Feline Pancreatic Lipase
LIN, WEN-YANG (WESLEY), Ph.D
Feline Pancreatic Lipase is a powerful diagnosing biomarker for feline pancreatitis, whereas serum amylase and serum lipase are usually used in diagnosing pancreatitis for canine, are not effectively in detecting pancreatitis for cats.
Anatomical physiology function of pancreas in cats
The feline pancreas is a digestive glandular organ, which presents a long v-shaped strip of configuration locating at abdomen between stomach and duodenum. The tail part of feline pancreas rests toward the dorsal extremity of the spleen and connect to mesocolon with omentum (Figure 1).
Figure 1. Anatomic view of the pancreas and its surrounding tissues
The normal pancreas colored on pale pink and perform both functions of endocrine and exocrine. The endocrine portion contains small clusters of pancreatic α- and β-cells within Langerhans (approximately 2% of the gland’s weight) that majorly generates two hormones proteins: glucagon and insulin. Glucagon works to elevate the level of blood sugar, whereas insulin would diminish excess circulating blood sugar. Both of glucagon and insulin would take part in regulating homeostasis of glycemic level.
Acinar and ductal cells are major members in the exocrine portion of pancreas. Acinar cells aggregate around the terminal pancreatic ductules to secrete digestive enzymes include trypsinogen, chymotrypsinogen, proelastase, procarboxypeptidase, ribonucleases, deoxyribonucleases, phospholipase A2, carboxylesterase amylase and lipase. Amylase and lipase are contributing to hydrolyze carbohydrates and fat. Others may play roles as proteases to cleave polypeptide chains. Feline’s ductal cell generates antibacterial proteins to protect small intestinal from bacterial infection. Moreover, ductal cell can also produce bicarbonate and water for neutralizing pH in the duodenum. Intrinsic factor such as vitamin B12 would be made from ductal cell too. The pancreas is the only generating organ of intrinsic factor for feline, whereas dogs could produce intrinsic factor from pancreas and stomach. All pancreatic enzymes would secret into small intestine for digesting fats, proteins and carbohydrates. Furthermore, the abnormal seep of exocrine enzymes to pancreas and its surrounding organs could cause pancreatic inflammation known as pancreatitis. The highest occurrence of feline pancreatic diseases is exocrine pancreatic insufficiency (EPI) and pancreatitis.
Pancreatitis in the cat
Feline pancreatitis is classified as acute (temporary morphological changes) and chronic (permanent morphological change) type according to the condition of histopathologic changes after treatment. Acute necrotizing pancreatitis (ANP) and acute suppurative pancreatitis are two of the most common types of acute feline pancreatitis, whereas chronic non-suppurative pancreatitis (CP) and pancreatic atrophy are chronic conditions.
Common acute pancreatitis in feline would show anemia, leukocytosis, hypokalemia, hypocalcemia, hyperglycemia, elevation of ALT, ALP, total bilirubin, cholesterol and decreasing level of albumin. Acute necrotizing pancreatitis (ANP) usually present pancreatic acinar cell necrosis, peripancreatic fat necrosis followed inflammation, hemorrhage, mineralization and fibrosis. Despite of its idiopathic character, several diseases have considered to be related with development of ANP including concurrent biliary tract disease, ischemia, pancreatic ductal obstruction, toxoplasmosis, feline Herpes virus infections, feline infectious peritonitis, pancreatic fluke infestations (Eurytrema procyonis, Amphimerus pseudofelinus), trauma, organophosphate poisoning and hepatic lipidosis. General anesthesia induced hypotension or surgical venous outflow occlusion would decrease pancreatic blood flow and cause ANP. Acute suppurative pancreatitis is less common than ANP in feline and neutrophilic inflammation would happen with it.
Besides, the continuous and progressive inflammatory process of the pancreas would lead to chronic non-suppurative pancreatitis (CP) in which lymphocytic inflammation, fibrosis, and acinar atrophy are the major features. The end stage of CP in most feline cases would usually result in pancreatic atrophy, which may or may not influence the endocrine portion of the gland. Felines who suffer pancreatic atrophy would occur cobalamin and fat-soluble vitamin malabsorption, severe maldigestion, acid injury in duodenal mucosa, and bacterial proliferation in the gut due to exocrine pancreatic insufficiency.
Since various types of pancreatitis such as acute and chronic pancreatitis, pancreatic abscess, pancreatic cyst/pseudocyst, exocrine pancreatic insufficiency, and neoplasia share overlapping symptoms, thus histopathology cab be used to discern different conditions.
Symptoms of feline pancreatitis
Symptoms of feline pancreatitis would occur lethargy, anorexia, dehydration, hypothermia, vomiting, weight loss, Jaundice, cholangiohepatitis, hepatic lipidosis, biliary obstructions, cranial abdominal masses and cranial abdominal discomfort. Besides, hepatic and intestinal disease would concurrent.
I. Acute feline pancreatitis:
Vomiting, poor appetite, poor activity, diarrhea, abdominal pain, drooling, fever, collapse.
II. Chronic feline pancreatitis:
Frequent vomiting, poor appetite, listless, frequent diarrhea, abdominal pain, drooling, fever, collapse, hypothermia, breathing too fast or too slow, fast heartbeat.
