There is not a lot of information on how to manage cats with EPI ... supposedly it is rare for cats to develop EPI... unfortunately, we are seeing more and more cats being diagnosed with this condition.
To best help serve the public and the veterinarian community, this page is divided into two sections....
"Soleil" the love of my life ..... was only five years old when she was diagnosed.
Soleil started developing symptoms a little over a year ago with occasional vomiting and gagging. They were treating her for hairballs. They gave her a medication to increase her intestinal motility and it nearly killed her. Following that, she received her yearly immunizations and she became very ill with fevers, lethargy, etc. This had never happened before. As an aside, I have decided not to give her immunizations anymore. She is an inside cat and the last time was too scary.
Shortly after that, she started eating me out of house and home but continued to lose weight. She got down to 6 lbs. 2 oz. (her six month kitten weight). She was so skinny . . . fur and bones. It made me cry just to look at her. She would keep me up all night crying. I would get up and pet her and try to console her, but I did not know what to do. It was horrible! Her bowel movements were very large and yellow in color. Finally, my local vet sent me to a specialist. They did an ultrasound which revealed thickened bowel and they told me they were pretty sure she had lymphoma. I was devasted! They did an endoscopy and biopsy of the affected area. I was happy five days later to get a call telling me she did not have lymphoma but she had inflammatory bowel disease. A few days later they called to tell me her lab results from blood tests were back and she had exocrine pancreatic insufficiency. Wow! They told me it was extremely rare in cats and they put her on 2.5 mg. of Prednisone every day for the inflammatory bowel disease and told me to mix Viokase with her food and she started a regimen of B12 injections. That all seemed fine except Soleil would NOT eat any food with the enzymes in it. For two months I syringe fed her with chicken baby food after adding Viokase and waiting 20 minutes. It was horrible but it was the only way I could get the enzymes in her. She started to gain some weight back which was good but she and I both hated the syringe feeding. She would run and hide from me when I got home and although I got pretty good at it she would still freak out because they occasionally get choked by that method of feeding no matter how hard you tried not too. She would fight me like crazy and I would stop and cry. It was terrible!
My next attempt at getting her the enzymes was to talk to a slaughter house in Lake Geneva, WI. They would sell me raw bovine pancreas. I cut it up and put it in a food processor and froze it in ice cube trays. My vet said I could mix this in her food and if she ate it, this would give her the enzymes she needed. My kitchen looked like a slaughter house by the time I was done with this process. Raw pancreas is good for three months if you freeze it. I tried feeding it to Soleil one evening and she threw up so bad I thought she was going to die. I think she just over ate because she was so hungry, but after several attempts at feeding her raw pancreas I found that she did not like that either and I went back to the dreaded syringe feeding.
Shortly after that my local vet told me about Flavorx. It is a company that sells materials to compound the Viokase to taste like chicken pot pie (or any flavor you want). My vet would compound the enzymes which I would syringe drizzle over her food mix it up and she ate it! I was so happy! No more syringe feeding! I asked my vet if I could do this myself at home. I wanted to have control over all of it. My vet wrote a letter to the company "Flavorx" giving me the ability to order all the compounding products directly from them and he then showed me how to compound the enzymes and I am able to do this at home now.
During all this, Soleil was receiving weekly, then bi-weekly B12 shots. These were SO important for her. Even after a long B12 therapy she was still low when tested. A few months ago she was tested again and her levels are normal but they recommend monthly B12 shots and then she gets rechecked in February. I will always continue to monitor this for her even though I hate when she gets the blood test because she has to fast for 12 hours prior. Nothing worse than withholding food from an EPI animal. I don't get much sleep. LOL! It is worth it though.
At some point during all this craziness I talked to a holistic vet (a friend of someone else I met on line with a dog with EPI). He suggested FortaFlora probiotics sprinkled on her food. This was to help with the inflammatory bowel disease and digestion. This seemed to help Soleil a lot and they smell like beef boullion and she seems to like the taste so I use about half packet of that on each of her two feedings daily. I mix it with the food after I mix the compounded enzymes with the food.
