[Updated February 24, 2016] 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.
Chronic pancreatitis refers to a continuing, smoldering, low-grade inflammation of the pancreas. Symptoms such as vomiting and discomfort after eating may occur intermittently, sometimes accompanied by depression, loss of appetite, and weight loss. In some cases, signs may be as subtle and nonspecific as a dog not wanting to play normally, being a picky eater, or skipping a meal from time to time. Chronic pancreatitis may periodically flare up, resulting in acute pancreatitis. Dogs with chronic pancreatitis often respond favorably to a low-fat diet. Pain medication can be helpful in relieving the symptoms of chronic pancreatitis and may speed recovery. Chronic pancreatitis is often subclinical and may be more common than is generally realized, with symptoms blamed on other diseases. It may also occur concurrently with conditions such as IBD (inflammatory bowel disease) and diabetes mellitus.
In addition to digestive enzymes (exocrine function), the pancreas also produces insulin (endocrine function). Dogs who are diabetic may have an increased risk for pancreatitis. Conversely, a dog whose pancreas is damaged due to pancreatitis may develop diabetes, which can be either temporary or permanent; 30 percent of diabetes in dogs may be due to damage from chronic pancreatitis. Exocrine pancreatic insufficiency (EPI), when the pancreas is no longer able to produce digestive enzymes, can also result from chronic pancreatitis, leading to weight loss despite consuming large amounts of food. When the pancreas is damaged, diabetes is likely to show up several months before EPI.
Causes of Pancreatitis
Pancreatitis is often blamed on high-fat diets, though there is little scientific evidence to support this. Active, working dogs, such as sled dogs, can eat as much as 60 percent fat in their diets without developing pancreatitis, but too much fat may cause trouble for middle-aged, overweight, relatively inactive dogs, who are the ones most commonly affected by pancreatitis. Too much fat can also cause problems for some dogs with chronic pancreatitis. Dietary indiscretion, such as eating rancid fatty scraps from the garbage, can also lead to pancreatitis, particularly when a dog accustomed to a low- or normal-fat diet ingests high-fat foods. That’s why pancreatitis incidents are thought to increase after Thanksgiving, when people may feed their dogs a meal of turkey skin and drippings. Low-protein diets have also been shown to predispose dogs to pancreatitis, especially when combined with high fat intake. Some prescription diets may be a concern, such as those prescribed to dissolve struvite bladder stones; to prevent calcium oxalate, urate, or cystine stones; and to treat kidney disease; especially for breeds prone to pancreatitis. Several medications have been associated with pancreatitis, most recently the combination of potassium bromide and phenobarbital used to control epilepsy. This combination has a much higher risk of causing pancreatitis than phenobarbital alone (no studies have been done on the use of potassium bromide by itself). Many other medications have been linked to pancreatitis, though the relationship is not always clear. These include certain antibiotics (sulfa drugs, tetracycline, metronidazole, nitrofurantoin); chemotherapy agents (azathioprine, L-asparaginase, vinca alkaloids); diuretics (thiazides, furosemide); other antiepileptic drugs (valproic acid, carbamazepine); hormones (estrogen); long-acting antacids (cimetidine, ranitidine); Tylenol (acetaminophen); and aspirin (salicylates). Corticosteroids, such as prednisone, are especially controversial: while veterinarians have long considered them to be the most common drug to cause pancreatitis, recent human studies have discounted this link. Based on anecdotal evidence, however, I believe the association does exist in dogs. I personally know dogs who developed pancreatitis within days of being given corticosteroids. Toxins, particularly organophosphates (insecticides used in some flea control products), as well as scorpion stings and toxic levels of zinc, may also lead to pancreatitis. Certain conditions may predispose a dog to pancreatitis. These include diabetes mellitus (though it is not clear whether pancreatitis precedes diabetes); acute hypercalcemia (high levels of calcium in the blood, usually from a calcium infusion or poisoning rather than diet or supplements); hyperlipidemia (high fat content in the blood, again usually due to metabolic disorder rather than diet); hypothyroidism; and Cushing’s disease (hyperadrenocorticism). Both diabetes and hypothyroidism can affect fat metabolism and lead to hyperlipidemia, which may predispose a dog to pancreatitis. Miniature Schnauzers are prone to developing hyperlipidemia and thus may have an increased risk of pancreatitis. Obesity predisposes dogs to pancreatitis, and the disease is often more severe in dogs who are overweight. Pancreatitis can occur in dogs of any age, breed, or sex. That said, most dogs with pancreatitis are middle-aged or older, overweight, and relatively inactive. Cavalier King Charles Spaniels, Collies, and Boxers have been shown to have an increased relative risk of chronic pancreatitis, and Cocker Spaniels an increased relative risk of acute and chronic pancreatitis combined. Dachshunds have been reported to be predisposed to acute pancreatitis. Other breeds mentioned as having an increased risk for pancreatitis include the Briard, Shetland Sheepdog, Miniature Poodle, German Shepherd Dog, terriers (especially Yorkies and Silkies), and other non-sporting