32. Pancreatic disease

Question 1

Pancreatitis Pathophysiology?

Answer 1

Pancreatitis
Pathophysiology:
Inactive pancreatic enzymes are activated prematurely within the pancreas leading to autodigestion.
Exhaustion of anti-inflammatory mediators combined with hypotension can result in shock and multiple, organ failure.
Risk factors:
> ingestion of high-fat foods
> Bile reflex and pancreatic duct blockage
> Pancreatic trauma(+/- abdominal surgery), ischaemia
> Drugs: Corticosteroids, potassium bromide and phenobarbitone combination therapy?
> Part of feline Inflammatory bowel disease and cholangiohepatltls
Feline pancreatitis:
> Usually low grade chronic process, associated with Inflammatory bowel disease,
cholanglohepalltis, diabetes mellitus
> Clinical signs are non-specific, I.e. lethargy and anorexia
> Difficult disease process to definitively diagnose
> Biochemistry profile likely to reflect concurrent hepatic Involvement
> Ultrasound does not commonly show typical changes
Treatment is supportive and should be directed at the inflammatory bowel disease and/or
cholangiohepatitis rather than the pancreatitis, early enteral nutrition (tube feeding) Is Important

Question 2

Clinical signs of Pancreatitis?

Answer 2

Clinical signs:
Dogs: Anorexia, vomiting, abdominal pain, pyrexia

Cats: Lethargy, anorexia, hypothermia most frequently, less commonly vomiting and abdominal pain

Question 3

Differential diagnosis of Pancreatitis>

Answer 3

Differential diagnosis: :
Acute gastroenteritis,
gastric ulceration, inflammatory bowel disease, obstruction, peritonitis,
liver failure, renal failure, neoplasia, hypoadrenocorticism and others

Answer 4

Diagnostics:
Technically difficult, should be based on a combination of supportive clinical signs and diagnostics
Biochemistry:
> Amylase: Poor specificity, should be > 3-4 times normal
> Lipase: More specific than amylase, serum levels should be increased by 3-4 times normal level
> Hyperlipidaemia
+/- Other secondary changes: Azotaemia, hepatopathy
Cats: Typically signs of liver disease (inc liver enzymes and bilirubin)
* Less commonly Increases In amylase and lipase
Pancreatic lipase immunoreactivity (cPLI and f PLI):
> Conflicting evidence and anecdotal reports regarding sensitivity and specificity
> False positive occur with non-pancreatic disease e.g. gastroenteritis, inflammatory bowel disease,
neoplasia, renal disease, diabetes Mellitus
May be used to track the progression/resolution of the disease lf 11 confirmed by other methods
> Should not be used as the sole diagnostic test for the diagnosis of pancreatitis
Imagery:
i> Ultrasonography: non-invasive gold standard
Cats commonly don’t see any changes as compared to dogs.
Radiography: Not very sensitive

Question 5

Treatment and long term treatment of Pancreatitis?

Answer 5

Treatment:
Antibiotics:
> Dogs: Not proven to be beneficial, only if signs of bacterial translocation, peritonitis
> Cats: Antibiotics can be considered due to concurrent cholangiohepatitls
Analgesia:
> Opioid pain relief e.g. methadone Q1D or fentanyl patch or CAI,
Fluids and electrolytes:
> Most important, correction of perfusion and hydration deficits and electrolyte derangements
Antiemetic: Metoclopramide CrI, maropitant 1 mg/kg SC SID for <5 days
Gastroprotectants: Proton pump Inhibitors, ~ antagonist
NPO if persistent vomiting
Nutrition:
> Micro-nutrition: If >2 days without food, begin micro-enteral nutrition 0.2mVkg/hr slow Infusion of
electrolyte solution via nasoesophageal tube helps to maintain the health of enterocytes
> Begin nutrition with small frequent, highly digestible low, fat food+/- enzyme supplementation
Monitor biochemistry (especially albumin) and electrolytes for imbalances/improvements

Long term management:
./ Low fat highly digestible food+/· pancreatic enzymes (powdered) at 1tsp each meal per 10kg BWt

Question 6

EPI Pathophysiology?

Answer 6

Exocrine pancreatic Insufficiency (EPI);
Pathophysiology:
Loss of exocrine pancreatic function, clinical signs when >90% of functionality lost
Pancreatic acinar atrophy is the most common cause In younger dogs, mainly German Shepherds
and Rough Coated Collies, otherwise secondary to chronic pancreatitis in older dogs
Not common in cats, affected cats commonly have a concurrent disease such as Inflammatory bowel
disease, hyperthyroidism and diabetes Mellitus
Reduced digestive enzymes leads to maldigestion
Reduce anti-bacterial secretions leads to small intestinal bacterial overgrowth, which can lead to vitamin
B12 malabsorption and other chronic nutrient deficiencies

Question 7

Clinical signs of EPI?

Answer 7

Clinical signs:
Weight loss despite polyphagia
Vomiting and diarrhoea
Large volumes of greasy grey faeces

Question 8

Diagnostics?

Answer 8

Diagnostics:
Trypsin-like immunoreactivity (TU): Performed when fasted for 12 hours
> Low levels are diagnostic
.Serum cobalamin and folate levels:
> Should be performed In all cases all suspected EPI

Question 9

Treatment of EPI?

Answer 9

Treatment:
Diet modification:
Highly digestible, high-quality protein and nutritionally balanced
> Supplementation with fat soluble vilamlns (A, K, E, D) and B12 (cobalamin)
./ Pancreatic enzymes (powdered) at 1tsp each meal per 10kg BWt
.Metronidazole 10mg,’ kg PO BID for 2 - 3 weeks for small intestinal bacterial overgrowth