EPI * Exocrine Pancreatic Insufficiency

Some times we hear of vomiting issues or regurgitation issues with EPI dogs..... and it is very difficult to figure out what  is going on with our dogs (and cats too).

I thought it might be helpful to put something in the FILES regarding this matter.... although this posting it doesn't give us a simple magic answer... it does give great suggestions and recomendations on what to observe to better inform your vet, what the possibilities might be and how to go about determining the cause.

The following is adapted from:

Diagnostic strategy for vomiting in dogs and cats (Proceedings)

Oct 1, 2008

By: Todd Tams, DVM, DACVIM

CVC PROCEEDINGS

Vomiting refers to a forceful ejection of gastric and occasionally proximal small intestinal contents through the mouth. The vomiting act involves three stages: nausea, retching, and vomiting. Serious consequences of vomiting include volume and electrolyte depletion, acid-base imbalance, and aspiration pneumonia.

Regurgitation is defined as passive, retrograde movement of ingested material, usually before it has reached the stomach. Regurgitation may occur immediately after uptake of foodor fluids or may be delayed for several hours or more.

It is essential that the clinician make a clear differentiation between regurgitation and vomiting at the outset. Failure to recognize the difference between regurgitation and vomiting often leads to misdiagnosis.

A complete historical review with emphasis on all body systems is essential for determining a realistic and effective initial work-up plan and treatment protocol.

(1) duration of signs

(2) signalment and past pertinent history

(3) environment and diet

(4) systems review (e.g., history of PU/PD,coughing and sneezing, dysuria or dyschezia, etc.)

(5) time relation to eating (vomiting ofundigested or partially digested food more than 8-10 hours after eating oftenindicates a gastric motility disorder [more common] or gastric outlet obstruction[less common])

(6) content of the vomitus (food, clearfluid, bile, blood, material with fecal odor), and

(7) type and frequency of vomiting(projectile?, chronic intermittent?, cyclic?, morning vomiting only?).

Most Common Causes of Acute or Chronic Vomiting in Dogs

First need to Rule-Out:

Dietary problem

Indiscretion (e.g., table scraps, garbage ingestion; foreign body)

Food adverse reaction (dietary sensitivity)

True food allergy

Parasites

Intestinal (including Giardia)

Gastric (Physaloptera)

Drug related problems

NSAIDS must always be considered

Other drugs (e.g., cardiac glycosides, antibiotics, chemotherapeutic agents)

Metabolic disorders

Renal disease

Liver disease

Electrolyte abnormalities

Rule-Outs for Chronic Vomiting, Once the Causes Listed Above are Ruled Out:

Motility Disorders

Gastric hypomotility

Inflammatory Disorders

Chronic gastritis (with or without Helicobacter)

Inflammatory bowel disease

Obstructive Disorders

Foreign bodyHypertrophic gastropathy (uncommon)

Neoplasia

Dietary problem

Food adverse reaction (dietary sensitivity)

IBD

Hyperthyroidism

Liver disease

Renal disease

GI lymphoma (intestinal is more common)

Chronic pancreatitis

Heartworm disease

Intermittent Chronic Vomiting

Chronic intermittent vomiting is a common presenting complaint in veterinary medicine. Often there is no specific time relation to eating, the content of the vomitus varies, and the occurrence of vomiting may be very cyclic in nature. Depending on the disorder, other signs such as diarrhea, lethargy, inappetence, and salivation (nausea) may occur aswell. When presented with this pattern of clinical signs, the clinician should strongly consider chronic gastritis, inflammatory bowel disease, irritable bowel syndrome, and gastric motility disorders as leading differential diagnoses.

Vomiting from systemic or metabolic causes may be an acute or chronic sign and generally there is no direct correlation with eating and no predictable vomitus content.

