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Pancreatitis in Dogs and Cats

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Title: Slide 1 Author: Wendy Blount Last modified by: Wendy Blount, DVM Created Date: 1/16/2007 5:47:12 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Pancreatitis in Dogs and Cats


1
Pancreatitis in Dogs and Cats
  • Two Different Animals
  • Wendy Blount, DVM
  • Nacogdoches, TX

2
Two types of pancreatitis
  • Acute Pancreatitis
  • Abrupt onset
  • often reversible after treatment
  • May lead to chronic pancreatitis
  • Acute necrotizing (cell death) pancreatitis is a
    life-threatening condition
  • Chronic Pancreatitis
  • Continuing inflammatory disease
  • Irreversible pathology
  • Relapsing acute pancreatitis
  • Exocrine pancreatic insufficiency (EPI)
  • Diabetes mellitus

Acute
Chronic
2/3
1/3
3
Pancreatitis Clinical Presentation
4
Pancreatitis - Predispositions
  • Chronic liver Disease Why?
  • Bile reflux into the pancreas
  • Especially in cats why?
  • Because bile pancreatic duct merge
  • Diabetes mellitus
  • Intestinal disease

5
Pancreatitis - Predispositions
  • Hyperlipidemia Why?
  • Blood sludging - pancreatic ischemia
  • Lipase and other enzymes released
  • Hydrolysis of TG in ECF by lipase releases free
    fatty acids (FFA)
  • FFA cause microthrombi and bind to calcium to
    cause further damage (saponification)
  • More lipase is released
  • Positive feedback vicious cycle

6
Pancreatitis - Predispositions
7
Pancreatitis - Predispositions
  • Obesity
  • Hypercalcemia

8
Pancreatitis - Predispositions
  • Obesity
  • Hypercalcemia
  • Hyperadrenocorticism
  • Hypothyroidism
  • High fat meal How much is too much?
  • gt50 calories as fat
  • Careful of U/D in Schnauzers
  • Refeeding after prolonged anorexia

9
Pancreatitis - Predispositions
  • Pancreatic neoplasia
  • If you are treating one of the worst cases of
    pancreatitis you have ever seen, rule out
    pancreatic adenocarcinoma
  • Infectious
  • Toxoplasma gondii
  • Feline liver flukes Amphimerus pseudofelinus
  • Feline pancreatic flukes Eurytrema procyonis
  • FIP

10
Pancreatitis - Predispositions
  • Drugs
  • Corticosteroids
  • Chemotherapeutics/immunosuppressives
  • L-asparaginase
  • Azathioprine (Imuran)
  • Estrogens
  • Others

11
Pancreatitis - Predispositions
  • Toxins
  • Organophosphates
  • Scorpion stings
  • Uremic toxins
  • Vaccines

12
Pancreatitis - Predispositions
  • Toxins
  • Organophosphates
  • Scorpion stings
  • Uremic toxins
  • Vaccines

13
Pancreatitis - Predispositions
  • Trauma to the pancreas
  • Abdominal surgery
  • Ischemia (post-GDV, anesthesia, hypotension,
    shock)
  • Bile duct obstruction
  • Protracted and severe vomiting why?
  • Bile reflux into the pancreatic duct
  • Especially in the cat

14
Pancreatitis - Predispositions
Hypothyroidism dogs High fat meal dogs Refeeding
after anorexia dogs Pancreatic neoplasia both
  • Dog vs. Cat - Quiz
  • Hyperlipidemia
  • dogs
  • Hypercalcemia
  • Both
  • Hyperadrenocorticism
  • both

15
Pancreatitis - Predispositions
Trauma to the pancreas dogs gtgt cats Bile duct
obstruction cats gt dogs Protracted severe
vomiting cats gt dogs Vaccines ?????
  • Corticosteroids
  • dogs
  • Organophosphates
  • both
  • Uremia
  • both

16
Breed Predisposition
  • Dogs
  • Miniature Schnauzer
  • Sheltie
  • Briard
  • Small dogs (yorkies, poodles)
  • Cats
  • Siamese
  • Himalayan

17
Common Concurrent Diseases especially in cats
  • Cholangiohepatitis
  • Inflammatory bowel disease
  • Triaditis
  • Nephritis
  • Hepatic lipidosis cats only

18
Most Common Clinical Signs
  • Dogs

19
Most Common Clinical Signs
  • Dogs
  • 95 of dogs with pancreatitis vomit
  • Anorexia (91)
  • Abdominal pain (58)
  • Cats
  • Anorexia/weight loss 97
  • Only 35 of cats with pancreatitis vomit
  • Dehydration 92

20
Most Common Clinical Signs
  • Dogs
  • 95 of dogs with pancreatitis vomit
  • Anorexia (91)
  • Abdominal pain (58)
  • Cats
  • Anorexia/weight loss 97
  • Only 35 of cats with pancreatitis vomit
  • Dehydration 92
  • Constipation