breeds. People sometimes develop autoimmune chronic pancreatitis, and it is theorized that dogs may as well. German Shepherd Dogs have been shown to develop immune-mediated lymphocytic pancreatitis, which predisposes them to pancreatic atrophy. Pancreatitis has been associated with immune-mediated diseases, which may include IBD, though the cause-and-effect relationship is not understood. While there is no scientific evidence to support this, some doctors have suggested that food allergies could be a rare cause of recurrent or chronic pancreatitis. I think IBD could possibly be both a cause and an effect of pancreatitis, or that both could be caused by an underlying autoimmune disease or food allergy. Dogs with immune-mediated pancreatitis may respond well to corticosteroids such as prednisone, which suppress the immune system, even though this drug has also been thought to cause acute pancreatitis. Trauma to the pancreas, such as a result of the dog being hit by a car, can lead to inflammation and pancreatitis. Surgery has also been linked to pancreatitis, probably due to low blood pressure or low blood volume caused by anesthesia. Gallstones (choleliths) can block the bile duct, and thus the flow of digestive enzymes from the pancreas and can lead to pancreatitis in people; it is likely that the same would be true for both species (pancreatitis can also block the flow of bile from the gall bladder). Other theoretical causes include bacterial or viral infections; vaccinations; obstruction of the pancreatic duct; reflux of intestinal contents up the pancreatic duct; impaired blood supply to the pancreas due to shock, gastric-dilatation volvulus (bloat), or other causes; and hereditary factors. In rare cases, pancreatitis can be caused by a tumor in the pancreas. In most cases with dogs, the cause is never found. In people, pancreatitis is most commonly caused by alcohol abuse.
Confirming the Diagnosis
Some blood test results are suggestive of pancreatitis, but not definitive. Substantially elevated (three to five times the normal level) lipase and amylase, in particular, are strongly supportive of a diagnosis of pancreatitis, but the absence of these signs does not rule it out; lipase and amylase may be normal in as many as half of all dogs with pancreatitis. With chronic pancreatitis, blood tests are often completely normal, and may be so with acute pancreatitis as well, particularly if it is not severe enough to cause complications. In 2005, IDEXX Reference Laboratories developed a blood test called Spec cPL (canine pancreas-specific lipase), based on the cPLI (canine pancreatic lipase immunoreactivity) test developed at Texas A&M University. There are three types of lipase: pancreatic, hepatic, and gastric. Standard blood tests cannot differentiate between them, but the Spec cPL measures only pancreatic lipase. Spec cPL is now considered the best choice for quick and accurate diagnosis, with results available in 12 to 24 hours. The cPLI test is equally accurate, but not as readily available and the results take longer. IDEXX claims that the Spec cPL test has a sensitivity greater than 95 percent, meaning almost every dog with pancreatitis will test positive (fewer than 5 percent false negatives), and a specificity also greater than 95 percent, meaning fewer than 5 percent of dogs who don’t have pancreatitis will have a false positive result. In comparison, the cPLI test has 82 percent sensitivity and 98 percent specificity. The Spec cPL test can be repeated every two or three days to help judge response to therapy, and after returning home, to confirm recovery. It can also be used to monitor response to changes in diet and other treatment for dogs with chronic pancreatitis. The Spec cPL test is recommended for any dog whose symptoms include vomiting, anorexia, or abdominal pain. It can also be used to monitor dogs with chronic pancreatitis, or those with conditions or whose medications predispose them to pancreatitis. In the future, this test may be done as part of standard blood work on normal, seemingly healthy dogs, to identify chronic pancreatitis that may be subclinical (not causing recognizable symptoms). In 2007, IDEXX introduced the SNAP cPL, a version of the Spec cPL test that can be done in-house by your veterinarian and return results in 10 minutes. If the SNAP cPL test results are abnormal, IDEXX recommends that you follow up with a Spec cPL test to establish a baseline cPL concentration and to monitor treatment. Radiographs detect only 24 to 33 percent of cases of acute pancreatitis, but are also used to identify other causes of vomiting and anorexia, such as intestinal obstruction. An experienced ultrasound practitioner can detect two-thirds of acute pancreatitis cases. Ultrasound may also be used to look for signs of peritonitis, pancreatic abscess or cyst, and biliary obstruction. Neither x-rays nor ultrasound can identify chronic pancreatitis. Biopsy of the pancreas can be used to identify pancreatic cancer. Biopsy may be an unreliable method of diagnosing pancreatitis, as often only part of the pancreas is affected. TLI (trypsin-like immunoreactivity) is a blood test that has only 33 percent sensitivity for pancreatitis, but it is very accurate for diagnosing EPI (exocrine pancreatic insufficiency). Dogs with chronic gastrointestinal problems should have TLI, cobalamin, folate and Spec cPL testing done to look for EPI, SIBO (small intestine bacterial overgrowth, also called ARD, or antibiotic-responsive diarrhea), and chronic pancreatitis. Dogs with EPI usually have lower-than-normal Spec cPL results, but TLI is considered more accurate for diagnosing EPI.
