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Pancreatitis in Dogs

A Pain in the Pancreas: Pancreatitis can be a serious acute condition, or just a chronic pain.

Article by Mary Straus published in the Whole Dog Journal, November 2008

Also see these related articles:

Photo: Obesity predisposes dogs to pancreatitis, and the disease is often more severe in dogs who are overweight.


Introduction

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, and 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).

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Acute pancreatitis

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 to stop vomiting (antiemetics) in dogs with pancreatitis include a metoclopramide infusion and chlorpromazine (once dehydration has been controlled).

Alternatively, dolasetron (Anzemet) and ondansetron (Zofran) – two  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 secondary infections 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.

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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 on their own, 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. (Update: newer recommendations are to begin feeding as soon as vomiting is under control, starting with very small amounts of low-fat, low-fiber food fed frequently throughout the day. See New Recommendations for Feeding Dogs with Pancreatitis for more info.)

Parenteral (IV) nutrition should be used only when absolutely necessary due to persistent, uncontrolled vomiting, and even then, survival rates improve when it is combined with enteral nutrition. A tube can be placed directly into the jejunum (part of the small intestine) via endoscopy if needed to provide enteral nutrition when vomiting cannot be controlled.

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Chronic pancreatitis

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.

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Pancreatic functions

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.

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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 that 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. Budesonide, a steroid that is absorbed primarily by the intestines, may be a safer choice when needed to treat IBD.

Trauma to the pancreas, such as the result of a 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.

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Confirming the diagnosis

Some blood test results are suggestive of pancreatitis, but not definitive. Substantially elevated (three to five times the upper end of the normal range, or five to ten times the individual dog's baseline level when healthy) 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. Kidney disease and dexamethasone treatment may also potentially cause marked elevations in amylase and lipase, while mild elevations are considered non-specific and may also result from gastrointestinal disease. This is further complicated by the fact that pancreatitis can cause elevated kidney values due to dehydration (prerenal azotemia).

Blood lipid (cholesterol or triglyceride) levels may be elevated, causing the blood to be lipemic. The liver enzymes ALT (alanine aminotransferase) and ALKP (alkaline phosphatase) may be elevated if the liver is involved, and bilirubin may be high if the bile duct is obstructed (cholestatis). C-reactive protein is markedly increased with necrotizing pancreatitis. Other non-specific findings may include thrombocytopenia (low platelets), elevated white blood count (especially neutrophils), anemia (mild, nonregenerative due to inflammation), low chloride, low phosphorus, azotemia (elevated creatinine and BUN), low albumin, low calcium, and either high or low glucose levels. There may also be protein in the urine, which is usually transient, and bilirubin and/or glucose in the urine, if cholestatis and/or transient diabetes are present.

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. [Note that concurrent hypoarenocorticism (Cushing's disease) or hypertriglyceridemia (elevated triglycerides) may be associated with false positive results. See Do concurrent diseases affect pancreatitis testing results? for more information.]

The Spec cPL test results are not affected by factors such as gastritis (inflammation of the stomach), chronic kidney disease, or corticosteroids. A Spec cPL result of 200 mcg/L or less is in the normal range and means pancreatitis is very unlikely. 201-399 is questionable and may indicate pancreatitis; symptoms should be treated and the test repeated in one to two weeks. A result of 400 or higher is consistent with pancreatitis.

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. The result is a color spot that is either lighter than the reference spot (normal range), the same as the reference spot (intermediate range, comparable to 201-399), or darker than the reference spot (consistent with pancreatitis). 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, but may be an unreliable method of diagnosing pancreatitis, as often only part of the pancreas is affected, so a biopsy may appear normal even if the pancreas is damaged.

TLI (trypsin-like immunoreactivity) is a blood test that has only 33 percent sensitivity and 65 percent specificity 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.

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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. Butorphanol (Torbugesic) is also sometimes used, but the pain relief it offers is mild and does not last very long. 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?

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What to feed in the beginning

The goal in the beginning is to feed a diet with low fat, moderate protein, and high carbohydrates, as carbs cause the least amount of pancreatic stimulation. An easy diet to start with is overcooked white rice made with extra water, combined with a low-fat protein source, such as cooked skinless chicken breast, low-fat cottage cheese, or boiled hamburger (boiling removes most of the fat).

Even if you normally feed a raw diet, the meat should be cooked for now, to remove fat and to destroy bacteria that can be problematic if the intestines have been damaged. Cooking or warming food usually makes it more appealing as well. Bones should not be fed at this time. Offer food at room or body temperature, as cold food takes longer to digest.

If possible, choose foods your dog has had before – ones you know agree with him and that he likes. White rice is the preferred carbohydrate choice, as it is easiest to digest, but you could use potatoes or sweet potatoes instead if you need to avoid rice due to allergies or intolerance (remove the skins to reduce fiber in the beginning).

