Pancreas

Question 1

what causes acute pancreatitis (the chemical pathway, not the patient factors)

Answer 1

premature activation of proenzymes in pancreatic parenchyma: likely secondary to fusion of zymogen and lysosome vacuoles that cause pH to drop, activating trypsinogen and the enzyme activation cascade
pancreatic secretory trypsin inhibitor (meant to prevent premature activation of proteases) overwhelmed

Question 2

end result of acute pancreatitis

Answer 2

pancreatic inflammation, edema, hemorrhage, necrosis
peripancreatic fat necrosis and saponification

Question 3

name at least 3 ethologies for dog acute pancreatitis

Answer 3

idiopathic, obesity, toxins or drugs (L-asparaginase, azathioprine…), dietary factors (indiscretion, high fat), hypertriglyceridemia, hypo perfusion, hereditary, trauma, hypercalcemia, hypothyroidism, DM, herperadrenocorticism

Question 4

name a least 3 ethologies for cat acute pancreatitis

Answer 4

idiopathic, hypo perfusion, trauma, neoplasia, hypercalcemia, toxins or drugs (L-asparaginase, azathioprine)
infectious diseseases, eg. flukes or toxoplasmosis
drug associations are less clear in cats

Question 5

what are 2 common comorbid conditions in cats with acute pancreatitis? what could this indicate about underlying disease?

Answer 5

IBD, neutrophilic cholangitis
underlying disease in hepatic llipodosis?

Question 6

what are most common C/S of acute pancreatitis in dogs?

Answer 6

vomit, abdominal pain (this is rarely seen in cats), anorexia
less common: icterus (obstruction of CBD?), tachycardia (pain, decreased perfusion), fever, diarrhea
note that the C/S depend on the severity of local and systemic inflammation

Question 7

what are most common C/S of acute pancreatitis in cats

Answer 7

weight loss, lethargy, anorexia, hypothermia (rather than fever), vomiting <50%
less common: tachycardia, icterus

note that the C/S depend on the severity of local and systemic inflammation

Question 8

signalment acute pancreatitis dog

Answer 8

Boxers, Yorkies, Mini Schnauzers, Collies, Cocker Spaniels, CKCS
maybe more females
middle aged (5 years) and above (if younger think acute gastroenteritis or FB)

Question 9

signalment acute pancreatitis cat

Answer 9

no breed sex or significant age predisp
most >7 years

Question 10

what are some bloodwork findings with acute pancreatitis? note various disorders would have similar signs, need more specific than bloodwork alone

Answer 10

leukocytosis, +- left shift, and hemoconcentration (inflammatory leukogram and dehydration)

elevated liver values, esp. cholestatic parameters (ALT, GGT, bili, cholesterol)

hyperalbuminemia

elevated BUN and creatinine

hypocalcemia, bc Ca going into saponified fat (more common in cats and a poor px indicator)

Question 11

do amylase and lipase correlate with severity of acute pancreatitis in DOGS?

Answer 11

NO. compatible with but not diagnostic or pathognomic in dogs! lacks Se and Sp
(dogs: serum amylase normal in up to 47%, serum lipase normal in up to 61% (rather than increased))

Question 12

do amylase and lipase correlate with severity of acute pancreatitis in CATS?

Answer 12

NO. no diff in mean values for cats with extra pancreatic disease, pancreatitis, or normal.
NO diagnostic benefit for pancreatitis dx in cats

Question 13

what is a specific diagnostic test for acute pancreatitis?

Answer 13

pancreas specific lipase (this is not influenced by renal elimination)

Question 14

what are the two forms of pancreas specific lipase tests? which is bedside and which is lab test

Answer 14

SNAP is bedside test, gives + or - result
- good to rule out pancreatitis if negative, but if positive could either be questionable or actually pancreatitis

SPEC test is lab test, gives 3 ranges of concentrations
- there is a normal level, cut off for pancreatitis, but also a questionable range

Question 15

AUS: see hypo echoic pancreas, hyper echoic surrounding tissue, and free abdominal fluid. what is likely issue?

Answer 15

acute pancreatitis. not that enlarged pancreas alone is not sufficient to dx

Question 16

are rads good for diagnosing acute pancreatitis

Answer 16

no, not sensitive, and subjective.
however they help RULE out DDX, eg. FB and obstruction

Question 17

what is gold standard for diagnosing acute pancreatitis? is this often done

Answer 17

biopsy. no, unless in sx for some reason.
note, biopsies can miss lesions, bc patchy distribution, and that normal gross appearance doesn’t exclude historical changes

Question 18

what is first tier treatment for acute pancreatitis

Answer 18

fluids (pancreas prefers PERFUSION; also supplement potassium), nutrition (early feeding beneficial), analgesics (buprenorphine or for dogs lidocaine CRI. NO NSAIDS due to dehydration and organ injury risk, antiemetics (maropitant, metoclopramide, ondansetron)

treat concurrent dz, discontinue meds that could provoke pancreatitis

Question 19

what is second tier tx for acute pancreatitis?