Recovering From Acute Pancreatitis
Whether in the hospital or at home, once vomiting is under control, water is slowly introduced, with a few laps or ice cubes every hour or so. If the dog keeps this down, liquids are tried next, followed by soupy, low-fat, high-carbohydrate foods. Frequent small amounts are less likely to cause problems than larger quantities, particularly in the beginning. Dogs who have been hospitalized can return home once they are able to keep food down without vomiting. Dogs are often sent home with pain medication, such as a Fentanyl patch or Tramadol. Controlling pain is important during recovery, so ask your vet for help if you feel your dog is uncomfortable. Dogs recovering from acute pancreatitis are frequently maintained on an easily digestible, fat-restricted prescription diet, particularly if they are overweight or have hyperlipidemia. While I am not a fan of these products due to their low-quality ingredients, I think that sometimes it is easier to follow your vet’s advice, as long as your dog is willing to eat this food and does not react adversely to it. You can later transition your dog back to a better quality commercial or homemade diet. But what if your dog won’t eat the prescription food, or reacts poorly to the food, or you just can’t bring yourself to feed a commercial food after feeding a homemade diet for so long? What should you feed your dog in that case?
Pancreatitis is both more common and more severe in overweight dogs. Inactivity may also be a contributor, so weight loss and exercise are both important. Many weight loss diets are extremely high in carbohydrates, with low fat and low protein – in fact, some have even less fat than the prescription diets that are recommended for dogs recovering from pancreatitis. A low-fat diet is not required for dogs to lose weight, and higher protein helps dogs lose fat, while low protein can lead to muscle loss. It’s better to feed a diet that has higher protein and moderate amounts of fat and carbohydrates to help your dog lose weight. Underlying metabolic disease such as hypothyroidism, hyperadrenocorticism (Cushing’s disease), and diabetes mellitus may be associated with increased risk of pancreatitis and should be managed appropriately. Hypothyroidism can contribute to obesity and may affect fat metabolism. Not all dogs who are hypothyroid have the classic signs, such as dry skin and hair loss. A full thyroid panel is more accurate than a simple screening test. Even dogs whose results are in the low normal range may benefit from thyroid supplementation. Noted thyroid specialist Dr. Jean Dodds at Hemopet will consult with you or your vet regarding test results for a small fee. If your dog is prone to hyperlipidemia (increased blood levels of cholesterol or triglycerides, even when fasted for 12 hours before the test), there are several things you can do to try to lower these levels and reduce the likelihood of pancreatitis. Feeding a low-fat diet, giving fish oil supplements, and treating hypothyroidism, which is often the underlying cause, are all helpful in reducing lipid levels in the blood. In addition, dogs prone to hyperlipidemia may benefit from the use of human statin medications, such as Lipitor, to control lipid levels. Though no studies have yet been done, anecdotal reports from vets who have tried this on an experimental basis have been positive. Whether or not too much fat was the initial cause of your dog’s pancreatitis, high-fat foods may trigger a recurrence, particularly if the pancreas was damaged. Be sure that your dog does not have access to your trash bin (use locking lids or an alarm if needed), and don’t feed high-fat foods or treats such as pig ears. Make sure that your dog does not get fatty treats from other family members, friends, or neighbors. Don’t try to tempt your dog with high-fat foods and additives if he doesn’t want to eat; this may be good advice even for dogs who have not had pancreatitis, unless you’re certain that the inappetence is not caused by pancreatitis nor a condition that would predispose a dog to it. Avoid medications that may be linked to pancreatitis, particularly any that may have contributed to the initial attack. If possible, find alternative therapies for dogs taking drugs known to cause pancreatitis, such as using Keppra (levetiracetam) in place of or in combination with potassium bromide or phenobarbital for seizures. In people, vaccinations have sometimes been associated with pancreatitis. Avoid overvaccinating your dog. The American Animal Hospital Association now acknowledges that there is no need for yearly “boosters” for most vaccines. (See “Vaccinations 101,” August 2008, for more information on current vaccination recommendations.) Periodic monitoring with the Spec cPL test may be helpful in preventing recurrent pancreatitis, especially after a change in diet.
