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Clin Path > GI & Pancreas Lecture 19 > Flashcards

GI & Pancreas Lecture 19 Flashcards

1
Q

what is the value of poop and fecal testing?

A

An incredibly important part of the laboratory work‐up
for GI disease

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2
Q

what are the two main exocrine pacreatic disorders?

A

Pancreatitis
Exocrine pancreatic insufficiency (EPI)

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3
Q

Describe the mechanism of pancreatitis.

A
  • Trigger (may or may not be obvious) –> inflammation –> cell damage +/- death –> enzyme leakage –> worsening cell damage
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4
Q

Pancreatitis occurs in

A

Dogs & cats

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5
Q

Pancreatitis can be

A

acute or chronic

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6
Q

What are the clinical signs of pancreatitis?

A
  • Severity highly variable
  • Abdominal pain
  • Loss of appetite
  • Vomiting
  • May affect peritoneum
  • Can cause obstructive cholestasis
  • Can cause secondary EPI
  • Can cause secondary DM

Clinical signs in cats may be subtle

EPI = exocrine pancreatic insufficiency
DM = diabetes mellitus

Inflamed pancreas can irritate gallbladder
Islet cell destruction results in DM
EPI and DM are relatively uncommon unless you have severe pancreatitis or constant reoccurance

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7
Q

How do you DX pancreatitis?

A
  • Clinical history
  • Physical examination
  • Minimum database
  • Specialized lab tests (more in a minute . . .)
  • Testing to rule out parasites or infections
  • Abdominal imaging
  • +/- Pancreatic cytology or histopathology

Diagnosis is based on looking at the
BIG PICTURE.

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8
Q

What is exocrine pancreatic insufficiency (EPI)?

A
  1. Acinar cell destruction
    a. due to primary (breed-associated)
    b. secondary (to chronic pancreatitis)
  2. Lack of digestive enzymes & bicarbonate‐rich fluid
  3. Inability to digest
    nutrients (maldigestion)
  4. Typically also imbalance of intestinal flora (intestinal dysbiosis)
  5. Maldigestion: weight loss & chronic diarrhea (good appetitecommon with primary)

basically a “failure” of pancreatic digestive fxn

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9
Q

How do you DX EPI?

A
  • Clinical history
  • Physical examination
  • Minimum database
  • Specialized lab tests (more in a minute . . .)
  • Testing to rule out parasites or infections
  • +/- Abdominal imaging
  • +/- Intestinal histopathology (R/O other diarrhea causes)

Diagnosis is based on looking at the
BIG PICTURE.

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10
Q

T/F: Not all animals with pancreatitis
have secondary EPI

A

True

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11
Q

T/F: All animals with EPI have
underlying pancreatitis

A

False, Not all animals …

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12
Q

Main differences between Pancreatitis and EPI?

A

Pancreatitis: pancreatic inflammation
EPI: Destruction of acinar
tissue
P: Enzyme leakage –>
inflammation
EPI: Pancreatic
insufficiency –>
maldigestion
P: Vomiting and abd. pain
EPI: chronic diarrhea and weight loss

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13
Q

Indication for lipase test?

A

Suspected pancreatitis. May be part of a routine small animal biochemical profile (varies by laboratory).

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14
Q

An increase on a lipase test means?

A

Increased lipase activity suggests leakage of lipase from damaged pancreatic tissue.

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15
Q

What is the DGGR method of lipase measurement?

A

DGGR is a reagent (lipase substrate) in the test system. DGGR is not 100% analytically specific for pancreatic lipase, and presence of other lipase types in plasma will mildly increase DGGR lipase activity.

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16
Q

What sample will you use to measure lipase?

A

serum or plasma

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17
Q

How do you interpret an increase in lipase?

A
  • a 3 to 5 fold increase above URL considered consistet with pancreatitis
  • However this is TOTAL LIPASE ad is not specific for pancreas alone
  • It can also be impacted by decreased GFR ad dexamethasone injections
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18
Q

What are the indications for the Pancreatic Lipase Immunoreactivity (PLI) test?

A

Suspected pancreatitis. This test must be ordered specially (not part of a routine biochemistry panel).
- ELISA –> categorical ie neg or pos (IDEXX) or radioimmunoassay –> quantitative ie concentration (texas GI lab)

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19
Q

What is the principle interpretation of a PLI test?

