Pancreatitis – Peeking Behind the Curtain
Nearly every day we see patients walk through our doors with the chief complaint being a recent episode of vomiting or diarrhea. While these patients may all have the same complaint, they won’t have the same explanation or cause. Some may have gotten into the trash and taken a bite of something they shouldn’t have; some may have eaten something in the backyard; some may have even been put on a new medication recently. These patients may present with different severity of symptoms in signs. Ranging from a happy go lucky lab who doesn’t realize anything is wrong, to an already picky Shih Tzu that hasn’t had anything to eat in 3 days and is severely dehydrated.
With the wide range of presentations, dispositions, and differentials, vomiting and diarrhea can be one of the most common yet difficult cases to manage. For this reason, we will often discuss running a variety of tests including a fecal parasite exam, routine bloodwork (CBC and Chemistry), X-rays, and – especially in our little guys – a pancreatitis test. If you have a small dog or cat, and you have brought them into the clinic any time in the past few years for vomiting and diarrhea, we have probably discussed pancreatitis as a potential differential. With the holidays coming up, this is prime time for dietary indiscretion and pancreatitis flare ups, so with this article we will dig deep into pancreatitis and discuss what it is, why it happens, and what we can do about it.
What is Pancreatitis?
Simply speaking, Pancreatitis is an inflammation of the Pancreas. While this is a very simple explanation, the disease process is far less easy to explain, control, and treat. The Pancreas is an endocrine organ that is nestled along the stomach and small intestine on one side and bordered on the other side by the colon. This is why pancreatitis can cause vomiting and diarrhea. Because of the local proximity, any inflammation to the pancreas can lead to stomach inflammation (Gastritis), small intestine inflammation (Enteritis), and large bowel inflammation (colitis). This combination of inflammation will cause vomiting and diarrhea that we see.
Why Does Pancreatitis Develop?
Long story short, we really don’t know. The most common theory, due to the number of patients diagnosed with pancreatitis during the holidays, is that these patients have a large fatty meal or significant dietary indiscretion causing the pancreas to work overtime. When these meals are eaten, the pancreas begins producing and releasing digestive enzymes to help break down the extra dietary load. One of these important digestive enzymes is our Pancreatic Lipase, which is a fat digestive enzyme released specifically by our pancreas. Eventually, this higher workload and demand on the pancreas will lead to the dreaded inflammation and clinical signs we see with pancreatitis.
Now, while a high fat diet is probably the most common reason for us to diagnose pancreatitis, it certainly isn’t the only reason. In fact, recent studies have outlined dozens of potential factors related to pancreatitis. Since none of these have been proven to be the single inciting factor, pancreatitis is always on our radar when it comes to vomiting and diarrhea. This also makes prevention slightly more difficult, because simply cutting high fat diets doesn’t outright eliminate the chance for pancreatitis to develop in the future. Not to mention, we often see the same patients being diagnosed with pancreatitis repeatedly simply because they may be more sensitive to dietary changes.
How is Pancreatitis Diagnosed?
The diagnosis of Pancreatitis can be supported by a variety of findings; however, there is no one single test that is 100% diagnostic for Pancreatitis. Using the history provided, our physical exam, and recommended diagnostics, we can come up with the most likely diagnosis. We will commonly ask for approval to run a “SNAP Pancreatitis” test. This is a test run on a patient’s serum, specifically looking for elevations in their circulating Pancreatic Lipase. Remember Pancreatic Lipase from the earlier section? That is what we are looking for and testing for on a “SNAP” test. This test is a qualitative test that aims to give us an indication of whether the amount of lipase is greater than normal, or within normal quantities.
When we evaluate the results of this test, we compare them to our physical exam and decide if the diagnosis fits the specific patient. While this test is incredibly useful in providing us with information in a timely manner, we need to rely on the rest of our physical exam, and other diagnostics available to us.
We may also recommend running full diagnostic blood work including a Complete Blood Cell Count (CBC) and Blood Chemistry with Electrolytes. Some things that may support Pancreatitis as a diagnosis would be liver enzyme elevation, total lipase elevation, globulin elevation, dehydration, etc. These tests are also useful to rule out other potential causes of vomiting and diarrhea such as primary liver disease, kidney disease, infection, and Addison’s, among others. We will likely also run a fecal panel to test for GI parasites which are a common cause of vomiting and diarrhea. Finally, we may recommend performing a GI ultrasound or taking GI X-rays. These can show pancreatic inflammation in some patients as well as may show key signs of other issues or problems to be aware of.
While we have a wide range of diagnostics available to us, nothing is slam dunk for pancreatitis, and we need to rely on a multitude of factors to guide our treatment plan moving forward. That simple term of Pancreatitis isn’t so simple anymore, is it?
“Okay Doc, so what can we do?”
Historically, Pancreatitis has been a pain to manage, simply because most of our treatment is based on supportive care, and significant hospitalization. Recently, a new tool has been added to our toolbox in the name of Panoquell. This has significantly improved our level of success and therapy for our canine patients. Unfortunately, Panoquell cannot be used in cats. Panoquell is a monoclonal antibody for use in dogs that specifically targets and treats the inflammation within the pancreas, allowing us to control the site of pain and sensitivity at the source.
In addition to Panoquell, some patients may need hospitalization with IV fluids, pain medications, anti-nausea medications, probiotics, and/or antibiotics. Hospitalization with IV fluid therapy is the best way to help blood flow to the pancreas and flush out all the inflammatory factors present within that can propagate the inflammation. Pain medications can help control visceral abdominal pain, and anti-nausea medications can help us get your pet to eat that much faster. Ultimately, feeding the gut and getting proper nutrition going is the best way to get on the road to healing.
Some patients aren’t nearly as symptomatic and affected by pancreatitis. In these patients, based on the vet’s judgment, outpatient therapy may be initiated using a lot of the same principles from the hospitalized therapy. This often requires the patient to still have an appetite so we can use oral meds at home.
Finally, we institute a low-fat diet option such as Hill’s I/D Low-Fat which we carry in hospital as a canned and dry food formulation. This, among other prescription low-fat options, provides an easily digestible protein and carbohydrate source without stimulating the pancreas more, further worsening the problem.
How Do I Manage Pancreatitis in the Long-Term?
The main stay of prevention is avoiding any potential triggers in the future. This is obviously easier said than done given the fact that we often don’t know what the true cause was. But at the very least, we need to avoid eating overly fatty foods, or getting fed from the table during holidays. We are looking at you Aunt Linda, “No, you can’t offer buddy a slice of Honey Baked ham.”
For patients that commonly have gastroenteritis, or pancreatitis flares, feeding a low-fat diet is the best and easiest way to limit pancreatic inflammation. For this reason, something like Hill’s I/D Low-Fat, Purina EN Low Fat, or Royal Canin GI Low Fat are perfect!
Fortunately, most of our patients, with appropriate care, treatment and monitoring should be improved by 7-10 days after diagnosis!
In Summary
We hope everyone has a fantastic holiday season, filled with warm embraces, many laughs, and meaningful time spent with loved ones. This includes our furry four-legged family members both big and small. But please remember, while we may be able to indulge in a slice of pumpkin pie, fried turkey, baked ham, mac’n’cheese, and casseroles of all kinds, the risk of pancreatitis isn’t worth the small offering to our pets.
