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What is the Pancreas? What Happens in Pancreatitis Feline Triaditis Causes of Pancreatitis Symptoms of Pancreatitis

 

Diagnosis: Bloodtests
Bloodwork Spec fPL Test PLI Test TLI Test Cobalamin & Folate

 

Diagnosis: Other Methods
Ultrasound Biopsy

 

Treatments
Diet Vitamin B12 Fluid Therapy Antibiotics Anti Nausea Medications
Acid blockers Pain Medications Digestive Enzymes Steroids Links

Harpsie's Experiences

 

Introduction

Pancreatitis is a horrible, nasty disease, which is very stressful to live with for both the affected cat and their human(s). It may be either acute or chronic. Harpsie was diagnosed with both pancreatitis and IBD on 20 February 2006, but the pancreatitis turned out to be a misdiagnosis. However, there were some changes in Harpsie's pancreas, which worsened over the next few months, and these were probably caused by the carcinomatosis (cancer) which ultimately killed him.

Indie, one of our other cats, has had pancreatitis twice but she did recover.

What is the Pancreas?

The pancreas is a gland located under the stomach with two main roles:

  • endocrine (hormonal), i.e. it controls the hormones (insulin and glucagon) which regulate blood sugar levels.

  • exocrine, i.e. it assists with the digestive process by producing digestive enzymes

What Happens in Pancreatitis

Usually it is the exocrine function which is affected. The pancreas becomes inflamed, and the enzymes which it would normally release into the intestines are instead released into the pancreas itself, causing pain and inflammation. The liver may also be affected (see below). If the part of the pancreas responsible for endocrine function also becomes damaged, diabetes may develop. During pancreatitis, toxins move throughout the body, and in the worst cases, respiratory failure or brain damage may result, though fortunately such severe effects are uncommon.

Pancreatitis can be either acute or chronic. Acute cases often resolve completely, whereas cats with chronic pancreatitis may have flare-ups at intervals.

Mar Vista Vet has a very helpful overview of feline pancreatitis.

Idexx has a good overview of pancreatitis.

Feline Triaditis

There is also a condition called feline triaditis. This is when the cat is suffering from the triple whammy of inflammation of the pancreas, the liver (usually in the form of cholangiohepatitis) and the intestines (IBD or inflammatory bowel disease).

Feline triaditis (2007) JM Steiner NAVC Clinician's Brief Mar 2007 is a helpful overview of triaditis.

A tail of triaditis (2007) Webb CB NAVC Clinician's Brief Nov 2007 discusses the case of a cat with triaditis.

Causes of Pancreatitis

Often the cause is never discovered, but cats with IBD or diabetes may be at increased risk. Cats who suffer trauma, such as from an accident, are also at risk, as are cats suffering from renal failure who have uraemia. Many cats with hepatic lipidosis go on to develop pancreatitis, and the prognosis is more guarded for such cats.

Symptoms

Unfortunately pancreatitis does not have a clear-cut set of symptoms unique to the disease. In one study, 100% of cats exhibited lethargy, and 97% exhibited poor appetite, and these symptoms have also been observed in other studies. Other common symptoms (seen in over 50% of cats with pancreatitis) include rapid breathing, low temperature and jaundice. Some cats may appear to be in pain, and/or may not want to be touched. Others may vomit, or develop ascites (fluid in the abdomen).

 

Idexx refer to ADR cats - cats who "ain't doing right" (which their UK site describes as "under the weather"). If your cat is off colour with no obvious cause shown in standard bloodwork, consider pancreatitis.

Manhattan Cats has a list of other symptoms which may be seen (scroll to the end of the page).  

 

Diagnosis

It can be difficult to diagnose pancreatitis in cats, partly because the symptoms may be caused by other conditions, and also because it can be hard to detect the pancreas on ultrasound. The following are the tests which are commonly used.

 

Ultrasound

Ultrasound is often used initially to see if there are any changes in the pancreas. If so, the vet may order further tests. Harpsie's ultrasound did look abnormal (his pancreas looked enlarged and his liver had nodules), so the vet ordered the PLI test. However, ultrasound may not detect the disease in every cat with pancreatitis.

 

Biopsy

This is the only definitive way to diagnose pancreatitis, but it is invasive, and is usually no longer  necessary in most cases since the development of the spec fPL test.

 

Bloodwork

There is now a special blood test for pancreatitis in cats (see below) but your vet may initially suspect pancreatitis from your cat's symptoms and certain results in general bloodwork. Up to 50% of cats with pancreatitis have hypocalcaemia (low calcium levels). BUN and creatinine may be elevated because of pre-renal azotaemia. ALT is often elevated, and thecat may be anaemic.

