Pancreas Flashcards
1
Q
What does Exocrine Pancreatic Insufficiency (EPI) describe?
A
A syndrome characterized by insufficient synthesis and secretion of digestive enzymes by the exocrine pancreas.
2
Q
What is the most common cause of EPI?
A
Destruction or depletion of pancreatic acinar cells.
3
Q
Name two conditions that can lead to EPI.
A
- Chronic pancreatitis (dogs and cats)
- Pancreatic acinar atrophy (PAA) (dogs only)
4
Q
What is isolated enzyme deficiency in the context of EPI?
A
A rare case where a single enzyme (e.g., lipase) may be deficient, typically not causing clinical signs due to redundancy in digestion pathways.
5
Q
What is pancreatic duct obstruction?
A
A condition where tumors, surgical damage, or trauma block the duct, leading to functional EPI despite normal acinar enzyme production.
6
Q
What is congenital aplasia or hypoplasia?
A
A suspected cause of EPI diagnosed at a very young age, with no formal cases reported in literature.
7
Q
What is redundancy in the digestion of macronutrients?
A
Each macronutrient can be digested by multiple independent mechanisms.
8
Q
What percentage of dietary fat is digested by gastric lipase in healthy humans and dogs?
A
~33%.
9
Q
How much pancreatic function must be lost before clinical signs of maldigestion occur in humans?
A
> 90%.
10
Q
What are the roles of the exocrine pancreas?
A
- Digestive enzyme production
- Zymogen secretion
- Zymogen activation
- Secretion of colipase
- Secretion of pancreatic juice
11
Q
What is the primary source of intrinsic factor in dogs and cats?
A
The exocrine pancreas.
12
Q
What are common causes of EPI in dogs?
A
- Chronic pancreatitis (~50% of cases)
- Pancreatic acinar atrophy (PAA)
13
Q
What breeds are at risk for pancreatic acinar atrophy (PAA)?
A
- German Shepherd Dogs
- Rough-Coated Collies
- Eurasians
- Cavalier King Charles Spaniels
- Shar-Peis
- West Highland White Terriers
14
Q
What is the suspected inheritance pattern of PAA?
A
Initially suspected to be autosomal recessive, but evidence suggests polygenic inheritance.
15
Q
List some proposed causes of EPI in humans.
A
- Diabetes mellitus
- Inflammatory bowel disease
- Celiac disease
- Pediatric intestinal transplantation
- HIV infection
- Total gastrectomy
- Sjögren’s syndrome
- Aging
- Tobacco use
- Critical illness
16
Q
What are the consequences of maldigestion in EPI?
A
- Presence of undigested food in the intestinal lumen
- Loose stool or diarrhea
- Weight loss
- Secondary intestinal dysbiosis
17
Q
What is the relationship between EPI and cobalamin deficiency?
A
EPI is frequently associated with cobalamin malabsorption and hypocobalaminemia.
18
Q
What percentage of dogs with EPI had decreased serum cobalamin concentrations?
A
82%. (79% in cats)
19
Q
What are the diagnostic cutoffs for serum TLI in dogs and cats?
A
- Dogs: ≤2.5 µg/L
- Cats: ≤8.0 µg/L (or undetectable)
20
Q
What is the starting dose of dried pancreatic extract for PERT?
A
1 teaspoon per 10 kg body weight per meal.
21
Q
What dietary management is recommended for EPI patients?
A
Individualize diet trials for each patient and avoid high insoluble fiber diets.
22
Q
What are the fat-soluble vitamins that may be decreased in dogs with EPI?
A
- A
- D
- E
- K
23
Q
True or False: Subclinical EPI requires diagnosis and treatment.
A
False.
24
Q
What are the fat-soluble vitamins mentioned in the text?
A
A, D, E, K
25
What observation is noted regarding serum concentrations of fat-soluble vitamins in dogs with EPI?
Decreased serum concentrations observed
26
Is systematic supplementation of fat-soluble vitamins routinely done?
No, over-supplementation could cause side effects
27
What dosage of Vitamin E is suggested based on anecdotal reports?
400–500 IU PO q24h for 1 month
28
What is the clinical relevance of decreased blood taurine concentrations in dogs with EPI?
Remains unclear
29
True or False: EPI is recognized as a risk factor for taurine-deficiency myocardial disease.
False
30
What should be reviewed if a patient fails to improve despite standard PERT and cobalamin supplementation?
