November 2008 Issue
Table of Contents
Pancreatitis can be a serious acute condition, or just a chronic pain.
Your dog has vomited several times, doesn’t want to eat, and is walking around with his back arched up, or lying in a corner refusing to get up. Should you:
A) Try tempting him to eat by adding bacon grease to his food or offering something tasty like ham or bologna
B) Wait a day or two to see if he gets better
C) Take him to your vet right away
The answer is C: Take him to your vet right away. These can be signs of pancreatitis. While it’s fine to wait to see if a dog improves on his own after a single vomiting episode with no other signs of illness, repeated vomiting can quickly lead to dangerous dehydration and electrolyte imbalance, especially if your dog isn’t drinking or can’t keep water down.
When signs of abdominal pain accompany vomiting, pancreatitis is high on the list of possible causes. The worst thing you can do is feed your dog fatty food at this time.
Pancreatitis literally means inflammation of the pancreas, the glandular organ that secretes enzymes needed to digest food. When something causes these enzymes to be activated prematurely, they can actually begin to digest the pancreas itself, resulting in pain and inflammation.
Pancreatitis occurs in two different forms, acute and chronic, and both may be either mild or severe. Acute pancreatitis occurs suddenly and is more often severe, while chronic pancreatitis refers to an ongoing inflammation that is usually less severe and may even be subclinical (no recognizable symptoms).
Acute pancreatitis can be extremely painful, and can become life-threatening if the inflammation spreads, affecting multiple organs and systems. Symptoms commonly include anorexia (loss of appetite), vomiting, weakness, depression, and abdominal pain. Abdominal pain in a dog may be exhibited as restlessness or not wanting to move; a hunched appearance or a “praying position,” with the chest down and the rear raised; or vocalization (crying or whimpering). Additional symptoms may include diarrhea, drooling, fever, and collapse.
For mild cases, all that may be needed is to withhold food and water for 24 to 48 hours (no longer), along with administering IV fluids to prevent dehydration and drugs to stop vomiting and control pain.
For moderate to severe cases, hospitalization and intensive treatment and monitoring is required. Supportive treatment includes intravenous fluids to keep the dog hydrated and restore electrolyte and acid-base balance. Potent pain medication is needed, such as injectable buprenorphine or other narcotic pain relievers. Treatment is generally required for three to five days, and sometimes longer. Surgery may be necessary, particularly if the pancreas is abscessed or the pancreatic duct is blocked.
Recommended medications that stop vomiting (antiemetics) in dogs with pancreatitis include a metoclopramide infusion and chlorpromazine (once dehydration has been controlled).
Alternatively, dolasetron (Anzemet) and ondansetron (Zofran) – antiemetics developed to combat vomiting that has been induced by chemotherapy – may be used. Cerenia (maropitant) is a new antiemetic drug approved for dogs that some vets are starting to use, though it has a limited track record. Metoclopramide (Reglan), a commonly used antiemetic, may be contraindicated in pancreatitis due to concern that it may decrease blood flow to the pancreas (antidopaminergic effect), though this has not been substantiated.
Antibiotics to control infections secondary to pancreatitis may be used, though this complication is not thought to be common in dogs. A plasma transfusion is sometimes given in moderate to severe cases in the hopes that it will inhibit active pancreatic enzymes and systemic inflammatory response; it also provides clotting factors that can help prevent and treat disseminated intravascular coagulation (DIC), an often lethal potential side effect of pancreatitis.
Antacids have not been shown to have any beneficial effect in the treatment of pancreatitis, though they may be given when vomiting is persistent or severe. Non-steroidal anti-inflammatory drugs (NSAIDs) are not effective and should be avoided due to concerns for gastric ulceration and kidney and liver damage. There are no studies yet to support the use of corticosteroids for treating pancreatitis in dogs.
Nutrition during acute pancreatitis
Traditionally, the standard recommendation has been to withhold all oral food and water until symptoms subside, in order to allow the pancreas to rest. If symptoms persisted for more than 72-96 hours, nutrition was given parenterally (intravenously, avoiding the stomach and intestines). It was thought that even the sight or smell of food could trigger pancreatic secretions that would make the problem worse.
Today, though, there is growing evidence in both humans and animals that recovery time is reduced and survival rates increased when patients are fed early in the recovery from pancreatitis. It is now accepted that prolonged withholding of oral food and water for more than 48 hours (including the time before the dog was brought in for treatment) can lead to increased intestinal permeability (“leaky gut”), atrophy of the digestive cells in the small intestine, and sepsis (blood poisoning). In turn, sepsis can contribute to multiple organ failure and decreased survival rates.
Without oral nutrition, the intestines starve, even if nutrition is provided to the rest of the body through IVs. This is because the intestines receive their nutrition only from what passes through them. Enteral feeding, in which nutrition is provided through the digestive system, is thought to decrease the potential for bacterial infection caused by intestinal permeation, and may reduce the time the dog needs to be hospitalized.
Because most dogs with pancreatitis are unwilling to eat, a liquid diet may be fed via a tube placed through the nose, esophagus, or stomach. Dogs may tolerate nasoesophageal feeding even when vomiting persists. There is evidence that pancreatic secretions are suppressed during an attack of pancreatitis, so food delivered in this manner stimulates the pancreas less than we used to believe, and helps to maintain the health of the gastrointestinal tract and decrease inflammation and side effects such as those listed above.
The ideal composition of this diet has not yet been determined. It is possible that the addition of omega-3 fatty acids, pancreatic enzymes, medium-chain triglycerides, and the amino acid l-glutamine to the liquid nutrition may also help with recovery, though this must be done with caution. Probiotics, however, are not recommended; a recent human study showed an increased death rate for patients with severe acute pancreatitis when probiotics were administered, possibly due to reduced blood flow to the small intestine.
Enteral (tube or oral) feeding should begin after 48 hours without food. Vomiting can be controlled with antiemetics and pain medication. The goal of nutrition in the short term is to improve barrier function (stop leaky gut syndrome) rather than to supply total caloric needs.
Parenteral (IV) nutrition should be used only when absolutely necessary, due to persistent, uncontrolled vomiting. Survival rates improve when it is combined with enteral nutrition. A tube can be placed into the jejunum (part of the small intestine) if needed to provide enteral nutrition when vomiting cannot be controlled.
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