21
Clinical Signs Dogs and Cats
  • Lethargy
  • Icterus why?
  • Diarrhea with or without blood
  • Fever (hypothermia more common in cats 68)
  • Abdominal pain, cranial abdominal mass
  • Hunched stance or praying position

22
Clinical Signs Dogs and Cats
  • Lethargy
  • Icterus why?
  • Diarrhea with or without blood
  • Fever (hypothermia more common in cats 68)
  • Abdominal pain, cranial abdominal mass
  • Hunched stance or praying position
  • Elevated respiratory rate
  • Necrotic skin lesions or red skin why?
  • Ascites

23
Pancreatitis - Sequella
  • SIRS
  • Systemic Inflammatory Response can Precipitate
  • Thromboembolic disease
  • Pulmonary thromboembolism
  • DIC
  • Pancreatic encephalopathy
  • Arrhythmia
  • Metabolic acidosis
  • Respiratory Distress (2 causes)

24
Pancreatitis Diagnosis
25
Diagnosis Clues in the Bloodwork
  • CBC nonspecific
  • Thrombocytopenia
  • Neutrophilia with left shift
  • Anemia
  • Serology
  • Lipemia after a prolonged fast (TG, chol)
  • Can present for opaque eyes or anterior uveitis
  • Hypocalcemia why?
  • Calcium consumed by saponification of fat
  • Hypoalbuminemia why?
  • Massive inflammation, vasculitis, sepsis

26
Diagnosis Clues in the Bloodwork
  • Serology Dogs and Cats
  • Nonspecific changes
  • Elevated liver enzymes
  • Elevated bilirubin why?
  • Azotemia
  • Hyperglycemia (cause or effect)
  • Hypoglycemia why?
  • Hypophosphatemia why?
  • Hypochloridemia why?

27
Diagnosis Clues in the Bloodwork
  • Serology Dogs only
  • Amylase
  • normal in 47
  • Lipase
  • Normal in 61
  • Serology Cats only
  • Elevated cholesterol (not as often triglycerides)
  • Amylase and lipase not at all useful

28
Diagnosis Clues in the Bloodwork
  • GI Serology Dogs and Cats
  • B12 may be low why?
  • Intrinsic factor from the pancreas is required
    for absorption
  • concurrent proximal small intestinal disease
  • Folate may be low if distal intestinal disease
  • Folate is absorbed in the ileum
  • REMEMBER B comes before F

29
Diagnosis Clues in the Bloodwork
  • GI Serology Dogs and Cats
  • TLI (trypsin like immunoreactivity)
  • Highly specific for EPI
  • Increased in SOME dogs and cats with pancreatitis

30
Diagnosis Clues in the Bloodwork
  • GI Serology Dogs and Cats
  • What is the BEST blood test to diagnose
    pancreatitis??
  • cPLI (canine Pancreatic Lipase Immunoreactivity)
  • 97 sensitive for pancreatitis
  • 82 specific for pancreatitis
  • fPLI (feline Pancreatic Lipase Immunoreactivity)
  • Much more sensitive and specific for pancreatitis
  • than any blood test or imaging
  • Antech and IDEXX
  • TAMU GI Lab (TVMDL sends to TAMU)

31
Diagnostic tools A comparison
32
SNAPR cPLTM
Features
  • 2 results Normal or Abnormal
  • Read time 10 minutes
  • Storage Refrigeration
  • Sample type Serum
  • Read Visual semi-quantitative
  • lt200 ug/L normal
  • 200-400 ug/L borderline
  • gt400 ug/L pancreatitis
  • Correlation to cPLI gt95
  • 96 of interpretations are correct

Sample
Reference
33
Comparing Spec cPL values to SNAP results
34
SNAP cPL for Screening
Dog w/ Vomiting, Anorexia, Abdominal pain
CBC Profile/lytes UA SNAP cPL
SNAP Abnormal
SNAP Normal
gt400
200-399
Treat for pancreatitis, Baseline cPLI
Abdominal radiographs Abdominal US Baseline cPLI
Pancreatitis is unlikely pursue other
differential diagnoses
monitor w/ cPLI
US/Rads confirm pancreatitis
US/Rads equivocal
Treat, Monitor, Retest Continue to rule out
other differential diagnoses
Treat for pancreatitis, Monitor with cPLI
35
Diagnosis Clues in the Bloodwork
  • Urinalysis nonspecific
  • Ketones
  • think diabetic with ketoacidosis (if glucosuria)
  • Or prolonged fasting/starvation
  • Transient proteinuria
  • Enzyme mediated glomerular damage