Enzyme type, dose, and formulation
31
List some concurrent diseases to investigate when managing non-responders.
* Chronic inflammatory enteropathy
* Diabetes mellitus
* Small intestinal dysbiosis
32
What is the purpose of a proton pump inhibitor trial in managing non-responders?
May help by increasing gastric pH, protecting pancreatic lipase
33
What is a potential risk of dietary fat restriction when managing EPI?
Risk of fat-soluble vitamin deficiency
34
What percentage of dogs report marked hypocobalaminemia?
36%
35
What is the positive predictive value of fecal elastase in dogs?
<60%
36
What is the mean survival for pancreatic adenocarcinoma in cats?
97 days
37
What is the median survival for dogs with marked hypocobalaminemia and EPI?
1,346 days
38
What is the median survival for dogs without marked hypocobalaminemia and EPI?
2,709 days
39
What new insight has been gained regarding pancreatic acinar cells?
Some regenerative capacity
40
What are the clinical presentations of pancreatic adenocarcinoma?
* Weight loss
* Anorexia
* Vomiting
* Lethargy
* Diarrhea
* Abdominal pain
41
What unique feature may be observed in cats with pancreatic adenocarcinoma?
Paraneoplastic alopecia
42
What diagnostic finding is often elevated in pancreatic adenocarcinoma?
Serum pancreatic lipase immunoreactivity (PLI)
43
What is the definitive diagnosis method for pancreatic adenocarcinoma?
* Cytologic evaluation of fine-needle aspirate
* Histopathological evaluation of pancreatic biopsy
44
What is the prognosis for pancreatic adenocarcinoma?
Poor
45
What treatments are primarily supportive for pancreatic adenocarcinoma?
Surgical removal of isolated masses, chemotherapy, radiation therapy
46
What is the exceptional case of a cat with pancreatic adenocarcinoma treated with surgery and toceranib phosphate?
Progression-free interval of 1,148 days
47
What are acute peripancreatic fluid collections?
Early in acute pancreatitis, no necrotic material, usually self-limiting
48
What are pancreatic pseudocysts?
Non-necrotic fluid collections enclosed by fibrous or granulation tissue
49
When is intervention needed for pancreatic pseudocysts?
* Size continues to grow
* Regression fails
* Infection occurs
50
What are acute necrotic fluid collections associated with?
Necrotizing pancreatitis
51
What is recommended if infection is suspected in fluid collections?
Antimicrobial therapy based on culture and sensitivity testing
52
What systemic parasitic infection can affect the pancreas in dogs?
Systemic schistosomiasis
53
What is the diagnosis method for systemic schistosomiasis in dogs?
Fecal PCR testing
54
What systemic parasitic infection can involve the pancreas in cats?
Systemic toxoplasmosis
55
What is the diagnosis method for systemic toxoplasmosis in cats?
Fecal smear + serologic testing
56
What can the liver fluke (Amphimerus pseudofelineus) cause in cats?
Pancreatitis
57
What can the pancreatic fluke (Eurytrema procyonis) cause?
* Pancreatic duct obstruction
* Chronic pancreatitis
* Pancreatic fibrosis and atrophy
58
What is the overall outlook for dogs and cats with EPI when appropriately treated?
Good quality of life and normal life expectancy
59
What are the general causes of acute pancreatitis?
* Pancreatic ischemia or hypoxia
* Oxidative stress
* Bacterial toxemia
* Hyperlipidemia
* Retrograde influx of bile or other substances into pancreatic ducts
* Pancreatic duct obstruction
## Footnote
In dogs and cats, the etiology remains mostly idiopathic, though several risk factors have been identified.
60
Which breeds of dogs are predisposed to acute pancreatitis?
* Terriers
* Non-sporting breeds
* Miniature Schnauzers
## Footnote
Genetic mutations known in humans have not been definitively associated with canine acute pancreatitis.
61
What are some other risk factors for acute pancreatitis in dogs?
* Neutering
* Obesity
* Hypertriglyceridemia
* High-fat diets (questionable)
* Dietary indiscretion
## Footnote
In Miniature Schnauzers with idiopathic hypertriglyceridemia, serum canine pancreatic lipase immunoreactivity (cPLI) correlates with serum triglyceride concentrations.
62
What infectious cause is associated with acute pancreatitis in dogs?
Babesiosis
## Footnote
Acute pancreatitis is a negative prognostic factor.