 

In dogs with pancreatitis, amylase and lipase (pancreatic enzymes) are often elevated, but unfortunately these will not necessarily be elevated in cats with pancreatitis, so normal levels do not rule out pancreatitis. ALT and AST, both liver enzymes, may be elevated.

 

Pancreatitis in cats (2004) Williams D Presentation to the World Small Animal Veterinary Association World Congress explains that amylase and lipase are not useful in diagnosing pancreatitis in cats.

 

Spec fPL Test

This test was developed by Idexx Laboratories in conjunction with Texas A&M University (TAMU) (TAMU developed the original test for pancreatitis in cats). Although this test is slightly less accurate than the PLI test, since it is available from Idexx laboratories around the world, it is probably easier for most people to have this test done. Results are usually available quickly, within a day. When a member of Tanya's CRF Support Group had it done in March 2011, it cost US$54.

 

In theory cats should be fasted for this test, but it is not essential. Results are interpreted as follows:

  • If the level is below 3.5, the cat probably does not have pancreatitis and other causes should be considered.

  • If it is between 3.6 and 5.3, the cat may have pancreatitis, and the test should be re-run in two weeks.

  • If it is over 5.3, the cat probably does have pancreatitis.

Idexx has more information about the test.

Idexx UK gives information about running the test in the UK

 

PLI Test

The Pancreatic Lipase Immunoreactivity (PLI) test was the forerunner to the spec fPL test. It was patented by Texas A&M University (TAMU) and could therefore only be run by them. This test was slightly more accurate than the spec fPL test at confirming pancreatitis in cats, but the cat needed to fast for 12 hours before having blood drawn for the test, and the results could take up to a week (although when we had it done for Harpsie, it took a dreadful 17 days!). Texas A&M no longer offer this test but instead use the spec fPL test.

 

TLI Test

The trypsin-like immunoreactivity (TLI) test is another older test, also devised by Texas A&M University, which has also been superseded by the spec fPL test. This test measures two enzymes, trypsinogen and trypsin, which are only produced by the pancreas. A cat needs to fast for 12 hours before having blood drawn for this test. TLI is not always elevated in cats with pancreatitis, so a normal TLI test does not rule out pancreatitis. If you have the spec fPL test run at TAMU, however, they may ask that you have this test done together with a folate test.

 

Cobalamin (Vitamin B12) and Folate Test

Up to 50% of cats with pancreatitis have below normal levels of folate, particularly if they are also suffering from IBD. Texas A&M University can measure levels of cobalamin and folate, and explains why they are  important.

 

Treatments

 

It is difficult to treat pancreatitis as such, so the goal of treatment is to keep the cat as comfortable as possible by treating whichever symptoms are present. Fluid therapy, diet and pain control are the main focus.

 

Treating feline pancreatitis (2009) is a helpful article by Dr J Robertson DX Consult Winter 2009 pp12-13 on how to manage pancreatitis and common concurrent conditions such as IBD or diabetes.

Treatment recommendations for feline pancreatitis (2011) is a paper by Idexx.

 

Warning: Probiotics

One study into humans with severe acute pancreatitis found that using probiotics more than doubled the risk of death. The same may not apply to cats but I would not take the risk. If you are using probiotics, therefore, I would speak urgently to your vet about stopping them. Medical Imaging reports on this study.

 

Fluid Therapy

Since cats with pancreatitis are often dehydrated, fluid therapy is often used to rehydrate them and make them feel better. Intravenous fluids (IV or "a drip") at the vet's office may be used initially, and thereafter you may need to give sub-cutaneous fluids at home.

 

Tanya's Comprehensive Guide to Feline Chronic Renal Failure has more information on fluid therapy.

 

Diet

A common part of treatment for pancreatitis in humans and dogs is fasting, or at least reducing fat intake. However, this does not seem to be particularly effective for cats, who have a physiological need to eat relatively frequently. For them, feeding little and often is usually more effective, unless the cat cannot stop vomiting, in which case the vet may wish to treat the cat in hospital. Your vet may prescribe a prescription food such as Hill's i/d to help manage the condition.

 

Treating feline pancreatitis (2009) is a helpful article by Dr J Robertson DX Consult Winter 2009 pp12-13 which explains why fasting is not recommended.

Feline GI pearls (2001) is a presentation by Dr M Scherk to the World Small Animal Veterinary Association World Congress 2001, which explains why fasting and reducing fat is of little benefit to cats with pancreatitis.

