Pancreatitis in cats: symptoms, causes and treatment of the disease

Pancreatitis is an inflammation of the pancreas, which is responsible for the digestion process in the pet’s body. This disease is rarely diagnosed in cats, but it requires professional treatment. Read more about the causes of the pathology, its symptoms and treatment below.

Read in this article

• Symptoms of the disease
• Causes of pancreatitis
• Forms and their features
• Diagnosis of the disease
• Treatment of pancreatitis: stages
• Water-salt balance
• Elimination of pain
• Antiemetic therapy
• Restoration of the body
• Diet
• Surgical intervention

Anatoly Chernikov

Chief veterinarian of the veterinary clinic 4 Lapas (Khimki), graduate of the Moscow State Academy of Veterinary Medicine named after.
K. I. Scriabin (2009). Specialist in the field of dentistry, gastroenterology, endoscopy. Regularly takes part in domestic and international Veterinary Conferences: Moscow International Veterinary Congress, National Veterinary Conference (NVC), Congress of the European Association of Veterinary and Comparative Dietetics (ESVCN), Southern European Veterinary Conference (SEVC), Conference of the International Community Felinological Medicine (ISFM), Conference of the Russian Gastroenterological Academy (RGA), International Veterinary Conference Purina Partners. The term “triaditis” refers to the simultaneous occurrence of three pathological processes in cats: pancreatitis, cholangitis and inflammatory bowel disease (IBD). Despite its wide popularity and frequent occurrence in various scientific literature sources, data on the true prevalence of triaditis and its etiopathogenesis are still lacking. To date, the prevalence of this problem according to various sources is estimated in the range of 17-39% among cats with inflammatory lesions of the organs of interest (cholangitis, pancreatitis or IBD). (1, 2, 3) Triaditis has also been reported to be found in 50–56% (4, 5) of cats diagnosed with pancreatitis and 32–50% of cats diagnosed with cholangitis/inflammatory liver disease. There is currently no reliable information about the gender, age or breed predisposition of triaditis. (6, 7)

Symptoms of the disease

Pancreatitis in the initial stages is practically asymptomatic, so it is difficult to detect it at home.

Among the main symptoms:

• sluggish and apathetic state,
• diarrhea,
• temperature increase,
• sudden weight loss,
• dehydration,
• lack of appetite,
• belly hard to the touch
• icteric mucous membranes,
• general weakness.

Note! Typically, an attack of vomiting or diarrhea is observed 10-15 minutes after the animal eats food.

Are you observing one or more signs in your pet? Do not hesitate, contact a veterinary clinic for professional help. The sooner pancreatitis is diagnosed, the faster and more effective its treatment!

Possible complications and concomitant diseases

In this article, we will review the most current information on the diagnosis and treatment of triaditis, focusing on individual comorbid pathologies: pancreatitis, cholangitis and IBD.

Pancreatitis

Pancreatitis in cats is considered an idiopathic disease, but can be triggered by specific etiological factors such as viral infection, toxoplasmosis, fluke infection, trauma and organophosphorus poisoning. (7,

Histologically, pancreatitis can be divided into acute and chronic. Acute pancreatitis (AP) is characterized by neutrophilic inflammation with associated interstitial edema and mesenteric fat necrosis, while chronic pancreatitis (CP) is characterized by lymphocytic inflammation, fibrosis, and acinar atrophy. Because cats with CP are more likely to have comorbidities than cats with AP, CP may be more common in triaditis. Inflammation of the pancreas can extend to the pancreatic duct and even the sphincter of Oddi, causing cholangitis and possibly extrahepatic biliary obstruction. Cholangitis occurring as a primary disease can cause inflammation extending to the sphincter of Oddi and pancreatic duct, and therefore, in turn, is a risk factor for the development of pancreatitis. (9)

Cholangitis

The diagnosis of cholangitis involves inflammation of the bile duct; if the inflammatory process spreads to the liver parenchyma, a diagnosis of cholangiohepatitis is made. Cholangitis is a fairly common disease in cats. One British study examined 1,500 feline liver biopsy samples. (10) The most common histopathological diagnoses were neutrophilic cholangitis (NC) and reactive hepatitis, while lymphocytic cholangitis (HL) was only fourth.

