ACVIM: SAIM Specialty boards study 2023 > Pancreas > Flashcards

Pancreas Flashcards

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1
Q

What dog breeds are predisposed to acute pancreatitis?

A

Miniature Schnauzer, Yorkshire Terrier, other terriers

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2
Q

What dog breeds are predisposed to chronic pancreatitis?

A

Cavaliers, English Cockers, Boxers, Collies

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3
Q

Miniature Schnauzers with a history of pancreatitis are how many more times likely to have hypertriglyceridemia than Miniature Schnauzers without pancreatitis?

A

5 times more likely

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4
Q

What canine infection has been linked to acute pancreatitis?

A

Babesiosis

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5
Q

What drugs were linked to acute pancreatitis in up to 10% of treated dogs?

A

Phenobarbital and potassium bromide

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6
Q

What is the key factor in initiating pancreatic inflammation?

A

Activation of trypsin within the acinar cells

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7
Q

What are 3 causes of trypsin activation within the acinar cell?

A
  1. Blockage of acinar cell apex in the pancreatic duct or abnormalities in calcium signaling, leading to co-localization and fusion of zymogen and lysosomal granules
  2. Autoactivation (more likely when pH >5)
  3. Cathepsin B
  4. Enterokinase entering the portal circulation due to biliary-pancreatic reflux
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8
Q

What is the self-defense mechanism against intrapancreatic trypsin activation and when it is overwhelmed?

A

Intracellular pancreatic secretory trypsin inhibitor - overwhelmed when more than 10% of intracellular trypsin is activated

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9
Q

What shifts the balance between apoptosis of pancreatic cells and necrosis?

A

Infiltration of neutrophils, production of nitric oxide, reactive oxygen species, and phospholipase A3

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10
Q

What breed is thought to develop an autoimmune form of chronic pancreatitis?

A

English Cocker Spaniels

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11
Q

What diagnostic has the highest reported sensitivity and specificity for diagnosis of feline pancreatitis?

A

Spec fPL

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12
Q

What is the overall agreement between Spec fPL and DGGR lipase? Between Spec cPL and DGGR?

A

fPL; kappa 0.65-0.75
cPL; kappa 0.68

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13
Q

What are the causes of EPI in dogs and cats?

A

Common:
- Destruction of the pancreatic acinar cells due to chronic pancreatitis (50% dogs, 100% of cats)
- Depletion of acinar cells due to pancreatic acinar atrophy (50% dogs)
Rare:
- Obstruction of the pancreatic duct by a tumor or surgical ligation
- Pancreatic aplasia/hypoplasia in very young patients

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14
Q

Pancreatic acinar atrophy occurs in what dog breeds?

A

GSD, Rough coated Collies, Eurasians
- May be autosomal recessive inherited in GSDs

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15
Q

Clinical signs of EPI occur when what percent of the pancreas function is lost?

A

> 90%

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16
Q

What are the clinical signs of EPI?

A
  • Weight loss with an increased appetite
  • Coprophagia or pica (D)
  • Loose stools
  • Borborygmi or flatulence
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17
Q

What does TLI measure?

A

Cationic trypsinogen and trypsin

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18
Q

Describe 2 scenarios where TLI may be normal despite the patient having EPI

A
  1. Dog with isolated pancreatic lipase deficiency (has trypsin, so TLI is normal)
  2. Patient with obstructed pancreatic duct (producing enzymes, just not getting to the SI)
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19
Q

What is the most common and effective method of pancreatic enzyme replacement?

A

Dried pancreatic extract from pork pancreas - powder formulation seems more effective than tablets/capsules

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20
Q

What breed may be predisposed to exocrine pancreatic tumors?

A

Airedale Terriers

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21
Q

What is a common paraneoplastic presentation of cats with pancreatic neoplasia?

A

Alopecia - most prominent on the ventral abdomen but can involve the limbs and paws

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22
Q

What percent of cats have evidence of pancreatitis on necropsy?