 

Pain Medications

Some cats cope better with pancreatitis if they are given pain medications. Buprenorphine (Buprenex) is commonly used in cats with pancreatitis. Pet Place has information about the use of this drug in cats. If your cat appears dull, or is tender in the abdominal area, discuss this possibility with your vet.

 

Vitamin B12

Pancreatitis may cause malabsorption of Vitamin B12, particularly in cats who also have IBD. Texas A&M University provides a treatment protocol if required, which calls for Vitamin B12 injections because oral supplementation is unlikely to be effective in cats with pancreatitis.

 

Antibiotics

Sometimes cats with pancreatitis are given antibiotics. Metronidazole (Flagyl) is commonly prescribed because it has anti-inflammatory properties. It tastes utterly foul, so if your vet prescribes this, try to give it in a gelcap.

 

Mar Vista Vet has more information about metronidazole.

 

Anti Nausea Medications

Please also read this page.

 

You may be offered Reglan, which is available by prescription only. This medication works by regulating stomach contractions, and therefore is helpful for nausea caused by a lack of motility in the stomach; but since Reglan can cross the blood/brain barrier, it also acts on the brain to control feelings of nausea, which can be helpful to cats with pancreatitis.

 

Reglan comes in 10 and 5mg tablets or a liquid, and must be given 20-30 minutes before eating. It may have various side effects, including constipation, hyperactivity and agitation or drowsiness; very occasionally, twitching may be seen. Reglan also lowers the seizure threshold, so should not be given to cats prone to seizures.

 

If you are giving Reglan at the same time as Pepcid AC, you should separate the dosing by at least two hours, since Reglan may bind with the Pepcid AC and thereby reduce its effectiveness.

 

Veterinary Partner has more information on Reglan.

Pet Place also has some information.

 

Acid Blockers

There are several medications which can be most effective in controlling stomach acid, thus reducing vomiting and nausea, and increasing appetite. Most of these medications are thought of as antacids, although in fact technically speaking they are histamine H2 antagonists that block the production of acid rather than neutralise it. Because they are long-acting, they are generally a good choice for treating stomach acid problems.

 

Famotidine (Pepcid AC)

Pepcid AC is the most commonly used medication in this family, and it is a very effective treatment. The active ingredient is famotidine USP, and Pepcid AC (Regular Strength) contains 10mg. Pepcid may be sold under a different name in your country (e.g. Amfamox in New Zealand and Australia).

 

You should only use Pepcid AC with your vet's approval and you should start with a low dosage of a quarter of a 10mg tablet once every other day; although you may find you need to increase the dosage up to a quarter of a 10mg tablet twice a day (with your vet's approval). Some cats, particularly those with advanced renal failure (creatinine over 5), do not do well on Pepcid AC, perhaps because their kidneys cannot excrete it efficiently, and these cats may in fact exhibit increased vomiting when given it (Drugs.com mentions how an overdose may cause vomiting) - this happened to our Thomas. Pepcid may also adversely affect cats with existing heart rhythm problems. In such cases you may wish to ask your vet about using ranitidine (Zantac 75) instead.

 

You need Pepcid AC but not the chewable type, and not other similar products with Pepcid in the name such as Pepcid Complete - the other versions have some ingredients which make them unsuitable for CRF cats. There is also a new version called Pepcid Maximum Strength, which is the same as Pepcid AC except that it contains twice as much famotidine, so be very sure you have the correct strength.

 

If you are giving Pepcid as well as metoclopramide (Reglan), you should separate the dosing by at least two hours, since it may bind with the Pepcid and thereby reduce its effectiveness.

 

Unfortunately, it appears that Pepcid AC has been discontinued in the UK, having been replaced by PepcidTwo. PepcidTwo contains magnesium and calcium in addition to famotidine, so it is not really suitable for cats. Pepcid AC used to be kept behind the counter rather than displayed on a self-service shelf, so you could ask the pharmacist if there is any Pepcid AC left in stock; if not, famotidine exists in generic form, but only in 20mg size, which could be difficult to cut; plus it requires a prescription from your vet.

 

General Medical shows which trade names Pepcid is known by in other countries.

Veterinary Partner has more information on Pepcid AC, and mentions how it may adversely affect cats with heart rhythm problems.

Pet Place has more information about Pepcid AC.

US Food & Drug Administration has information about the need to reduce the normal dose in (human) renal failure patients since  Pepcid is excreted by the kidneys.

