Practice Scenario
Get to know AUTUMN
A 5-year-old, spayed female Domestic Longhair cat
- Autumn is presented for vomiting, ptyalism, and anorexia. Some remodeling was done in the home and Autumn has been hiding under the bed for most of that time. The owner also reports she is unsure how much Autumn has eaten in the past week. Yesterday, the cat began vomiting bile and drooling.
- Autumn previously had a body condition score of 7/9 but today is scored a 6/9. Her body weight has decreased by approximately 1.5 pounds since her last exam which was 6 months ago.
- On exam, Autumn exhibits icterus of the sclera, pinnae, and mucous membranes. She is about 10% dehydrated and salivating, with elevated heart and respiratory rates. The rest of her exam is unremarkable.
Pancreatic Disorders
Pancreatitis in Cats
Although its exact incidence in cats is unknown, pancreatitis is now recognized as a common and clinically important inflammatory disorder of the feline exocrine pancreas.
Pancreatitis is divided into acute and chronic forms based on histology, not time course as can be the case for other health conditions.1─3 Both forms can be mild to severe in presentation. However, chronic pancreatitis, which is more common in cats than the acute form,2 tends to be mild while acute pancreatitis is usually more severe.4
Clinical signs associated with pancreatitis in cats are vague, nonspecific, and frequently subtle.3,5 The most common clinical signs and physical examination findings are lethargy, partial or complete anorexia, dehydration, and weight loss, regardless of the type of pancreatitis. Other clinical signs and findings may include vomiting, hypothermia, diarrhea, abdominal pain, pale mucous membranes, and icterus.3,5─7 Clinical presentation may be complicated by the potential for one or more concurrent conditions, including diabetes mellitus, chronic enteropathies, hepatic lipidosis, and cholangitis.4,6,7
Management of cats with pancreatitis is generally supportive care aimed at controlling symptoms. Due to anorexia and the risk of developing hepatic lipidosis, cats with moderate to severe disease typically need to be hospitalized for intensive medical management and nutritional support. Those cats with mild disease often can be managed on an outpatient basis using dietary modification and medical management.
Key Messages
- Management of cats with pancreatitis has been divided into hospitalized patient and outpatient care because:
- a definitive diagnosis of acute versus chronic pancreatitis is not always possible8
- pancreatic biopsy is performed infrequently, particularly in first-opinion practices, since patients are often poor anesthetic risks6
- initial medical management should not wait until diagnosis is confirmed via histopathology1 as results are unlikely to change patient management7
- Regardless of pancreatitis type, management of cats with pancreatitis focuses on a combination of nausea and/or vomiting control; pain management; nutritional support, including consideration of appetite stimulation and parenteral cobalamin (vitamin B12) supplementation if indicated; and replacement of fluids and/or electrolytes.
- Since chronic pancreatitis often occurs concurrently with other diseases and has no specific treatment options (other than symptomatic and supportive care), management of concurrent disease usually takes clinical priority.4,8
- A nutritional assessment that includes evaluation of the current foods’ nutritional content should be performed to determine if the food is appropriate for the patient.
- Dietary modification is typically not needed unless concurrent disease or persistent hyperlipidemia is present.
- A low-fat diet and/or omega-3 fatty acid supplementation may benefit cats with persistently elevated cholesterol.8
- Many cats with pancreatitis present with a history of anorexia or hyporexia of varying duration. Early enteral nutrition is recommended to prevent hepatic lipidosis, protein-energy malnutrition, atrophy of gut villi, bacterial translocation, and lean muscle loss. The current standard of care is to:1
- administer antiemetics immediately at presentation, then as needed to control nausea and vomiting
- begin enteral feeding as soon as possible
- If oral intake is inadequate, an appetite stimulant may help restore voluntary food intake and enable oral feeding.
- A feeding tube should be placed if a cat does not respond to an appetite stimulant, has experienced prolonged anorexia, or has severe pancreatitis with or without concurrent disease.
- Feeding tubes (e.g., nasogastric, nasoesophageal, and esophagostomy) are well tolerated, allow convenient delivery of nutrients, and are associated with few complications.
- Nasoesophageal and nasogastric feeding tubes are good options for initial or short-term support since they can be inserted without sedation. Only liquid diets should be used with these tubes due to their small diameter.
- If the cat is stable for general anesthesia and long-term assisted feeding is anticipated, esophagostomy tubes are well tolerated. Esophagostomy tubes allow tailored feeding of canned diets as a gruel.
- If the patient is vomiting, it is essential to confirm placement of the feeding tube before each use.
- The dietary needs of hospitalized cats with pancreatitis have not been determined. In most cases, a highly digestible diet that is high in protein (7─8 g/100 kcal ME or > 40% of ME calories) and low in carbohydrate is recommended.
- If the cat will eat voluntarily, foods designed for critical care/recovery or for management of GI conditions can be gradually introduced. In cases with suspected food intolerance, a hydrolyzed or novel protein formula may be needed.