36
Diagnosis Clues in the Bloodwork
  • Coagulation panel
  • Thrombocytopenia
  • Vasculitis (enzyme mediated)
  • DIC
  • PT, PTT, ACT
  • Elevated
  • FDP, d-Dimers (Cornell Coag Lab)
  • high

37
Diagnosis Clues in the Bloodwork
  • Electrolyte panel/blood gases (venous is fine)
  • HCO3,TC02, pH, pC02
  • Low - Metabolic acidosis
  • What clue will your patient give you to check
    venous blood gases?
  • Panting

38
Diagnosis Clues in the Bloodwork
  • Electrolyte panel/blood gases (venous is fine)
  • HCO3,TC02, pH, pC02
  • Low - Metabolic acidosis
  • What clue will your patient give you to check
    venous blood gases?
  • Panting
  • Potassium
  • Low why?
  • H outside the cell exchanged for K inside the
    cell
  • K lost in the urine
  • Especially a problem with diabetics why?
  • Insulin is required to get potassium into the
    cell where it is needed

39
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US

40
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US

41
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US

42
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US

43
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US

44
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US

45
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US
  • Pancreatitis (gt 1 cm thick)
  • Enlarged pancreas
  • Hypoechoic
  • May have cavitary lesions
  • Fluid accumulation around the pancreas
  • Pancreatic duct may be tortuous and dilated

46
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US
  • Pancreatitis (gt 1 cm thick)
  • Enlarged pancreas
  • Hypoechoic
  • May have cavitary lesions
  • Fluid accumulation around the pancreas
  • Pancreatic duct may be tortuous and dilated

47
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US
  • Pancreatitis (gt 1 cm thick)
  • Enlarged pancreas
  • Hypoechoic
  • May have cavitary lesions
  • Fluid accumulation around the pancreas
  • Pancreatic duct may be tortuous and dilated

48
Diagnosis Abdominal Ultrasound
  • BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
    PANCREATITIS
  • Highly specific, but not that sensitive
  • 60 of cats with pancreatitis have normal US
  • Pancreatitis (gt 1 cm thick)
  • Enlarged pancreas
  • Hypoechoic
  • May have cavitary lesions
  • Fluid accumulation around the pancreas
  • Pancreatic duct may be tortuous and dilated

49
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous

50
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous

51
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge

52
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge

53
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge

54
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge
  • Ascites

55
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge
  • Ascites

56
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge
  • Ascites

57
Diagnosis Abdominal Ultrasound
  • Duodenum
  • Dilated and hypomotile (lt5 waves per minute)
  • Sometimes corrugated
  • Common Bile Duct
  • Dilated and tortuous
  • Gall bladder
  • Enlarged, wall edema/hyperechoic, sludge
  • Ascites (fluid analysis chart)
  • Peripancreatic fat and omentum
  • hyperechoic

58
Diagnosis Abdominal Ultrasound
  • Ultrasound truly IS for everyone
  • Time-consuming
  • 30 minutes to warm up reagants
  • 10 minutes to run the test
  • Expensive
  • Used Toshiba Analog 12k in 2000
  • 3 US a week x 150 x 50 weeks 22.5K
  • Subject to user experience
  • No more subjective than x-rays

59
Diagnosis Radiographs
  • Abdominal radiographs
  • Often normal (sensitivity 24)
  • Ascites generalized or localized
  • Peritonitis loss of detail ground glass
  • Stomach displaced left, dilation
  • Duodenum displaced caudal and right, gas
  • Dilated, thickened, corrugated
  • Colon displaced caudal

60
Diagnosis Radiographs
  • Abdominal radiographs
  • Often normal (sensitivity 24)
  • Ascites generalized or localized
  • Peritonitis loss of detail ground glass
  • Stomach displaced left, dilation
  • Duodenum displaced caudal and right, gas
  • Dilated, thickened, corrugated
  • Colon displaced caudal

61
Diagnosis Radiographs
  • Abdominal radiographs
  • Often normal (sensitivity 24)
  • Ascites generalized or localized
  • Peritonitis loss of detail ground glass
  • Stomach displaced left, dilation
  • Duodenum displaced caudal and right, gas
  • Dilated, thickened, corrugated
  • Colon displaced caudal

62
Diagnosis Radiographs
  • Abdominal radiographs
  • Often normal (sensitivity 24)
  • Ascites generalized or localized
  • Peritonitis loss of detail ground glass
  • Stomach displaced left, dilation
  • Duodenum displaced caudal and right, gas
  • Dilated, thickened, corrugated
  • Colon displaced caudal
  • Calcification of fat

63
Diagnosis Radiographs
  • Abdominal radiographs
  • Often normal (sensitivity 24)
  • Ascites generalized or localized
  • Peritonitis loss of detail ground glass
  • Stomach displaced left, dilation
  • Duodenum displaced caudal and right, gas
  • Dilated, thickened, corrugated
  • Colon displaced caudal
  • Calcification of fat