I did receive another tip for feeding cats enzymes from her specialist. It did not work for Soleil but it might work for someone else. You buy fish oil tablets and mix the liquid from the tablet with the Viokase (making a paste). Some cats like this and will lap it up getting them their enzymes, but miss finicky did not care for it at all, but a good suggestion if it works, I guess. It is a cheap way to compound the enzymes yourself if it works.
Also during my research I found a product called "Cat Man Do" sprinkles. These are dried bonitos fish flakes. You sprinkle them over the food. I sent some of these to my friend Melissa, mentioned above, and she said her cat loves them. I bought some but never tried them with Soleil because I finally got the compounding flavored enzymes working well. I would think these may help disguise the taste of the enzymes if the cat likes them. You can order them on line.
Soleil is now on Prednisone, 2.5 mg. five days a week. She needs this for her inflammatory bowel disease and it seems to keep her under great control. I hate having to give her this, but when I cut back further she starts gagging again.
I also purchased a pediatric scale for Soleil because it is hard to tell when a cat is gaining or losing weight and waiting between vet appointments to have her weighed was too stressful. The scale cost about $70.00 and it was worth every penny. I ordered it on line. I can see immediately if there is any problem going on if she starts losing weight. It weighs in ounces and pounds.
One other great item for those working cat mommies (such as myself) is the timed feeder from Petsmart. My friend Melissa told me about this and it works great if you are going to be away from home for more than ten hours or so. It has a slot under the trays that you can place an ice pack keeping the food and enzymes fresh. As you know, you can't leave the enzymes out all day. You set the timer and the door opens at the specified time. Voila! Dinner is served! I rarely use this, but it has come in handy on a few occasions.
I have the additional complication of having two cats. Soleil's BIG sister weighs 13 1/2 lbs. They were not really litter mates, but I call them sisters anyway. I have the challenge of getting Luna to lose weight and Soleil to gain weight. The only good thing about Luna's additional weight is that she can no longer jump up on the counter tops. This is where I have to feed Soleil so that Luna cannot get to her food. Luna has to eat before I leave now because I cannot leave un-enzymed food down during the day or Soleil will eat that first.
Soleil weighed in last night at 7 lbs. 6 oz. This is a really good weight for her. When she was two years old she weighed 7 lbs. 8 oz. She has always been a small cat and was the runt of the litter when I adopted her. She is a polydactyl kitty. She has seven claws on her front paws and six claws on each back paw. She has big mitten feet but they are so cute!
Currently I am feeding Soleil Fancy Feast Chicken with some spinach in a broth (green can). This is the food I mix the enzymes and probiotics in. Then I top it off with Blue Buffalo dry food (Gluten free/grain free) chicken Freedom. She loves that and seems to digest it very well. I give her the Blue Buffalo for treats occasionally too, just not a lot without being in the enzymes.
If anyone goes the compounding route with the vet syrups and flavorings, they must NOT use the conventional syrup to compound the enzymes if their cat has diabetes. Diabetes is somewhat common in cats with EPI. I don't know about dogs. However, there is another solution. I believe it is called Versa Free (it contains no sugar). This is what I believe you would use for a diabetic cat. Basically, if someone has a diabetic EPI cat they should definitely consult with their vet first. I'm sure they would anyway, but just wanted to add this bit of info.
Thanks for listening to my story, Carol.
I give him weekly subcutaneous injections of 250mcg of vitamin B12. I noticed dramatic improvements in his energy level after beginning the B12 injections, and his stools seem to be approaching closer to normal as well. The hope is that we may be able to reduce the frequency of the injections in the future, but we aren't to that point yet; every few months, I will try to space the injections out a little bit further, but doing so has so far resulted in a return to loose stools. Tim is generally pretty good about his injections and allows me to give them without putting up much of a fight, though I do occasionally have to fall back on the "kitty burrito" method of wrapping the cat in a towel while giving the injection. He loves his food, so if I give him the injection while he is eating, he often does not notice that I have done anything!
Sadly MaryJo suddenly lost King Kitty to a respiratory illness in December 2012, but in honor of his legacy, MaryJo will gladly help anyone needing assistance with their EPI cat.