Diagnostic Plan

If reasonable concern is established basedon the history (e.g., patient is inappetent, ingested a toxin, is vomiting frequently) or physical assessment (e.g., patient is listless, dehydrated, inpain), then a minimum data base of CBC, complete biochemical profile (orspecific tests for evaluation of liver, kidney, pancreas, electrolytes),complete urinalysis (pre-treatment urine specific gravity extremely important for diagnosis of renal failure), and fecal examination is essential. T4 and both a heartworm antibody test and heartworm antigen test are considered routine baseline tests for vomiting cats (approximately 40% ofvomiting cats will have vomiting as a clinical manifestation of the disease).Survey abdominal radiographs are indicated if thorough abdominal palpationis not possible or suggests an abnormality (e.g. foreign body, pancreatitis,pyometra). Unfortunately these tests are often not done early enough. Even if baseline results are unremarkable they are more than justified because they help to rule out serious problems at the outset (e.g., vomiting due to renalfailure, diabetes mellitus, liver disease). Alternatively, any abnormalities provide direction for initial treatment and further diagnostics.

The decision for performing more in-depth diagnostic tests is based on ongoing clinical signs, response to therapy, and initial test results. These tests include ACTH stimulation to confirm hypoadrenocorticism in a patient with an abnormal Na:K ratio or to investigate for this disorder if electrolytes are normal, complete barium series or BIPS study (for gastric or intestinal foreign body, gastric hypomotility,gastric outflow obstruction, partial or complete intestinal obstruction), cPLI*or fPLI*(canine and feline lipase immunoreactivity, respectively, for diagnosis of pancreatitis in dogs and cats), and serum bile acids assay(to assess for significant hepatic disease). Barium swallow with fluoroscopyis often necessary for diagnosis of hiatal hernia disorders and gastroesophageal reflux disease. Serum gastrin levels are run if agastrinoma (Zollinger-Ellison Syndrome) is suspected.

Pancreatitis: Pancreatitis continuesto be a challenging disorder to accurately diagnose, short of thorough direct examination and biopsy. Assays for amylase and lipase are of very limited value,especially in cats. In general, the following can be stated regarding the various diagnostic tests for pancreatitis:

Value of the Various Diagnostic Tests for Pancreatitis

Amylase/Lipase

- of value as a screening test in dogs only

  - need to be 3x or >above normal reference range in order to suggest pancreatitis

- normal does not rule-outpancreatitis

AbdominalUltrasound

- highly specific, but not very sensitive,especially in cats

Serum PLI

- highly sensitive for pancreatitis

Pancreatic Lipase Immunoreactivity (cPLI andfPLI)

- Exocrine Pancreatic Insufficiency (EPI)

o cPLI is reliably significantly decreased

o cPLI is specific for EPI

- Chronic Renal Failure

o Increased, but usually still withinreference range

- Dogs with Biopsy Proven Pancreatitis

o cPLI sensitivity is > 80%

o currently recommended cutoff value for dogsis >200 ug/L

o preliminary results are also promising forcats

Negative contrastgastrography

BIPS are barium impregnated polyethylenespheres. Traditionally, veterinarians have relied on barium liquid as the contrast agent of choice for gastrointestinal studies. However, recognized limitations of barium liquid have led to the development of barium-impregnated solid radiopaque markers for the diagnosis of motility disorders and bowel obstructions. Barium liquid contrast studies are of limited value indetecting hypomotility. Radiopaque markers can be used to investigate a numberof common gastroenteric problems. These spheres have been specifically validated for use in dogs and cats and are the only radiopaque markers with which there is extensive clinical experience inveterinary medicine. BIPS are manufactured in New Zealand and are now available in many countries. Information on availability of this product, including instructions on use and interpretation of radiographic studies, can be found at( http://www.medid.com/;800-262-2399).

One of the most reliable and cost efficient diagnostic tools currently available for evaluation of vomiting is flexible GI endoscopy. Endoscopy allows for direct gastric and duodenal examination,mucosal biopsy from these areas, and in many cases gastric foreign body retrieval. Endoscopy is considerably more reliable than barium series for diagnosis of gastric erosions, chronic gastritis, gastric neoplasia, and inflammatory bowel disease (a common cause of chronic intermittent vomiting indogs and cats). It is stressed that biopsy samples should always be obtained from stomach and whenever possible small intestine regardless of gross mucosal appearance. Normal gastric biopsies may support gastric motility abnormalities,psychogenic vomiting, irritable bowel syndrome, or may be non contributory(i.e., look elsewhere for diagnosis). Many dogs with vomiting due to inflammatory bowel disease have no abnormalities on gastric examination o rbiopsy. If only gastric biopsies are obtained, the diagnosis may be missed.