63
Which drugs have been reported to have idiosyncratic reactions associated with pancreatitis?
* Potentiated sulfonamides
* Azathioprine
* L-asparaginase
* Meglumine antimoniate
* N-methylglucamine
* Chlorpropamide
* Phenobarbital and potassium bromide
## Footnote
These drugs are associated with elevated cPLI concentrations and pancreatitis.
64
What is a notable difference between acute pancreatitis in dogs and cats?
No breed, sex, obesity, or hypertriglyceridemia associations have been clearly identified in cats
## Footnote
Bacterial colonization has been documented in cats with spontaneous pancreatitis.
65
What are potential infectious agents that can cause pancreatitis in cats?
* Toxoplasma gondii
* Eurytrema procyonis
* Amphimerus pseudofelineus
* Feline coronavirus
* Parvovirus
* Herpesvirus
* Calicivirus
## Footnote
These infectious causes are rare.
66
What initiates intracellular trypsinogen activation in acute pancreatitis?
* Pancreatic ischemia
* Hypoxia
* Oxidative stress
* Bacterial toxemia
* Apical block of acinar cell secretion
## Footnote
These can result from retrograde influx of bile into the pancreatic duct or abnormal intracellular calcium signaling.
67
What happens when protection against trypsin activation fails?
Apical block leads to accumulation and fusion of zymogen granules and lysosomes at the cell apex, causing intracellular activation of trypsinogen to trypsin
## Footnote
If >10% of intracellular trypsinogen is activated, or SPINK1 mutations are present, SPINK1 inhibition is overwhelmed.
68
What are some clinical signs of local inflammatory response in acute pancreatitis?
* Pain
* Swelling
* Reddening
* Increased organ temperature
## Footnote
Pain is a hallmark sign in humans and reported in approximately 50% of canine cases.
69
What are potential endocrine and exocrine dysfunctions due to acute pancreatitis?
* Transient diabetes mellitus
* Transient exocrine pancreatic insufficiency (EPI)
## Footnote
These complications correlate with the extent of pancreatic necrosis.
70
What is chronic pancreatitis characterized by?
Persistent lymphocytic or lymphoplasmacytic inflammation, accompanied by irreversible fibrosis and pancreatic atrophy
## Footnote
The disease may be subclinical or recurrent.
71
What are the two major pathways leading to pancreatic sentinel cell activation in chronic pancreatitis?
* Acinar cell-associated events
* Tissue-associated events
## Footnote
These pathways involve oxidative stressors, acidosis, and damage to pancreatic duct epithelial cells.
72
What are the pathophysiologic consequences of chronic pancreatitis?
Gradual replacement of functional exocrine and endocrine tissue by fibrosis
## Footnote
Clinical course can vary, remaining subclinical or manifesting with recurrent episodes of acute-on-chronic pancreatitis.
73
What are common clinical signs of acute pancreatitis in dogs?
* Lethargy (88%)
* Anorexia (86%)
* Vomiting (83%)
* Abdominal pain (59%)
74
What is a key consideration when interpreting clinical signs of pancreatitis?
Selection bias must be considered, as many studies include only dogs showing clinical signs.
75
What are common physical exam findings in severe acute pancreatitis?
* Dehydration (97%)
* Abdominal pain (58%)
* Fever (32%)
* Icterus (26%)
76
What clinical signs are associated with chronic pancreatitis in dogs?
* Lethargy (80%)
* Decreased appetite (70%)
* Vomiting (63%)
* Diarrhea (36%)
* Abdominal pain (27%)
77
What are common biochemical abnormalities seen in pancreatitis?
* Elevated liver enzymes (ALT, AST, ALP)
* Hyperbilirubinemia
* Elevated creatinine, BUN, or SDMA
* Hypertriglyceridemia
* Hypercholesterolemia
* Hypoalbuminemia
* Hyperglycemia
* Hypoglycemia
78
What is the most sensitive and specific serum test for diagnosing pancreatitis?
Pancreatic Lipase Immunoreactivity (PLI)
79
What imaging modality is currently considered the best for diagnosing pancreatitis in dogs?
Abdominal ultrasound
80
What are ultrasonographic findings suggestive of pancreatitis?
* Hypoechoic areas within the pancreas
* Increased echogenicity of surrounding mesentery
* Enlargement and/or irregularity of the pancreas
81
What are the limitations of DGGR-based lipase assays?
