Gastroenterology Pt. 2 Flashcards by Mark Sunarich

Acute pancreatic or peripancreatic inflammation is always a differential diagnosis for:

¡ Acute vomiting (dogs > cats)
¡ Abdominal pain (dogs > cats)
¡ Acute unexplained depression (cats > dogs)

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is acute pancreatitis easily diagnosed?

¡ Has posed a diagnostic challenge for decades

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Why is pancreatitis problematic for diagnosis?

¡ Signs fairly non-specific
¡ Frequent comorbid disorders
¡ Wide variation in severity & progression
¡ Routine lab work and radiology have poor sensitivity & specificity

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Definitive test for acute pancreatitis diagnosis? issues?

biopsy and histology
* Impractical(invasive,expensive)
* Irregulardistributionofinflammation
> Up to 6 samples needed to rule out in dogs!

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radiological findings suggestive of pancreatitis?

“Sentinel loop”: dilated duodenum
Pancreatic mass effect: intestines shifted to left
Loss of detail right cranial quadrant (effusion)

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ante-mortem gold standard for pancreatitis diagnosis? sensitivity?

¡ Ultrasound is a current imperfect ante-mortem gold standard
¡ 70-80% sensitivity for moderate-marked acute pancreatitis
¡ NORMAL ULTRASOUND DOES NOT RULE OUT PANCREATITIS
¡ Not as good with chronic pancreatitis
¡ Poor correlation of severity of changes with outcome

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pancreatitis changes with ultrasound

¡ Pancreas enlarged, irregular, hypoechoic
¡ Hyperechoic peripancreatic fat (steatitis, necrosis)
¡ Duodenum: corrugated, distended, hypomotile (paralytic ileus = radiologic sentinel loop)
¡ Pseudocyst, abscess
¡ Focal effusion
¡ Distention of bile duct

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pancreatitis bloodwork: what we see on CBC

CBC
* Stress leukogram
* Inflammatory leukogram
> Inflammation increases with severity of pancreatitis

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pancreatitis bloodwork: what we see on chemistry

±↑azotemia (dehydration, kidney
injury)
±↑liver enzymes
±↑amylase, lipase
±↑bilirubin (extrahepatic biliary duct compression/obstruction)

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How do pancreatic lipase tests work for diagnosis of pancreatitis? Types?

¡ Catalytic enzymatic test (function)

-fat substrate > lipase in serum > end product

¡ Reported as Units of activity
¡ Test has evolved
>Specificity for pancreatic lipase has improved

¡ 1,2-DG-lipase
> Most common in current use

¡ More recently Roche DGGR-lipase
>AHL, Precision PSL (Antech)
>Improved sensitivity and specificity

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best type of pancreatic lipase to test for pancreatitis?

Roche DGGR-lipase

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what is the PLI test? what does it tell us?

immunologic test (not function)
* Pancreatic lipase immunoreactivity (“PLI”), IDEXX, ELISA
> SNAP cPL (qualitative)
> Spec cPL (quantitative)

¡ 70-80% sensitivity for moderate-marked acute pancreatitis
¡ DGGR-lipase ~ cPLI
¡ NORMAL DGGR-lipase/PLI DOES NOT RULE OUT PANCREATITIS

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INCREASED DGGR-
LIPASE/CPLI – DIAGNOSTIC MEANING: for acute pancreatitis? agreement with ultrasound?

¡ Relation of level to outcome controversial
¡ Levels trend down as animal improves
¡ Agreement with ultrasound only 25%!

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INCREASED DGGR-
LIPASE/CPLI – DIAGNOSTIC MEANING for chronic pancreatitis?

¡ Not as sensitive as for acute

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INCREASED DGGR-
LIPASE/CPLI – DIAGNOSTIC MEANING for pancreatic neoplasia?

¡ Primary & infiltrative

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Does increased DGGR lipase/CPLI elevation mean pancreatitis is the cause of observed clinical signs?

Elevation does NOT mean pancreatitis is the cause of clinical signs
¡ Elevation does not rule out other disorders
¡ DGGR-Lipase/PLI is not a stand-alone test
> The same applies to ultrasound but ultrasound also looks at the entire abdomen

-Results have to be interpreted in context of other clinical, laboratory and imaging findings

INCREASED DGGR LIPASE/PLI – causes for elevation other than pancreatits?

Dehydration & kidney failure (only mild effect)
¡ Lipase cleared by the kidney, but will only cause mild increase (low level leakage)

old approach for pancreatitis treatment in dogs?

¡ Traditional approach focused on Nothing Per Os (NPO)
* Not of proven value, severe pancreatitis has high mortality

current treatment for pancreatitis in dogs?

