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CONTROVERSIES in the NUTRITIONAL MANAGEMENT of PANCREATITIS Justin Shmalberg, DVM, Diplomate ACVN & ACVSMR University of Florida

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CONTROVERSIES in the NUTRITIONAL MANAGEMENT of PANCREATITIS Justin Shmalberg, DVM, Diplomate ACVN & ACVSMR University of Florida ACVN NUTRITION NOTES Peer Reviewed To Feed or Not to Feed? CONTROVERSIES IN THE NUTRITIONAL MANAGEMENT OF PANCREATITIS Justin Shmalberg, DVM, Diplomate ACVN & ACVSMR University of Florida The American College of Veterinary veterinary nutrition Nutrition (acvn.org) and Today’s Veterinary • Encourage continuing education for both Practice are delighted to bring you the specialists and general practitioners Nutrition Notes column, which provides the • Promote evidence-based research highest quality, cutting edge information on • Enhance dissemination of the latest companion animal nutrition, provided by the veterinary nutrition knowledge. ACVN’s foremost nutrition specialists. The ACVN achieves these objectives in The primary objectives of the ACVN are to: many ways, including designating specialists • Advance the specialty area of veterinary in animal nutrition, providing continuing nutrition education through several media, supporting • Increase the competence of those veterinary nutrition residency programs, and practicing in this field offering a wide array of resources related to • Establish requirements for certification in veterinary nutrition, such as this column. Pancreatitis is a common clinical condition of RISK FACTORS both dogs and cats (Figure 1), and significant In most patients, the definitive cause of research has been devoted to improved diagnostic pancreatitis is unknown. Published risk factors for identification of the disease.1-3 pancreatitis are extensive and include endocrine However, nutritional management of pancreatitis disease, obesity, breed, and others.1-6 The continues to be guided primarily by the human nutritional factors that are anecdotally reported literature and clinical experience due to lack of con- to precede episodes in dogs include dietary Learn More trolled clinical trials. Any nutritional intervention indiscretion and consumption of more dietary fat For more information in the treatment of pancreatitis is predicated on the than normal for a particular dog. on acute pancreatitis practitioner distinguishing acute or chronic pancre- In a single retrospective study that interviewed in dogs and cats, atitis from other causes of gastrointestinal signs. owners of dogs affected by pancreatitis and those read the following articles from Today’s Veterinary Practice, available at tvpjournal.com: A Case of Canine Acute Pancreatitis: From Diagnosis to Treatment (September/October 2016) Feline Pancreatitis: A B Current Concepts in Diagnosis & Therapy FIGURE 1. Ultrasound images of pancreatitis demonstrating (A) heterogeneous echogenicity in (January/February the pancreas of a dog affected by chronic pancreatitis and (B) significant pancreatic enlargement, 2015) hypoechoic regions in the pancreas, and adjacent hyperechoic peripancreatic fat in a dog with acute pancreatitis. tvpjournal.com | November/December 2016 | An Official Journal of the NAVC | TODAY’S VETERINARY PRACTICE 45 Peer Reviewed ACVN NUTRITION NOTES presenting with renal disease, factors that were • Enteral nutrition by jejenostomy tube more prevalent in the pancreatitis group included:5 maintained intestinal villous height and • Dietary indiscretion of items in the trash, which mucosal thickness better than parenteral conferred greatest risk (13× more likely) nutrition in dogs with experimentally induced • Unusual food items consumed prior to pancreatitis.8,9 However, this information may presentation (4×–6× more likely) not be relevant to most practitioners, who will • Table scraps given in the preceding week or choose between fasting or enteral support, generally (2× more likely) rather than intravenous nutrition. • Obesity (2.6× more likely). 3. Feeding during illness helps provide essential nutrients that affect cellular function. However, CLINICAL SIGNS • Many of these nutrients are present in reserve, Cranial abdominal pain and nausea are thought to and dogs are more resistant to starvation than 1-3 be characteristic of acute pancreatitis in dogs. humans, with higher rates of fat oxidation at Dogs with chronic pancreatitis may display rest.10 vague signs of anorexia, hyporexia, lethargy, or • Protein catabolism may occur in critical illness behavioral changes, and an acute trigger may not despite the presence of adequate caloric intake be immediately identified in these patients. due to increased protein requirements.11 Cats commonly present with nonspecific signs This increased interest in early enteral nutrition of anorexia and lethargy for both acute and chronic is challenged by some who routinely fast animals disease, which makes detection more challenging.4 with