Gastroenterology Pt. 2 Flashcards
Acute pancreatic or peripancreatic inflammation is always a differential diagnosis for:
¡ Acute vomiting (dogs > cats)
¡ Abdominal pain (dogs > cats)
¡ Acute unexplained depression (cats > dogs)
is acute pancreatitis easily diagnosed?
¡ Has posed a diagnostic challenge for decades
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
Definitive test for acute pancreatitis diagnosis? issues?
biopsy and histology
* Impractical(invasive,expensive)
* Irregulardistributionofinflammation
> Up to 6 samples needed to rule out in dogs!
radiological findings suggestive of pancreatitis?
- “Sentinel loop”: dilated duodenum
- Pancreatic mass effect: intestines shifted to left
- Loss of detail right cranial quadrant (effusion)
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
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
pancreatitis bloodwork: what we see on CBC
CBC
* Stress leukogram
* Inflammatory leukogram
> Inflammation increases with severity of pancreatitis
pancreatitis bloodwork: what we see on chemistry
- ±↑azotemia (dehydration, kidney
injury) - ±↑liver enzymes
- ±↑amylase, lipase
- ±↑bilirubin (extrahepatic biliary duct compression/obstruction)
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
best type of pancreatic lipase to test for pancreatitis?
Roche DGGR-lipase
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
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%!
INCREASED DGGR-
LIPASE/CPLI – DIAGNOSTIC MEANING for chronic pancreatitis?
¡ Not as sensitive as for acute
INCREASED DGGR-
LIPASE/CPLI – DIAGNOSTIC MEANING for pancreatic neoplasia?
¡ Primary & infiltrative
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