64
Diagnosis Radiographs
  • Abdominal radiographs
  • Often normal (sensitivity 24)
  • Ascites generalized or localized
  • Peritonitis loss of detail ground glass
  • Stomach displaced left, dilation
  • Duodenum displaced caudal and right, gas
  • Dilated, thickened, corrugated
  • Colon displaced caudal
  • Calcification of fat

65
Diagnosis Radiographs
  • Upper GI Barium Series
  • Delayed emptying of stomach and duodenum
  • Corrugation of duodenal wall
  • Thoracic radiographs
  • Can be normal
  • Pleural effusion

66
Diagnosis Radiographs
  • Upper GI Barium Series
  • Delayed emptying of stomach and duodenum
  • Corrugation of duodenal wall
  • Thoracic radiographs
  • Can be normal
  • Pleural effusion

67
Diagnosis Radiographs
  • Upper GI Barium Series
  • Delayed emptying of stomach and duodenum
  • Corrugation of duodenal wall
  • Thoracic radiographs
  • Can be normal
  • Pleural effusion
  • Pulmonary edema
  • Severe vasculitis
  • if severe hypoalbuminemia
  • 25-50 of cats have either pleural effusion or
    ascites
  • Sometimes pneumonitis (interstitial pattern)

68
Diagnosis Abdominocentesis, Thoracocentesis
  • Usually modified transudate
  • Occasionally exudative (suppurative)
  • Rarely hemorrhagic

69
Diagnosis Exploratory Laparotomy
  • Pancreas
  • Edematous, hemorrhagic, abscesses, cysts

70
Diagnosis Exploratory Laparotomy
  • Pancreas
  • Edematous, hemorrhagic, abscesses, cysts

71
Diagnosis Exploratory Laparotomy
  • Pancreas
  • Edematous, hemorrhagic, abscesses, cysts
  • Enlarged if acute
  • Very small, wasted, fibrotic if chronic
  • Can appear grossly normal in cats

72
Diagnosis Exploratory Laparotomy
  • Pancreas
  • Edematous, hemorrhagic, abscesses, cysts
  • Enlarged if acute
  • Very small, wasted, fibrotic if chronic
  • Can appear grossly normal in cats

73
Diagnosis Exploratory Laparotomy
  • Pancreas
  • Edematous, hemorrhagic, abscesses, cysts
  • Enlarged if acute
  • Very small, wasted, fibrotic if chronic
  • Can appear grossly normal in cats
  • Peripancreatic tissues
  • Saponification of fat
  • Inflammation
  • Adhesions

74
Diagnosis Exploratory Laparotomy
  • Pancreas
  • Edematous, hemorrhagic, abscesses, cysts
  • Enlarged if acute
  • Very small, wasted, fibrotic if chronic
  • Can appear grossly normal in cats
  • Peripancreatic tissues
  • Saponification of fat
  • Inflammation
  • Adhesions

75
Diagnosis Exploratory Laparotomy
  • Histopathology - pancreas
  • Definitive diagnosis in cats
  • Chronic pancreatitis fibrosis, inflammation,
    nodular hyperplasia
  • Acute pancreatitis edema, hemorrhage, necrosis,
    inflammation
  • Few side effects after Bx of cat pancreas

76
Diagnosis Exploratory Laparotomy
  • Histopathology - pancreas
  • Definitive diagnosis in cats
  • Chronic pancreatitis fibrosis, inflammation,
    nodular hyperplasia
  • Acute pancreatitis edema, hemorrhage, necrosis,
    inflammation
  • Few side effects after Bx of cat pancreas

77
Diagnosis Exploratory Laparotomy
  • Histopathology - pancreas
  • Definitive diagnosis in cats
  • Chronic pancreatitis fibrosis, inflammation,
    nodular hyperplasia
  • Acute pancreatitis edema, hemorrhage, necrosis,
    inflammation
  • Few side effects after Bx of cat pancreas

78
Diagnosis Exploratory Laparotomy
  • Histopathology - pancreas
  • Definitive diagnosis in cats
  • Chronic pancreatitis fibrosis, inflammation,
    nodular hyperplasia
  • Acute pancreatitis edema, hemorrhage, necrosis,
    inflammation
  • Few side effects after Bx of cat pancreas
  • Culture/Cytology any abscesses
  • Usually sterile (do cytology first)
  • Bacterial infection is not very common in dogs
    and cats

79
Pancreatitis Treatment
80
Pancreatitis Treatment Dogs and Cats
  • PRIMARY THERAPIES
  • Fluid therapy
  • Colloids
  • Antibiotics
  • Analgesia
  • Antioxidants