- If a nasoesophageal feeding tube has been placed, a liquid veterinary diet formulated for convalescence or critical care can be fed. These diets are energy dense and typically have a moderate to high protein content.
- In a retrospective study that evaluated nasogastric tube feeding in cats with acute pancreatitis, feeding a high-fat (45% of total calories), moderate-protein (35% of total calories) liquid enteral diet was well tolerated.9
- When feeding hospitalized cats that have been anorexic, nutrition should be reintroduced gradually over several days to avoid refeeding syndrome.
- The starting point for assisted feeding is to calculate the patient’s resting energy requirement (RER):
- RER (kcal/day) = 70 x BWkg0.75 or RER (kJ/day) = 293 x BWkg0.75
- On the first day, feed 25% to 33% of the calculated RER divided into 4 or more feedings daily. The amount given per meal when bolus feeding should be limited to 5 to 10 mL/kg BW. Feed slowly over 10 to 15 minutes to allow for stomach expansion.10
- Watch for signs of nausea such as drooling or licking of the lips. If seen, temporarily stop the feeding and resume once resolved.
- If food is well tolerated, the percentage of RER can be increased by 25% to 33% every 12 to 24 hours, until full RER is reached.
- The starting point for assisted feeding is to calculate the patient’s resting energy requirement (RER):
- For cats with severe pancreatitis, intractable vomiting, and persistent anorexia, partial or total parenteral nutrition should be considered to prevent further undernutrition.11
Outpatient Nutritional Management
- Since chronic pancreatitis often occurs concurrently with other diseases and has no specific treatment options (other than symptomatic and supportive care), management of concurrent disease usually takes clinical priority.4,8
- A nutritional assessment that includes evaluation of the current foods’ nutritional content should be performed to determine if the food is appropriate for the patient.
- Dietary modification is typically not needed unless concurrent disease or persistent hyperlipidemia is present.
- A low-fat diet and/or omega-3 fatty acid supplementation may benefit cats with persistently elevated cholesterol.8
Nutritional Support of the Hospitalized Cat With Pancreatitis
- Many cats with pancreatitis present with a history of anorexia or hyporexia of varying duration. Early enteral nutrition is recommended to prevent hepatic lipidosis, protein-energy malnutrition, atrophy of gut villi, bacterial translocation, and lean muscle loss. The current standard of care is to:1
- administer antiemetics immediately at presentation, then as needed to control nausea and vomiting
- begin enteral feeding as soon as possible
- If oral intake is inadequate, an appetite stimulant may help restore voluntary food intake and enable oral feeding.
- A feeding tube should be placed if a cat does not respond to an appetite stimulant, has experienced prolonged anorexia, or has severe pancreatitis with or without concurrent disease.
- Feeding tubes (e.g., nasogastric, nasoesophageal, and esophagostomy) are well tolerated, allow convenient delivery of nutrients, and are associated with few complications.
- Nasoesophageal and nasogastric feeding tubes are good options for initial or short-term support since they can be inserted without sedation. Only liquid diets should be used with these tubes due to their small diameter.
- If the cat is stable for general anesthesia and long-term assisted feeding is anticipated, esophagostomy tubes are well tolerated. Esophagostomy tubes allow tailored feeding of canned diets as a gruel.
- If the patient is vomiting, it is essential to confirm placement of the feeding tube before each use.
- The dietary needs of hospitalized cats with pancreatitis have not been determined. In most cases, a highly digestible diet that is high in protein (7─8 g/100 kcal ME or > 40% of ME calories) and low in carbohydrate is recommended.
- If the cat will eat voluntarily, foods designed for critical care/recovery or for management of GI conditions can be gradually introduced. In cases with suspected food intolerance, a hydrolyzed or novel protein formula may be needed.
- If a nasoesophageal feeding tube has been placed, a liquid veterinary diet formulated for convalescence or critical care can be fed. These diets are energy dense and typically have a moderate to high protein content.
- In a retrospective study that evaluated nasogastric tube feeding in cats with acute pancreatitis, feeding a high-fat (45% of total calories), moderate-protein (35% of total calories) liquid enteral diet was well tolerated.9
- When feeding hospitalized cats that have been anorexic, nutrition should be reintroduced gradually over several days to avoid refeeding syndrome.
- The starting point for assisted feeding is to calculate the patient’s resting energy requirement (RER):
- RER (kcal/day) = 70 x BWkg0.75 or RER (kJ/day) = 293 x BWkg0.75
- On the first day, feed 25% to 33% of the calculated RER divided into 4 or more feedings daily. The amount given per meal when bolus feeding should be limited to 5 to 10 mL/kg BW. Feed slowly over 10 to 15 minutes to allow for stomach expansion.10
- Watch for signs of nausea such as drooling or licking of the lips. If seen, temporarily stop the feeding and resume once resolved.
- If food is well tolerated, the percentage of RER can be increased by 25% to 33% every 12 to 24 hours, until full RER is reached.
