Exocrine Pancreas Flashcards by Adriane Gorski

What is the primary profile for the pancreas?

Amylase
Lipase
Primary renal profile (BUN, creatinine, SG)

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What is the secondary profile for the pancreas?

Calcium
Albumin
Hepatobiliary profile
Glucose
Cholesterol
Leukon
\+/- triglycerides

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What is a primary rule out when suspecting pancreatitis? Hint: this condition presents with many of the same clinical signs

Acute gastritis

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What is the most common suspect for pancreatitis?

Dog

obese female, smaller breed

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What are common signs of pancreatitis?

Vomiting
Weakness
Anterior abdominal pain (>50% of cases)

Less common signs:
Dehydration
diarrhea
fever

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What endocrinopathies can pancreatitis be associated with?

Diabetes mellitus
Cushing’s disease
Hypothyroidism
Hyperlipidemia (Schnauzers)

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What other associations besides endocrinopathies can there be for pancreatitis? These may cause pancreatitis…

Hypercalcemia +/-
Renal failure
Glucocorticoids +/-
Other drugs

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What are 3 complications seen with pancreatitis?

DIC
Abscess, sepsis
Diabetes mellitus 
- Transient diabetes is common during acute phase
- Persistent diabetes is possible

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What are 5 potential outcomes of pancreatitis?

Recovery
Acute death
Chronic, recurrent pancreatitis &/or sepsis
Exocrine insufficiency (EPI) –> maldigestion
Diabetes mellitus

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What is amylase and lipase? Where are they stored? How are they released with disease?

Enzymes/zymogens

stored in acinar cells that leak into blood from degenerating cells or obstructed ducts

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Where are basal blood levels from? What tissues?

non-pancreatic origin
Amylase - many tissues: primarily pancreas, duodenal mucosa, and potentially liver

Lipase - primarily from pancreas, gastric mucosa, adipose

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What are causes of increased lipase?

Pancreatitis
Corticosteroids – no histologic lesions
- Dexamethasone reported to increase lipase up to 5x (NO lesions/signs/increase amylase)

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How is amylase and lipase degraded and excreted?

Associated with renal function! Especially amylase
filtered in kidney (~GFR) and then degraded in tubules

Some clearance by mononuclear phagocyte system – impaired by uremia – decrease clearance – increase amylase, +/- lipase

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What will values look like with pre and post renal azotemia? Renal azotemia?

may cause 2-3x increase

no clear cutoff for increase – > 2-3x increase

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What enzyme is more specific for pancreatitis? Why?

Lipase - amylase has more tissues involved

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What is unpredictable about lipase values?

Rate of increase
Magnitude of increase
Rate of decline with resolution

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What is amylase’s half life? Lipase?

- Not important to Dr. C -

Amylase - 5 hours

Lipase - 2 hours

What is a nonspecific finding in dogs for pancreatic enzymes?

< 3x increase in amylase or lipase: doesn’t rule out pancreatitis, just doesn’t confirm!

uremia?/pancreatitis?/other tissue source?/combination?

What are the 4 main differentials for a 3x increase in amylase or lipase in a dog?

Pancreatitis (diagnostic if renal azotemia is absent)
Renal azotemia (examine renal profile)
Combination
+/- Dexamethasone (lipase increase, not amylase)

T/F

The magnitude of enzyme increase corelates with severity

False

improves specificity but won’t determine severity

RED FLAG

What determines severity of pancreatitis?

severity of leukon changes and/or clinical signs

What does the magnitude of enzyme increase positively correlate with in a dog?

Positively correlates with confidence in the dx – higher the values, the more specific they are for dx

What if there are enzyme results w/in the reference range, can we rule out pancreatitis in a dog?

We can not rule out pancreatitis

How can we monitor progression or resolution for dx of pancreatitis in dogs?

Follow enzymes

compare individual’s levels with reference ranges

When is it appropriate to make a dx of pancreatitis with enzyme levels < 3x increase in dogs?

No renal abnormalities | Other parameters are strongly supportive

What should your top differential be for a 30-50,000 IU/L range lipase and normal amylase?

Acinar cell adenocarcinoma of the pancreas

What supports pancreatitis in cats?

Increased enzymes - lipase may be increased but is inconsistent - amylase may be normal or even decreased

What is a classic leukon pattern associated with pancreatitis?

Inflammatory leukogram +/- stress (glucocorticoid-induced lymphopenia) Inflammation: neutrophilia, left shift, toxicity, possible monocytosis

What is an important differential diagnosis for severe inflammatory leukogram?

``` Pancreatitis Pyometra Pyelonephritis Abscess Prostatitis ```

What is seen with calcium during pancreatitis? Mechanism?

pancreatic enzymes released in omentum --> digestion of fat --> precipitation of calcium salts in areas of fat necrosis --> mild to moderate decrease during acute phase of the disease Increase glucagon release --> increase calcitonin --> decrease calcium

What are the potential markers for cholestasis associated with pancreatitis in order of what happens first?

increased serum bilirubin (Bc) Increased urine bilirubin Increase ALP Increase GGT

What is a classic acute pancreatitis picture called? What does it look like?

Acute post-hepatic obstruction | Increase urine bilirubin, increase Bc +/- Bd, normal enzymes

What are the four mechanisms for elevated glucose levels with pancreatitis?

1. Glucocorticoids 2. Epinephrine 3. Glucagon release (alpha cells) 4. Hypoinsuilinism (+/- transient)

What does TLI measure? What is an advantage or diadvantage of TLI for pancreatitis?

Measures trypsin and trypsinogen Advantage: Increases earlier than amylase and lipase - useful for acute dz phase Disadvantage: short half life and affected by renal excretion. Only useful for very acute dz phase. Little advantage over amylase/lipase

What does TLI stand for? PLI?

TLI - Trypsin like immunoreactivity | PLI - Pancreatic Lipase Immunoreactivity

What is the recommended test for identification of pancreatitis in dogs or cats? Why?

PLI | Identifies a pancreas specific lipase

Can you use any PLI for testing cats or dogs?

No, they are species specific

What test is preferred for detecting pancreatic insufficiency (EPI)?

TLI

What are reported advantages of PLI?

1. more sensitive than the TLI or lipase for pancreatitis | 2. Not affected by gastritis, renal failure, or prednisone administration

When looking at spec cPL results, when do you need to retest and when is it positive for pancreatitis?

200-400: retest | > 400 : positive

What can you decide from a negative SNAP cPL? What if it's positive?

100% rule out of pancreatitis Positive -- confirm with spec cPL

What else can be done to look for pancreatitis?

Cytology of peritoneal effusion -- often serosanguinous, non-septic exudate Peritoneal effusion fluid enzymes: amylase and lipase in fluid > serum levels suggests pancreatitis