Pancreatitis: chronic

• Chronic pancreatitis in the dog is not commonly diagnosed antemortem.
• It may develop as a sequelae to acute pancreatitis Pancreatitis: acute.
• Cause: usually unresolved acute pancreatitis.
• Signs: episodic signs of abdominal pain/vomiting or subclinical condition manifest as/resulting in diabetes mellitus or exocrine pancreatic insufficiency.
• Diagnosis: laboratory tests, ultrasonography, histopathology.
• Treatment: acute episodes as for acute pancreatitis; dietary modification, pancreatic enzyme supplementation.
• Prognosis: guarded unless underlying etiology identified and controlled.
  
  Print off the owner factsheet on Pancreatitis Pancreatitis to give to your client.
  Follow the management tree for vomiting/anorexia Vomiting in suspected pancreatitis vomiting/anorexia in suspected pancreatitis.

• Subclinical.
• Vomiting (intermittent).

• Anorexia.
• Weight loss.

• Diarrhea - (especially in case of EPI Exocrine pancreatic insufficiency ).
• Polyuria/polydipsia if diabetes mellitus Diabetes mellitus.

• Recurrent episodes of acute pancreatitis Pancreatitis: acute.
• Jaundice.

• Sequelae of unresolved acute pancreatitis Pancreatitis: acute.

• High nutritional plane - high fat diets.
• Hereditary predisposition ?miniature Schnauzer Schnauzer: miniature Schnauzer, English Cocker spaniel English Cocker Spaniel.
• Obesity.
• Dietary indiscretion.

• Chronic damage to pancreatic tissue may → fibrosis and reduced pancreatic function:
  • Diabetes mellitus Diabetes mellitus.
  • Exocrine pancreatic insufficiency Exocrine pancreatic insufficiency.

• Months to years.

• Vomiting/polyuria/polydipsia/diarrhea.
• Abdominal pain/acute abdomen Investigation of Acute Abdomen.

• Intermittent vomiting.

• Weight loss.
• Anorexia.

• Diarrhea Diarrhea: chronic.
• Polyuria/polydipsia.

• Anterior (cranial) abdominal pain (in acute recurrent pancreatitis, absent in sub-clinical).

• Jaundice (if inflammation causes swelling and obstruction of bile duct).

• In acute phase changes as for acute pancreatitis, eg raised canine pancreatic lipase Canine pancreatic lipase immunoreactivity (cPLI) test , amylase Blood biochemistry: amylase and lipase Blood biochemistry: lipase.
• Trypsin like immunoreactivity Blood biochemistry: trypsin-like immunoreactivity may be low in chronic cases with EPI and normal, high or low in acute cases.
• Hypocobalaminemia Blood biochemistry: vitamin B12 is frequent with chronic pancreatitis, especially in case of EPI.
• Hyperglycemia Blood biochemistry: glucose if insulin deficient due to islet cell destruction.
• Recurrent hypercholesterolemia Blood biochemistry: cholesterol and/or hyperbilirubinemia Blood biochemistry: direct bilirubin when acute-on-chronic-episodes.
• Measurement of an elevated canine pancreatic lipase concentration in serum (cPLI test Canine pancreatic lipase immunoreactivity (cPLI) test , available from Idexx Reference Laboratories or the Gastrointestinal Laboratory at Texas A&M University).
  A negative cPLI does not exclude chronic pancreatitis, as cPLI indicates active acute inflammation and may not be elevated when inflammation is mild and/or chronic.

• Pancreas may appear small and irregular or, in case of acute-on-chronic pancreatitis, swollen with mottled echogenicity  Ultrasonography: pancreas. Distinguish from pancreatic cancer Pancreas: neoplasia.
• Biliary obstruction.

• Increased fibrous tissue.
• Possibility of acinar architecture +/- inflammatory infiltrate.
• Signs correlated to the degree of pancreatic necrosis and pancreatic fat necrosis.
• Evidence of auto-immune disease in certain breeds (eg English Cocker spaniel).

• Other causes of vomiting Vomiting.
• Other causes of EPI.
• Pancreatic neoplasia Pancreas: neoplasia.
• Other causes of:
  • Abdominal pain.
  • Chronic diarrhea.
  • Reduced weight.
  • Polyuria/polydipsia.
  • Jaundice if present.

• Intestinal foreign body Intestine: linear foreign bodies.
• Bilious vomiting syndrome Gastroduodenal reflux.

• Manage acute episodes as for acute pancreatitis Pancreatitis: acute.
• Dietary manipulation with low fat, high carbohydrate feeding.

• Treat concurrent diabetes mellitus Diabetes mellitus and/or EPI Exocrine pancreatic insufficiency.

Treatment

• Pain relief, eg tramadol Tramadol , gabapentin Gabapentin , maropitant Maropitant citrate.
• Pancreatic enzymes supplements have been shown to decrease the frequency and severity of acute episodes in human patients with chronic pancreatitis. This remains unproven in dogs.
• There is not enough evidence to support the use of immunosuppressive drugs in cases of auto-immune chronic pancreatitis in dogs (although this is the treatment of choice in human patients) and their effects may be limited in end-stage disease where fibrotic tissue replaces normal pancreatitic parenchyma.

• Fair if underlying cause identified and managed.
• Relapses still likely in spite of all efforts.
• Risk of development of diabetes mellitus and EPI. These were not associated with worse prognosis or poorer response to therapy.

• Cessation of vomiting on therapy.
• Improving demeanor, appetite and weight gain.
• Diabetes and EPI are unlikely to resolve once established.

• Underlying disease not addressed.
• Severity of pancreatic damage → diabetes mellitus or EPI.

Refereed papers

• Recent references from PubMed and VetMedResource.
• Bostrom B M, Xenoulis P G, Newman S J, Pool R R, Fosgate G T & Steiner J M (2013) Chronic pancreatitis in dogs: a retrospective study of clinical, clinicopathological, and histopathological findings in 61 cases. Vet J 195 (1), 73-79 PubMed.
• Watson P J, Roulois A, Scase T, Holloway A & Herrtage M E (2011) Characterisation of chronic pancreatitis in English Cocker Spaniels. JVIM 25 (4), 797-804 PubMed.
• Watson P J, Archer J, Roulois A J, Scase T J & Herrtage M E (2010) Observational study of 14 cases of chronic pancreatitis in dogs. Vet Rec 167 (25), 968-976 PubMed.
• Watson P J, Roulois A J, Scase T, Johnston P E, Thompson H & Herrtage M (2007) Prevalence and breed distribution of chronic pancreatitis at post-mortem examination in first-opinion dogs. JSAP 48 (11), 609-618 PubMed.
• Mansfield C S & Jones B R (2000) Plasma and urinary trypsinogen activation peptide in healthy dogs, dogs with pancreatitis and dogs with other systemic diseases. Aust Vet J 78 (6), 416-422 PubMed.