The most common type of cholangitis in cats is NH, which is characterized by infiltration of the bile ducts by large numbers of neutrophils. (11) It is believed to occur as a result of a bacterial infection originating from the intestines. NC can be divided into acute and chronic forms. Acute neutrophilic cholangitis (ANC) is characterized only by neutrophilic inflammation, while chronic neutrophilic cholangitis (CNC) is accompanied by tissue infiltration not only by neutrophils, but also by lymphocytes and plasma cells. In the chronic process, fibrosis and proliferation of the bile ducts are more pronounced, which is the main predisposing factor to the formation of extrahepatic biliary tract obstruction (HEBO). (11) VOT, in turn, is a risk factor for the development of triaditis. (12)

HL is characterized by wall infiltration of lymphocytes and plasma cells, with varying degrees of fibrosis and biliary hyperplasia. The nature of the inflammatory infiltrate suggests an immune-mediated pathogenesis. (13) The disease affects cats of different age groups. HL was most frequently diagnosed in Persian cats, indicating a possible genetic predisposition. (14)

Chronic cholangitis associated with liver fluke infestation (family Opisthorchiidae), the third distinct type of feline cholangitis, is rare. Its role in the development of feline triaditis has been little studied.

Inflammatory bowel disease (IBD)

The exact cause of IBD remains unknown. However, the gut microbiome, food antigens, genetic predisposition, and dysregulation of the intestinal immune system are thought to play important roles in pathogenesis. (15, 16) Feline IBD primarily affects middle-aged animals, although it can also be detected in cats under 2 years of age. It is difficult to identify specific breeds susceptible to the disease, although among Siamese cats, IBD is the most common in the literature. (17)

The severity of inflammation of the gastrointestinal tract is usually assessed on a simple four-point scale: normal (0), mild (1), moderate (2) or severe (3). (18)

First aid for an attack of pancreatitis

To reduce pain, you can use a heating pad filled with cold water. It needs to be applied to the abdominal area, namely to the epigastric region (the area under the xiphoid process, corresponding to the projection of the stomach onto the anterior abdominal wall). This allows you to reduce the intensity of pain, slightly reduce swelling and inflammation.

The patient must comply with the hospital regime. This will reduce blood flow to the organ, and therefore reduce inflammation.

Eating is prohibited. The digestion process can cause more severe pain, nausea and vomiting. And the diet will reduce the production of enzymes that increase the inflammatory response and pain. You need to fast for 3 days. You can drink clean water without gases.

It is imperative to call a doctor for an examination, even if the patient is not exactly sure that this is an attack of acute pancreatitis. As we already know, this pathology can subside and then rapidly recur. At this time, you can take a painkiller to reduce discomfort.

Prevalence of triaditis

Several studies have examined the prevalence of triaditis. In one of them, 78 cats were studied. It was found that 39% of cats with cholangitis also had IBD and pancreatitis (ie, triaditis), and the prevalence of IBD and pancreatitis was higher in cats with cholangitis (83% and 50%, respectively) compared with cats with non-inflammatory liver disease . (1)

In another study of 44 cats diagnosed at necropsy with moderate to severe cholangitis, the majority had CNC (n = 33) or ONC (n = 7); 60% also had pancreatitis, 50% also had IBD, and 32% had both (ie, triaditis). (2)

In a study of 115 cats, 45% of apparently healthy cats had pancreatic lesions at postmortem examination, (19) highlighting the difficulty of diagnosing the disease.