Please feel free to contact MaryJo at: email@example.com
The following EPI in Cats information is taken in it's entirety from the Mercola Pets website written by Dr. Karen Becker:
By Dr. Becker
Exocrine pancreatic insufficiency (EPI), also called pancreatic insufficiency and maldigestion syndrome, is thought to be rare in cats. However, according to dvm360, new research suggests veterinarians should look more closely at EPI as a potential cause of diarrhea and chronic weight loss in kitties.
The pancreas has many functions. It produces not only insulin, but also various enzymes that provide for the digestion of food. Many people are aware the pancreas plays a role in insulin production and diabetes; relatively few people realize the role the pancreas can play in digestive diseases.
Pancreatic enzymes include amylase, which breaks down starches; lipase, which breaks down fats; and trypsin and chymotrypsin, which break down proteins.
The actions of these enzymes are crucial to the digestive process. They allow nutrients from the diet to be absorbed by the cells of the intestine, where they pass into the bloodstream and are transported throughout the body for use by tissues. When a cat eats, the pancreas gets a signal to release digestive enzymes, which travel into the small intestine via the pancreatic duct (“exocrine” glands secrete their products into ducts, whereas “endocrine” glands secrete their products directly into the bloodstream).
Once they reach the center of the intestine, the enzymes go to work breaking down food particles.
Exocrine pancreatic insufficiency means there is a decrease or lack of digestive enzymes being produced by the pancreas. In kitties with the disorder, proteins, starches and fats from the diet aren’t broken down sufficiently to be absorbed through the intestinal wall. This means nutrients can’t get into the bloodstream to supply nourishment to the body’s tissues. Much of the food that is eaten remains undigested in the GI tract and ultimately leaves the body in feces. If left untreated, a cat with EPI can literally starve to death despite how much food is consumed.
Pancreatic insufficiency can have several potential causes, but the most common source in cats is chronic inflammation of the pancreas. Other causes are parasitic infestations, as well as cancer.
Signs a kitty may be dealing with EPI include weight loss; constant hunger; lots of watery, loose or semi-loose stools that may have a foul odor and contain large quantities of undigested fat; and poor coat condition. Cats with this disorder look and behave as though they are starving to death … because they are.
Occasionally, cats with EPI are also diabetic.
A test called the feline trypsin-like immunoreactivity (fTLI) assay is considered diagnostic for EPI. Prior to the availability of the fTLI, diagnosis was trickier and involved taking a symptom history and running repeated fecal digestion tests.
In 2010, the GI Laboratory at Texas A&M University received 775 samples from veterinarians of fTLI assay results that were consistent with a diagnosis of feline EPI.
Then in 2011, researchers from the GI Laboratory and Department of Clinical Sciences at Texas A&M conducted an EPI survey of veterinarians who submitted samples. One hundred-fifty surveys were returned. The average age of affected cats with the condition was eight years. Males represented 59 percent of the samples; females, 41 percent.
Average body condition of the kitties was poor. Of the cats for which cobalamin (vitamin B12) levels were measured, 77 percent were deficient and many had no detectable levels of B12 at all. For those that had folate concentrations tested, 47 percent showed an increase.
As for symptoms, in 91 percent of the cats, weight loss was the primary symptom. Weight loss varied from 1.4 ounces to 15 pounds, with an average of 3 pounds. Loose stools were seen in 62 percent of affected cats; poor haircoat in 50 percent; loss of appetite in 45 percent and increased appetite in 42 percent; and depression was present in 40 percent of the kitties. Almost 60 percent of the cats had coexisting diseases including inflammatory bowel disease (IBD), diabetes,pancreatitis and hepatic lipidosis.
Of the kitties with EPI, 68 percent were given pancreatic enzyme supplementation. Of those, 66 percent showed a good response, 24 percent had a partial response, and 10 percent had a poor response to the treatment.
According to dvm360, the results of the survey are evidence that exocrine pancreatic insufficiency is not as uncommon in cats as previously thought. However, symptoms in cats vary noticeably from canine symptoms. In cases of feline EPI, diarrhea isn’t a consistent finding and isn’t as severe as it is in dogs dealing with the disease. Also in cats, excessive hunger is not consistently present, and in fact about half the cats in the survey showed a decrease in appetite.
Treatment with pancreatic enzyme supplementation appears to be successful in a large percentage of kitties with EPI. If there are also low cobalamin levels, subcutaneous (under the skin) supplementation for several weeks is often required to help resolve gastrointestinal symptoms.
