Pancreatitis

The information contained in this article is provided for educational purposes only and is not intended to replace veterinary advice. Please consult with your vet for further information.

 

Pancreatitis

Pancreatitis literally means inflammation of the pancreas.

Pancreatitis occurs when the digestive enzymes, which normally do not become active till they reach the intestines, become active in the pancreas itself, causing inflammation and irritation to the pancreatic tissue as they “attack” it.

The enzymes will also often affect the liver, and can back up through the bile duct, causing inflammation there also.

Pancreatitis is more widespread than many realize:

According to the Merck Veterinary Manuel¹, “Pancreatitis is the most common exocrine pancreatic disease in both dogs and cats”.
One 2007 Study² found that 45% of clinically normal cats (so those showing no symptoms of any illness) showed signs of pancreatitis at autopsy.

Pancreatitis is often referred to as being either acute or chronic. The difference refers only to the duration, not to the severity, of the attack: Acute pancreatitis happens suddenly then is over; chronic pancreatitis is on-going, leading to more permanent damage. To quote the Merck Veterinary Manuel¹:

Both acute and chronic pancreatitis can be subclinical, mild and associated with vague clinical signs, or severe and associated with pancreatic necrosis and systemic complications. Thus a distinction between the two is clinically of little significance.

Over time, untreated sub-clinical and mild chronic pancreatitis or repeated attacks of acute pancreatitis will lead to increased scarring and damage of the pancreas and other nearby organs. One of the side-effects may be the development of feline diabetes.

A severe pancreatitis attack is a very serious situation that left untreated can be life-threatening as inflammation spreads throughout the body affecting multiple organs and systems, and leading to such conditions as shock and respiratory failure, amongst others. Hepatic Lipidosis (also known as fatty liver disease) may be associated also, as the cat will refuse to eat.

Pancreatitis may often be associated with inflation of the liver and the intestines also: the combination of the three is called Feline Triaditis.

 

Causes

The cause of pancreatitis for an individual cat is usually unknown. Some risk factors which may be implicated or predispose a cat to pancreatitis in some cases are:

• Parasites: liver or pancreatic flukes, toxoplasmosis
• Bacterial: bacteria ascending from the gastro-intestinal tract into the pancreatic duct
• Certain viruses: Feline Calcivirus……
• Blunt trauma: being run over or falling from a high place, for example
• Certain pesticides or medications have been brought into question by some vets and researchers
• Siamese cats seem to be slightly more predisposed to pancreatitis than other breeds.

To note: while a high fat diet is implicated in pancreatitis in dogs, this is not true for cats. A high fat diet is not considered a risk factor.

 

Symptoms

One of the difficulties in realizing that your cat may have pancreatitis is that symptoms are often very vague – or even basically imperceptible – if the pancreatitis is mild or sub-clinical.

Your cat may show one or more of the following symptoms :

• Anorexia
• Lethargy/Weakness
• Dehydration
• Weight loss
• Vomiting – much more rare in cats than in dogs, and may be intermittent so not realized as being clearly linked to other possible symptoms
• Abdominal pain – which may only be shown by your cat trying to find “cool” places to lie to soothe its tummy (bathroom basin, tile floor….) or sitting/lying in a “hunched up” way to avoid pressure on its tummy
• Diarrhea
• Fever
• Jaundice – if the liver has become affected, usually only seen in severe cases
• Light coloured stools – if the liver has become affected

One further symptom/sign in diabetic cats is BGs that are difficult to control. If an FD cat is proving difficult to regulate and other possible reasons have been ruled out, pancreatitis should definitely be considered as a possible cause.

A cat with mild pancreatitis may simply seem a little bit “under the weather” or not quite his usual active self.

A cat suffering from a severe attack will show stronger signs of the symptoms above – and will be a very sick cat.

 

Diagnosing Pancreatitis

The most accurate test that exists for pancreatitis is the Spec fpl1 from Idexx. It is also the only test that allows a measure of the severity of the disease. It provides three ranges of results:

• ≤ 3.5µg/L: unlikely the cat has pancreatitis
• 3.6 – 5.3µg/L: the cat may have pancreatitis; the test should be repeated in two weeks
• ≥ 5.4µg/L: the cat most likely has pancreatitis

False negatives may occur in the lower ranges; if your cat continues to show symptoms you should consider retesting a few weeks later.

Idexx also commercializes the “snap fpl” test which your vet can do in his clinic (the Spec fpl1 needs to be done in an Idexx lab). This test however simply gives a yes/no result – it does not provide any information on the severity of the disease. While in some countries – North America in particular – the Spec fpl1 is quite expensive, it is worthwhile having done if you are able to afford it.