81
Pancreatitis Treatment Dogs and Cats
  • Fluid therapy why so crucial
  • Need to support pancreatic perfusion
  • Pancreatitis pancreatic ischemia bad things
  • 35-45 ml/lb/day until eating well
  • less if low albumin, until colloids restored
  • Supplement potassium according to the sliding
    scale
  • One scale for animals with severe acidosis
  • One scale for animals with normal venous blood
    gases

82
Pancreatitis Treatment Dogs and Cats
  • Fluid therapy why so crucial
  • Why do pets with acidosis need more potassium?
  • In a state of acidosis, there are excess hydrogen
    ions (H) in the extracellular fluid
  • As the acidosis is corrected by therapy,
    potassium that had left the cells in exchange for
    H goes quickly back into the cells
  • This can drop potassium precipitously, causing
    arrhythmia, weakness or even respiratory
    paralysis
  • Most common culprits are DKA and RTA

83
Pancreatitis Treatment Dogs and Cats
  • Fluid therapy why so crucial
  • Why do pets with acidosis need more potassium?
  • In a state of acidosis, there are excess hydrogen
    ions (H) in the extracellular fluid
  • As the acidosis is corrected by therapy,
    potassium that had left the cells in exchange for
    H goes quickly back into the cells
  • This can drop potassium precipitously, causing
    arrhythmia, weakness or even respiratory
    paralysis
  • Most common culprits are DKA and RTA

84
Pancreatitis Treatment Dogs and Cats
  • Fluid therapy why so crucial
  • Add glucose if hypoglycemic
  • Add bicarbonate if
  • Acidosis is immediately life threatening
  • Acidosis will not be corrected by treating other
    problems
  • See handout
  • LRS wont work if severe liver disease and needs
    alkalinizing why??
  • Liver must transform lactate to bicarbonate

85
Pancreatitis Treatment Dogs and Cats
  • Fluid therapy why so crucial
  • Add glucose if hypoglycemic
  • Add bicarbonate if
  • Acidosis is immediately life threatening
  • Acidosis will not be corrected by treating other
    problems
  • See handout
  • LRS wont work if severe liver disease and needs
    alkalinizing why??
  • Liver must transform lactate to bicarbonate

86
Pancreatitis Treatment Dogs and Cats
  • Flop
  • Chief Complaint Not doing well since treating
    abscess on a toe 1 week ago, vomiting blood
  • 3 days ago regular vet did a UA and blood glucose
  • UA showed ketones and glucose , blood
    glucose 296
  • Has been treating with IV fluids since, getting
    worse
  • Did not start insulin because cat not eating
  • Exam - Dehydrated, lethargic, icteric, RR 56
  • vomited coffee grounds and collapsed on abdominal
    palpation, HR 65/bpm
  • Responded to atropine IV and fluid bolus

87
Pancreatitis Treatment Dogs and Cats
  • Flop - diagnostics
  • CBC granulocytes 16,000
  • Profile glucose 200, BUN 41
  • TG 500, Chol 297
  • Bili 4.2, ALT 148, ALP normal
  • Ca 7.0, Phos 1.6
  • UA SG 1.027, ketones , glucose , inactive
    sediment
  • Electrolytes K lt2.0, Na 133, iCa 1.08
  • pH 7.032, BE -24, HCO3 7, TCO2 8
  • pCO2 26.5,
  • No chest rads or abdominal US done
  • Urine culture pending

88
Pancreatitis Treatment Dogs and Cats
  • Flop - diagnosis
  • Initial life threatening problems
  • Severe ketoacidosis
  • treatment insulin, bicarbonate, IV fluids
  • Severe hypokalemia
  • treatment IV KCl or K-phosphates
  • Severe hypophosphatemia
  • treatment IV K-phosphates
  • (pancreatitis, hematemesis, abscess on toe)
  • (treatment feed, antacids, sucralfate,
    antibiotics)

89
Pancreatitis Treatment Dogs and Cats
  • Flop - treatment
  • IV fluids of course 45 ml/lb/day
  • Rehydrates and corrects acidosis which fluids?
  • Buffered LRS, Ringers, Normosol, Plasmalyte,
    etc.
  • Potassium chloride no disadvantage
  • Potassium phosphates no disadvantage
  • (sliding scale) (IV drip rate calculator)
  • Insulin
  • Advantage corrects ketoacidosis
  • Disadvantage makes hypokalemia and
    hyposphatemia worse
  • Bicarbonate
  • Advantage corrects acidosis
  • Disadvantage will make hypokalemia worse
  • Cefazolin 100 mg IV TID, cimetidine 25 mg IV TID