A more recent prospective study aimed to examine the incidence of IBD, cholangitis, pancreatitis, or a combination of these conditions in symptomatic and asymptomatic cats by comparing clinicopathologic features with histopathologic and laboratory findings. (3) In 57% of cats, inflammation affected more than one organ; 34% had concurrent IBD and cholangitis; 17% were diagnosed with triaditis; and 6% had IBD and pancreatitis. It is important to note that triaditis was only identified in symptomatic cats (20%). A positive correlation was also found between the severity (score) of IBD lesions and the number of comorbidities. (3)

Etiology of triaditis

The etiology of feline triaditis is poorly understood. The disease can occur due to an infectious or autoimmune process, as well as a physical (mechanical) problem such as a blocked duct or injury. It is also unclear whether each pathology develops separately or whether they have a common etiology. The anatomy of the cat's gastrointestinal tract may also play an important role: the small intestine is comparatively shorter than that of the dog; a higher concentration of bacteria is observed in the duodenum; The pancreatic duct joins the common bile duct before entering the duodenum at the papilla. (20) Such conditions increase the risk of bacterial penetration from the duodenum into the liver and pancreas, resulting in parenchymal inflammation. Vomiting can cause chyme to reflux into the pancreatic duct and/or bile duct, spreading gut microbiota. Intestinal inflammation can promote the translocation of intestinal bacteria into the liver and pancreas. (21, 22)

Impaired flow of bile or pancreatic juices may also play a role in triaditis. The sphincter of Oddi is a muscular valve that controls the flow of bile and pancreatic juices. Sphincter blockage or dysfunction may predispose cats to pancreatitis and cholangitis. In medical practice, dysfunction of the sphincter of Oddi, in particular its spasm, in connection with IBD is diagnosed quite often. (23) One study reported six cats with sphincter of Oddi obstruction, and three of these cats had concurrent IBD. (24)

The pathophysiology of triaditis may also have an autoimmune component. (21) Changes in intestinal mucosal permeability that occur in IBD may also allow bacterial cell antigens to cross natural barriers, promoting the production of autoreactive antibodies. (25)

Clinical signs of triaditis

Clinical signs associated with feline pancreatitis are vague and nonspecific (Table 1). Anorexia was reported in 63-97% of cases and lethargy in 28-100%. Weight loss, dehydration, pallor and jaundice are often detected only when examined by a doctor. (2, 6, 9) Unlike dogs, fever is less common with pancreatitis in cats. In a study of cats with pancreatitis, only 25% of animals had hyperthermia, while in 50% the temperature was, on the contrary, below normal. (8)

In many cases of severe triaditis, vasculitis develops and signs of blood clotting disorders are observed.

Most cases of mild CP remain subclinical. (14) In one study, 45% of apparently healthy cats showed signs of pancreatic disease at postmortem examination. (26) Pancreatitis is common in diabetic cats and may be a contributing factor to the worsening of the disease and/or leading to the development of diabetic ketoacidosis. Cats with NH are often young (3-5 years old) and have an acute illness. Clinical signs are often nonspecific, including anorexia, lethargy, vomiting, and weight loss, with jaundice, dehydration, fever, hepatomegaly, and abdominal pain occurring in less than half of all cases. (27) Cats with HL may exhibit clinical signs of anorexia, lethargy, vomiting, and weight loss. As with NH, severe cases may develop signs of hepatic encephalopathy or coagulopathy. (28)

Clinical signs of IBD are similar to those of other chronic gastrointestinal diseases (eg, lymphoma), and include diarrhea, vomiting, hyporexia, and/or weight loss. (29) However, clinical manifestations may be less significant. So in many cats with IBD, only hyporexia appears.

There is also a connection between kidney inflammation and triaditis. When cholangitis and/or pancreatitis occurs, inflammatory mediators can exert their influence on the kidneys. (1, 2) In one study, 63 cats, 27% of cats with AP and 15% of cats with CP, had kidney disease. (thirty)

Table 1. Symptoms of triaditis

Signs highlighted in yellow are most characteristic of the pathological process.