Other exams which may point to, but cannot diagnose pancreatitis are:

• Blood Tests
– As the liver is often affected also, tests measuring liver enzyme values may be elevated: Bilirubin, ALT (also known as SGPT) and AST (also known as SGOT).
– BUN/Urea may be elevated if your cat is dehydrated.
– Cobalamine (B12) levels are often low.

• Ultrasound
Ultrasound may indicate some abnormalities, however, the technician doing the exam must be highly skilled to fully see and understand the results, and even a highly-trained technician will only be able to detect about half of all pancreatitis cases through ultrasound.

 

Treating Pancreatitis

1) Severe attack

Depending upon the severity, vet care may be necessary.

Steps that need to be taken in the case of a severe pancreatitis attack are:

• Getting your cat’s BG levels down! During severe attacks, your cat will probably need to have its scale increased. FD and Pancreatitis are a vicious circle: the pancreatitis makes the BGs go up…. The higher BGs aggravate the pancreatitis … which pushes the BGs up, etc. Controlling the BGs by adjusting scale as needed is therefore essential.

• Syringe feeding if your cat is refusing to eat because of the pain, nausea and the acidy tummy it is experiencing: doing so is very important to prevent hepatic lipidosis

– If your cat is hospitalized, your vet may insert a feeding tube to ensure it does get the food it needs. The feeding tube may need to stay in for a while, including after you bring him home.

• Giving Sub-q fluids to help rehydrate your cat, who is probably dehydrated as not eating enough, and to help hydrate the pancreas is important (please see the information on SubQ Fluids in the Knowledge Centre for more information)

In addition, your vet may prescribe several medications:

• Pain killers (for example buprenorphine) – severe pancreatic flare-ups are very painful; controlling the pain is important.

Buprenorphine is available in oral form in a number of countries, including the US,  and can be given at home.  In other countries (many in Europe) however, it is a controlled substance that can only be administered by a vet in the form of an injection.

Tramadol is another pain killer that can help.  Tramadol has historically been given orally, and has a taste that cats detest (and which can make them drool excessively, if you manage to get the tramadol into them).

There is now a vet version available in tablet form:  Tralieve.  The dose is 1/4 tablet BID.  If your cat does well on that and is still showing signs of pain, it can be increased to 1/2 tab BID.  Do discuss with your vet the best dose for your cat.

• Anti-vomitives if your cat is experiencing vomiting:  Cerenia is most commonly given (1/2 tab once a day)
• Appetite stimulants such as Mirtazapine or Cyproheptadine to try and incite your cat to eat alone
• In very severe cases with widespread inflammation, steroids such as prednisone may be needed. The use of steroids with an FD cat should be a last resort, and insulin scales will need to be adjusted to deal with them.
• Antibiotics may be prescribed; however, unless there is a secondary infection, they are usually not indicated as bacterial infections are rarely if ever involved with pancreatitis itself. The side effects of many antibiotics, such as nausea, may even make the situation worse.

Note: in the past, fasting a cat for 24-hours with severe pancreatitis was recommended, and this advice may still be seen in certain articles or followed by some vets. Fasting is NOT recommended for cats due to the risk of hepatic lipidosis (fatty liver) disease developing, which can be fatal.

 

2) Mild chronic pancreatitis and on-going treatment after a severe attack

As for a severe attack, it is important to try to keep your cat’s blood glucose levels as regulated in normal numbers as possible.

It is important to ensure that your cat is eating enough. It may be necessary to continue or to occasionally syringe feed if they are not. Keeping your cat well hydrated is also important: simply adding a spoon or two of water to his meals will help.

In terms of treatment for the disease, there are several medications and supplements that will make a true difference for your cat. They will help reduce the damage caused by mild chronic pancreatitis and improve your cat’s condition, will help your cat if it has just suffered a severe attack, and will help prevent severe attacks from happening in the future.

Many FD cats will benefit from being placed on at least low level doses of supplements even if not diagnosed with pancreatitis: they will help protect against the disease occurring and/or the severity of it if it does.

All capsule or liquid supplements may simply be mixed into your cat’s food, though if your cat is a very fussy eater, filling empty capsules with the different supplements and pilling him may be an easier way for you to administer them.

It is best to start out with smaller doses and move up to the full dose to let your cat get used to the taste. It is also recommended to start with one supplement, adding a new one every 4-5 days. Adding one by one will let you see which is causing the problem if your cat reacts badly to one (it causing his blood glucose to go up, for example).