* Vary significantly due to various factors
* Not exclusively specific for pancreatic lipase.
82
What is the sensitivity and specificity of the SPEC-CPL in necropsy studies for moderate to severe pancreatitis?
* Sensitivity: 91%
* Specificity: 98–100%
83
What are the cytologic features of acute pancreatitis?
* Intact and degenerate neutrophils
* Degenerate pancreatic acinar cells
84
What are macroscopic findings suggestive of pancreatitis during surgery or necropsy?
* Peripancreatic fat necrosis
* Pancreatic hemorrhage and congestion
* Dull, granular capsular surface
85
What histopathological features are associated with chronic pancreatitis?
* Fibrosis
* Acinar atrophy
86
What factors affect the sensitivity and specificity of abdominal ultrasound in diagnosing pancreatitis?
* Skill of the ultrasonographer
* Equipment quality
* Stringency of applied criteria
87
Fill in the blank: The most common electrolyte disturbance in pancreatitis is _______.
Hypokalemia
88
What should be considered when interpreting results from the Laboklin C-PLI assay?
Caution, as it has not undergone full analytical validation.
89
What is the role of fine needle aspiration (FNA) in diagnosing pancreatitis?
To assist in diagnosing and differentiating pancreatitis and other exocrine pancreatic diseases.
90
What are the permanent changes associated with chronic pancreatitis?
Fibrosis and acinar atrophy
## Footnote
Chronic pancreatitis leads to irreversible damage in the pancreas.
91
What are the key characteristics of acute pancreatitis?
No permanent changes; presence of neutrophils, edema, necrosis
## Footnote
Acute pancreatitis is characterized by an inflammatory response without lasting damage.
92
What is a major limitation in diagnosing pancreatic conditions via FNA or biopsy?
Localized lesions are common; sampling error is a major issue
## Footnote
Accurate diagnosis may require multiple samples due to variability in lesions.
93
What is the ideal method to improve diagnostic sensitivity for pancreatic conditions?
Evaluate multiple pancreatic sections
## Footnote
Although often not feasible clinically, this approach can enhance diagnostic accuracy.
94
What are the risks associated with biopsies for pancreatic conditions?
Expensive and potentially risky, especially for hemodynamically unstable patients
## Footnote
Invasive procedures can pose significant health risks.
95
What is the specificity percentage of abdominal ultrasound with stringent criteria?
92%
## Footnote
While highly specific, this method has low sensitivity.
96
What is the diagnostic yield of FNA cytology for pancreatic conditions?
74%
## Footnote
FNA cytology is useful but does not exclude pancreatitis if negative.
97
What is considered the gold standard for diagnosing pancreatic conditions?
Histopathology
## Footnote
Although it is the most reliable method, sampling errors can occur.
98
What was the previously considered prevalence of pancreatitis in cats?
Less than 3.5%
## Footnote
This prevalence has changed due to advances in testing and imaging.
99
What is the overall prevalence of pancreatitis among necropsy cats?
67%
## Footnote
This includes both acute and chronic cases.
100
What percentage of necropsy cats with pancreatitis were apparently healthy?
45%
## Footnote
This suggests the histopathologic definition of pancreatitis may be too broad.
101
What are the most common clinical signs of pancreatitis in cats?
* Lethargy: 51–100%
* Inappetence: 62–97%
* Vomiting: 35–52%
* Weight loss: 30–47%
* Diarrhea: 11–38%.
102
What is the most commonly used imaging modality for assessing feline pancreatitis?
Abdominal ultrasound.
103
True or False: There is no age, sex, or breed predisposition for pancreatitis in cats.
True.
104
What are recognized causes of pancreatitis in cats?
* Pancreatic neoplasia
* Gastrointestinal foreign bodies
* Abdominal trauma
* Hypercalcemia
* Organophosphate or cholinesterase inhibitor intoxication
* Topical exposure to fenethion
* Idiosyncratic adverse drug reactions.
105
List some non-infectious diseases associated with pancreatitis in cats.
* Diabetes mellitus
* Inflammatory bowel disease (IBD)
* Hepatic lipidosis
* Cholangitis
* Nephritis
* Immune-mediated anemia.
106
What are the limitations of the Trypsin-Like Immunoreactivity (TLI) test in diagnosing pancreatitis?
Poor diagnostic sensitivity and limited tissue specificity.
107
What percentage of feline acute-on-chronic pancreatitis cases are classified as idiopathic?