Chronic pancreatitis

This form of the disease is more dangerous and insidious. Pancreatitis slowly develops and “destroys” the cat’s body. Without any noticeable symptoms, the animal gets worse and worse. A chronic process can develop for years, and the owner of the animal will not know about it - this is its main danger.

The disease is indicated only by changes in the pet's behavior (the animal becomes lethargic and drowsy), incessant rumbling in the stomach, dulling of the fur and yellowish stools.

Diagnosis of triaditis

Considering the large number of factors involved in the etiopathogenesis of the disease, the diagnosis of triaditis must be approached comprehensively. The diagnosis is made based on the clinical signs listed above (Table 1), the results of blood tests and visual diagnostics (Table 2). The gold standard for assessing the nature of the pathological process and making a final diagnosis is a biopsy, however, given the invasiveness of the method and the often serious condition of the patients, its intravital implementation in most cases seems very difficult. The table below shows the main diagnostic findings characteristic of the inflammatory process in each of the examined organs of interest.

Table 2. Used diagnostic tests and pathognomonic signs

Treatment of triaditis

Since triaditis is a simultaneous occurrence of pancreatitis, cholangitis and IBD, treatment should also comply with the standards for the treatment of these pathologies, taking into account the severity of the general pathological process. (31)

Cats with mild clinical signs, without hemodynamic compromise, can be treated as an outpatient, but cats with severe clinical signs require hospitalization and aggressive treatment, including fluid therapy, analgesics, antiemetics, and force feeding, to prevent the development of hepatic lipidosis. Intravenous fluid therapy helps restore hydration and normal organ perfusion, and eliminates fluid losses due to vomiting, diarrhea, gastrointestinal motility disorders and ascites. When conducting infusion therapy, it is important to monitor acid-base and electrolyte balances. So calcium and potassium levels are subject to careful monitoring. Hypokalemia is most common in cats with triaditis and can be treated parenterally by adding potassium chloride to the electrolyte solution or orally by adding potassium gluconate (initial dose is 2.2 mmol/L per 4.5 kg every 12 hours).

The use of synthetic colloids has been questioned in recent years. (32) The use of plasma may be beneficial for cats with severe liver disease and/or AP who have developed coagulopathy or disseminated intravascular coagulation.

Table 3. Drugs used for feline triaditis

In cats with triaditis, it is important to assess the level of pain (for example, using the Glasgow Feline Pain Scale) and promptly manage it. If opioid medications are not available, gabapentin or lidocaine as a continuous infusion can be used to control pain.

Antiemetic therapy plays an important role in the treatment of triaditis. Although vomiting may not be apparent, patients may experience nausea, which may worsen anorexia. Maropitant citrate is a very effective antiemetic and is also useful in reducing visceral pain, further justifying its use in pancreatitis in cats. (33) Ondansetron acts at the serotonin 5-HT3 receptor and is a very effective antiemetic in cats. Metoclopramide may also be effective, but its use in cats is currently questionable. (34)

Nutritional support is critical in treating triaditis. Insufficient enteral nutrition can cause atrophy of the intestinal mucosa and an increase in infectious complications due to bacterial translocation from the intestine. Also, with insufficient nutrition, cats can develop liver lipidosis. (8, 27) Enteral nutrition stabilizes gastrointestinal barrier functions, improves enterocyte health and immune function of the intestinal mucosa, improves gastrointestinal motility, and ultimately reduces mortality.

Appetite stimulants can help maintain natural nutrition and thereby reduce the need for an esophagostomy (or gastrostomy). Mirtazapine is widely used as an appetite stimulant in cats. Because mirtazapine is metabolized by the liver, it is recommended that it be used with extreme caution in cats with hepatic diseases. However, in cases of severe anorexia and vomiting, placement of a feeding tube is the first choice. Forced oral syringe feeding is not recommended as it can cause stress and lead to food aversions.