90
Pancreatitis Treatment Dogs and Cats
  • Flop reassess in 4 hours
  • Glucose - 99 (1 unit NPH SC)
  • PCV 23
  • pH 7.228, HC03 10, TCO2 11
  • pC02 23.9,
  • iCa 1.07, Na 130, K 2.3
  • Phosphorus 0.7
  • Red tinged urine, serum icteric
  • Hydration normal, general condition slightly
    improved, no vomiting, not eating

91
Pancreatitis Treatment Dogs and Cats
  • Flop 2 days later
  • Glucose - 325
  • PCV 20
  • pH 7.403, HC03 18.8, TCO2 20
  • pC02 30
  • iCa 0.92, Na 134, K 3.7
  • Phosphorus 3.4
  • Urine clear, serum slightly icteric
  • Hydration normal, general condition greatly
    improved, eating small amounts, no vomiting

92
Pancreatitis Treatment Dogs and Cats
  • Colloids why so crucial
  • Low albumin vasculitis fluid therapy
    pulmonary edema
  • Hetastarch 5-10 ml/lb/day
  • Plasma 10 ml/lb/day, over 2-3 hours
  • Premedicate with diphenhydramine
  • Can repeat daily until improved
  • Also treats DIC
  • Provides antiproteases and alpha-macroglobulins
  • Whole blood if significantly anemic (hemolysis)

93
Pancreatitis Treatment Dogs and Cats
  • Antibiotics controversial
  • Increased survival in people with pancreatitis
    who are treated with antibiotics
  • But bacterial pancreatitis is much less common in
    dogs and cats
  • Should prevent systemic infection from bacterial
    translocation across the gut
  • Treat concurrent infection, of course (UTI)
  • Penicillins (avoid Clavamox it causes vomiting)
  • Cephalosporins
  • Quinolones alone arent the best choice why?

94
Pancreatitis Treatment Dogs and Cats
  • Analgesia THIS IS A PAINFUL DISEASE
  • Butorphanol (1 mg/10 lbs q2-4hrs PRN for pain)
  • Buprenorphine (0.015 mg/kg q6-12hrs)
  • Opiate pure agonists whats the catch?
  • Oxymorphone
  • Morphine
  • Hydromorphone
  • Meperidine
  • Fentanyl injectable or patch
  • Intraperitoneal lidocaine or bupivocaine
  • Be careful of NSAIDs Why?

95
Pancreatitis Treatment Dogs and Cats
  • Antioxidants
  • Milk thistle
  • SAMe
  • VetriScience Cell Advance
  • Vitamin E/selenium
  • Free radical damage is rampant in pancreatitis
  • People with recurring pancreatitis have fewer
    episodes when they take daily antioxidants

96
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • Heparin
  • Questionable efficacy in cats
  • Some think it is primary therapy for dogs why?
  • Even if not in DIC, they are hypercoagulable
  • May promote pancreatic microcirculation
  • Preventing a thromboembolism is
  • Way better than treating one

97
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • Antiemetics used to be controversial
  • Definitely make the patient more comfortable
  • May prevent death from vagal surge
  • Some would rather not cover up their vomiting
  • Early return to alimentation
  • I use them, and they are currently recomended

98
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • Antiemetics - controversial
  • Metoclopramide, Cisapride
  • Ondansetron (Zofran), dolasetron (Anzemet) - 5HT3
    antagonists 0.3-0.6 mg/kg SID to BID
  • Maropitant (Cerenia) - neurokinin-1 receptor
    antagonist 1 mg/kg SID
  • Careful of phenothiazines why?
  • dont want hypotension

99
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • B vitamins (especially B12)
  • H2 blockers/H pump blockers, sucralfate/barium
  • if blood in the stool or vomit
  • May prevent reflux esophagitis if vomiting
  • is severe
  • Famotidine, Ranitidine, Cimetidine, (omeprazole)
  • There is some evidence cimetidine
  • and ranitidine might aggravate
  • pancreatitis in people

100
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • Treat hyperlipidemia
  • Handout
  • Hyperlipidemia predisoposes to pancreatitis
  • Calcium
  • Therapy rarely needed
  • Only if clinical signs, and calcium lt 6.5 mg/dl
  • Bicarbonate
  • Some cats with severe chronic pancreatitis need
    long term oral HC03

101
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • Surgery/laparoscopy
  • Biopsy to diagnose neoplasia in dogs and cats
  • Biopsy to diagnose pancreatitis in cats
  • Debridement
  • Restore bile flow (stent)
  • To treat abscesses or pseudocysts
  • That recur after US guided
  • drainage

102
Pancreatitis Treatment Dogs and Cats
  • SECONDARY THERAPIES - As indicated
  • Antihelminthics
  • In the rare case of liver flukes or pancreatic
    flukes in cats
  • Fenbendazole
  • Praziquantel (high dose in notes)

