EPI - We Learn More

Over the past few weeks I have learned a lot about Catcher's issues. Simply put Exocrine Pancreatic Insufficiency means that he cannot absorb the nutrients he is digesting. Which explains his wasting over the last few weeks.

From an online article:

"The pancreas has two functional parts. The endocrine part secretes insulin and glucagon, which are essential for the metabolism of carbohydrates. The exocrine part consists of units called acini that produce and secrete enzymes essential for the digestion of protein, into the small intestine. With EPI, there is a gradual wasting away (atrophy) of the acini. Clinical signs do not develop until most of the acini are gone. As dogs lose the ability to digest protein, they progressively lose weight despite a voracious appetite.

Affected dogs lose weight despite voracious appetites, and usually pass large amounts of semi-formed feces. They often eat their own stools, or other inappropriate substances. Some dogs with this condition do not show these typical signs, and may experience intermittent watery diarrhea or vomiting.

Although this disorder cannot be cured, management is generally fairly straightforward. Powdered pancreatic enzyme extract is mixed in with each meal. Within a few days, your dog's appetite and stools should become more normal, and s/he will begin to gain weight. Enzyme supplementation of your dog's food will be necessary for life." 1998 Canine Inherited Disorders Database.

From the Cornell website:

Description: EPI is characterized by inadequate production of digestive enzymes from pancreatic acinar cells. This might be a result of chronic pancreatitis, juvenile pancreatic atrophy, decreased function in severe protein-calorie malnutrition, or rarely following acute hemorrhagic pancreatitis. The lack of digestive enzymes and bicarbonate secretion results in acidification of the gut, malnutrition and weight loss, with voluminous stools containing undigested fat, muscle fibers and protein.

Signs: Abdominal distention, Abnormal behavior, aggression, changing habits, anorexia, diarrhea, dullness, flatulence, increased borborygmi, internal abdominal mass, lack of growth or weight gain, pale, pica, polydipsia, polyphagia, rough hair coat, steatorrhea (fatty stools, feces), Tachycardia, underweight (poor condition, thin, emaciated, unthriftness, ill thrift), unusual or foul odor (stools, feces), vomiting or regurgitation, weight loss

After reading several different articles, and talking with my friend Jenn whose collie is suspected to have EPI, I realized that Catcher had certainly been showing most of the symptoms. The problem was that they were intermittent, and any of those symptoms could be evidence of something else. For a long time we suspected that his off and on again diarrhea was due to a parasite problem (he had picked up whipworms at daycare as a puppy and we'd been treating with panacur regularly to break the cycle). It was only when looking at everything as a whole did the pieces of the puzzle begin to fit together.

I was still left with asking how and why. How did an adolescent dog who was perfectly healthy (as proven by multiple blood workups) develop all of these conditions (KCS, EPI, Diabetes) within 2 months of each other. What had changed? Did his neuter have any effect on this? The unfortunate problem was that no one had any answers. All 3 conditions are fairly rare in Border Collies, especially ones under the age of two. EPI and Diabetes are both pancreatic and if untreated EPI can lead to Diabetes. However, the KCS was a totally unrelated issue.

Another Re-Check

Today Catcher had a re-check for his eyes, which getting a bit better during this whole fiasco. He was up to getting the Tacrolimus 3x daily, BNP 2x daily, plus artificial tears and saline flushing as often as possible.

Weight: 39.2# (we've gained some, that's good)
Schirmer Tear Test: Left Eye: 18 Right eye: 15 (at least there is some tear production)

However, the stain did have some uptake. (Damn.) Another mild abrasion. Other than that he's doing well.

We rechecked his pre-anesthetic profile today as well. I don't have the results, but I think everything seemed fine.

Second Birthday

It's been one week since Catcher's diagnosis and today is his 2nd birthday.  One week ago I didn't think that I would be able to celebrate today with him.

Blood Tests Offer a Diagnosis

Catcher returned to the vet today for a recheck of his glucose levels.

At 1:00pm BG: 139 (yay!)

Our plan: to recheck a preanesthetic profile on Thursday.

and here is where it begins to get interesting...

Results are in from the Tick Panel, TLI, and Immune panels...

Lyme - Positive 1:400*
Antinuclear Antibody (ANA): Positive 1:25
Rheumatoid factor: Negative
Ehrlichia Canis: Negative
Rocky Mountain Spotted Fever: Negative
Trypsin-Like Immunoreactivity: 2.1**
Coombs Test: Negative
Platelet Count: 238 (within normal limits of 164-510 thous/uL)

* Now remember that Catcher had an all around negative 4DX test in February. We decided to rerun a 3DX and see what it said. Negative all around. Hmmm. Notes from lab report: "A positive titer indicates exposure to the Borrelia Burgdorferi or similar antigen but does not confirm the presence of the disease. Titers may be affected by vaccination or disease." So we decided it was a false positive due to vaccine history.

