19. Acute and chronic pancreatitis, exocrine pancreas insufficiency in dogs and cats Flashcards
Classifying pancreatitis?
CLASSIFYING PANCREATITIS
§ Acute/Chronic/Recurrent
§ Mild/Severe/Fatal
§ Acute serous/Acute-haemorrhagic-necrotising/Purulent
Pathogenesis of acute pancreatitis?
Acute Pancreatitis pathogenesis?
After generalisation of pancreatitis, local, regional & multisystemic
effects are seen throughout the body:
Local effects
§ Oedema; Inflammation; Haemorrhage; Necrosis
§ Acute fluid accumulation
Regional effects
Damage of adjacent organs
§ Cholestasis; Extrahepatic biliary obstruction (EHBO)
§ Duodenitis; Colitis; Local peritonitis
Multisystemic effects
§ SIRS (systemic inflammatory response syndrome) →
MODS (multiple organ dysfunction syndrome)
§ Kidney: Acute kidney failure
§ Respiratory: ARDS; Pleuritis
§ Cardiac: Arrhythmia
§ GIT: Ischaemia; Inflammation
§ DIC; Septicaemia; Coagulation; Fibrinolysis; Free radicals
Acute Pancreatitis Diagnosis, Clinical findings, Diagnostic imaging, Lab D and Differential Diagnosis?
DIAGNOSIS
High risk
§ See “predisposed” earlier
§ High fat diets; Hyperlipidaemia
§ Drugs: KBr; Phenobarbital; Tetracyclines; Furosemide
§ Toxins: Organophosphates; Zinc
§ Pathogens: Babesia spp.; Leishmania spp.
§ Pancreatic trauma; Abdominal surgery
§ Ischaemia; ↓ Perfusion
§ Duodenal reflux; Ductal hypertension
Aetiology: Gall stones; Hereditary; Idiopathic
Clinical findings
§ Vomiting § Fever
§ Anorexia § Diarrhoea
§ Lethargy § Jaundice
§ Abdominal pain (Fig 11.2) § Dyspnoea
Diagnostic imaging
Abdominal Ultrasound (specific)
↓ Echogenicity → Pancreatic necrosis
Peripancreatic region: ↑ Echogenicity → Peritonitis
Abdominal radiology (non-specific) **_Lab. D_**
Pancreatic lipase immunoreactivity (PLI) (organ-specific)
Spec cPL (canine pancreatic lipase); fPL (Fe.)
Snap cPL (patient-side test)
VetScan cPL (patient-side test)
ELISA tests
(-) Result → Ø Pancreatitis
(+) Result → Confirm with specific cPL
Haematology (non-specific)
↑ PCV: Dehydration; Hypovolaemia
↑ WBC + ↑CRP: Leucocytosis; “Left shift”
↓ Thrombocytes
APTT; PTT; D-dimer
Plasma: Icterus; Lipemic
Biochemistry (non-specific)
Azotaemia: Dehydration; Hypovolaemia
↑ Cholesterol; ↑ Blood lipid
↑ Liver enzymes; ↑ Bilirubin: Hepatocellular injury; Ischaemia;
Cholestasis
Amylase & Lipase (low-specificity): Dggr-lipase
Other (non-specific)
§ ↑ Blood glucose
§ ↓ Blood calcium
§ ↓ Blood potassium
§ ↓ Blood sodium
§ Metabolic acidosis
Differential diagnosis
§ Gastritis § Ileus
§ Gastroenteritis § Pyometra
§ Peritonitis § Prostatitis
§ Acute renal insufficiency § Pyelonephritis
Treatment of acute Pancreatitis?
TREATMENT
Fluid therapy (essential)
The pancreas is susceptible to hypovolaemia; We aim to maintain
homeostasis and ↑ the pancreas’ microcirculation
Either:
§ Crystalloids
§ Colloids
§ Plasma transfusion (suggested in DIC cases)
Analgesia
Used even if there is no apparent abdominal pain
§ Opioids
§ FLK CRI (Fentanyl-ketamine-lidocaine)
§ Fentanyl patch
§ Ø NSAIDS (potential ulcerogenic/nephrotoxic effect)
Antiemetics
Given initially (or symptomatically); Even if there is no vomiting
§ Maropitant
§ Ondansetron
§ Metoclopramide
Management of complications
§ Gastric acid suppressants: Omeprazole
§ Antibiotics: Amoxiclav; Metronidazole
§ Glucocorticoids
§ Surgery (if unavoidable)
Special diet
Aims to prevent malnutrition, feed enterocytes & rest the pancreas
Feed ASAP – High digestibility; Low-fat
Chronic Pancreatitis?
Chronic Pancreatitis
Recent studies show that chronic pancreatitis is more common than acute
Predisposed: Cats > Dog; Middle/old-aged
Types: Idiopathic; Autoimmune
§ Idiopathic pancreatitis: Toy breeds; Terriers; Spaniels;
Collie; Boxer; Sled dogs
§ Autoimmune pancreatitis: Cocker spaniel
Immunosuppressants may be beneficial
CLINICAL SIGNS
May be exhibited for months → years
§ Recurrent postprandial pain
§ Ø Appetite
§ Vomiting
§ Haematochezia/colitis
§ Severe acute peritonitis (recurring)
§ Most common cause of extrahepatic bile duct obstruction
§ End stage: DM; EPI
DIAGNOSIS
See acute pancreatitis
cPLI is the preferred test for chronic pancreatitis too
Definitive diagnosis: Histology (impractical)
§ Signs of irreversible morphological damage
§ Fibrosis; Atrophy; Lymphocytic infiltration
TREATMENT
§ Low-fat
§ Analgesics
§ Treatment of any acute pancreatitis, EPI or DM
Feline Pancreatitis?
FELINE PANCREATITIS
Cause: Trauma; Ischaemia; Concurrent disorders
Aetiology: Bacterial translocation; Haematogenous spread
Clinical signs
Acute: Vomiting; Abdo. Pain; Anorexia; Lethargy; Hypothermia
Chronic: Weight loss; Signs of concurrent disorders
Diagnosis
§ fPL test
§ Blood work: See dog pancreatitis
Treatment
Acute: See dog pancreatitis; Give additional abx; Feeding tube
Chronic: See above; Improve appetite (B12); Steroids; Antioxidant
EPI?
Exocrine Pancreas Insufficiency
AETIOLOGY
Occurs by two main pathomechanisms:
§ Pancreatic acinar atrophy (PAA)
§ Chronic pancreatitis
Pancreatic acinar atrophy
§ 60% of cases are German Shepherds; Collie; Chow-chow
§ Young > Old
§ Autoimmune cause; Ø DM
Chronic pancreatitis
§ Cats & spaniels (end stage/old > young)
§ DM is possible
SYMPTOMS
§ Acute: Polyphagia; Weight loss; Cachexia; Claylike faeces
§ Chronic: Alert; Good general state
DIAGNOSIS
↓ TLI (Trypsin-like immunoreactivity) (Highly specific for EPI)
§ Concentration of trypsin-like substances in the blood
§ cTLI in dogs; fTLI for cats
TREATMENT
§ Pancreatic enzyme substitution: Powder; Capsule;
Beef/pork pancreas
Dose dependent: Gastric acid suppression
§ Diet: High-digestibility; Moderate fat; Ø Fibre
§ Cobalamin supplementation
§ Antibiotic therapy