A
  • Both tests use reagent antibody to detect pancreatic lipase specifically
  • Both use fasting sample –> optimally 12 to 18 hours
  • PLI is increased in pancreatitis
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20
Q

How do you avoid error in the SNAP PLI tests?

A

Follow manufacturer instructions carefully
* Don’t use expired tests
* Warm components to ROOM TEMPERATURE
* Place kit on horizontal surface
* Measure drops carefully
* “SNAP” (depress the activator) correctly

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21
Q

How is EPI DX?

A

TLI = Trypsin‐like (trypsin + trypsinogen) immunoreactivity
* Fasting, non‐hemolyzed serum (Texas GI Lab)
* Decreased in EPI
* (Can be increased in pancreatitis & when GFR ↓)

EPI = exocrine pancreatic insufficiency
PLI = pancreatic lipase immunoreactivity
GFR = glomerular filtration rate

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22
Q

What are the confirmatory test results for pancreatitis ?

A

Increased PLI
Increased Lipase
(Increased TLI) a

NOTE: For diagnosing pancreatitis, PLI is
MORE diagnostically sensitive than TLI!

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23
Q

What are the confirmatory test results for EPI?

A

Decreased TLI

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24
Q

Disorders that affect intestinal function may cause:

A

− Maldigestion (similar to EPI)
− Malabsorption
− Protein loss (of albumin & globulins)

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25
Q

Enteropathy can also cause:

A
  • Chronic diarrhea & weight loss
  • Gut microflora may be abnormal (“dysbiosis”)
  • Vomiting occurs in some cases
26
Q

What is protein-losing enteropathy (PLE)?

A

A syndrome not a specific disease caused by various things, but usually diarrhea or weight loss.

27
Q

In Protein‐losing enteropathy (PLE) Excessive fecal protein loss can cause

A
  • panhypoproteinemia (decreased TP, ALB, GLOB) on a chem panel
  • May cause antithrombin loss and predispose to pathologic thrombosis
28
Q

Intestinal dysbiosis causes pathologic alteration of intestinal microbiome leading to..

A
  • Altered bacterial numbers
  • Altered bacterial subpopulations
  • Altered bacterial function
  • Or some combination of the above!
29
Q

The gut microbiome is an active research area in human and vet med because?

A
  • Flora impact immunity, gut fxn
  • Sophisticated molecular techniques
  • Relevant to fecal transplantation
30
Q

What is cobalaminn and folate used for?

A
  • Cobalamin is a required cofactor in metabolic pathways involving folate
  • Active Folate is used in DNA synthesis in many tissues
31
Q

How does the GI tract utilize cobalamin?

A
  • Microflora USE it
  • Absorbed in ILEUM*
  • Serum sample
  • Project from light
  • ng/L

*Requires INTRINSIC FACTOR (from the pancreas in dogs & cats)
Think of these as biomarkers of intestinal
dysbiosis, maldigestion, and malabsorption.
Realize these are VERY CRUDE indicators of what’s going on with the microflora!

32
Q

How does the GI tract utilize Folate

A
  • Microflora MAKE it
  • Absorbed in PROXIMAL SI
  • Serum sample
  • Project from light
  • microg/L

Think of these as biomarkers of intestinal
dysbiosis, maldigestion, and malabsorption.
Realize these are VERY CRUDE indicators of what’s going on with the microflora!

33
Q

Whats the most common indication for cobalamin testing?

A

Chronic small bowel diarrhea +/- weight
loss; suspected EPI.

34
Q

Whats the principle of cobalamin testing?

A

Low [cobalamin] due to overgrowth of bacterial flora and/or maldigestion.

35
Q

How do you interpret cobalamin tests?

A

Low [cobalamin] suggests intestinal dysbiosis and/or cobalamin malabsorption.

36
Q

Most cases of low cobalamin are due to what?

A

Most cases of low cobalamin are due to dysbiosis or an acquired malabsorption disorder.

37
Q

Low cobalamin in a zebra

Whats a A less common indication for low cobalamin testing?

A

Suspected congenital cobalamin deficiency

38
Q

Low cobalamin in a zebra

Whats the priniciple for low cobalamin?

A

Low [cobalamin] due to congenital defect
in cobalamin‐intrinsic factor complex receptor

39
Q

Low cobalamin in a zebra

How do you interpret low cobalamin in a zebra?