Answer 19

second tier: Abx, plasma.
not commonly used

Question 20

what is third tier tx for acute pancreatitis

Answer 20

surgical.
not commonly pursued.

Question 21

when to consider Abx for tx acute pancreatitis?

Answer 21

consider Abx if: febrile, evidence ofGi compromise, dramatic leukocytosis, direct evidence of bacteria (culture)
this is a second tier tx

Question 22

when to consider plasma for tx acute pancreatitis?

Answer 22

coagulopathy secondary to SIRS

(theory is that it contains protease inhibitors and scavenges to activated proteases/lipases. but there is no proven clin benefit)

Question 23

what can prolonged anorexia cause? give 3 negative effects

Answer 23

villous atrophy
bacterial translocation
immunosuppression

hence why early feeding in acute pancreatitis is important

Question 24

first tier tx acute pancreatitis: when to consider nutrition?
if can give PO, what food?

Answer 24

as soon as stabilized (old school wait 24 h, not anymore)
once hydrated, analgesics, antiemetics +- pro kinetics, consider: per os or NG tubes.
highly digestible low fat is most common

Question 25

first tier tx acute pancreatitis for cats: when to consider nutrition?
what do we often start with, PO or NE tube?

Answer 25

as with dogs, once stabilized
often need more permanent feeding method; often have concurrent dz eg. hepatic lipidosis or cholangitis
often start w NE tubes

Question 26

what is chronic pancreatitis

Answer 26

continuing inflammatory disease of pancreas with presence of IRREVERSIBLE FIBROSIS AND ATROPHY
hard to definitively dx w/o biopsy, and acute pressure of chronic dz can mimic acute pancreatitis

Question 27

dog with intermittent anorexia, abdominal pain, vomiting, food aversions, who (not always but some cases) EPI and DM. suspicious of?

Answer 27

chronic pancreatitis

Question 28

cat with insidious weight loss, intermittent GI signs, sisgns of cholangitis and IBD. what are you suspicious of?

Answer 28

triaditis IBD pancreatitis neutrophilic colangiti

Question 29

for dx of chronic pancreatitis, are pancreatic specific lipase and US as sensitive as for acute pancreatitis

Answer 29

atrophic tissue present, so not as Se PSL
US not as Se bc inflammation not as present; may see hyperechogenicity of pancreatic parenchyma consistent w fibrosis

Question 30

what are mainstays of tx for chronic pancreatitis

Answer 30

supportive therapy as per acute dz, if needed
analgesia as needed
low fat diets
address fxnl loss if needed: insulin, pancreatic enzymes
address concurrent dz in cats

Question 31

progressive lymphocytic inflammation leads to pancreatic atrophy. this is inability to produce sufficient pancreatic enzymes to digest fats, carbohydrates and proteins. what is condition

Answer 31

EPI exocrine pancreatic insufficiency

Question 32

young adults predisposed, before 4 years of age in most, but older animals if due to underlying pancreatic dz: G step, Rough Collies common.
symptoms show when >90% tissue loss: chronic diarrhea yellowy gray and fatty and frothy. weight loss with polyphasic, flatulence, coprophagia. what is condition

Answer 32

EPI exocrine pancreas insufficiency

Question 33

how is exocrine pancreatic insufficiency diagnosed

Answer 33

TLI serum trypsin like immunoreactivty, a referral lab test, w clinical signs.
TLI LOW consistent w dx
this is Se and Sp

Question 34

treatment for exocrine pancreatic insufficiency

Answer 34

pancreatic enzyme tabs: powder better, Viokase V, given w food
freeze fed pancreatic tissue, may be illegal idk
highly digestible high quality diet, not restricted, and do not restrict fat
cobalamin some cases
antibiotics some cases

Question 35

hypocobalaminemia common in dogs and cats with EPI, so supplement if needed PO or parenteral. why does this occur?

Answer 35

cobalamin absorption (in the ileum) requires intrinsic factor IF which is produced from pancreas (cats and dogs) and gastric wall (dogs) so get hypocobalaminemia.

Question 36

when can Abx be considered for exocrine pancreatic insufficiency

Answer 36

not responding to therapy (tylosin or metronidazole)
commonly used adjectively bc intestinal bacterial overgrowth presumed present in some patients