- The starting point for assisted feeding is to calculate the patient’s resting energy requirement (RER):
- For cats with severe pancreatitis, intractable vomiting, and persistent anorexia, partial or total parenteral nutrition should be considered to prevent further undernutrition.11
“I am concerned that your cat has not been eating during the last [number] days. I am also concerned about [his/her] dehydration and weight loss. These signs can be associated with several different conditions, including pancreatitis, so I recommend we do some blood and urine testing here in the hospital and take X-rays to give us a better idea of what is going on. Depending on what we find, we can then determine the next steps, such as antinausea and appetite stimulant medications, and IV fluids.”
Related Tools and Content:
Nutritional Assessment Is an Iterative Process: Extended Evaluation
An extended nutritional evaluation is important for pets at risk for nutrition-related problems.
1 min to 5 min
Feline Hepatic Lipidosis
Prompt and intensive nutritional support is fundamental to the treatment of hepatic lipidosis in cats.
1 min to 5 min
Feline Chronic Enteropathy
Diet modification can play either a central or an adjunct role in a multimodal approach to managing cats with chronic enteropathy.
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Feline Cholangitis
In addition to medical management, intensive nutritional support is essential for cats diagnosed with cholangitis.
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The Purina Body Condition System
The Purina Body Condition System is an easy and practical tool for assessing a pet's body composition.
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How to Perform a Body Condition Assessment - Cat
Assess a cat's Body Condition Score in just 3 simple steps.
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Use Muscle Condition Scoring to Detect Muscle Loss in Patients
Muscle condition scoring is a hands-on method for evaluating lean body mass that can be used as part of nutritional assessments.
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Lean Body Mass & Protein
Discover the importance of Lean Body Mass (LBM) in overall health for dogs and cats, and the role a high-protein diet can play in slowing LBM loss.
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To Share With Pet Owner:
Evaluating Your Cat’s Body Condition
Assess your cat's Body Condition in just 3 simple steps.
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References
- Armstrong, P. J., & Crain, S. (2015). Feline acute pancreatitis: Current concepts in diagnosis and therapy. Today’s Veterinary Practice, 5(1), 22─27.
- De Cock, H. E. V., Forman, M. A., Farver, T. B., & Marks, S. L. (2007). Prevalence and histopathologic characteristics of pancreatitis in cats. Veterinary Pathology, 44(1), 39─49. doi: 10.1354/vp.44-1-39
- Ferreri, J. A., Hardam, E., Kimmel, S. E., Saunders, H. M., Van Winkle, T. J., Drobatz, K. J., & Washabau, R. J. (2003). Clinical differentiation of acute necrotizing from chronic nonsuppurative pancreatitis in cats: 63 cases (1996─2001). Journal of the American Veterinary Medical Association, 223(4), 469─474. doi: 10.2460/javma.2003.223.469
- Forman, M. A., Steiner, J. M., Armstrong, P. J., Camus, M. S., Gaschen, L., Hill, S. L., Mansfield, C. S., & Steiger, K. (2021). ACVIM consensus statement on pancreatitis in cats. Journal of Veterinary Internal Medicine, 35(2), 703─723. doi: 10.1111/jvim.16053
- Hill, R., & Van Winkle, T. Acute necrotizing pancreatitis and acute suppurative pancreatitis in the cat. A retrospective study of 40 cases (1976─1989). Journal of Veterinary Internal Medicine, 7(1), 25─33. doi: 10.1111/j.1939-1676.1993.tb03165.x
- Armstrong, P. J., & Williams, D. A. (2012). Pancreatitis in cats. Topics in Companion Animal Medicine, 27(3), 140─147. doi: 10.1053/j.tcam.2012.09.001
- Bazell, J., & Watson, P. (2014). Pancreatitis in cats: Is it acute, is it chronic, is it significant? Journal of Feline Medicine and Surgery, 16(5), 395─406. doi: 10.1177/1098612X14523186
- Mansfield, C. (2016). The challenges of pancreatitis in cats: A diagnostic and therapeutic conundrum. In S. Little (Ed.), August’s consultations in feline internal medicine (Volume 7, pp. 169─179). Elsevier.
- Klaus, J. A., Rudloff, E., & Kirby, R. (2009). Nasogastric tube feeding in cats with suspected acute pancreatitis: 55 cases (2001─2006). Journal of Veterinary Emergency and Critical Care, 19(4), 337─346. doi: 10.1111/j.1476-4431.2009.00438.x
- Perea, S. C. (2008). Critical care nutrition for feline patients. Topics in Companion Animal Nutrition, 23(4), 207─215. doi: 10.1053/j.tcam.2008.08.001
- Jensen, K. B., & Chan, D. L. (2014). Nutritional management of acute pancreatitis in dogs and cats. Journal of Veterinary Emergency and Critical Care, 24(3), 240─250. doi: 10.1111/vec.12180