Certain supplements can help reduce the risk of acute pancreatitis or control the effects of chronic pancreatitis. Digestive enzyme supplements that contain pancreatin may be helpful for dogs who have had acute pancreatitis or suffer from chronic pancreatitis. It is theorized that these may reduce the load on the pancreas and inhibit pancreatic secretion. These supplements are sold over-the-counter for humans or dogs; the prescription-strength enzymes needed by dogs with EPI can also be tried to see if they seem to reduce pain from chronic pancreatitis. Note that enzymes seem to help some dogs, but not others. If your dog does not respond well to one brand, you can try adjusting the dosage or using a different brand, but don’t continue to give them if they cause any problems. You can also try feeding small amounts of raw pancreas, giving pancreatic glandular supplements, such as Pancreatrophin from Standard Process, or giving plant-derived digestive enzymes, which may be helpful if your dog has trouble digesting carbohydrates. Fish body oil, such as salmon oil or EPA oil (not cod liver oil), can help to lower blood lipid levels (both triglycerides and cholesterol) in dogs with hyperlipidemia. Studies have also found it to be beneficial in treating acute pancreatitis, while its effects on chronic pancreatitis are unknown. The dosage needed to treat hyperlipidemia may be as high as 1,000 mg of fish oil (supplying 300 mg combined EPA and DHA) per 10 lbs of body weight. Dogs with normal lipid levels should do fine on that amount per 20 to 30 lbs of body weight daily, preferably split into two doses. If you use a supplement with more or less EPA and DHA, adjust the dosage accordingly. Vitamin E should always be given whenever you supplement with oils – give around 5 to 10 IUs per pound of body weight daily. Probiotics are beneficial bacteria that live in the intestines and help to keep bad bacteria in check. While probiotics are not recommended for dogs with acute pancreatitis, their effect on chronic pancreatitis is unknown. As they are known to help with some gastrointestinal problems, and since their population may be depleted during acute pancreatitis, I think it makes sense to give them once your dog has recovered. You can use products made either for dogs or for people. Prebiotics are indigestible carbohydrates that feed the beneficial bacteria in the intestines and are often included in probiotic supplements. Certain prebiotics called oligosaccharides have been shown to decrease triglyceride and cholesterol blood levels, which can be helpful for dogs prone to hyperlipidemia. These ingredients may be listed on the label as fructooligosaccharides (FOS), oligofructose, inulin, or chicory. (See “Probing Probiotics,” August 2006, for more information on both probiotics and prebiotics.) Dogs fed a very low-fat diet may become deficient in the fat-soluble vitamins A and E. Adding fish oil and coconut oil to the diet can help with this. Dogs with damage to the pancreas may also suffer from vitamin B12 (cobalamin) deficiency – in this case, monthly injections may be needed if the dog is unable to absorb B12 when given orally. Chronic pancreatitis may interfere with absorption of vitamin B, so supplementing with B-complex vitamins makes sense. Human studies suggest that antioxidants, which are found mostly in fruits and vegetables, may help protect against pancreatitis, and reduce the pain of chronic pancreatitis. Vitamin E and selenium (which work synergistically), vitamin C, beta-carotene, and methionine have been found to be effective in helping to prevent pancreatitis in human studies. Other natural antioxidants sometimes recommended for chronic pancreatitis, though evidence is lacking, include SAM-e (S-adenosyl methionine); alpha lipoic acid (not recommended for diabetics); OPCs, found in grapeseed extract and pycnogenol; resveratrol; and milk thistle. There are a number of combination antioxidant products made for dogs, such as Small Animal Antioxidants and Immugen from Thorne Veterinary, and Cell Advance made by Vetri-Science. In their book, All You Ever Wanted to Know About Herbs for Pets, Greg Tilford and Mary Wulff-Tilford suggest herbs to support the liver and digestive system. “Dandelion, burdock root, or Oregon grape can help improve digestion and reduce pancreatic stress by gently increasing bile and enzymatic production in the liver. …Yarrow is said to help reduce pancreatic inflammation and improve blood circulation to the organ.”
Long-Term Low-Fat Diets
Next month, we will discuss commercial and homemade diets for dogs with chronic pancreatitis, EPI, and other conditions that may require a low-fat diet to be fed long-term. You will learn what defines a low-fat diet, and how to calculate the amount of fat in any food or combination of foods, whether kibble, canned, dehydrated, frozen, or fresh. The following month, we will present actual low-fat diets that people are feeding to their dogs. For a list of scientific references for the material in this article, send a request to Mary Straus at WDJ@dogaware.com. Mary Straus researches canine health and nutrition topics as an avocation. She is the owner of DogAware.com. She lives in the San Francisco Bay Area with her 16½-year-old dog, Piglet.