Contributors: Phil Nicholls, Kenneth Simpson, Julien Bazelle

 Species: Feline   |   Classification: Diseases

Introduction Pathogenesis Diagnosis Treatment Outcomes Further Reading

Introduction

  • Signs: often vague (lethargy, anorexia); vomiting, abdominal pain, diarrhea or asymptomatic.
  • Diagnosis: elevated feline pancreatic lipase, ultrasonography, histopathology.
  • Treatment: intravenous fluid support, dietary modification, enteral/parenteral nutrition, pain relief, anti-nauseous medications.
  • Prognosis: variable.
    Print off the owner factsheet on Pancreatitis Pancreatitis to give to your client.Follow the diagnostic tree for Vomiting/anorexia in suspected pancreatitis Vomiting

Presenting Signs

  • May be no clinical signs.

Acute Presentation

Geographic Incidence

  • Worldwide distribution.

Age Predisposition

  • Young to middle aged adult (mean age //www.vetlexicon.com5 years).

Breed Predisposition

  • +/- higher incidence in Siamese Siamese.

Pathogenesis

Etiology

Predisposing Factors

General

  • Hyperstimulation of pancreas.
  • Blocked pancreatic ducts.

Pathophysiology

  • Hyperstimulation of pancreas or blocked pancreatic duct  →  fusion of zymogen granules and lysozymes  →  activation of intrapancreatic trypsin and pancreatic autodigestion.
  • Oxygen-derived free radicals  →  damage to cell membranes  →  increased capillary permeability  →  edema.
  • Increased levels of proteases and phospholipase in pancreas and blood stream  →  necrosis  →  multisystem involvement including pulmonary edema and vasculitis. Trypsin activates coagulation cascade and fibrinolytic system can  →  disseminated intravascular coagulation.
  • Serum antiproteases and alpha-2 macroglobulin bind trypsin and are removed from circulation. Manifestations of pancreatitis are only seen when compensatory mechanisms are overwhelmed.
  • Pancreatitis is often found concurrently with other diseases, such as cholangiohepatitis Liver: cholangitis, and inflammatory bowel disease Inflammatory bowel disease: overview. The concurrent occurrence of these three disorders in cats is termed "triaditis". Chronic pancreatitis can also be associated with exocrine pancreatic insufficiency Exocrine pancreatic insufficiency and diabetes mellitus Diabetes mellitus

Timecourse

  • Acute progression: 24-48 hours, but many cats appear to have chronic relapsing pancreatitis.

Diagnosis

Presenting Problems

  • Anorexia Anorexia.
  • Weight loss Weight loss.
  • Vomiting Vomiting in 35-90% of cases.
  • Diarrhea in 11-57%. 
  • Icterus in 31-37%.
  • Abdominal pain in 19-29%. 
  • Fever in 19-25%. 

Client History

  • May be no clinical signs.
  • Anorexia.
  • Lethargy.
  • Vomiting or signs of nausea (35% cases).
  • Dyspnea.
  • Diarrhea.

Clinical Signs

  • Some cases subclinical.
  • Dehydration.
  • Thin/poorly muscled.
  • Cranial abdominal pain in 25% cases (more often associated with experimental disease).
  • Hypothermia (although some cases may be pyrexic).
  • Palpable abdominal mass.
  • Occasionally dyspnea.

Diagnostic Investigation

2-D Ultrasonography  

  • Is supportive of pancreatic abnormalities in acute pancreatitis Ultrasonography: pancreas (but the sensitivity of ultrasonography compared with histology only 24-84%).
  • Small amount of free peritoneal fluid can be visible Abdomen: ascites - DV ultrasound .
  • Hyperechoic mesentery Pancreas: pancreatitis - ultrasound is the most sensitive single ultrasonographic findings.
  • Pancreas is often very difficult to image but may be seen as hypoechoic or heterogenous mass.
  • May detect concomitant liver and GI disease.
  • Sensitivity increased with disease severity.
  • Recently endosonography has been trialed for diagnosis but was not shown to be any better than ultrasonography except perhaps in obese cats where standard ultrasounds are difficult.

Biochemistry

Hematology

  • Thrombocytopenia (8-33%)  Hematology: platelet count may contribute to coagulopathy.
  • Anemia (non-regenerative>regenerative) may be present in 20-55% of cases, or in 13% of cases increased PCV Hematology: packed cell volume due to dehydration.
  • Neutrophilia often not marked, and 5-13% cases show leukopenia.
  • Coagulation abnormalities are very common, prothrombin time Hematology: activated partial thromboplastin time  and thromboplastin time are frequently prolonged.
  • Vitamin K deficiency is common in cats with pancreatitis, inflammatory bowel disease or liver disease.

Radiography

  • Rarely specific or diagnostic.
  • Help ruling out other conditions.
  • Poor abdominal contrast due to localized peritonitis or fluid accumulation on lateral and dorsoventral abdominal radiographs.
  • Hepatomegaly is a common finding Liver: hepatomegaly - radiograph lateral  .