 

Digestive Enzymes

Humans with pancreatitis have reported that they experience less pain when given digestive enzymes, though others have apparently felt worse. It is not known if the same applies to cats, but some vets do recommend trying them. Viokase is one commonly used brand. Obviously, if you feel the digestive enzymes are making your cat worse you should speak to the vet about stopping them.

 

Steroids

Since there is often inflammation present in cases of pancreatitis, corticosteroids may be prescribed to help dampen down the inflammation. A commonly used corticosteroid in cats is pred (prednisone or prednisolone). Cats metabolise prednisolone better than prednisone (they have to convert prednisone into prednisolone in their bodies anyway before they can use it) so it is usually better to give prednisolone in the first place. Vet Contact reports on a study entitled Bioavailability and activity of prednisone and prednisolone in the feline patient (2004) Graham-Mize CA &  Rosser EJ Veterinary Dermatology 15 (s1), pp 10 which supports this view.

 

Your vet may want to start at a higher dose to reduce the inflammation, then reduce to a maintenance dose. If your cat can eventually come off the steroids, they should not be stopped suddenly, but rather the dose must be tapered. This is because using corticosteroids may suppress the adrenal glands' ability to produce cortisone naturally; so tapering the dose minimises the risk of adrenal insufficiency occurring as a result.

 

Unfortunately cortico-steroids can have serious side effects with long-term use (including triggering diabetes, fluid retention and resulting hypertension, and masking infections). Corticosteroids cannot normally be used in diabetic cats. If your cat develops congestive heart failure (CHF) within a week of starting corticosteroids, the steroids may be the cause. One study, Corticosteroid-associated congestive heart failure in 12 cats (2004) Smith SA, Tobias AH, Fine DM, Jacob KA, Ployngam T The International Journal of Applied Research in Veterinary Medicine 2 (3) pp159-170 found that some cats developed a unique form of congestive heart failure within seven days of starting steroids. Five of the cats died, but the seven that survived did much better than the typical CHF patient once taken off the steroids.

 

Newman Veterinary has helpful information about steroids.

Veterinary Partner discusses pred and explains how corticosteroids work.

Mar Vista Vet discusses the potential problems of ongoing steroid use.

Links

Mar Vista Vet has a very helpful overview of feline pancreatitis.

Manhattan Cats also has helpful information, including a detailed list of symptoms.

Feline pancreatitis - species specific diagnostic and therapeutic approach (2007) is a presentation by C Mansfield to the World Small Animal Veterinary Association World Congress 2007.

Feline pancreatitis: diagnosis and management (2011) is a presentation by Dr J Armstrong to the 83rd Annual Western Veterinary Conference.

Update on the diagnosis and management of feline pancreatic disease (2003) Marks SL is a presentation to the Waltham Feline Medicine Symposium 2003.

Feline GI pearls (2001) is a presentation by Dr M Scherk to the World Small Animal Veterinary Association World Congress 2001. Some of the information here (e.g. diagnostic methods) is now out of date but the basic information is very good.

Update of feline gastrointestinal syndromes: pancreatitis and triaditis (2010) is a more recent presentation by Dr Scherk, to the 82nd Western Veterinary Conference.

Columbia Animal Hospital provides helpful information about pancreatitis in cats.

Pancreatitis in cats (2004) Williams D Presentation to the World Small Animal Veterinary Association World Congress has a detailed overview of pancreatitis.

Feline Pancreatitis List is a support group for people dealing with pancreatitis in their cat. This group has open archives, i.e. if you post a message, it is visible to anyone online.

 

Harpsie's Experiences

 

Harpsie was poorly at the beginning of February 2006, with severe vomiting and discomfort. We ascribed this to switching from the UK to the US version of his broncho-dilator (for asthma), because he vomited within ten minutes of being given the US version, and the vomiting ceased when we obtained additional supplies of the UK version.

 

Harpsie had bloodwork done at that time, it was more or less normal apart from ALT being a fraction elevated (101, with top of the range being 100), which was nothing unusual for Harpsie. The vet could find nothing obviously wrong, though he had lost a lot of weight (he used to be  10 lbs, but by the beginning of February he was down to 8 lbs 4 oz).

 

Harpsie steadily improved as we discontinued the US version of his asthma medication. He went to acupuncture on 14th February and he was doing great and bossing everybody around.

 

He ate well after acupuncture, as was usual for him. He was purring away, demanding cuddles etc. He had had acupuncture on his back legs too for the first time because they seemed a little weak, so he slept all the next day which was normal when he got needles in new places. By that evening he was fine, purred, ate, bossed (bossing is a very important part of Harpsie's daily activities).