103
Pancreatitis Treatment Dogs and Cats
  • CONTROVERSIAL THERAPIES
  • Dopamine CRI
  • Protective effect when administered to cats with
    experimental pancreatitis within 12 hours
  • No effect after 12 hours
  • Can cause vomiting, nausea, seizures in cats
  • Peritoneal dialysis
  • To remove chemical irritants from the abdomen
  • When ascites (especially exudative)

104
Pancreatitis Treatment Dogs and Cats
  • CONTROVERSIAL THERAPIES
  • Oral pancreatic enzymes
  • Reported to reduce pain in people with
    pancreatitis
  • Less likely to be effective in dogs because they
    do not have a protease negative feedback
  • Some have observed clinical benefits
  • in dogs who have pain associated
  • with chronic pancreatitis

105
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • TPR, blood pressure BID or more
  • Low body temp indicates big trouble
  • High fever spikes might indicate infection
  • Increased heart rate??
  • Pain
  • Hypovolemia (need more fluids)
  • Increased respiratory rate??
  • Pain
  • Pulmonary edema, pleural effusion, pneumonitis
  • acidosis

106
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • Electrolytes/blood gases, lactate
  • SID-BID when critical
  • QOD when stable
  • Weigh BID when concerned about kidney function
  • Why?
  • Increase in body weight 10 is the first sign
  • of fluid retention
  • If you catch this early, you can prevent
  • pulmonary edema, and give your patient
  • more time to start making urine

107
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • Electrolytes/blood gases, lactate
  • SID-BID when critical
  • QOD when stable
  • Weigh BID when concerned about kidney function
  • Why?
  • Increase in body weight 10 is the first sign
  • of fluid retention
  • If you catch this early, you can prevent
  • pulmonary edema, and give your patient
  • more time to start making urine

108
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • Electrolytes/blood gases, lactate
  • SID-BID when critical
  • QOD when stable
  • Weigh BID when concerned about kidney function
  • Why?
  • Increase in body weight 10 is the first sign
  • of fluid retention
  • If you catch this early, you can prevent
  • pulmonary edema, and give your patient
  • more time to start making urine

109
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • HCT
  • SID if stable
  • BID if phosphorus low, especially if DKA
  • Albumin
  • daily if lt1.5
  • QOD if gt2.0, as long as on fluid therapy
  • Monitor for DIC
  • Platelets
  • If decreasing, do PT, PTT, FDP/d-dimers
  • No need for BMBT

110
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • Glucose
  • Every 2 hours when unstable
  • Give insulin ONLY as needed
  • Glucose can be very erratic in DKA
  • When stable enough, can do every 2 hours during
    the day, and not overnight
  • If you MUST spot check, then do so 6 hours
  • after insulin (glucose low)
  • Insulin nadir is much more important
  • than peak when deciding dose

111
Pancreatitis Treatment Dogs and Cats
  • Patient Monitoring
  • Urine ketones if diabetic daily until stable
  • cPLI or fPLI
  • Long term, to monitor resolution of pancreatitis,
    and need for ongoing dietary therapy and
    antioxidant supplementation
  • Abdominal US
  • To follow resolution of pancreatic abscesses or
    cysts

112
Treatment Canine Pancreatitis
  • Glucocorticoids contraindicated
  • NPO
  • Offer water after no vomiting for 24 hours
  • Offer food when no vomiting for 8-12 hours with
    free choice water
  • 2-3 very small meals the first day (2 teaspoons
    to 2 tablespoons)
  • Gradually work up to full feed over 3-5 days
  • If any vomiting, start over at the top
  • Use antiemetics for early alimentation

113
Treatment Canine Pancreatitis
  • Nutrition
  • Low fat Why?
  • lt15-20 of calories
  • Low fiber, at first Why?
  • Can go to higher fiber later
  • Low protein Why?
  • lt25 of calories
  • Carbs stimulate amylase which has little to do
    with pathology of pancreatitis

114
Treatment Canine Pancreatitis
  • Nutrition
  • Suitable commercial diets
  • Hills I/D canned and dry
  • Purine CNM EN canned and dry
  • Select Care Canine Sensitive Formula canned and
    dry
  • Home made food
  • Fat free cottage cheese and white rice is ideal
  • Turkey breast (without skin) and potatoes

115
Treatment Canine Pancreatitis
  • Nutrition
  • Monomeric (elemental food)
  • Water soluble liquid foods in their simplest
    nutritional state
  • Should in theory minimally stimulate the pancreas
  • Some have added glutamine to support enterocyte
    recovery from disuse atrophy
  • Can cause diarrhea, as many are hyperosmolar

116
Treatment Canine Pancreatitis
  • 3-5-7 Rule
  • 3 days with no food, and you should be
    formulating a nutritional plan
  • Never let a patient go more than 5 days without
    nutrition
  • 7 days without nutrition has serious implications
  • After Recovery
  • 2 weeks or more after recovery, consider
    switching to low fat, high fiber diet (use cPLI,
    fPLI)
  • May or may not eventually be able to go back to a
    maintenance type diet (use cPLI, fPLI)