Also, EPI can be associated with small intestinal dysbiosis (also called small intestinal bacterial overgrowth, or SIBO), especially when low B12 and high folate levels are present.
Cat owners and especially veterinarians should consider fTLI, cobalamin and folate tests for kitties with unexplained weight loss or chronic diarrhea, regardless of the pet’s age. These tests could conceivably eliminate the need for more expensive and invasive diagnostic procedures.
EPI should also be viewed as a possible concurrent condition in diabetic cats whose blood sugar levels are well controlled but who have weight loss and/or diarrhea.
in accordance with Mercola's copywrite permission, the following must be included when copying the article:
EPI in Cats
The following is from: http://www.ivis.org/advances/rcfeline/chap4part9/chapter.asp?LA=1
In: Encyclopedia of Feline Clinical Nutrition, Pibot P., Biourge V. and Elliott D.A. (Eds.). International Veterinary Information Service, Ithaca NY (www.ivis.org), Last updated: 28-Apr-2009; A5106.0409
The exocrine pancreas plays a central role in the digestion and absorption of nutrients. Pancreatic acinar cells synthesize and secrete enzymes that digest proteins, fats and carbohydrates (protease, lipase and amylase). Pancreatic duct cells furthermore secrete bicarbonate to maintain an optimal pH for digestive and absorptive function, as well as intrinsic factor to facilitate cobalamin absorption.
Exocrine pancreatic insufficiency (EPI) results from deficient synthesis and secretion of pancreatic digestive enzymes. The lack of digestive enzymes in the duodenum leads to maldigestion and malabsorption of intestinal contents. The exocrine pancreas has a large functional reserve capacity and clinical signs of maldigestion do not occur until 90% of secretory capacity is lost.
EPI is an uncommon cause of chronic diarrhea in cats; however, in the past it has been under diagnosed due to the lack of specific clinical and laboratory findings. Diagnostic accuracy has now been facilitated by the fTLI test, which is a species specific radioimmunoassay.
Clinical signs in affected cats are not specific for EPI: the most commonly reported clinical signs in cats with EPI are weight loss and soft voluminous feces (Steiner & Williams, 2005). Polyphagia despite weight loss is not as commonly seen as in dogs. Many cats also develop a greasy, unkempt hair coat, especially in the perianal and tail regions, resulting from the high fat content of their feces. Some cats have watery diarrhea secondary to intestinal disease. Affected cats may also have a previous history of recurring bouts of acute pancreatitis (e.g., anorexia, lethargy, vomiting) that resulted in chronic pancreatitis and EPI. Concurrent disease of the small intestine, hepatobiliary system and endocrine pancreas may be present.
The main differential diagnoses for a cat presented with diarrhea, weight loss and changes in appetite are hyperthyroidism, diabetes mellitus and chronic small intestinal disease (most commonly inflammatory bowel disease). Physical examination may help in differentiating these, e.g., by palpating a thyroid nodule or thickened intestinal loops. However, these diseases may be coexisting, especially in older cats, and laboratory testing and imaging (particularly ultrasound) are mandatory.
Routine Laboratory Tests
Results of hematology and serum biochemistries are generally within normal limits or show nonspecific changes. Older cats may have evidence of concurrent renal disease, whereas cats with hyperthyroidism often have increased serum liver enzyme concentrations. Microscopic examination of feces will demonstrate steatorrhea and undigested fat, but this is not pathognomonic for EPI.
Serum concentrations of cobalamin and folate should also be determined in all cats with suspected EPI, because of the common occurrence of low levels (especially for cobalamin) (Steiner & Williams, 1999).
A feline-specific radioimmunoassay for trypsin-like immunoreactivity (fTLI) has now been developed and validated, it is sensitive and the test of choice to diagnose EPI in cats. Fasting serum fTLI concentrations less than 8 μg/L (reference range = 17 - 49 μg/L) are diagnostic for feline EPI (Steiner & Williams, 2000). When the fTLI concentration is between 8 - 17 μg/L, the test should be repeated ensuring adequate fasting; it is also possible the cat has partial EPI that in time may progress to complete EPI. The TLI test is a simple and reliable way of confirming the diagnosis of EPI; however; it is essential to use an assay specific for feline TLI since there is no cross reactivity between canine and feline TLI.
