Ch 97 - Pancreas Diseases

Question 1

How often may Spec CPLI and SNAP CPLI give a false positive result for pancreatits?

Answer 1

Approximately 40%

Question 2

What is the reported prognosis for sugical treatment of a pancreatic abscess?

Answer 2

Overall 40% survival however this may be skewed by intraop euthanasia.

One study reported a 62% survival for abscess omentalisation

Question 3

How do you diagnose a pancreatic pseudocyst?

Answer 3

Aspiration of the fluid filled contect and assessment of concentration of amylase and lipase. Higher concentrations in the pseudocyst fluid than of serum confirms the diagnosis

Question 4

When does a pancreatic pseudocyst require surgical intervention?

What are the surgical treatment options?

Answer 4

• Clinical signs perist after aspiration
• Pseudocyst enlarges or fails to resolve
• Percutaneous aspiration is not possible
• Recurrence
• Causing a pancreatic duct obstruction

Treatment options:

• Omentalisation
• Cystoduodenotomy
• Cystojejunostomy
• Cystogastrostomy
• Complete excision

Question 5

What is the prognosis for pancreatic carcinoma in dogs and cats?

What biochemiscal parameter may be suggestive of pancreatic carcinoma in dogs?

Answer 5

Extremely poor - Aggressive behaviour, majority have metastasised to liver and local lymoh nodes at time of diagnosis, resistant to chemotherapy. Surgical options should not be highly consided but if obstructive, a gastrojejunostomy can be considered for palliation.

Serum lipase concentration over 25x the normal upper limit

Question 6

How can an insulinoma lead to irreversible para/tetraparesis and ataxia?

Answer 6

Chronic hypoglycaemia can lead to neuronal demyelination and axonal degeneration.
Can also cause facial nerve paralysis, oesophageal dysfunction, decreased anal tone and peripheral polyneuropathies

Question 7

How do you diagnose an insulinoma?

Answer 7

Normal to increased insulin concentrations at a time of documented hypoglycaemia is diagnostic. Decreased fructosamine concentration is also supportive.

Question 8

What treatment options are available for pre-op stabilisation of blood glucose concentrations prior to surgery for insulinoma?

Answer 8

• Small, frequent feeds of a high protein, high complex carbohydrate diet
• Glucocorticoid therapy - Increases hepatic glucose production and decreases cellular glucose uptake
• 5% dextrose CRI - Can stimulate insulin secretion causing hypoglycaemia so close monitoring is necessary
• Glucagon CRI - Use for intractable hypoglycaemia
• Avoid pre-op fasting, instead offer a small amount of canned food 2-3hr prior to surgery

Question 9

Is surgical excision of an insulinoma usually curative?

What can be done during surgery of the insulinoma cannot be identified? What is a reported complication of this technique?

Answer 9

Not usually curative due to the high rate of metastasis at the time of surgery. Reported 50% metastasis to liver and lymph nodes

If cannot identify insulinoma can inject 3mg/kg of 1% methylene blue in 250ml of 9% saline over 30 minutes. Maximal staining is achieved within approx 30 min. Heinz body anaemia has been reported as a complication

Question 10

What are the options of treatment of persistent or recurrent hypoglycaemia after surgical removal of an insulinoma?

Answer 10

• Medical management
• Streptozocin - a chemotherapeutic, nitrosurea antibiotic which selectively destroys beta cells in the pancreas or at metastatic sites. Requires saline diuresis during administration to minimise nephrotoxicity (Adverse events includ GI toxicity 63% and diabetes mellitus 42%)
• Diazoxide - Inhibits insuline secretion and stimulates hepatic gluconeogenesis
• Octreotide - Long-acting systemic somatostatin analogue. Inhibits insulin secretion and synthesis. Insulin suppression only lasts 3-4hr
• Glucocorticoids

Question 11

What is the prognosis for insulinomas in dogs?

Answer 11

Depends on stage of disease at time of diagnosis and what paper you read..

• Dogs undergoing surgery and subsequent medical management as needed were more likely to become euglycaemic, remain euglycaemic for longer and have longer survival than those which do not undergo surgery (Tobin et.al)
• No detectable mets at time of surgery remained euglycaemic for 14 months vs 2.5m with mets. MST with no detectable mets at time of surgery 18m vs 7-9m with mets (Caywood et.al)
• MST for partial pancreatectomy 785d, if treated with pred at time of relapse increased to 1316d (Polton et al)
• Poorer prognosis if tumour >2cm, has metastasised to the liver and lymph nodes, Ki67 index >2.5% (Buishand et al)

Question 12

What is a gastrinoma?

Answer 12

Malignant transformation of the somatostatin-secreting delta islet cells into cells which secrete excessive gastin. This results in gastric acid hypersecretion and subsequent oesophageal and gastroduodenal erosions and ulcerations

Question 13

What term is given to the syndrome in which there is a non-beta cell neuroendocrine pancreatic tumour, hypergastrinaemia and gastrointestinal ulceration?

Answer 13

Zollinger-Ellison Syndrome

Question 14

How do you diagnose a gastrinoma?

Answer 14

Increased fasting gastrin serum concentration is highly suggestive of gastrinoma, especially in the prescense of gastric hyperacidity (pH<3)

Question 15

What are the treatment options for gastrinoma?

Answer 15

Medical management:

• proton pump inhibitors (omeprazole)
• Gastroprotectants (sucralfate, misoprostal)
• Octreotide - Suppresion of gastrin secretion with a somatostatin analogue

Surgical Management

• Partial pancreatectomy with staging biopsies of LNs and liver (approx 70% mets at time of diagnosis)
• Resection of GI ulceration if necessary

Question 16

What is the main presenting complaint for dogs with a glucagonoma (rare)

Answer 16

Superficial necrolytic dermatitis (hepatocutaneous syndrome).

Prognosis for glucagonoma is poor due to high rate of surgical complications and high rate of early metastasis