** Reference range for TLI is 5-35ug/L. Catcher read 2.1. Anything <2.5 is consistent with Exocrine Pancreatic Insufficiency.

(There is also a note regarding the ANA about age or inflammatory disease but I can't decipher it)

D-Day + 1

I brought Catcher back to the vets to be admitted for the day. He seemed much happier. The techs all praised how good he had been the day before. I warned them to watch out because he was feeling better and I could see him eyeing the quick pace of the techs as they rushed around the back rooms.

Observations from the chart:
owner gave insulin @ 11:30pm. Chem profile run @ 7:30am. Restarted fluids @ 84ml/hr. 2 cc Cerenia in fluid bubble. owner says he ate a 1/2 cup of food last night. Ate well for us. Restarted Lactated Ringers with Dextrose.

Blood Glucose @ 11:40: 364 (off glucose drip 30 min prior to BG) gave 6 units NPH
2:15 - Disconnect IV fluids. Remove IV catheter. BG: 393 @ 2:45
Write script for NPH insulin - 6 units twice daily
Re-check Mon or Tues ~6 hours post injection

We were sent home with a box of syringes, bottle of insulin, and the instructions to give him 6 units twice daily, making sure that he had eaten before giving it to him. We were to bring him back Mon or Tues to test his blood. We were still awaiting the results of the bloodwork sent to Idexx.

D-Day

Today was one of the hardest days of my life. When I woke up this morning Catcher was extremely lethargic. He's not been eating well the past few days. Over the weekend I was at a seminar in Methuen and he began tanking water and urinating frequently. The poor guy had several accidents in his crate during the day and at night he would scream to wake me up and let him out. I feared I knew what was causing it, but clung to the hope that it was a displacement behavior due to stress. He got better Monday and had a good day. Tuesday he started seeming lethargic again. He has been unable to keep any food down for the last 2 days. Last night his temperature was 102.8. I called my vet first thing this morning. Of course they were closed for a staff meeting until 10:00 but I left a message saying it was urgent.

When they re-opened for appointments they called me back and we rushed him in. His temp was 102.0. We ran a urinalysis and blood work. While waiting for the results I took what I thought may be the last picture I would have of him.

 Here are the notes from his chart:

Findings:
Weight: 37 pounds (he lost close to six pounds in 3 weeks)
weight loss, decreased appetite
started Tacrolimus yesterday, clinical signs of pu/pd (increased water consumption and urination) began prior
run full urinalysis, CBC, chem profile, radiograph thorax/abdomen (suspect blockage)

Urinalysis:
Glucose ++++ Ketones ++
Cloudy, dark
negative for: Leukocytes, nitrite, protein, blood
Normal for Urobilinogen
Specific Gravity 1.020 - 1.033 (two different numbers on two different spots)
Ketones 40
Glucose >2000

At this point I'm sitting on the floor with him in my lap wondering if we're going to survive the morning.

Radiographs: 2 views, lateral thorax and abdomen. Normal findings, no blockage (damn, that would have been the better hope)

They tested his blood glucose it was 448. His ALP - 339. ALT - 132. Na - 135. K - 5.2 (N)

We decided the best course of action (and really only course) was to admit Catcher for the day. They would give him an IV and start him on insulin. He was so sick he could barely move. I left him there and headed to work (as I wasn't being allowed to take the day off). I spent the rest of the day trying to hold back hysterical tears while awaiting news from Mom. I told her that I couldn't lose him one week before his 2nd birthday. That after the 12th I would make any decision needed, but he was having a 2nd birthday.

Treatments for the rest of the day:
IV catheter: 84 ml/hour
0.04 ml (4 u) reg insulin IM & 2 cc Cerenia SQ @ 1pm
Blood glucose @ 2:30: 422
Gave 2 units insulin @ 2:40pm

Notes/Suspected Diagnosis:
Treating for Diabetic Ketoacidosis (frightening words to me). Given recent diagnosis of KCS suspicious of underlying autoimmune disorder. Sent tick panel, TLI, and Immune Profile to Idexx. Currently treating with more aggressive protocol of hourly reg. Insulin IM injections and will switch to SQ reg insulin or Humilin N insulin accordingly. Tentative plan of stabilizing, sending home for the night, then arrange drop off again in AM to continue treatment.

Continued Treatments:
3pm: Brighter. BG @ 2:30: 422 - begin hourly 2 units reg. insulin IM
3:30 - 2 units
4:30 - 2 units
5:30 - Blood Glucose 188

Catcher was sent home with the instructions to give him some dinner at 10:30. I believe we were sent home with I/D but cannot be positive. Then to wait one hour to make sure he held it down and give him insulin at 11:30 pm. He did seem brighter when he got home that night. I kept him with me in the living room. I slept on the couch, and he slept next to me on the floor.