Overcooking starchy foods such as rice or potatoes increases their digestibility. Cooking white rice with extra water creates a type of porridge called rice congee, which is soothing to the stomach and digestive tract, and can help relieve vomiting and diarrhea. To make congee, boil one cup of white rice (not Minute Rice) in four cups of water for 20 to 30 minutes. You can offer the rice congee liquid alone to start with, then include the rice, and next add the protein. This progression can happen over the course of a few hours or a day or two.

At first, feed a higher percentage of carbohydrates, and a lower percentage of protein, such as two-thirds carbs and one-third protein. If your dog is doing fine, the ratio can then be slowly changed to half and half after the first few days.

Whatever you feed, start with small amounts fed frequently, six to eight meals a day or more. Small meals stimulate the pancreas less, and are less likely to trigger vomiting. Small meals are also easier to digest than larger meals, and less likely to cause discomfort. If your dog is able to keep the food down without vomiting or showing signs of pain, you can begin to feed larger amounts at longer intervals, but proceed slowly, especially in the beginning; you don’t want to make changes too quickly and end up with a setback.

Contact your vet for advice if your dog vomits. You will probably need to stop feeding again briefly (12 to 24 hours), then start over by introducing water and progressing to bland foods again. Your dog may also need anti-vomiting medication.

It is not necessary for your dog’s diet be complete and balanced in the short term; an adult dog will do fine on an incomplete diet for a few days to a few weeks. Start with a very simple diet, and then add more ingredients as your dog recovers and you see he is doing well.

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Homemade chicken broth

Broth can be used to make rice and to add to foods to improve flavor and encourage your dog to drink more. Many store-bought broths are high in sodium, however; even some “reduced sodium” varieties have hundreds of mg per serving. Look for broths with less than 100 mg sodium per serving. You can make your own nonfat, no-sodium broth if you prefer.

Remove the skin from a whole chicken or chicken pieces. Place the chicken in a pressure cooker or stockpot with water. With a pressure cooker, cook on high for 2 hours; with a stockpot, simmer on low heat for 16-24 hours.

Remove the chicken and bone from the broth. Pour the broth into a fat separator, which looks like a pitcher with the spout coming from the bottom. After 10 minutes, the fat will float to the top. Pour off the small amount of fat at the top and pour the low fat broth into a container. Refrigerate the broth and when it is cold, any fat remaining will be gelatin on the top. You can remove it or pour the broth through a very fine mesh strainer, which will stop the fat and allow the plain broth through.

You can also use the water that you boil chicken or other foods in for flavor and nutritional value, since boiling removes some nutrients that are then left in the water. Just use the method above if needed to remove the fat before feeding.

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Healing the digestive tract

L-glutamine is an amino acid that can help the intestinal mucosa to recover from the effects of going without food. A typical dose is 500 mg per 25 lbs of body weight daily, but 10 times that much can be used to supply nutrition when necessary.

L-glutamine is available both as a powder and in capsules. The powder can be dissolved in water or mixed in food. Glutamine is unstable at room temperature for extended periods, so any uneaten portion should be removed after 15 minutes. L-glutamine can be found at supplement shops online and at health food stores.

Seacure is a highly nutritious supplement designed to treat malnutrition. Seacure can help to heal the intestines and provide other health benefits. Made of hydrolyzed whitefish, Seacure has a fishy smell. Sprinkled on your dog’s food, it helps make the food more attractive to your dog. (See “Securing Seacure,” WDJ April 2003, for more information.)

The herbs slippery elm and marshmallow can help to soothe a throat and stomach that have been irritated by vomiting. One product that contains both is Phytomucil from Animals’ Apawthecary. You can also make your own by steeping 1 teaspoon of either or both dried herbs in 8 ounces of very hot water. Optionally, add a teaspoon of honey for flavor. Give anywhere from 1 teaspoon to 4 tablespoons, depending on the size of the dog, every four hours.

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Transitioning to a normal diet

Once a dog has had an attack of acute pancreatitis, he may be less able to tolerate fat in the future, depending on how much the pancreas was damaged. Some dogs are able to return to a normal diet after they have fully recovered, while others may need a low-fat diet for the rest of their lives to prevent chronic pancreatitis and further acute episodes.

Dogs who experience a single, acute, uncomplicated episode are more likely to be able to return to a normal diet, while dogs with repeated episodes of acute pancreatitis, hyperlipidemia, or steatorrhea (large, greasy, foul-smelling stools caused by fat malabsorption) should be kept on a fat-restricted diet.

Dogs with chronic pancreatitis may also do better on a lower-fat diet. Drugs that predispose dogs to pancreatitis should be avoided if possible in these dogs. If such drugs are needed, e.g., to control seizures, these dogs, too, may benefit from a low-fat diet. Dogs who have had acute pancreatitis should never be fed really high-fat meals, even if they are able to return to a normal diet afterwards.

Continue to feed a low-fat diet with moderate protein for at least 7 to 10 days or longer, depending on the speed of your dog’s recovery and the severity of the episode. Gradually increase the size of each meal and the time between meals until your dog is eating two or three meals a day.

