EPI


Description

  Exocrine pancreatic insufficiency (or EPI as it is often known) is a condition in which the pancreas stops producing and secreting enough digestive enzymes to digest food in the small intestine. Diarrhoea and foul smelling faeces due to high fat content (called steatorrheoa)  results, and because food ingredients are not being digested the animal becomes malnourished, and in some cases nutritional deficiency as well as energy deficiency results.

EPI is one of the conditions which can contribute to the malabsorption syndrome.
 
 

                       Cause
Exocrine pancreatic insufficiency (EPI) can result from primary pancreatic disease (discussed here) or from a number of functional causes resulting from any disease that interferes with secretion of enzymes by the pancreas or of activation of the enzymes in the intestine lumen.

Juvenile pancreatic atrophy and recurrent inflammation of the pancreas (chronic pancreatitis) are by far the most common causes of EPI, but other causes are seen including obstruction of the pancreatic duct (by inflammation or cancer) which carries the secreted enzymes from the pancreas into the lumen of the duodenum. Recently the cause of pancreatic acinar atrophy has been determined to be immune-mediated

In dogs and cats the result is inadequate concentrations of all the pancreatic enzymes and of bicarbonate in the intestine lumen.
 
 

                       Breed Occurrence
Exocrine pancreatic insufficiency (EPI) occurs most frequently in dogs, and rarely in cats. The German Shepherd Dog is the breed most likely to be presented with EPI - see also pancreatic atrophy. In Finland the Rough-coated Collie is also predisposed to develop the condition.
 
 

                      Signs

 EPI can be subclinical for many months or even years

                            Weight loss.
                            Diarrhoea.
                            Steatorrhoea.
                            Increased gut sounds are often present on auscultation(called borborygmi).
                            If the condition has been present for any length of time signs of nutritional deficiency might become obvious, including poor hair condition (dry and brittle) and sometimes pallor due to anaemia and low circulating blood protein concentrations - hypoproteinaemia.
 
 

                       Diagnosis
 The diagnosis of exocrine pancreatic insufficiency needs to be confirmed by use of laboratory tests. The most often used test for dogs is the TLI test but other tests are often used, and are still needed in complicated cases with more than one concurrent disease:

Laboratory tests for faecal fat (to confirm the presence of steatorrhoea.
                                 Direct-indirect Sudan III staining.
                                 Faecal analysis for % fat content.
                                 Trypsin-like immunoreactivity (TLI) Test.
                                 BT-PABA Test.
                                 Xylose absorption test - If bacterial overgrowth is present.
                                 Breath hydrogen test.
 
 

                       Treatment
Treatment involves the use of replacement pancreatic enzymes given orally. Suitable products are available in powder or crushed non-enteric-coated tablets. Enteric-coated tablets are not usually recommended because dissolution of the coating by alkaline pH in the intestine is unreliable. Because some enzyme is denatured by acid in the stomach, premixing the enzyme supplement with the food and left for about three quarters of an hour at room temperature is sometimes recommended.

H2 - receptor inhibitors (e.g. cimetidine) are useful because they reduce gastric acid secretion, and so less pancreatic enzyme is denatured during passage through the stomach.

If bacterial overgrowth is present oral antibiotics (e.g. neobiotic) may be indicated.

With enzyme replacement and cimetidine (300mg), or (if appropriate) 300mg neomycin, faecal fat concentrations can be returned to normal.(Strombeck and Guilford - Small Animal Gastroenterology 2e Wolfe) Other authors recommend different doses eg 300mg cimetidine / 20 kg body weight (Murdoch DB in Canine Medicine and Therapeutics -  Blackwell Scientific Publications 3e 1991)

 The following dietary management is recommended:

Feed a highly digestible, palatable, complete ration. Avoid home made rations.
The ideal profile is a diet that is : low in fat content, contains medium-chained fatty acids, avoid excess carbohydrate, low fibre.
Feed multiple small meals (at least 3 times daily)