Pancreatitis

Cats with pancreatitis should be monitored for the development of exocrine pancreatic insufficiency and hypocobalaminemia. If necessary, cobalamin should be administered parenterally or orally. A recent study examining the use of corticosteroids in dogs for the treatment of pancreatitis reported an earlier reduction in C-reactive protein concentrations and an earlier improvement in clinical signs after initial treatment with prednisolone (1 mg/kg/day) compared with the non-prednisolone group. (35) However, there is currently insufficient evidence to support the use of corticosteroids in the treatment of pancreatitis in cats.

Cholangitis

Treatment of cholangitis is ideally based on bile culture results and histopathological diagnosis; however, symptomatic therapy is also important. Because NH is often associated with bacterial infection, the use of antibiotics is warranted. If possible, bacterial culture and antibiotic susceptibility testing of bile aspirate or liver biopsy/aspirate are performed. As a rule, a 4-week course of antibiotics is indicated, and in acute cases the positive effect appears faster than in chronic cases.

While awaiting bacterial culture results, empirical treatment with amoxicillin with clavulanic acid is acceptable. (36.37)

Drugs metabolized by the liver (for example, metronidazole) should be used with caution.

Symptomatic adjunctive therapy may include ursodeoxycholic acid (UDCA), S-adenosylmethionine (SAME), silybin, silymarin and their derivatives (38) or other antioxidants such as N-acetylcysteine ​​or vitamin E (tocopherol). Cats with liver disease or severe IBD have a high prevalence of coagulopathies. As a rule, the use of vitamin K in such cases has a positive effect. (39)

HL is believed to be an immune-mediated disease and many cats will require immunosuppressive therapy with drugs such as prednisolone, cyclosporine or chlorambucil. A retrospective study comparing UDCA (alone) and steroids (also alone) in the treatment of LC showed that the former was inferior. (40)

IBD

Treatment of IBD (Table 3) is best performed after a biopsy, when the type of disease (lymphocytic, eosinophilic, neutrophilic, granulomatous) and the degree of structural changes (predominant villous smoothing, fusion) have been determined, and after lymphoma has been excluded. Mild lymphocytic-plasmacytic enteritis (which does not cause significant structural changes) often responds to dietary therapy (selection of a hypoallergenic or hydrolyzed diet). Patients who do not respond to diet monotherapy and who have moderate or severe lymphocytic-plasmacytic enteritis usually respond to diet and antibiotic therapy (tylosin), or diet therapy, antibiotic therapy (tylosin) and immunosuppressive therapy (prednisolone).

Lymphocytic-plasmacytic enteritis is the most common form of IBD in cats. Treatment for this disease usually involves changing the diet with a potential new protein or using a diet containing hydrolyzed protein. A new protein is a protein source that the cat has not previously eaten, such as rabbit or salmon, and therefore is not sensitized to it. It is expected that such a product will not cause a hyperimmune response in the cat, aggravating the course of IBD, although this possibility still remains. Also on sale are specialized industrial diets with hydrolyzed proteins and refined carbohydrates. The protein in hydrolyzed diets is broken down by enzymes into small peptides that are less allergenic than whole proteins. (41) The use of such feeds as a treatment for animal IBD is currently the gold standard, facilitating early reduction of doses of immunosuppressive therapy, alleviating the course of the disease and improving the prognosis. Thus, the Pro Plan® Veterinary Diets HA ST/OX Hypoallergenic diet based on hydrolyzed soy protein has proven itself well as a therapeutic food for cats with IBD, both in mono mode for mild cases of the disease, and in complex therapy.

Immunosuppression plays an important role in the treatment of IBD and is considered for treatment when dietary interventions fail to respond. First of all, we are, of course, talking about the use of prednisolone, however, in case of recurrence of clinical signs, when the dose of prednisolone is reduced, therapy with other immunosuppressive drugs, such as chlorambucil or cyclosporine, can be started. (29) Chlorambucil or cyclosporine should also be used as first-choice treatment over prednisolone in cats with concomitant diabetes.