Imaging findings are inconsistent; abdominal radiography and ultrasonography generally do not show any abnormalities.
Chronic pancreatitis is the most common cause of feline EPI (Figure 26), occurring mainly in mature and older cats. In most cases, it is idiopathic. Rare causes of feline EPI without chronic pancreatitis are pancreatic duct obstruction by liver flukes or pancreatic neoplasia (adenocarcinoma), leading to acinar atrophy. Fecal examination can help in the diagnosis of a fluke infestation, whereas abdominal ultrasonography is essential in detecting a pancreatic mass.
Pancreatic acinar atrophy (PAA) similar to the disease commonly observed in dogs has not been documented in cats. Chronic pancreatitis is the most common cause of EPI in cats. (© courtesy KW Simpson).
There is no breed or sex predisposition for the development of EPI in cats.
Cats with EPI have an extensive and chronic disease, which is usually due to chronic and irreversible pancreatitis.
The typical signs of EPI (diarrhea, weight loss and polyphagia) are due to decreased intraduodenal concentrations of pancreatic digestive enzymes and bicarbonate with resultant malassimilation of fats, carbohydrates and proteins. This leads to malabsorption, osmotic diarrhea and steatorrhea, and malnutrition. In addition, there are secondary disturbances of intestinal mucosal growth and transport mechanisms that aggravate malabsorption. Cats normally have high numbers of anerobic organisms in their proximal small bowel (Johnston et al., 1993) and it is not known whether they develop changes in the nature and number of small intestinal flora, which is common in dogs with EPI.
Fat malabsorption may result in deficiencies of the fat-soluble vitamins (esp. vitamins K and E). Vitamin K-dependent coagulopathy has been reported in a cat with EPI (Perry et al., 1991) and may occur in other cases as well. Vitamin E deficiency could aggravate oxidative stress, but there are no reports documenting this in feline EPI.
Many cats with EPI have low serum cobalamin concentrations, which impairs their response to treatment. Cobalamin is absorbed in the distal small intestine after it has formed a complex with intrinsic factor, a protein that in cats is exclusively secreted in the pancreatic juice (Fyfe, 1993). The lack of pancreatic intrinsic factor in EPI impacts severely the ability to absorb cobalamin. In addition, concurrent small intestinal disease (Weiss et al., 1996) may further impair cobalamin absorption in cats. Cats seem predisposed to develop markedly reduced serum cobalamin levels under those circumstances (Simpson et al., 2001). Uncorrected cobalamin deficiency may lead to villous atrophy, intestinal inflammation and worsening malabsorption, with resultant failure to respond to pancreatic enzymes alone.
Serum folate concentrations may be decreased in the case of concurrent small intestinal disease resulting in malabsorption of folate. This differs from the situation in canine EPI, where folate levels are often increased due to secondary small intestinal bacterial overgrowth. Cats have however normally high levels of bacteria in their small intestine and bacterial overgrowth is not a recognized syndrome in this species (Johnston et al., 1993; 2001).
Addition of exogenous pancreatic enzymes to the food is essential for resolution of clinical signs.
Adequate management of cats with clinical EPI depends on long term enzyme replacement and dietary manipulation.
It is important that dietary management and enzyme supplementation are kept constant, since variation and especially the consumption of a non-supplemented meal can cause a return of the diarrhea.
Raw chopped pancreas (30 - 90 g per meal twice daily) may be used as an alternative and can be very effective. It can be stored frozen for at least three months, but is generally less convenient to use and has the potential for causing gastrointestinal infections (e.g., Salmonella, Campylobacter). Bovine pancreas is safest, since there is always a risk of transmitting Aujeszky’s disease when using porcine extracts. Raw chopped pancreas can however be a solution when the cat develops aversion to the powdered extract.
Cats with EPI almost always have marked depletion of body cobalamin stores and severely decreased serum cobalamin concentrations. In addition, many cats with EPI have concurrent small intestinal disease which further impairs cobalamin absorption. Supplementation is by parenteral cobalamin (250 - 500 μg/kg subcutaneously every two or three weeks) to maintain normal serum concentrations of cobalamin (Ruaux et al., 2005).