Greater than 95%.
108
What is the sensitivity of the Spec fPL test for moderate to severe pancreatitis?
100%.
109
What is the significance of elevated liver enzymes in serum biochemistry for pancreatitis?
Indicates potential liver involvement, with common elevations in ALT, ALP, and hyperbilirubinemia.
110
Fill in the blank: The ideal biomarker for pancreatitis should be specific for pancreatitis and synthesized only by _______.
[pancreatic acinar cells].
111
What are the ultrasound findings associated with pancreatitis?
* Hypoechoic/heteroechoic pancreatic enlargement
* Hyperchoic peripancreatic mesentery
* Peripancreatic effusion.
* Pancreatic lymph node enlargement.
112
What is the diagnostic accuracy of abdominal ultrasound in pancreatitis?
* Sensitivity: 11–67%
* Specificity: 73%.
113
What are the histologic classifications of acute pancreatitis?
* Acute necrotizing pancreatitis: Significant necrosis.
* Acute suppurative pancreatitis: Neutrophilic inflammation without necrosis.
114
What are common electrolyte abnormalities in severe pancreatitis?
* Hypokalemia
* Hypochloremia
* Hyponatremia
* Hypocalcemia.
115
What is an important consideration when performing ultrasound-guided fine needle aspiration (FNA) of the pancreas?
Quick and gentle smearing is critical due to fragile pancreatic acinar cells.
116
What are the histological features of chronic pancreatitis?
* Lymphocytic/lymphoplasmacytic inflammation
* Mild fibrosis
* Acinar atrophy
* Retention cysts and/or periductal fibrosis
## Footnote
These features indicate ongoing inflammatory processes and structural changes in the pancreas.
117
What factors influence the treatment of pancreatitis in cats?
* Severity and duration of clinical signs
* Presence of comorbidities
* Hydration status
* Presence of abdominal pain
## Footnote
These factors guide the overall management strategy for feline pancreatitis.
118
What is the key goal of fluid therapy in cats with pancreatitis?
Restore euvolemia to maintain pancreatic perfusion and oxygenation
## Footnote
Proper hydration is crucial to support pancreatic function and overall health.
119
What are the risks of prolonged inappetence in cats with pancreatitis?
* Dehydration
* Malnutrition
* Gastrointestinal barrier dysfunction
* Immune suppression
* Hepatic lipidosis
## Footnote
These risks highlight the importance of addressing appetite in affected cats.
120
What is the recommended approach for nutritional support in severe acute pancreatitis?
Early enteral nutrition (<24 hours) recommended
## Footnote
This approach is based on human data suggesting benefits of early feeding after acute illness.
121
What type of diets are recommended for cats with pancreatitis?
* Highly digestible gastrointestinal diets
* Adequate arginine and methionine
* Adequate protein
## Footnote
These dietary components help prevent complications such as hepatic lipidosis and malnutrition.
122
What is the diagnostic sensitivity of ultrasound for pancreatitis?
11–67%
## Footnote
This indicates variable effectiveness in detecting pancreatitis through ultrasound imaging.
123
What is the first-line analgesic for pain management in cats with pancreatitis?
Opioids
## Footnote
Opioids are the primary choice for managing pain in feline pancreatitis cases.
124
What should be assumed about all cats with pancreatitis regarding pain?
They should be assumed to be painful and treated accordingly
## Footnote
Even in the absence of overt signs, pain management is crucial.
125
What is the role of maropitant in managing vomiting in cats?
Highly efficacious antiemetic with potential visceral analgesic effects
## Footnote
Maropitant is effective in controlling vomiting and may also help with pain.
126
When are glucocorticoids indicated in the management of pancreatitis?
For treating comorbid sterile inflammatory diseases
## Footnote
Their routine use in uncomplicated pancreatitis is not recommended due to potential risks.
127
What is a potential complication of severe pancreatitis that may require surgical intervention?
Pancreatic abscess
## Footnote
While rare, surgical intervention may be critical for addressing specific complications.
128
What are the important points regarding pain management in cats with pancreatitis?
* Assume all cats are painful
* Opioids are first-line treatment
## Footnote
Addressing pain effectively is vital for recovery and comfort.
129
What is the significance of infected pancreatic necrosis in moderate to severe pancreatitis cases?
Found in ~35% of cases
## Footnote
This highlights the need for careful monitoring and potential antibiotic therapy in severe cases.