Possible Causes of feline pancreatitis
Scientists presumed that premature trypsin activate of digestive zymogens in pancreatic acinar cells would cause pancreatic autodigestion, acinar cell necrosis, hemorrhage, and fat necrosis, saponification, mast cell degranulation, leukocyte chemotaxis, platelet aggregation, vasodilation, surfactant degradation within the lungs and initiation of disseminated intravascular coagulation (DIC) for worse cases.
Diagnosis and general considerations
Since symptoms of feline pancreatitis were similar to common flu, vets probably can’t judge it correctly at the early stage without proper diagnostic tools. It’s not an easy task to diagnose pancreatic disease within cats. Single diagnostic method is not recommended. The diagnosis of feline pancreatitis relied on combinational diagnostic tools include historical data, physical examination results, laboratory, and Bio-imaging. Especially, histopathology plays the role as the definitive conclusion for feline pancreatitis.
Middle-aged felines are susceptible to pancreatitis; whereas, older felines (mean 12.8 years, range 4–20 years) are susceptible to neoplasia, cyst/pseudocysts.
Radiography, computed tomography (CT) and ultrasonography were effective imaging tools applied in diagnosing feline pancreatitis. Among all imaging tools, ultrasonography is the most reliable imaging modality for the diagnosis of feline pancreatic diseases, which can help identify soft tissue masses, cysts/pseudocysts, abscesses, or neoplasia and lesions of feline pancreatitis.
The general clinicopathologic test for feline pancreatitis include complete blood cell count, serum bilirubin, cholesterol, glucose, total protein, albumin, and serum activity of liver enzymes (serum alanine aminotransferase and alkaline phosphatase), calcium, urea, creatinine, and potassium. However, serum lipase and amylase activities can’t be diagnostic indicator for feline pancreatic disease. Nevertheless, feline trypsin-like immunoreactivity (fTLI) and feline pancreatic lipase immunoreactivity (fPLI) have been validated as effective and reliable species-specific immunoassays for measuring feline pancreatic disease. In laboratory test, feline trypsin-like immunoreactivity (fTLI) is less sensitive in detecting feline pancreatitis than feline pancreatic lipase immunoreactivity (fPLI) (see Table 1).
Measuring feline pancreatic lipase (fPL)
Feline pancreatic lipase immunoreactivity (fPLI) has been recommended as a highly sensitive and specific blood test for diagnosing pancreatitis in cats. The fPLI test requires only a simple blood sample and is performed within few minutes. It’s able to diagnose moderate to severe pancreatitis (Table 1). Besides, fPLI can be applied in monitoring feline response to treatment due to its rapid blood clearance. Some commercial fPL rapid tests has released for detecting feline pancreatitis at the early stage.
Table 1. Pancreas-specific serum tests (https://veteriankey.com/pancreas-4/)
Treatment for feline pancreatitis
I. Intravenous fluid therapy and electrolyte supplementation
Pancreatitic felines usually occur hypokalemic and hypocalcemic, thus it’s an important issue of maintaining fluid, acid–base and electrolyte deficits. Crystalloids (lactated Ringers or 0.9% NaCl) should be given at first. Calcium gluconate is recommended under a dose of 50–150 mg/kg IV over 12–24 hours. Once cats present a low packed cell volume below 15–20%, plasma transfusion of after blood typing would be necessary. Transfusion of whole blood probably can elevate concentrations of albumin for maintaining plasma oncotic press and reducing pancreatic edema. The level of α-macroglobulins may also uplifted by plasma transfusion that can bind on certain proteases to combat DIC.
II. Nutritional Support
Ideally, low fat and high carbohydrate diet with small frequent portions is suggested. Fasting is only recommended for severe vomiting at risk for aspiration pneumonia in cats. Some cases of feline chronic pancreatitis will occur exocrine pancreatic insufficiency and then oral pancreatic enzyme extract will be required. Vitamin B12 supplement may help in cases with concurrent GI disease.
Feline pancreatitis usually present abdominal pain in cats, thus opioid analgesia is considered to be ideal analgesic therapy. Buprenorphine, methadone, morphine, or fentanyl can be potent and useful in relieving pain. Non-steroidal anti-inflammatory drugs are avoided due to its renal toxicity in dehydrated or hypovolaemic felines. In addition, anti-emetics such as maropitantm and metoclopramide would benefit cases with vomiting and inappetance. Antibiotic treatment may be required in some cases of chronic pancreatitis who have gram-negative bacteria associated around the pancreatic ducts. If cases show evidence of gastric ulceration, antacids such as omeprazole and ranitidine are recommended. Furthermore, corticosteroids are suggested to apply in concurrent Inflammatory bowel disease (IBD) alongside considering monitoring fPLI concentrations. Finally, concurrent diseases such as inflammatory liver, pancreatic, intestinal disease, diabetes mellitus and hepatic lipidosis can also be present.
When occurring situations like persistent pancreatic mass, sepsis or extraluminal bile duct obstruction aren’t responsive to medical treatment, administration of surgery should be considered. Common invasive surgery to deal pancreatic related diseases include splenectomy, cholecystoduodenostomy, cholecystojejunostomy, cholecystostomy and choledochal stenting.
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