Cats with EPI with or without concurrent small intestinal disease may also have low serum folate concentrations and should be treated with oral folate at 400 μg once daily for 2 - 4 weeks or longer, until serum levels have normalized.
Malabsorption of fat-soluble vitamins (vitamin A, D, E and K) may occur in EPI, although the clinical importance in cats is unknown. Cats with evidence of a coagulopathy should be supplemented with vitamin K. It may also be helpful to increase dietary vitamin E levels because of its antioxidant function, especially in cats that do not respond to enzymes and supportive management alone and especially in cats with concurrent diseases.
Cats with chronic pancreatitis resulting in EPI as well as diabetes mellitus will need insulin treatment in addition to management of the EPI.
High digestibility is a mainstay of dietary management, since it requires less gastric, pancreatic, biliary and intestinal secretions for digestion, and thus facilitates absorption in the upper small intestine. Dietary modification may be required in cats that present with severe weight loss and protein-calorie malnutrition, and also in cats that do not respond adequately to this management.
Cats with EPI should be fed a highly digestible, good quality and energy dense diet, with an appropriate pancreatic enzyme supplement mixed into it (Simpson, 2005). (© C. Hermeline).
The diet during early refeeding should contain higher protein levels, since many patients with EPI suffer from protein-calorie malnutrition. If response to treatment is poor, concurrent intestinal disease has to be investigated further, e.g., by a dietary trial with an antigen restricted diet. A diet based on rice and soy protein hydrolysate proved to be beneficial in the management of canine EPI (Biourge & Fontaine, 2004). This strategy remains to be validated in cats.
Fat malabsorption and steatorrhea are major signs in patients with EPI (Williams, 2005). However, fat restriction is of questionable benefit for cats, especially since this species needs a relatively high-fat diet. In addition, there is evidence that higher fat diets promote better digestibility (Suzuki et al., 1999). The cause is unclear, but it may be related to improved preservation of exogenous pancreatic enzymes, particularly lipase. Furthermore, a higher fat and thus more energy dense diet will help an animal in poor body condition to regain its optimal body weight faster. Dietary fat levels can therefore be within the normal range, but high digestibility is essential.
Diets containing moderate amounts of fermentable fiber will help to improve GI health by its positive actions upon the mucosal barrier.
Cats are poorly adapted to handling carbohydrates, so excessive amounts should be avoided.
The diet should contain high-normal concentrations of B-vitamins, since body stores are often depleted.
Ensure that the enzyme supplement being fed is appropriate (non-enteric coated powder), not outof- date, and fed at the right dose with each meal.
Concurrent small intestinal disease may cause continued malabsorption despite adequate enzyme supplementation. Dietary modifications, e.g., to an antigen-restricted or protein hydrolysate diet, can help to evaluate for dietary intolerance/sensitivity. The diet should be fed exclusively, with added enzyme supplementation, for at least two to three weeks. If gastrointestinal signs resolve after the dietary trial, the cat should be challenged with components of its former diet in order to confirm a diagnosis of dietary intolerance/sensitivity.
If dietary modification is not effective, the cat should be investigated for structural intestinal disease (e.g., inflammatory bowel disease) with abdominal ultrasound and endoscopy with intestinal biopsy. Cats with concurrent inflammatory bowel disease usually can be successfully managed with oral prednisolone (Steiner & Williams, 2005).
Feline exocrine pancreatic disease, particularly acute pancreatitis, is more common than previously thought. It however requires a high level of clinical suspicion. Assay of serum fPLI combined with abdominal ultrasound is recommended for the diagnosis of pancreatitis, whereas a severely decreased serum fTLI concentration is diagnostic for EPI in the cat. In both pancreatitis and EPI, concurrent diseases should be assessed and addressed as necessary.
Provision of adequate calories and nutrients is essential in the management of cats with exocrine pancreatic disease. Supportive therapy is important to prevent complications and decrease mortality in acute pancreatitis, and early enteral feeding may be required in order to prevent secondary hepatic lipidosis. Cats with EPI will at least require dietary supplementation with pancreatic enzymes for resolution of clinical signs, and additional treatment with parenteral cobalamin is necessary in many cases.