Contributors: Phil Nicholls, Kenneth Simpson, Julien Bazelle
Species: Feline | Classification: Diseases
- 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.
- May be no clinical signs.
- Recognized in association with cholangiohepatitis Liver: cholangitis, and/or inflammatory bowel disease Inflammatory bowel disease: overview, triaditis or hepatic lipidosis Liver: lipidosis and signs may be indistinguishable from these:
- Anorexia Anorexia /lethargy/weight loss.
- Cranial abdominal pain.
- Worldwide distribution.
- Young to middle aged adult (mean age //www.vetlexicon.com5 years).
- +/- higher incidence in Siamese Siamese.
- Idiopathic (most common).
- Other possibilities include:
- Biliary tract inflammation (may be associated with cholangiohepatitis Liver: cholangitis but pancreatitis tends to be mild in these cases).
- Inflammatory bowel disease Inflammatory bowel disease: overview.
- Infection: feline leukemia virus Feline leukemia virus disease, Toxoplasma gondii Toxoplasma gondii, feline herpes virus Feline herpes virus: feline rhinotracheitis virus , enteric bacteria translocation.
- Aberrant migration of liver flukes Pancreas: fluke.
- Pancreatic ischemia/trauma Pancreas: trauma, eg RTA, hypotension, surgery.
- Vomiting can raise intraduodenal pressure and predispose to reflux of enteric contents into the pancreatic duct.
- Pancreatic duct obstruction.
- Drugs, eg organophosphates Organophosphorus poisoning.
- Metabolic, eg hypercalcemia Hypercalcemia: overview and hyperlipidemia Hyperlipidemia.
- Hyperstimulation of pancreas.
- Blocked pancreatic ducts.
- 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.
- Acute progression: 24-48 hours, but many cats appear to have chronic relapsing pancreatitis.
- May be no clinical signs.
- Vomiting or signs of nausea (35% cases).
- Ataxia Ataxia.
- Some cases subclinical.
- 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.
- Hepatomegaly Hepatomegaly.
- Occasionally dyspnea.
- 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 .
- Hyperechoic mesentery 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.
- Feline trypsin-like immunoreactivity (FTLI) Blood biochemistry: trypsin-like immunoreactivity. This should not be used for the diagnosis of feline pancreatitis but may inform about the development of exocrine pancreatic insufficiency in patients with chronic pancreatitis.
- Serum pancreatic lipase immunoreactivity (fPLI) Feline pancreatic lipase immunoreactivity (fPLI) test. There are two tests available; Spec fPL and SNAP fPL. Spec fPL is considered the most sensitive (42-100%) and specific (69-100%) blood marker of pancreatitis and is more sensitive for acute and severe pancreatitis. A Spec fPL within the reference range does not exclude pancreatitis and an elevated Spec fPL does not confirm pancreatitis is the cause of the clinical signs. SNAP fPL is a semi-quantitative test, the results of which should be confirmed by Spec fPL. However 97.5% of patients with negative SNAP fPL have Spec fPL within reference ranges.
- New colorimetric lipase assay DGGR lipase activity. Recently developed and as sensitive as fPLI.
- Azotemia Azotemia ; usually prerenal.
- Elevated hepatic enzymes are a common finding (may be due to secondary hepatic lipidosis Liver: lipidosis or concomitant cholangiohepatitis Liver: cholangitis).
- Hypokalemia Blood biochemistry: potassium and hypophosphatemia Blood biochemistry: phosphate.
- Hyperglycemia or hypoglycemia Blood biochemistry: glucose.
- Hyperlipidemia Hyperlipidemia.
- Hypocalcemia Blood biochemistry: total calcium.
- Hypoalbuminemia Blood biochemistry: albumin may occur which results in hypocalcemia Blood biochemistry: total calcium on blood sample.
- Hyperbilirubinemia Blood biochemistry: direct bilirubin.
Lipase and amylase concentrations usually within normal range.
- 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.
- 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 .
- 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.
- 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.
- Inflammatory bowel disease Inflammatory bowel disease: overview (may be concurrent disease).
- Intestinal foreign body Intestine: foreign body - linear.
- Cholangiohepatitis Liver: cholangitis (may be concurrent disease).
- Feline infectious peritonitis Feline infectious peritonitis.
- Neoplasia Large intestine: neoplasia .
- Causes of icterus:
- Hepatic lipidosis Liver: lipidosis.
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.
- Acute pain control:
- Longer duration pain control:
- Pain control at home:
- Tramadol Tramadol.
- Sublingual buprenorphine.
- Treat other conditions such as inflammatory bowel disease or liver disease.
- Cobalamin injection if documented hypocobalaminemia Blood biochemistry: vitamin B12.
- 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.
- If progress poor (and evidence of anemia or coagulopathy), consider blood Blood transfusion or plasma transfusion to supply serum antiproteases.
- 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.
- 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 4 (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 (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 (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 3 (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 5 (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.
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- 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 7 (1), 25-33 PubMed.