If your dog is doing well and showing no sign of discomfort after eating, you can then begin to gradually increase the amount of fat in the diet. Begin adding small amounts of his regular food back into his diet. If the diet he was eating before was high in fat, try feeding foods with a moderate amount of fat to start with, though you may eventually be able to transition back to somewhat higher-fat foods if your dog gets a lot of exercise, is lean rather than overweight, and you have reason to believe that something other than diet caused the acute pancreatitis.

Remember that lower-fat diets provide fewer calories, so the total amount you feed will need to be increased when you reduce the amount of fat in the diet. The increase will depend on how much fat was in your dog’s previous diet. If possible, determine how many calories your dog was getting before and try to match that with the new diet (or moderately decrease the calories, if your dog is overweight). Weigh your dog frequently and then adjust the amount you are feeding up or down as needed to maintain proper weight. If your dog lost weight due to acute pancreatitis, don’t try to put the pounds back on too quickly; slow and gradual weight gain or loss is healthier than trying to make large changes in a short period of time.

Keep a close eye on your dog, particularly after meals, watching for signs of discomfort such as a hunched appearance, whining, panting, restlessness, or not wanting to move around. If you see any of these signs, return to a lower-fat diet and smaller, more frequent meals, and wait longer before trying again to increase the amount of fat even more slowly, using different foods. If the signs of discomfort return, you may need to keep your dog on a lower-fat diet indefinitely.

Also watch for signs of digestive upset, such as burping or flatulence (gas), borborygmus (stomach gurgling), lip licking, or heavy swallowing. These are not signs of pancreatitis, but could indicate that the diet you’re feeding does not agree with your dog. Try feeding a different brand of food, using different ingredients, a grain-free diet or one with a different protein source, adding digestive enzymes, or feeding smaller, more frequent meals, to see if that helps.

These symptoms can also be signs of EPI, especially if accompanied by increased appetite, weight loss, and large “cow-patty” stools. EPI is treated with prescription-strength digestive enzymes such as Viokase, Pancrezyme, or generic equivalents. Raw pancreas can also be used, or human pancreatin supplements, which consist of freeze-dried pork pancreas.

With pancreatin supplements, strengths such as 4x or 10x indicate that the product is concentrated and the dosage is equivalent to 4 or 10 times as much as is shown on the label. Each mg of pancreatin contains 25 USP units of protease and amylase, and 2 USP units of lipase. Dogs with EPI may also require cobalamin (vitamin B12) injections, and often a low-fat diet as well.

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Preventing recurrence

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. (See “Diet and the Older Dog,” December 2006, for more information on this topic.)

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. [Update: A new drug, Bezafibrate, appears to be a safe and effective drug for the treatment of hyperlipidemia in the dog. See the second study discussed in the blog post at Top 10 Clinical Endocrinology Research Abstracts Presented at the 2013 ACVIM Meeting for more information.]

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 combination with potassium bromide or phenobarbital for seizures.

In people, vaccinations have sometimes been associated with pancreatitis. Avoid over-vaccinating 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.

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Supplements

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. 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 2 IUs per pound of body weight daily (it’s OK to give higher amounts every second or third day, if that is easier).

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 the B vitamins, so giving a B-complex supplement 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. Low levels of vitamins A, C, and E, selenium, and carotenoids in the blood may lead to chronic pancreatitis due to the destructive effects of increased free radicals. A German study found that vitamin E and selenium, which work together synergistically, were protective against recurrent attacks of pancreatitis in people. The following dosages are what were used in the primary studies for adult humans:

Dosage should be adjusted based on the size of your dog – for example, if an adult human weighs 120 lbs, then a 60-lb dog would take half the human dose, a 30-lb dog would take ¼ the human dose, etc. Higher dosages of the vitamins would be safe, but you should not exceed the recommended dosage of the others.

Other natural supplements with antioxidant properties sometimes recommended for chronic pancreatitis, though evidence is lacking, include SAM-e (S-adenosyl methionine); alpha lipoic acid; oligomeric proanthocyanidins (OPCs, found in grape seed extract and pycnogenol); resveratrol; and milk thistle. Note that alpha lipoic acid lowers blood sugar and so it should be used with caution for dogs with diabetes.

Rather than trying to give antioxidant supplements individually, there are a number of combination products made for dogs, such as Small Animal Antioxidants and Immugen from Thorne Veterinary, and Cell Advance made by Vetri-Science, also called Cell Revive and Cell Discovery.

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.”

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Long-term low-fat diets

In the next article, 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 article will present actual low-fat diets that people are feeding to their dogs.
 

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If you have any questions or comments, you can contact me, but I have less time to answer questions than I used to, and it may be several days to a week before I can respond. My name is Mary Straus and you can email me at either or

   


Rocky is a Yorkie-Poodle mix who had suffered from digestive problems his whole life. Click on his image to read about the diet his owner finally found to help him.
Pashoshe Fisher, a Chihuahua, was a wonderful, joyful companion to his owner for 19 & a half years. He was on a high quality raw diet for over half his life.
This is Ella, my Norwich Terrier.