Computed tomography

  • The normal pancreas is readily identified using CT Computed tomography: abdomen - it is homogenous with smooth margins.
  • The value of CT in identifying pancreatitis is low with a sensitivity of 20%.

Magnetic resonance imaging

  • Magnetic resonance cholangiopancreatography has been recently suggested as a useful diagnostic tool but remains to be evaluated in a clinical setting.

Gross Autopsy Findings

  • Check for other concurrent disease, eg enteropathy, liver disease.
  • Do not confuse nodular pancreatic hyperplasia (common incidental finding) with lesion.
  • Examine promptly and handle pancreatic tissue gently.

Histopathology Findings

  • Variable infiltration of pancreatic tissues with neutrophils/lymphocytes.
  • Mild to severe pancreatic edema, hyperemia, necrosis and hemorrhage.
  • +/- peripancreatic fat necrosis.
  • Variable degree of fibrosis depending on chronicity.
  • The lesions can have a patchy distribution, and multiple biopsies are recommended.
  • Recently developed histological classification scheme (De Cock et al, 2007), but the clinical significance of a low level of lymphocytic infiltration (<10%) remains uncertain.
  • Cholangiohepatitis and IBD are commonly seen in association with pancreatitis.
  • Thromboembolic complications including pulmonary thrombi.

Differential Diagnosis

Treatment

Initial Symptomatic Treatment

  • Remove inciting cause if possible.
  • Intravenous fluid therapy Fluid therapy: overview to replace losses and for maintenance. Plasma 10-20 mg/kg if reduced protein or non-responsive to electrolyte therapy.
  • Correction of electrolyte abnormalities, eg hypokalemia Hypokalemia.
  • No evidence that starvation improves prognosis in cats as most have been anorectic >1 week prior to diagnosis.
  • No evidence that low fat diet is beneficial in cats with pancreatitis. Current recommendations: diet low in carbohydrate, high in proteins and with moderate amount of fat to avoid the development of malnutrition and hepatic lipidosis Nutrition: disease modulation. In cats with pancreatitis or hepatic lipidosis, oral nutrition is often inadequate and aggressive enteral nutrition via gastrotomy tubes or enterostomy tubes Gastrostomy: percutaneous tube (endoscopic) has been recommended. Parenteral nutrition if enteral nutrition is not tolerated.
  • Anti-emetics should be considered in all cats with suspicion of pancreatitis, given the difficulty to recognize nausea in cats. NK-1 receptor antagonist (maropitant Maropitant citrate.) or 5-HT3 antagonists (ondansetron Ondansetron, dolasetron) more efficient than metoclopramide Metoclopramide.
  • Maropitant is not only a strong anti-emetic drug but may also decrease visceral pain.
  • Re-introduce or feed a diet with low carbohydrate, high protein and moderate fat composition.
  • Control DIC Disseminated intravascular coagulation - plasma/heparin.
  • The use of antibiotics is controversial.
  • Amoxicillin Amoxicillin may be used but no proven beneficial effect.
  • The importance of analgesia is easily overlooked as evidence of abdominal pain is not easy to detect in cats.
  • Treat other conditions such as inflammatory bowel disease or liver disease.
  • Cobalamin injection if documented hypocobalaminemia Blood biochemistry: vitamin B12.

Standard Treatment

  • Butorphanol Butorphanol tartrate 0.1-0.4 mg/kg SC QID for pain relief or oxymorphone   Oxymorphone 0.05-0.1 mg/kg SC q6h.
    Do not use morphine as this may stimulate closure of the sphincter of Oddi, thus preventing pancreatic flow.

Monitoring

  • Hydration: adjust fluid rate for maintenance.
  • Bleeding tendency: may signal disseminated intravascular coagulopathy.
  • Test for and treat vitamin K deficiency.
  • Blood [glucose] Blood biochemistry: glucose for monitoring transient or permanent diabetes mellitus.

Subsequent Management

Treatment

  • If progress poor (and evidence of anemia or coagulopathy), consider blood Blood transfusion or plasma transfusion to supply serum antiproteases.

Outcomes

Prognosis

  • Prognosis very variable - related to extent of pancreatic necrosis and presence of complications.
  • Very poor prognosis for suppurative pancreatitis.
  • Poor prognosis if associated with concurrent disease (survival rate probably <50%).
  • Other negative prognostic factors: hypocalcemia, hypokalemia, hepatic lipidosis.

Expected Response to Treatment

  • Appetite returns and improvement in general demeanor in 3-4 days.

Reasons for Treatment Failure

  • Severe necrotizing pancreatitis overwhelming compensatory mechanisms.
  • Development of disseminated intravascular coagulation.
  • Development of pancreatic pseudocyst   →   sterile necrosis and pancreatic abscess   →   poor prognosis.
  • Development of renal failure.
  • Long-term complications: diabetes mellitus Diabetes mellitus, exocrine pancreatic insufficiency Exocrine pancreatic insufficiency.

Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Forman M A, Steiner J M,  Armstrong P J, Camus M S, Gaschen L,  Hill S L, Mansfield C S, Steiger K (2021) ACVIM consensus statement on pancreatitis in cats. JVIM 35(2), 703-723 PubMed onlinelibrary.wiley.com/doi/10.1111/jvim.16053.
  • Marolf A J, Kraft S L, Dunphy T R et al (2013) Magnetic resonance (MR) imaging and MR cholangiopancreatography findings in cats with cholangitis and pancreatitis. J Feline Med Surg 15 (4), 285-294 PubMed.
  • Oppliger S, Hartnack S, Riond B et al (2013) Agreement of the serum Spec fPL" and 1,2 -omega-dilauryl-rac-glycero-3-glutaric acid-(5'-methylresorufin) ester lipase assay for the determination of serum lipase in cats with suspicion of pancreatitis. JVIM 27 (5), 1077-1082 PubMed.
  • Boscan P, Monnet E, Mama K et al (2011) Effect of maropitant, a neurokinin 1 receptor antagonist, on anesthetic requirements during noxious visceral stimulation of the ovary in dogs. Am J Vet Res 72 (12), 1576-1579 PubMed.
  • Giorano T, Steagall P V, Ferreira T H et al (2010) Postoperative analgesic effects of intravenous, intramuscular, subcutaneous or oral transmucosal buprenorphine administered to cats undergoing ovariohysterectomy. Vet Anaesth Analg 37 (4), 357-366 PubMed.
  • Trepanier L (2010) Acute vomiting in cats: rational treatment selection. J Feline Med Surg 12 (3), 225-230 PubMed.
  • Chan D L (2009) The inappetent hospitalized cat: clinical approach to maximising nutritional support. J Feline Med Surg 11 (11), 925-933 PubMed.
  • Schweighauser A, Gaschen F, Steiner J et al (2009) Evaluation of endosonography as a new diagnostic tool for feline pancreatitis. J Fel Med Surg 11 (6), 492-498 PubMed.
  • De Cock H E, Forman M A, Farver T B et al (2007) Prevalence and histopathologic characteristics of pancreatitis in cats. Vet Pathol 44 (1), 39-49 PubMed.
  • Forman M A, Marks S L, De Cock H E et al (2004) Evaluation of serum feline pancreatic lipase immunoreactivity and helical computed tomography versus conventional testing for the diagnosis of feline pancreatitis. JVIM 18 (6), 807-815 PubMed.
  • Steiner J M (2003) Diagnosis of pancreatitis. Vet Clin North Am Small Anim Pract 33 (5), 1181-1195 PubMed.
  • Simpson K W (2002) Feline pancreatitis. J Feline Med Surg (3), 183-184 PubMed.
  • Mansfield C S & Jones B R (2001) Review of feline pancreatitis part 1 - the normal feline pancreas, the pathophysiology, classification, prevalence and aetiologies of pancreatitis. J Feline Med Surg​ (3), 117-124 PubMed.
  • Mansfield C S & Jones B R (2001) Review of feline pancreatitis part 2 - clinical signs, diagnosis and treatment. J Feline Med Surg (3), 125-132 PubMed.
  • Gerhardt A, Steiner J M, Williams D A et al (2001) Comparison of the sensitivity of different diagnostic tests for pancreatitis in cats. JVIM 15 (4), 329-333 PubMed.
  • Simpson K W (2001) The emergence of feline pancreatitis. JVIM 15 (4), 327-328 PubMed.
  • Washabau R J (2001) Feline acute pancreatitis - important species differences. J Feline Med Surg (2), 95-98 PubMed.
  • Swift N C, Marks S L, MacLachlan N J et al (2000) Evaluation of serum feline trypsin-like immunoreactivity for the diagnosis of pancreatitis in cats. JAVMA 217 (1), 37-42 PubMed.
  • Zhao P, Tu J, Martens A et al (1998) Radiologic investigations and pathologic results of experimental chronic pancreatitis in cats. Acad Radiol (12), 850-856 PubMed.
  • Bruner J M, Steiner J M, Williams D A et al (1997) High feline trypsin-like immunoreactivity in a cat with pancreatitis and hepatic lipidosis. JAVMA 210 (12), 1757-1760 PubMed.
  • Steiner J M & Williams D A (1997) Feline pancreatitis. Cont Educ Pract Vet 19, 590-602.
  • Hines B L, Salisbury S K, Jakovljevic S et al (1996) Pancreatic pseudocyst associated with chronic-active necrotising pancreatitis in a cat. JAAHA 32 (2), 147-152 PubMed.
  • Weiss D J, Gagne J M & Armstrong P J (1996) Relationship between inflammatory hepatic disease and inflammatory bowel disease, pancreatitis and nephritis in cats. JAVMA 209 (6), 1114-1116 PubMed.
  • Akol K G, Washabau R J, Saunders H M et al (1993) Acute pancreatitis in cats with hepatic lipidosis. J Vet Intern Med (4), 205-209 PubMed.
  • Hill R C & Van Winkle T J (1992) Acute necrotising pancreatitis and acute suppurative pancreatitis in the cat; a retrospective study of 40 cases (1976-1989). JVIM (1), 25-33 PubMed.

Other Sources of Information