodies, intussusception (telescoping of the bowel onto itself), or stricture can be associated with chronic diarrhea.
• Metabolic disorders including kidney and liver failure, diabetes mellitus and hypoadrenocorticism (Addison’s disease) may be associated with weight loss and diarrhea.
• Duodenal ulcers can cause diarrhea and melena (black tarry stools secondary to the presence of digested blood).
• Small intestinal bacterial overgrowth is characterized by an overgrowth of normal intestinal bacterial flora and may be associated with chronic diarrhea.
• Lymphangiectasia is a chronic protein-losing disorder of the intestinal tract that is associated with chronic diarrhea.
• Short bowel syndrome may develop after a large portion of the intestinal tract has been removed surgically. Chronic diarrhea may be observed in this syndrome.
• Gluten-sensitive enteropathy is an intestinal disorder seen most commonly in Irish Setters. It is an inflammatory disease that occurs in response to diets containing gluten (a protein of wheat).
• Irritable bowel syndrome (spastic colon) is a chronic intermittent disorder that is associated with diarrhea, abdominal pain and gas.

Veterinary care should include diagnostic tests and subsequent treatment recommendations.

Diagnosis In-depth for Exocrine Pancreatic Insufficiency

Certain diagnostic tests are needed to confirm the diagnosis of EPI and exclude other diseases that may cause similar symptoms. The following diagnostic tests often are recommended:

• Your veterinarian will take a complete medical history and perform a thorough physical examination.
• Multiple examinations of fecal specimens (fecal flotations, direct smears, zinc sulfate preparations) may be performed to exclude chronic intestinal parasitism before proceeding with additional diagnostic tests.
• A complete blood count (CBC or hemogram) to evaluate low total protein concentration, inflammation, anemia or low platelet count.
• A serum biochemistry profile to evaluate the general health of your pet and to determine the effect of EPI on other organ systems. Tests such as serum albumin and total protein concentration and serum cholesterol concentration help exclude protein-losing intestinal disorders. Animals with EPI usually have normal serum protein concentrations.
• Urinalysis to evaluate kidney function and check for urinary tract infection.
• Abdominal X-rays to evaluate abdominal organs (liver, kidneys, spleen) and check for masses. Abdominal X-rays usually are normal in dogs with EPI.
• Serum trypsin-like immunoreactivity (TLI) is considered the “gold standard” for the diagnosis of EPI. Dogs with EPI have extremely low serum concentrations of TLI. Blood for TLI should be drawn after a 12-hour fast. A limited number of laboratories perform this test, but most veterinarians will be able to draw the blood sample and send it to the appropriate lab.

Your veterinarian may recommend additional diagnostic tests to exclude or diagnose other conditions or to better understand the impact of EPI on your dog. These tests ensure optimal medical care and are selected on a case-by-case basis. Examples include:

• Serum folate and cobalamin concentrations may be recommended if small intestinal bacterial overgrowth is suspected.
• Abdominal ultrasound examination to evaluate the size and internal structure of abdominal organs (liver, spleen, kidneys) and to assess for the presence of abnormal structures or masses that may be present in dogs with chronic diarrhea or weight loss. You may be referred to a veterinary internist experienced in ultrasonography for this test.
• Gastrointestinal endoscopy and biopsy may be recommended if the dog with EPI is not responding appropriately to therapy or if results of other tests are not consistent with a diagnosis of EPI. If anemia or hypoproteinemia (low serum protein concentration) has been identified, endoscopy may be recommended to identify inflammatory bowel disease, gastrointestinal ulceration, or cancer. This procedure necessitates general anesthesia and usually requires referral to a veterinary internist.
• An adrenocorticotropic hormone (ACTH) stimulation test may be recommended to rule out hypoadrenocorticism (Addison’s disease). This test may be recommended in dogs with certain electrolyte abnormalities (low serum sodium and chloride concentrations, high serum potassium concentration) or a chronic history of gastrointestinal signs and weight loss.

Treatment of Exocrine Pancreatic Insufficiency in Dogs

Most dogs with EPI are treated as outpatients. They generally are otherwise in good health, and most respond well to therapy. Some animals with EPI may have concurrent disorders (bacterial growth, inflammatory bowel disease). These disorders should be considered in the patient that is not responding well to therapy for EPI. Treatment of EPI must be individualized based on the severity of the condition and other factors that must be analyzed by your veterinarian.

Treatments may include:

• Dietary modification is the cornerstone of treatment. It is best to use a diet that is highly digestible, low in fat, and low in fiber. Severely malnourished dogs initially may require supplementation with vitamins and minerals.
• Pancreatic enzyme replacement is crucial. Powdered, non-encapsulated preparations are the most effective. A product called Viokase® is commonly used and is very effective. Enzyme supplementation must accompany each meal, and is a lifelong commitment.
• Antibiotic therapy using drugs such as metronidazole or oxytetracycline is recommended in patients with suspected bacterial overgrowth. Bacterial overgrowth is not uncommon in dogs with EPI, and intermittent antibiotic treatment may be necessary over the course of the animal’s lifetime.

Home Care of Dogs with Exocrine Pancreatic Insufficiency

Optimal treatment for your dog requires a combination of home and professional veterinary care. Follow-up can be crucial, especially if your dog does not improve as expected.

Administer as directed all medications prescribed by your veterinarian. Contact your veterinarian if you are having difficulty treating your dog.

Diarrhea usually resolves within 1 to 2 weeks of treatment. Stabilization of body weight is followed by weight gain. You should contact your veterinarian if your dog does not respond as expected. Your veterinarian may recommend additional diagnostic tests to evaluate for other concurrent illnesses or may institute antibiotic therapy (metronidazole, oxytetracycline) if intestinal bacterial overgrowth is suspected.

After several weeks to months, your veterinarian may be able to decrease the amount of pancreatic supplementation administered.

EPI is an irreversible disease and lifelong treatment is required. The prognosis in dogs with EPI alone is good with appropriate therapy.