Investigating pancreatic disease Flashcards by Sophie Robinson

Which structure in the pancreas is responsible for hormone production?

Islets of Langerhans

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What is produced by acinar cells in the pancreas?

Digestive enzymes

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Which structures are anatomically associated with the pancreas?

Stomach
Liver
Duodenum
Colon

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Describe the pathogenesis of acute pancreatitis

Trypsin is activated in the pancreas
Sterile inflammation
Thought to be caused by inappropriate activation of digestive enzymes
Normally the pancreas produces enzymes in an inactive form or enzymes that don’t work without a co-enzyme
Necrosis, blood and inflammatory cells

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What is the aetiological cause of most cases of pancreatitis?

Idiopathic

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List some predisposing factors for pancreatitis

Breed - Spaniels & terriers especially
Female > Male
Neuter > entire
Obesity
Drugs
Concurrent diseases
Dietary factors

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Which 4 diseases are associated with feline pancreatitis?

Cholangitis
IBD
Hepatic lipidosis
Diabetes mellitus

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How does a high fat diet link to pancreatitis?

Hyperlipidaemia
- Obesity
- Diabetes mellitus
- Primary hyperlipidaemia
Dietary indiscretion: Raiding bins, table scraps etc

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List the clinical signs of acute pancreatitis in dogs

Dehydration
Anorexia
Vomiting
Weakness
Abdominal pain - prayer position
Diarrhoea
Jaundice

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List the clinical signs of acute pancreatitis in cats

Lethargy
Anorexia
Vomiting
Abdominal pain
Diarrhoea

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List the diagnostic methods that can be used for acute pancreatitis

History / physical examination
Laboratory tests
Diagnostic imaging: Radiography, Ultrasonography
Pancreatic biopsy

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Describe the haematology and biochemistry results seen in cases of acute pancreatitis

Increased WBCs
Increased glucose
Decreased calcium
Increased liver enzymes
Increased bilirubin

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Why is decreased calcium seen in acute pancreatitis?

Decreased calcium due to fat necrosis -> calcium deposition in this area

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When is jaundice seen in acute pancreatitis?

If there’s obstruction of the pancreatic duct

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Name two pancreatic enzyme tests

Total amylase and lipase
Pancreatic lipase

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Describe the pancreatic lipase test

More specific
Less affected by azotaemia?
SNAP test is available

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If amylase and lipase results come back normal, what is the next step in reaching a diagnosis?

Diagnostic imaging

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Describe the use of radiography in diagnosing acute pancreatitis

Rules out other disease
Not great for pancreatic disease

Describe the use of ultrasound in diagnosing acute pancreatitis

Hyper-echoic or hypo-echoic
Pancreas enlarged & swollen
Mesenteric changes (hyper-echoic)

Which test is needed for a definitive pancreatitis diagnosis?

Pancreatic biopsy

List the treatment options for pancreatitis

All therapy is supportive
Nutritional support
Pancreatic enzymes
Fluid therapy
Analgesia
Anti-emetics
Antibacterials?
Steroids?
Surgery?

Describe the initial diet therapy in the first 3-7 days of pancreatitis

Feed as soon as vomiting stops
Nutritional support
Use a feeding tube if possible

Describe the diet therapy from around day 3-28 following acute pancreatitis

First, small amounts of water…If OK, start food cautiously
Low fat diet, small frequent meals
Can use pancreatic enzymes as long as they dont affect appetite

Why do animals with pancreatitis need to be on a low fat diet?

Fat stimulates release of pancreatic enzymes

Describe analgesia given to patients with acute pancreatitis

Essential part of treatment Avoid NSAIDs Buprenorphine Paracetamol (DOGS ONLY) Tramadol Gabapentin

Describe anti-emetic therapy for patients with acute pancreatitis

Vomiting & nausea are common Use of anti-emetics advisable Allows early enteral nutrition Maropitant or metoclopramide

When should antibacterials be considered in cases of acute pancreatitis?

Most cases of pancreatitis are sterile But, intestinal wall ‘leaky’ -> bacteraemia Therefore, consider prophylactic use

Name the 3 aetiological causes of exocrine pancreatic insufficiency

Pancreatic acinar atrophy Pancreatic hypoplasia Chronic pancreatitis

Describe the features of Pancreatic acinar atrophy

Atrophy – normal at birth and something has led to the destruction of those cells - Most common in dogs - 66% of cases are GSD - Heritable in GSD and rough collies

Describe the features of pancreatic hypoplasia

Rare congenital (<6 months) – never developed properly from birth Associated juvenile diabetes mellitus

Describe the features of chronic pancreatitis

Similar signs as acute but more subtle More common in cats (still rare!)

List the clinical signs of exocrine pancreatic insufficency

- Faecal changes - Appetite changes - Vomiting - Poor coat condition - Poor BCS

Describe the faecal changes seen in exocrine pancreatic insufficency

Large volumes Foul smelling Greasy (steatorrhoea) Putty-like to overt diarrhoea

Describe the appetite changes seen in exocrine pancreatic insufficency

Polyphagia (increased appetite) Coprophagia (ingesting faeces) Pica (depraved appetite)

How is exocrine pancreatic insufficency diagnosed?

Trypsin-like immunoreactivity - Blood test - Best test: very specific Normal dogs TLI = >5 μg/L Dogs with EPI = <2.5 μg/L Equivocal = 2.5-5.0 μg/L (repeat in 4wk)

How is exocrine pancreatic insufficency treated?

- Pancreatic enzymes - Dietary management - Cobalamin supplementation

Describe dietary management to treat exocrine pancreatic insufficiency

- Feed a highly digestible diet - No need to fat restrict: need calories for weight gain - NOT high fibre - Exclusion diet not necessary - Insure adequate food intake: 2x maintenance for ideal weight

Describe cobalamin supplementation to treat exocrine pancreatic insufficiency

- Dogs with EPI commonly have low cobalamin concentrations - Injection or oral vitamin B supplementation - Pancreas does not produce intrinsic factor - Poor prognostic indicator - Shorter survival in EPI with low cobalamin - Supplement cobalamin if deficient

Describe the effects of bacterial overgrowth secondary to EPI

Bacterial overgrowth can occur secondary to EPI as food isn’t digested in the SI giving the bacteria a media for growth and proliferation -> worsening diarrhoea

Is exocrine pancreatic insufficiency significant in cats?

A rare disease in cats Median age 7 years (0.3-15 years)

List the clinical signs of EPI in cats

Very similar to dogs - Weight loss (or poor growth) - Diarrhoea - Polyphagia, coprophagia, anorexia, flatulence - Vomiting Signs of any concurrent disease - Lethargy, hair loss, PU/PD, weakness

How is EPI diagnosed in cats?

Serum trypsin-like immunoreactivity

How is EPI treated in cats?

Oral pancreatic enzyme Cobalamin Dietary modification Antibacterials Treat other diseases