Exocrine Pancreatic Insufficiency (EPI): Nutritional Management

Introduction to Exocrine Pancreatic Insufficiency (EPI)

• Condition characterized by a deficiency of pancreatic enzymes

• Affects digestive processes in dogs and cats

• Primarily caused by pancreatic acinar atrophy (PAA)

  • Damage from chronic inflammation to the pancreas (during pancreatitis)

• Requires lifelong management and nutritional intervention

Pathophysiology of EPI

• Requires approximately 90% reduction in lipase production

• Results in extensive loss of pancreatic acini cells

• Leads to malassimilation of nutrients

  • Occurs when nutrients fail to cross the intestinal wall and the body is unable to maintain weight

• Affects fat, protein, and carbohydrate digestion

Clinical Signs in EPI Patients

• Chronic small bowel diarrhea

• Steatorrhea (fatty stools)

• Significant weight loss and poor BCS (body condition score)

• Failure to thrive

• Ravenous appetite despite still experiencing weight loss

• Frequent defecation (6–10 bowel movements daily)

• Foul-smelling, pale, greasy stools that are high in volume

• SIBO – small intestinal bacterial overgrowth → caused by the deficiency of pancreatic secretions which play a role in antibacterial factors and decreased immunity because of malnutrition

Nutritional Management Goals

• Provide sufficient energy and nutrients

• Maintain ideal body condition

• Avoid nutrient deficiencies

• Minimize diarrhea

Enzyme Replacement Therapy

• Lifelong treatment and involves replacing the digestive enzymes

• Use dried, powdered pancreatic extracts from bovine or porcine pancreas (contains lipase, amylase, protease)

• Powder extracts more effective than tablets or capsules

• Can also use raw pancreas that has been frozen and thawed → risks associated with consuming raw meat

• Administer with every meal!

• Dosage varies by species and individual needs

Dietary Considerations: Digestibility

• Recommend highly digestible foods

• Use refined meat and carbohydrate sources → e.g., eggs, cottage cheese, muscle, corn, rice, barley, etc.

• Coupled with pancreatic enzyme preparations

Fat Management in EPI Diet

• Feeding a highly digestible food in conjunction with enzyme supplementation is more effective than just decreasing the fat content of the current food

• Consider medium-chain triglycerides (MCTs) → may result in total fat assimilation, however this can decrease the food's palatability

• Balance fat content carefully

Fiber Recommendations

• Low fiber content: ≤5% dry matter or even lower

• Fiber can impair pancreatic enzyme activity

  • It may bind with what little enzymes are available

• Lower fiber may reduce fecal weight and fat excretion

• Lower fiber may also reduce bloating and flatulence

  • Fiber tends to ferment

• Study on humans showed the above when reducing the fiber content from 4% to 1%

Vitamin and Micronutrient Management

• Address deficiencies in fat-soluble vitamins (A, D, E, K) from lack of pancreatic lipase and absorption of the above vitamins

  • We still need these!!

• Can provide supplementation for all of them but be cautious not to cause toxicity

• Monitor cobalamin (vitamin B12) levels → common to have deficiencies which leads to poorer outcomes and treatment failure

  • Pancreas secretes a factor that binds with B12 to create absorption

  • Supplement with IM or SQ injections

• Folate also needs to be monitored as this can become elevated for most dogs

  • Altered gut environment = dysbiosis

  • Folate synthesized by the bacteria here

Feeding Strategies

• Cats with EPI often have a high chance of also having inflammatory bowel disease → recommend feeding a hypoallergenic intestinal diet

• Multiple small meals daily

• Add pancreatic enzymes immediately before feeding

• Adjust daily energy requirement (RER × 2)

• Target body condition score of 3/5 or 4.5/9

• Treats need to match the nutrient profile listed throughout the presentation

Treatment Success Factors

• Early diagnosis → once clinical signs of maldigestion are observed, 90% of the pancreas is already dysfunctional

• Consistent enzyme replacement

• Appropriate nutritional management

• Regular veterinary monitoring

• Owner education and compliance