 

But then he began to go downhill. He was very quiet, slept a lot, stopped purring, would not interact, was very wobbly, was not impressed by his food choices, even though I offered him several hypoallergenic foods from different manufacturers. Five days after acupuncture I opened six different commercial foods and he simply refused to eat any of them. He would go up to them and then walk away without  even tasting them. He was not vomiting, but Pepcid and Slippery Elm Bark were tried, to no effect.

 

I began syringe feeding Harpsie his watered-down hypoallergenic food, but he really, really hated it (and this is the easiest cat on the planet to pill). In view of his recent weight loss, he simply had to eat. So in desperation, I opened a tin of a/d, and over the course of a day he ate all of it. The next morning he was bossy, purring, interacting, and his old self. Of course I knew he would shortly be a scratching, bleeding mess too, as his food allergies kicked in, but getting food into Harpsie was more important than his allergies by this point.

 

I arranged to take Harpsie to the vet on 20 February. I wrote at the time that I was a bit worried in case he had cancer or something like that (though we initially ascribed his weight loss to a change in his prescription food formulation, which I still think was definitely a factor). The vet had long suspected that Harpsie had mild IBD, so that was also a possibility. All I knew was that he was too thin and seemed rather fragile, and just seemed to be so up and down lately.

 

The ultrasound confirmed that Harpsie had IBD (the ultrasound showed thickened intestines), and the vet was almost certain that he had pancreatitis because of changes in the pancreas on ultrasound. Since Harpsie had not eaten since the previous day and the ultrasound confirmed his stomach was empty, the vet was able to draw blood for the PLI test and send it off. He hoped that results would be back in a week.

 

Harpsie also had cysts in his liver (caused by his PKD), and many cysts in his kidneys (also caused by his PKD). That was not surprising but unfortunately he also had at least three nodules in his liver, one of which was pretty large The vet felt these did not look cancerous (though he could not guarantee it). He felt a biopsy would be overkill at this point, but we agreed we would keep an eye on them. They were too large to remove.

 

Harpsie was also constipated. He had been on lactulose a couple of weeks earlier but I had just stopped it because he was pooping OK over the weekend. We started lactulose again.

 

The vet felt the pancreatitis was mild, and would probably resolve itself, but the PLI test results expected the following week would give us more information. In the meantime, Harpsie had lost a further 4 oz, and was now exactly 8 lbs. Typical weight for him was 10 lbs, and the vet said he was definitely too thin. The vet agreed that the hypoallergenic diet was no longer a priority, getting some weight on him was.

 

Harpsie continued to be prepared to eat Hill's a/d, so that was what we gave him. I also had cyproheptadine to use as an appetite stimulant if required. The plan was that once the test results were back the following week, we would work out a more detailed treatment plan.

 

The next day was no fun, as the day progressed Harpsie began wobbling around howling, it was as if he simply could not get comfortable. By evening it was dreadful. He did eat that morning though, in fact he ate three helpings of a/d in half an hour (and at that point I had not given him any cypro yet. But then as the day wore on, he stopped eating. I think perhaps he felt better in the mornings, then worsened as the day progresses. So I started him on the cyproheptadine to get him to eat throughout the day.

 

On the following day Harpsie was quieter, but he never looked particularly comfortable, so I contacted the vet and we agree that Harpsie might benefit from painkillers. I gave Harpsie some torbutrol left over from his dental surgery, but although it made him more subdued, it did not seem to make him any more comfortable.

 

The following Saturday, 25 February, we had to take Harpsie to the vet as an emergency because he was so ill. You can read about it here. After this episode, we believed something else was causing Harpsie's problems rather than pancreatitis, and when the results of the PLI test came back (a mere 17 days after sending off the blood), they confirmed that Harpsie did not have pancreatitis. In retrospect, I believe that when the pancreatitis was tentatively diagnosed, we were actually seeing the early signs of the carcinomatosis (cancer) that ultimately killed him. Harpsie did recover from his crisis on 25 February, but he remained rather dull and quiet until his cancer was diagnosed 10 weeks later, and he died a mere 15 days after that.

 

Indie, one of our other cats, did not do well following a dental. She did not regain her appetite as we had expected. Eventually we ran the PLI test on her, and it came back that she had mild pancreatitis. She did eventually make a full recovery.  

 

 

 

 

 

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This page last updated: 10 June 2011

 

Links on this page last checked: 2 February 2008

 

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