A

Low [cobalamin] supports this congenital deficiency in a young dog of certain breeds*

*Reported in giant schnauzers, Australian shepherd dogs, beagles, and border collies.

40
Q

How does low cobalamin manifest as?

A

Manifests as unthrifty, young animal.
May see non-regenerative anemia.

41
Q

Can low cobalamin be nutritional?

A
  • Extremely unlikely, if intestinal function is normal. –> This is why we can use it as a biomarker of
    intestinal dysbiosis or malabsorption!
  • In cattle, may be associated with low‐cobalt diet.
  • Body stores take a LONG TIME to get depleted.
42
Q

Summary

Altered cobalamin: Decreased due to? Increased?

A

Decreased:
- Intestinal dysbiosis
(due to EPI or other cause)
- Ileal disease (malabsorption)
Congenital defect in ileal receptor (rare)
- Nutritional deficiency (really rare)

Increased (rare):
- Over‐supplementation
- Hepatocyte damage

43
Q

What are the indications for folate testing?

A

Chronic small bowel diarrhea +/- weight
loss; suspected EPI

44
Q

Whats the principle of folate presence?

A

Overgrowth of bacterial flora causes
increased [folate]

45
Q

How do you interpret folate tests?

A

Increased [folate] concentration suggests intestinal dysbiosis; low [folate] suggests intestinal malabsorption (or certain
medications – see subsequent slide).

46
Q

Can low folate be due to nutrition?

A
  • Extremely unlikely, if intestinal function is normal. –> This is why we can use it as a biomarker of
    intestinal dysbiosis or malabsorption!
  • Chronic antibiotic use (kills microflora) can cause.
  • Methotrexate treatment can also cause.
47
Q

Summary

Folate is decreased because? Increased?

A

Decreased:
- Proximal intestinal dz
(maldigestion, malabsorption)
- Certain drugs
(e.g., antibiotics, other)

Increased:
- Over‐supplementation
- Intestinal dysbiosis
(due to EPI or other cause)

48
Q

Dog has decreased cobalamin, N folate, N TLI. Whats your DX?

A

Congenital cobalamin deficiency OR disease of distal small intestine (ileum).

49
Q

Dog has decreased cobalamin, increased folated, decreased TLI. Whats your DX?

A

EPI, with intestinal dysbiosis

50
Q

Dog has increased cPLI, N cobalamin, N folate. Whats your DX?

A

Pancreatitis

51
Q

Dog has N cobalamin, decreased folate, N TLI. Whats your DX?

A

Proximal small intestinal disease (duodenum, jejunum), or possibly antibiotic or methotrexate use

52
Q

Dog has decreased cobalamin, increased folate, N TLI. Whats your DX?

A

Intestinal dysbiosis (but not due to EPI)

53
Q

Dog has decreased alb, decreased glob, N TLI. Whats your DX?

A

PLE a top differential, assuming patient has GI signs & there is no other explanation for the protein changes!

54
Q

Dog has N cobalamin, N folate, decreased TLI. WHats your DX?

A

EPI (but no apparent dysbiosis)

55
Q

What are some tests of SI permeability/absorption?

A

Administer oral test substance –>substance absorbed
from gut to blood –> timed blood samples –> measure
substance –> plot absorption curve ([X] over time).
* Info about SI function from time to peak absorption,
fold‐change over baseline, curve shape, and AUC.
* Most commonly done in HORSES with chronic GI dz
(e.g., malabsorption and/or inflammatory bowel
disease suspected)

56
Q

What are some indications for glucose absorption testing?

A

Suspect IBD; diarrhea, poor body condition, mild/recurrent colic

57
Q

Whats the principle of glucose absorption testing?

A

SI inflammation impairs intestinal mucosal function & absorption of glucose

58
Q

How is the glucose absorption testing procedure done?

A

Fast horse 12 to 18 hr. Give oral glucose solution. Take timed blood samples.
Measure glucose & plot results over time.

59
Q

How do you interprate glucose absorption test?

A

Delayed or subnormal absorption indicates compromised SI function and
supports a dx of IBD.

60
Q

What components of rumen fluid are evaluated?

A
  • Microflora morphology and motility
  • pH
  • Chloride concentration
61
Q

When you work up a cow what is part of it?

A

Part of work‐up for any cow with signs of decreased rumen
motility.
Usually collected via orogastric tube. (May need rumen‐centesis if accurate pH is critical.)

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