A
  • 66% (50% chronic, 6% acute, 9% both)
  • When only healthy cats are considered 45% had evidence of pancreatitis
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23
Q

Zymogens can be activated within the pancreatic acinar cell by what mechanism, leading to pancreatitis?

A

Activated by thrombin during bacterial toxemia, ischemia, or hypoxia

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24
Q

The pancreatic inflammation in acute pancreatitis is dependent on ongoing stimulation of what pathway?

A

NFkappaB

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25
What events follow activation of trypsinogen and acinar cell death?
Influx of neutrophils, increased vascular permeability, and loss of apical paracellular barriers
26
Explain the pathophysiology of chronic pancreatitis that develops independent of acute pancreatitis
- Not trypsinogen dependent - Cholecystokinin and oxidative stressors sensitize acinar cells to injury and necrosis via calcium ion signaling and collapse of the mitochondrial membrane potential
27
What cell, if exposed to ongoing low-grade inflammation, results in the development of periacinar fibrosis?
Pancreatic stellate cells
28
FNA of the pancreas yields diagnostic samples what percent of the time?
67%
29
Why are assays designed to measure lipase (with the exception of fPL) not specific for pancreatitis?
Many other tissues in the body produce lipase, which will be measured on these assays (gastric, hepatic, etc)
30
What is the PPV and NPV for Spec fPL in sick cats?
PPV 90%, NPV 76% - Positive: pancreatitis is probable but cannot be used to rule out pancreatitis
31
What is the agreement between ultrasound and DGGR-lipase or Spec fPL?
Terrible: kappa =0.22 and 0.26
32
Why does lack of enteral nutrition lead to worse outcomes in pancreatitis?
Lack of enteral nutrition leads to impaired gastric motility, villous atrophy, compromised intestinal blood flow, altered barrier function, and disruption of microbiota
33
FISH has identified bacteria in the pancreas of what percent of cats with moderate to severe pancreatitis?
35%
34
What clinicopathologic abnormality has been associated with poor outcome in acute pancreatitis?
Low ionized calcium
35
If corticosteroids or cyclosporine are prescribed for chronic feline pancreatitis, when should fPL be re-evaluated?
At 2-3 weeks - if no improvement, consider discontinuation
36
In a recent retrospective study of cats with pancreatitis, what was the survival to discharge rate?
77%
37
In a recent retrospective study of cats with pancreatitis, what percent of cases were idiopathic?
86% - Causes included general anesthesia, trauma, hemodynamic compromise, organophosphate intoxication
38
In dogs with acute pancreatitis treated with prednisone (1mg/kg/day), what variables improved compared to the control group?
- C reactive protein improved faster - Clinical scores improved earlier - Mortality rate 1 month after discharge was 11% vs 46%
39
Compared to ultrasound, CT scan was better at identifying what in dogs with acute pancreatitis?
Portal vein thrombosis
40
In a retrospective cohort study establishing a pancreatitis scoring system (CAPS), what risk factors were identified for short term death?
- Presence of SIRS - Coagulation disorders - Increased creatinine - Ionized hypocalcemia
41
In the canine acute pancreatitis scoring system (CAPS), a cut off of what number had an 89% sensitivity and 90% specificity for predicting short term death?
11
42
Asymmetric dimethylarginine (ADMA) is a potential biomarker for acute pancreatitis in dogs. What did it correlate with?
ADMA is higher on admission in dogs with pancreatitis vs controls, higher in dogs with more severe pancreatitis (CAPS >11), and was associated with increased mortality
43
In a study of ultrasound findings in dogs with acute pancreatitis, 65% of dogs had evidence of pancreatitis on intake. What percent developed those signs within 2 days of admission?
27%
44
What percent of dogs with elevated DGGR lipase (>3x upper reference) had acute pancreatitis? What other conditions caused elevations?