Important: please check the ingredients to make sure that they are appropriate:

– Capsules should not contain substances that are bad for an FD cat such as rice flour or “hidden” sugars
– Liquids should not have more than 5% alcohol

• Antacids/Stomach aids

The burning/acidy tummy is the symptom that is most felt by your cat – it is the reason he doesn’t want to eat, it causes pain and nausea. So, while it treats a symptom and not the root problem, giving your cat antacids or supplements that help with digestive issues will provide the most immediate relief.

Some antacids that may be used:

1. In North America: PepsidAC (famotidine)
You should get regular strength (10mg famotidine – the active ingredient). The dose is ¼ tablet or 2.5mg BID (twice a day. This amount may be increased to 1/2 tablet or 5.0mg BID if your cat is suffering badly for 1-2 weeks maximum.

Cats may stay on the lower dose indefinitely, though if your cat is doing better, it is good to see if you can stop use.

Famotidine does have certain side effects: it may adversely affect cats with heart rhythm problems and may actually increase vomiting in some CRD (chronic renal disease) cats with high creatinine. It may also reduce absorption of B12, so supplementing with that is recommended (B12 supplementation also helps with pancreatitis – see below).

Famotidine is available in some European countries with a prescription, however it is usually only sold in 20mg tablets – which are more or less impossible to cut into the 1/8ths necessary to dose 2.5mg. If your cat is very sick and needs the higher 0.5mg BID (or 1/4 tablet) it can be used for a week to 10 days.

2. Outside of North America, Ranitidine (also known by the brand name Zantac) is available in many countries.

Depending on the country a prescription may be required. Where it is not, it may be possible to buy on line.

The dose is 2mg/kg BID.

As for PepsidAC, Ranitidine is not recommended for cats with heart murmurs. It may also cause diarrhea or vomiting in some cats.

            3. Should be available worldwide:  Omiprazole or Cimetidine 

     Omiprazole is stronger than famotidine, and is recommended over Cemetidine which is much weaker.

     Brand names differ depending on the country.  Both are usually prescription.

Another stomach aid that can be used is Slippery Elm Bark powder.

4. Slippery Elm Bark is a natural remedy that coats the stomach and intestines, reducing irritation and helping reduce both nausea and stomach acid. Slippery Elm can also help with malabsorption problems. For more information about SE, please follow this link to Little Big Cat.

The dose is 1/4-1/8 of a teaspoon or one 350-400mg capsule once a day.

IMPORTANT: as it coats the lining of the stomach Slippery Elm can interfere with the absorption of other supplements or medications. It should therefore be given 2 hours before or after any other treatments.

• Liver/Pancreas support

The following medications and supplements help support the liver, almost always affected, and may also help the pancreas.

1.  Milk Thistle

The active ingredient in Milk Thistle, sylmarin, helps support liver function and has shown in some preliminary research to protect and even regenerate both liver and pancreas cells. Milk Thistle is available in liquid or powder (capsule) form.

Dose: usually around 12 drops a day of the liquid and 75-80 mg of sylmarin (not the total capsule, the amount of sylmarin – a 100mg capsule with 80% sylmarin containes 80mg of sylmarin) is recommended. It is quite bitter, so starting slowly and moving up to the full dose is recommended. The full amount should be split and given BID.

In very severe cases, higher doses of MT may be given. The maximum dose, usually only used for very severe pancreatitis or liver cancer cases is 200mg a day – outside of extreme situations, that dose should not be maintained long-term.

2. SamE

SamE protects liver cells from damage and helps in its support.For some more about information about SamE, see this link: Pet Education/SamE.

SamE comes in tablets with an enteric coating, and cannot be cut into smaller portions or crushed. You do need therefore to make sure that you buy a vet/cat version – “human” SamE tablets are too big for a cat to swallow.

Dose: The small dog/cat pills are 90mg. For cats up to 12 lbs/6kg the usual dose is one pill a day. For those weighing 12-25lbs/6-12k the usual dose is two pills. Please check with your vet for the correct dose for your cat.

3. Denemarin

Denemarin is a vet medication that is a combination of Milk Thistle and SamE. It only contains 9mg of MT in one tablet – dosing is the same as for the vet SamE – and can be supplemented with additional MT to reach the usual 75-80mg dose.

4. L-Carnitine

L-Carnitine helps move fats through the liver and turns fats into energy. It is important to buy only l-carnitine and not Acetyl or D-carnitine which are not good for cats.

More information on the benefits of L-Carnitine supplementation may be found here in the article by VCA Hospitals.