Ultrasonography can be useful in the diagnostic work-up of a number of disorders that can cause vomiting. Among the problems that may be detected with ultrasonography are certain disorders of the liver (e.g., inflammatory disease, abscessation,cirrhosis, neoplasia, vascular problems), gall bladder (cholecystitis,choleliths, gallbladder mucocele), GI foreign bodies, intestinal and gastricwall thickening, intestinal masses, intussusception, kidney disorders, andothers. Needle aspirations and/or biopsies can be done at many sites unde rultrasound guidance.

Abdominal exploratory is indicated for a variety of problems including foreign body removal, intussusception, gastric mucosal hypertrophy syndromes,procurement of biopsies, and for resection of neoplasia

*fPLI is only available at Texas A&M University. Serum samples can either be sent directly to the GI Laboratory at Texas A&M University, or they canbe forwarded to Texas A&M by a commercial laboratory.

The address is:

GI Lab at TexasA&M University

College of Veterinary Medicine

TAMU 4474

College Station, TX 77843-4474

979-862-2861

http://www.cvm.tamu.edu/gilab/

Diagnosis of Vomiting

Stage1—Baseline Assessment

History and physical examination Conservative vs. more aggressive diagnostic plan based on patient's condition and clinician's concern
Stage 2—Further assessment (if vomiting persists or initial tests indicate further investigation should be performed promptly):

• Special Blood Tests

—Corticotropin stimulation

—cPLI or fPLI (pancreatitis)

—Leptospirosis serology

—Bile acids assay (to asses liver function)

—Coagulation tests (consider in patientswith hematemesis/melena)

• Contrast Radiography

—Barium contrast

—Air contrast gastrogram (to further assessfor gastric foreign body)

—BIPS (barium-impregnated polyethylenespheres; with food to assess GI motility)

• Ultrasonography

—Evidence of GI or non-GI disease

—Aspirates or biopsy

—Abdominocentesis

• Nuclear Scintigraphy

—Transcolonic portal angiography fordetection of portosystemic anomaly

—GI motility study

Stage 3—Invasive Procedures

• Flexible GI endoscopyb(minimally invasive)

—Examination, biopsy, foreign body retrieval

• Laparoscopy

—Biopsies (e.g., liver, pancreas)

—Aspirates (e.g., gall bladder, lymph nodes,mass lesion)

—Intestinal biopsy

• Surgical intervention

— Therapeutic or exploratory with multiple biopsies

*GI parasites, including Giardia,should always be considered in dogs with acute or intermittent vomiting. Best baseline testing on a single fecal sample includes centrifugal flotation and Giardiaantigen test.

bEndoscopy is a diagnostic ortherapeutic tool that can be used in Stage 1, Stage 2, or Stage 3, depending onthe clinical situation.

References

DeNovo RC: Diseases of the stomach. In TamsTR, ed: Handbook of small animal gastroenterology, ed 2, Philadelphia, 2003, WBSaunders.

Richards JR, Dillon R, Nelson T, Snyder, P:Heartworm-associated respiratory disease in cats – a roundtable discussion.Veterinary Medicine June 2007.

Tams TR: Gastrointestinal symptoms. In TamsTR, ed: Handbook of small animal gastroenterology, ed 2, Philadelphia, 2003, WBSaunders.

Tams TR: Chronic diseases of the smallintestine. In Tams TR, ed: Handbook of small animal gastroenterology, ed2, Philadelphia,2003, WB Saunders.

great info...I personally do have intermittent issues with Jackie vomiting - stomach heaving - good to see info on this.  Have not needed it yet, but good to know it is out there...