32% - other conditions were renal, endocrine, immune mediated diseases, and upper airway obstruction So commonly elevated with other critical illnesses
45
What percent of dogs with acute pancreatitis were hypercoagulable on TEG? What other coag parameters were abnormal?
100% hypercoagulable (15 dogs) - Increased D dimers (1,144) - Increased fibrinogen (837) - Lower antithrombin
46
What coagulation factor was associated with mortality in dogs with acute pancreatitis?
Low antithrombin activity
47
What inflammatory cytokines were higher in dogs with acute pancreatitis compared to controls? Which one correlated with cPLI and CRP?
IL-6 and TNF-alpha IL-6 correlated with CRP and cPLI
48
Which pancreatic lipase test had the highest repeatability?
Spec cPL (coefficient of variation 5.5%) In house assays (VetScan cPL and Vcheck cPL) were more variable (17 and 24%)
49
In a study of 60 cats presented for necropsy, what was the sensitivity and specificity of fLP vs DGGR?
Spec fPL - sensitivity 42%, specificity 100% DGGR = sen 36.8%, spe 100%
50
In cats with CKD, was fTLI or fPLI affected by azotemia?
fTLI was significantly higher in azotemic animals; fPLI was not affected - can be used in cats with CKD to diagnose pancreatitis
51
What is the difference between a catalytic assay and an immunologic assay?
- Catalytic: reflects the enzymatic activity of a sample by quantifying substrate utilization or product accumulation (detected by colorimetric reaction) - ex. DGGR - Immunologic: uses antibodies to measure enzyme concentration (ELISA) - ex Spec cPL
52
How does pancreatitis lead to hypocalcemia?
Formation of calcium salts with fatty acids in areas of necrosis
53
What factors can alter the specificity of a catalytic assay?
The substrate used for the assay, presence of cofactors (for lipase, bile acids, colipase), pH
54
The original catalytic 1,2-diglyceride assays lacked specificity and could be elevated with what other disease conditions?
Renal or hepatic disease
55
In a paper evaluating 50 dogs with GI disease, what was the sensitivity and specificity of DGGR lipase for the diagnosis of pancreatitis?
Sensitivity 85-90% Specificity: 65-75%
56
How is the canine cPL performed through Texas A&M? What is normal?
- Sandwich ELISA utilizing 2 monoclonal antibodies, each recognizing a specific epitope of pancreatic lipase - Normal = <200 - Pancreatitis = >400
57
In multiple studies, what have the sensitivities and specificities for cPL been?
Sensitivity - depends on clinical severity - Mild cases = lower (down to 21%) - Moderate to severe cases = better (70-90%, depending on the study) Specificity - 75-88% (depending on the study)
58
In a study evaluating AUS for the diagnosis of pancreatitis in 157 dogs, what was the sensitivity and specificity of AUS?
- Using 1 abnormality: high sensitivity (89%) but low specificity (43%) - Using 3 abnormalities: high specificity (92%) but low sensitivity (43%)
59
In a study evaluating CT angiography for the diagnosis of pancreatitis, a heterogenous pancreas was associated with what?
Longer hospitalization, increased risk of relapse, and higher likelihood of portal vein thrombosis
60
What ultrasonographic changes can be seen with feline EPI?
- Minimal to none in 39% of cats - 46% displayed pancreatic duct dilation or tortuosity - 46% displayed a "thin" pancreatic parenchyma
61
The concentrations of what lipid soluble vitamins were lower in dogs with EPI on supplemental pancreatic enzymes?
- Retinol and alpha-tocopherol - Dogs with weight loss had lower vitamin D than healthy dogs
62
How does EPI affect appetite in cats?
Variable: 45% had anorexia and 42% had increased appetite
63
What was the most common clinical signs in cats with EPI?
Weight loss (92%) Unformed feces (62%)
64
What percent of cats with EPI had hypocobalaminemia? Did cobalamin supplementation improve outcome?
- 77% - Yes, improved response to treatment (OR 3)
ACVIM: SAIM Specialty boards study 2023
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