Current approach is earlier feeding, especially with severe pancreatitis
* Introduce food within 48 hours
* Use antiemetics to control vomiting
* Nasogastric tube trickle feeding or small frequent amounts
* Esophagostomy tube

diet for pancreatitis treatment in dogs

Reduced fat, low protein, high
carbohydrate diet
* Traditionally used as prevention
* Higher fat diets often used in tube feeding in critical care
> Patients not receiving full calories yet, still lower in fat overall

5 treatment strategies for pancreatitis in dogs

-feeding
-fluid therapy
-analgesia (not NSAIDs)
-Antiemetics
-Gastroprotectants

controversial pancreatitis treatments?

¡ Antibiotics
> Tendency to use in severe cases >Cephalosporins (cefazolin, cefoxitin)

¡ Fresh-frozen plasma
* Fallen out of favor

¡ Surgical debridement
* If not resolving with medical management

PANCREATITIS: PROGNOSIS IN DOGS

Mild edematous pancreatitis
* Good prognosis (mimics acute gastritis)

Hemorrhagic necrotizing pancreatitis
* Variable prognosis
* Difficult to predict – 30-40% mortality in some studies

what tools are NOT good for predicting the prognosis of hemorrhagic necrotizing pancreatitis?

Amylase, lipase, PLI & ultrasound NOT prognostic

ØFever, inflammatory leukogram, bilirubin level not directly prognostic

pancreatitis clinical signs in cats (vs dogs)? differentials?

Depression > Always a differential diagnosis for unexplained depression > Hypothermia (shock) Vomiting and demonstrable abdominal pain not as common as in dog > Ascites and/or pleural effusion in some cases

trigger of pancreatits in dogs that is not really in cats?

¡ High fat meal/diet change not a trigger for cats

comorbid risk factors for pancreatitis in cats?

Comorbid risk factors/diseases common * Liver disease, small intestinal disease * Critical illness * Look for concurrent disorder May be a primary disorder

most sensitive way to diagnose pancreatits in cat

DGGR-lipase/PLI and ultrasound are most sensitive tests (similar to dog) * If both are negative pancreatitis is very unlikely * If both are positive pancreatitis is very likely, but pancreatitis may not explain all the signs

tests that are not useful for diagnosing pancreatitis in cats

¡ Amylase not useful ¡ Regular 1,2 DG-lipase very poor sensitivity

INCREASED DGGR/FPLI – DIAGNOSTIC MEANING possibilities for cats?

-The pancreas is abnormal -Acute pancreatitis * Solitary disorder (10%) or comorbid (90%) -Chronic pancreatitis -Pancreatic neoplasia * Primary & infiltrative (e.g. lymphoma) -Dehydration & kidney failure only mild effect

feline pancreatitis treatment

¡ Treatment is supportive ¡ Same principles as dog ¡ **Feed as early as possible** because often not vomiting and there is associated risk of hepatic lipidosis

feline pancreatitis prognosis

¡ Historically considered poor, but changing as ability to diagnose milder cases has improved ¡ May not affect outcome of comorbid disorders * Eg. diabetes, inflammatory bowel disease ¡ Poor-to-fair if complicating another serious disorder ¡ Good if primary disorder

vomiting is usual presenting complaint for pancreatitis in dogs or cats, or both?

Dogs -not as common in cats

Unexplained depression is a usual presenting complaint t for pancreatitis in dogs or cats, or both?

Cats Acute unexplained depression (cats > dogs) -not as common in dogs

ingestion of a high fat diet can be a trigger for pancreatitis in dogs, cats, or both?

dogs only

A normal lipase or ultrasound does not rule out pancreatitis in cats, dogs, or both?

Both! **A normal ultrasound and/or lipase/PLI does not rule out pancreatitis**

Identify the true statement ¡ A) Ultrasound is superior to radiographs for gastric foreign bodies ¡ B) All gastric foreign bodies must be removed surgically ¡ C) Abdominal effort is typically present in acute vomiting but not regurgitation ¡ D) The timing of food ejected is helpful in differentiating vomiting from regurgitation

¡ C) Abdominal effort is typically present in acute vomiting but not regurgitation

Identify the incorrect statement in regards to canine acute pancreatitis? ¡ A) Identification of a sentinel loop on abdominal radiographs helps rule out pancreatitis ¡ B) Lack of evidence of pancreatitis on abdominal ultrasound does not rule out pancreatitis ¡ C) A normal CPLI and lipase cannot rule out pancreatitis ¡ D) Pancreatitis is often a comorbid disorder

A) Identification of a sentinel loop on abdominal radiographs helps rule out pancreatitis

Identify the true statement in regards to feline pancreatitis: ¡ A) A high fat meal is often a trigger for feline acute pancreatitis ¡ B) Ascites and pleural effusion can be seen with feline pancreatitis ¡ C) Vomiting and abdominal pain are common signs of feline pancreatitis ¡ D) Delaying feeding is recommended for treatment of pancreatitis

¡ B) Ascites and pleural effusion can be seen with feline pancreatitis