The use of probiotics in chronic gastrointestinal diseases has been proven to be beneficial, so the clinically proven probiotic Pro Plan® Veterinary Diets® Fortiflora® can be used as an adjuvant therapy for IBD. (42) If cobalamin deficiency is detected or suspected, the vitamin must be replenished by parenteral administration.

Antimicrobial therapy using tylosin or metronidazole may be justified in the presence of intestinal infiltration by macrophages or neutrophils, with risks of translocation of intestinal microflora and the development of a generalized septic process. Metronidazole should be given at a lower dose to patients with severe liver disease because it is metabolized by the liver. (43)

Fecal microbiota transplantation may be considered in cases of intractable diarrhea.

In the absence of severe autoimmune inflammation of the intestines, the use of easily digestible gastroenterological diets, such as Pro Plan® Veterinary Diets EN ST/OX Gastrointestinal, is allowed. The use of wet gastrointestinal diets will also be more appropriate when feeding animals through a feeding tube. Of course, when choosing a diet, it is important to rely on the results of histological examination and clinical effectiveness.

Treatment of pancreatitis in cats

Treatment in each individual case is prescribed individually after an accurate diagnosis has been established and concomitant diseases and symptoms have been identified.

The therapeutic strategy is selected taking into account the complexity of the course, stage, form and neglect of the pathological process. Self-medication is unacceptable!

1. Starvation diet for 1-3 days to reduce the enzymatic functions of the diseased gland.
2. Infusion therapy to combat dehydration. The drugs used are: 0.9% saline solution, Ringer's solution, Dextran-70.
3. Antispasmodic and painkillers: Spazgan, No-shpa, Baralgin, Papaverine, etc.
4. Antiemetics: Metoclopramide, Maropitant, Cerucal, Chlorpromazine.
5. Heart remedies: Camphor, Cordiamine.
6. Enzymes: Pancreatin.
7. In acute pancreatitis, Gordox is prescribed to reduce the secretion of digestive enzymes.
8. Animals with anorexia are fed through a nasoesophageal tube or PEG tube. Mirtazapine is used to stimulate appetite.
9. In case of complications, a plasma transfusion or a complete blood transfusion is prescribed.
10. A course of antibacterial therapy is indicated only to prevent septic phenomena.
11. In the most severe cases, laparoscopy is performed to remove the necrotic part of the affected organ.

For the most effective treatment, it is important to identify the disease as early as possible.

Forecast

The prognosis for cats with triaditis depends on the severity of their disease. Cats with mild disease can be treated as an outpatient and have a good prognosis. However, cats with acute severe disease, especially those with systemic complications (systemic hypotension, hepatic encephalopathy, coagulopathy, vasculitis, disseminated intravascular coagulation, etc.), may have a poor prognosis and require more aggressive therapy.

Several risk factors have been reported in patients with triaditis. Hypoalbuminemia and hypoglycemia are markers of a severe and life-threatening condition. (15) Many affected cats develop a chronic form of the disease with recurrent episodes of triaditis. Chronic pancreatitis may predispose to exocrine pancreatic insufficiency and/or diabetes; chronic/severe cholangitis may predispose to cholangiohepatitis, cholelithiasis, chronic biliary cirrhosis and possibly cholangiocarcinoma; Chronic lymphoplasmacytic IBD may predispose to intestinal lymphoma.

Prevention

1. Follow the vaccination schedule, regularly deworm and do not neglect preventive examinations.
2. Strictly adhere to the diet, monitor the quality of food and ready-made commercial feed, and stop attempts at home to “treat” your pet with food from the table.
3. Monitor your pet's weight and prevent obesity.
4. Strictly adhere to the recommendations of veterinary specialists during treatment of chronic pancreatitis in the acute phase and during remission. Do not replace medications or change dosages of medications.
5. Get rid of all poisonous houseplants.
6. Place household chemicals out of the reach of cats.

Strict adherence to these simple rules will help your pet stay healthy longer.

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