Dose: 250mg daily¸best split into two doses.

5. Taurine

Taurine is a bit in a class of its own. It is absolutely essential for cats. Insufficient levels of taurine can lead to such problems as blindness and heart disease. As such, it is included in all complete cat food and added to all raw food recipes.

Extra taurine has shown though in some research to be more than beneficial in helping with pancreatitis and associated liver problems. Taurine has even shown to perhaps regenerate liver and pancreas cells. There is also preliminary research showing that it may help control diabetes as well as some of the side effects of FD, such as neuropathy.

Dose: 500mg/day (best given as 250mg BID) can be given. Excess taurine is simply excreted through urine.

• Anti-inflammatory/potentially beneficial for pancreatitis

• Curcumin

Curcumin has become a little of a wonder supplement of late. While not a cure for everything (!) it is a powerful anti-inflammatory and antioxidant with anti-bacterial, anti-viral, anti-fungal and anti-cancer characteristics. Some research also shows that it may help control blood glucose levels.

Important note: if your cat has been diagnosed with, or there is suspected bile duct obstruction or gall stones, Curcumin should not be given. One of its properties is to increase contractions of the gall bladder. If the duct is partially blocked and bile or gall stones are having problems passing, it may make the situation worse. If you have any doubt, you should NOT give curcumin to your cat.

As it is also an anti-coagulant, care should be used if your cat is on medications that are also antiplatelet/anti-coagulant. Please check with your vet before giving Curcumin if that is the case.

Some research with mice shows that curcumin may aid with pancreatitis, helping protect and heal the pancreas ³

It is also reported to aid in liver function and can help with heartburn.

            It is important to maker sure that the curcumin you use also includes pepper (peperine).

    You can also make Golden Paste: Golden Paste Recipe

Dose: Curcumin extract can come in different strengths. The rule of thumb, as for all supplements, is to apply the 1/10 – 1/6 of the recommended dose for people.

• B12/Cobalamine

• Cobalamine, a B12 vitamin, in particular is often depleted with pancreatitis.
B12 can be very beneficial to cats suffering from pancreatitis. It is usually given in the form of injections and will be provided by your vet.

You can also though find it in capsule form – you should just open the capsule and sprinkle on food. It may be beneficial to add a folic acid supplement to that to help with absorption.

Dose: A 1500mcg capsule, such as that made by Doctor’s Best, should be dosed twice a day.

• Immune system boosters

• Agaricus Blazeii, a mushroom, provides excellent immune system support. It is available in liquid or powdered form.

Dose: for capsules, a ¼ of a 250mg capsule once a day is recommended. For liquids the dose is 5-6 drops BID.

• Pancreatic Enzymes

As pancreatitis advances, the pancreas can slow down or even stop making the pancreatic enzymes needed to help digest the protein, fat and carbohydrates in food. Adding pancreatic enzymes can help. Various pancreatic enzymes exist, you should make certain to choose an animal rather than plant based form.

Dose: depends on the pancreatic enzymes used; use the 1/10-1/6 of the recommended human dose rule

• Other support

Depending on your cat and its situation, other supplements or mediations that may be useful include probiotics if your cat is showing signs of poorly absorbing its food, Vitamin B-Complex which can help combat stress, or Ursidiol, a bile enzyme that may help with some chronic liver problems as well as help prevent the build-up of bile acids.

 

Please consult with your vet for more information and the best course of action for your cat and its specific situation.

Please also post on forum for more information. Senior members have personally dealt with pancreatitis and can help you.

 

For more information about pancreatitis:

Idexx (in English)
• Diagnosing and Managing Feline Pancreatitis
• Treatment recommendations for Feline Pancreatitis

Idexx (en Français)
• Recommandation pour le traitement des pancréatites felines

Today’s Veterinary Practice Journal – Jan-Feb 2015
• Current Concepts in diagnosis & Therapy/Feline Acute Pancreatitis
(also contains information on Chronic Pancreatitis)

 

¹Merck Veterinary Manuel : Pancreatitis in small Animals http://www.merckmanuals.com/vet/digestive_system/the_exocrine_pancreas/pancreatitis_in_small_animals.html
²De Cock HE, Forman MA, Farver TB, et al. Prevalence and histopahologic characteristics of pancreatitis in cats. Vet Pthol 2007;44;39-49
³ Indian J Med Res. 2011 Nov; 134(5): 717–724. doi: 10.4103/0971-5916.91009
PMCID: PMC3249972 Preventive action of curcumin in experimental acute pancreatitis in mouse

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