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ACVIM Specialty 2023 > Pancreas > Flashcards

Pancreas Flashcards

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
Q

What events follow activation of trypsinogen and acinar cell death?

A

Influx of neutrophils, increased vascular permeability, and loss of apical paracellular barriers

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26
Q

Explain the pathophysiology of chronic pancreatitis that develops independent of acute pancreatitis

A
  • 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
Q

What cell, if exposed to ongoing low-grade inflammation, results in the development of periacinar fibrosis?

A

Pancreatic stellate cells

28
Q

FNA of the pancreas yields diagnostic samples what percent of the time?

A

67%

29
Q

Why are assays designed to measure lipase (with the exception of fPL) not specific for pancreatitis?

A

Many other tissues in the body produce lipase, which will be measured on these assays (gastric, hepatic, etc)

30
Q

What is the PPV and NPV for Spec fPL in sick cats?

A

PPV 90%, NPV 76%
- Positive: pancreatitis is probable but cannot be used to rule out pancreatitis

31
Q

What is the agreement between ultrasound and DGGR-lipase or Spec fPL?

A

Terrible: kappa =0.22 and 0.26

32
Q

Why does lack of enteral nutrition lead to worse outcomes in pancreatitis?

A

Lack of enteral nutrition leads to impaired gastric motility, villous atrophy, compromised intestinal blood flow, altered barrier function, and disruption of microbiota

33
Q

FISH has identified bacteria in the pancreas of what percent of cats with moderate to severe pancreatitis?

A

35%

34
Q

What clinicopathologic abnormality has been associated with poor outcome in acute pancreatitis?

A

Low ionized calcium

35
Q

If corticosteroids or cyclosporine are prescribed for chronic feline pancreatitis, when should fPL be re-evaluated?

A

At 2-3 weeks - if no improvement, consider discontinuation

36
Q

In a recent retrospective study of cats with pancreatitis, what was the survival to discharge rate?

A

77%

37
Q

In a recent retrospective study of cats with pancreatitis, what percent of cases were idiopathic?

A

86%
- Causes included general anesthesia, trauma, hemodynamic compromise, organophosphate intoxication

38
Q

In dogs with acute pancreatitis treated with prednisone (1mg/kg/day), what variables improved compared to the control group?

A
  • C reactive protein improved faster
  • Clinical scores improved earlier
  • Mortality rate 1 month after discharge was 11% vs 46%
39
Q

Compared to ultrasound, CT scan was better at identifying what in dogs with acute pancreatitis?

A

Portal vein thrombosis

40
Q

In a retrospective cohort study establishing a pancreatitis scoring system (CAPS), what risk factors were identified for short term death?

A
  • Presence of SIRS
  • Coagulation disorders
  • Increased creatinine
  • Ionized hypocalcemia
41
Q

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?

A

11

42
Q

Asymmetric dimethylarginine (ADMA) is a potential biomarker for acute pancreatitis in dogs. What did it correlate with?

A

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
Q

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?

A

27%

44
Q

What percent of dogs with elevated DGGR lipase (>3x upper reference) had acute pancreatitis? What other conditions caused elevations?

A

32% - other conditions were renal, endocrine, immune mediated diseases, and upper airway obstruction

So commonly elevated with other critical illnesses

45
Q

What percent of dogs with acute pancreatitis were hypercoagulable on TEG? What other coag parameters were abnormal?

A

100% hypercoagulable (15 dogs)
- Increased D dimers (1,144)
- Increased fibrinogen (837)
- Lower antithrombin

46
Q

What coagulation factor was associated with mortality in dogs with acute pancreatitis?

A

Low antithrombin activity

47
Q

What inflammatory cytokines were higher in dogs with acute pancreatitis compared to controls? Which one correlated with cPLI and CRP?

A

IL-6 and TNF-alpha
IL-6 correlated with CRP and cPLI

48
Q

Which pancreatic lipase test had the highest repeatability?

A

Spec cPL (coefficient of variation 5.5%)
In house assays (VetScan cPL and Vcheck cPL) were more variable (17 and 24%)

49
Q

In a study of 60 cats presented for necropsy, what was the sensitivity and specificity of fLP vs DGGR?

A

Spec fPL - sensitivity 42%, specificity 100%
DGGR = sen 36.8%, spe 100%

50
Q

In cats with CKD, was fTLI or fPLI affected by azotemia?

A

fTLI was significantly higher in azotemic animals; fPLI was not affected - can be used in cats with CKD to diagnose pancreatitis

51
Q

What is the difference between a catalytic assay and an immunologic assay?

A
  • 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
Q

How does pancreatitis lead to hypocalcemia?

A

Formation of calcium salts with fatty acids in areas of necrosis

53
Q

What factors can alter the specificity of a catalytic assay?

A

The substrate used for the assay, presence of cofactors (for lipase, bile acids, colipase), pH

54
Q

The original catalytic 1,2-diglyceride assays lacked specificity and could be elevated with what other disease conditions?

A

Renal or hepatic disease

55
Q

In a paper evaluating 50 dogs with GI disease, what was the sensitivity and specificity of DGGR lipase for the diagnosis of pancreatitis?

A

Sensitivity 85-90%
Specificity: 65-75%

56
Q

How is the canine cPL performed through Texas A&M? What is normal?

A
  • Sandwich ELISA utilizing 2 monoclonal antibodies, each recognizing a specific epitope of pancreatic lipase
  • Normal = <200
  • Pancreatitis = >400
57
Q

In multiple studies, what have the sensitivities and specificities for cPL been?

A

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
Q

In a study evaluating AUS for the diagnosis of pancreatitis in 157 dogs, what was the sensitivity and specificity of AUS?

A
  • Using 1 abnormality: high sensitivity (89%) but low specificity (43%)
  • Using 3 abnormalities: high specificity (92%) but low sensitivity (43%)
59
Q

In a study evaluating CT angiography for the diagnosis of pancreatitis, a heterogenous pancreas was associated with what?

A

Longer hospitalization, increased risk of relapse, and higher likelihood of portal vein thrombosis

60
Q

What ultrasonographic changes can be seen with feline EPI?

A
  • Minimal to none in 39% of cats
  • 46% displayed pancreatic duct dilation or tortuosity
  • 46% displayed a “thin” pancreatic parenchyma
61
Q

The concentrations of what lipid soluble vitamins were lower in dogs with EPI on supplemental pancreatic enzymes?

A
  • Retinol and alpha-tocopherol
  • Dogs with weight loss had lower vitamin D than healthy dogs
62
Q

How does EPI affect appetite in cats?

A

Variable: 45% had anorexia and 42% had increased appetite

63
Q

What was the most common clinical signs in cats with EPI?

A

Weight loss (92%)
Unformed feces (62%)

64
Q

What percent of cats with EPI had hypocobalaminemia? Did cobalamin supplementation improve outcome?

A
  • 77%
  • Yes, improved response to treatment (OR 3)

ACVIM Specialty 2023 (38 decks)

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