acute pancreatitis. These clinicians argue that there is no evidence—in naturally occurring CANINE ACUTE PANCREATITIS pancreatitis in companion animals—that shows To feed or not to feed? a favorable effect of nutrition and that assistive No objective information is available to determine enteral feeding, when necessary, adds risk and cost whether fasting is associated with beneficial or to treatment of a patient with pancreatitis. It is poor outcomes in dogs with pancreatitis. important to consider, however, that: • Fasting was, and continues to be, a mainstay • If enteral tubes are placed inappropriately, of acute pancreatitis treatment by many aspiration may be a risk, but aspiration due to veterinarians.2 placement errors is rare and risk is mitigated • The premise for this approach is to avoid both pancreatic stimulation and premature activation by documenting negative pressure in a feeding of zymogens, but these effects have not been demonstrated in clinical patients receiving KEY POINT: Short-term fasting has not been nutritional support. associated with poorer outcome in dogs • Many veterinarians relate personal observations with pancreatitis, and the benefits of feeding that early feeding is associated with increased require additional validation in dogs with nausea or morbidity, especially in the presence of naturally-occurring pancreatitis. abdominal pain or severe gastrointestinal signs prior to feeding. Some practitioners, nutritionists, and internists advocate early enteral nutrition in dogs with acute episodes of pancreatitis because: 1. A large body of evidence from human critical care medicine supports decreased morbidity and mortality associated with early enteral nutrition 2. While evidence for early enteral nutrition in dogs is comparatively sparse: • Early enteral nutrition accelerated recovery in dogs with parvoviral enteritis, with food administered by nasogastric tube irrespective of FIGURE 2. Radiographs should confirm place- whether dogs were vomiting or regurgitating;7 ment of nasoenteral tubes; this lateral radio- graph shows a nasogastric tube placed in a cat however, the significance to older dogs and with the distal tip clearly evident in the stomach. those with pancreatitis remains unclear. 46 TODAY’S VETERINARY PRACTICE | An Official Journal of the NAVC | November/December 2016 | tvpjournal.com ACVN NUTRITION NOTES Peer Reviewed tube, absence of a cough when sterile saline is Resting energy requirement (RER) can be given via the tube, radiographic confirmation estimated in 2 ways: 0.75 (Figure 2) of correct placement, or even 1. 70 × (BWkg) = RER (kcal/day) 12 capnography. 2. [30 × (BWkg)] + 70 = RER (kcal/day) • The expense of feeding dogs with severe acute The first formula is the more accurate of the 2 pancreatitis amounts to a small fraction of the equations, while the second is an approximation of overall care (< 5%), but these costs could be RER for dogs weighing 5 to 25 kg. Body weight significant if the owner’s budget is limited. should always be entered in kg. In the absence of evidence specific to canine If partial intolerance to enteral nutrition is pancreatitis, practitioners should evaluate the risks present, it is likely that a lesser amount provides of enteral feeding in the context of the patient’s some benefit in maintaining absorptive surface overall clinical picture. Dogs with intractable area of the intestines. Illness factors, which increase vomiting or regurgitation, in normal body calculated RER, should not be used as the available condition, or those with owners who have financial literature suggests that such values overestimate limitations may tolerate a period of fasting without calories needed in hospitalized patients.17 any clinically relevant adverse effects. Animals may require assistive enteral feeding. • Syringe feeding is not recommended due to KEY POINT: Maintenance of enteral nutrition the practical inability to deliver full nutrient appears beneficial in humans with critical illness requirements with this method and the risk of and is likely worth the time and effort of inter- food aversion and aspiration. vention—when risks of feeding the patient are • Nasoesophageal and nasogastric tubes are often used low—until additional studies are performed. in management of canine and feline pancreatitis. • Esophagostomy tubes are generally reserved for Enteral or parenteral feeding? severe chronic pancreatitis in dogs, or in cats Enteral nutrition in humans with pancreatitis may with concurrent morbidities that make the need prevent bacterial translocation, metabolic and for continued supportive feeding likely. electrolyte complications of parenteral feeding, immune system impairment, villous atrophy, and What should the patient be fed? 13 reduced mortality. However, human guidelines Commercially available low fat enteral diets also suggest that parenteral nutrition should be (Table 1) may best be reserved
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