117
Treatment Canine Pancreatitis
  • Nutrition
  • Suitable High Fiber Low Fat foods for long term
  • Hills R/D and W/D
  • Purina CNM OM canned and dry
  • Purina CNM DCO dry, Purina CNM GL dry
  • Select Care Canine HiFactor Formula canned and
    dry
  • Royal Canin Canine High Fiber canned and dry
  • Royal Canin Gastrointestinal Low Fat
  • Dogs with persistently high triglycerides
  • will probably have to stay on this type diet

118
Treatment Feline Pancreatitis
  • Glucocorticoids
  • Indicated for feline pancreatitis why?
  • Controlling concurrent IBD and cholangiohepatitis
    will remove predisposition to pancreatitis
  • Can be immune mediated per se in cats
  • Prednisone 1 mg/lb/day
  • Dexamethasone 0.1 mg/kg every other day
  • Wean to lowest effective dose over 2-4 months,
    after clinical response

119
Treatment Feline Pancreatitis
  • Nutrition FEED!!!
  • Place feeding tube ASAP why?
  • Pancreatitis fatty liver disaster
  • Place E-tube first
  • Place G-tube if E-tube can not be maintained due
    to uncontrollable vomiting
  • Why not place G-tube right away?
  • 10-25 are dislodged even with
  • proper placement
  • Can result in gastric perforation

120
Treatment Feline Pancreatitis
  • Nutrition
  • If vomiting becomes difficult to control
  • Drip liquid diet CRI if bolus feeding is not
    tolerated
  • Try Cerenia, Anzemet, Zofran
  • If all else fails, consider a jejunostomy tube

121
Treatment Feline Pancreatitis
  • Nutrition
  • As always, cats do best on a high protein,
  • low carb diet (especially diabetics)
  • No need to be concerned about fat content in cats
  • There is only one dry diet with gt45 protein and
    lt8 carbs
  • Innova EVO (California Naturals), Wellness CORE
  • Purina DM and Hills Prescription Diet M/D have
    15 carbs (protein is fine)
  • Studies used to market DM and M/D are on canned
  • Binkys Page Dry Cat Foods Canned Cat Foods
  • Percent Calories Calculator

122
Treatment Feline Pancreatitis
  • Nutrition
  • Appetite stimulants can be used
  • Cyproheptadine 2 mg per cat PO BID 30 min prior
    to feeding
  • Mirtazipine 3-4 mg per cat twice a week
  • Diazepam is risky with concurrent liver disease

123
Pancreatitis Prognosis
124
Pancreatitis Prognosis
  • Dogs variable
  • Good if response to short term therapy
  • Guarded if severe pancreatitis
  • Better for lean dogs than fat dogs why?
  • Less necrosis of fat to deal with
  • Clinical response is probably the best predictor
  • 100 recovery is possible
  • Some dogs are prone to repeated episodes

125
Pancreatitis Prognosis
  • Cats - variable
  • Tend to take longer than dogs to respond
  • Some cats can begin eating in days
  • Some have to be fed by tube for months
  • Worse if concurrent hepatic lipidosis
  • Worse if suppurative pancreatitis rather than
    mononuclear
  • Cats who have it once tend to get it again
  • Owners learn to catch it early and intervene

126
Pancreatitis Prognosis
  • Cats - variable
  • Tend to take longer than dogs to respond
  • Some cats can begin eating in days
  • Some have to be fed by tube for months
  • Worse if concurrent hepatic lipidosis
  • Worse if suppurative pancreatitis rather than
    mononuclear
  • Cats who have it once tend to get it again
  • Owners learn to catch it early and intervene

127
Pancreatitis Prognosis
  • Things associated with poor prognosis
  • Shock
  • Oliguria
  • Icterus
  • Hypocalcemia
  • Hypoglycemia
  • Hypoproteinemia
  • Acidosis
  • Falling hematocrit

128
Pancreatitis Prognosis
  • Things associated with poor prognosis
  • Thrombocytopenia
  • DIC

129
Handouts
  • PowerPoint Presentation behind the yellow tab
  • Bicarbonate Administration
  • Fluid Analysis Diagnostic Chart
  • Hyperlipidemia
  • IV Potassium Supplementation
  • Cornell Comparative Coagulation Lab Instructions,
    Submission Form and test list

130
Handouts
  • Client Information Handouts
  • Canine Pancreatitis
  • Feline Pancreatitis
  • Canned Cat Food Content
  • Dry Cat Food Content
  • Fish Oil
  • Web Resources
  • Cat Food Percent Calories Calculator
  • IV Fluid Rate Calculator
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