Pancreas Flashcards
Which drugs have been associated with the development of pancreatitis?
Potassium bromide, azoathioprine, asparaginase. Hypothyroidism, obesity, hyperadrenocorticism and diabetes mellitus are also thought to increase risk of disease.
When does inflammation of the pancreas occur?
Wheen normal protective mechanisms against premature activation of trypsinogen are overwhelmed. Premature activation of trypsinogen within the pancreas results in digestion of pancreatic proteins and activation of more trypsinogen. This results in release of pro inflammatory cytokines with necrosis and in severe cases severe systemic inflammation.
What is the signalment for acute pancreatitis?
Mostly middle aged dogs and cats though any age may be affected. Dog more frequently affected with acute pancreatitis whereas cats more generally have more chronic disease. Terrier breeds and miniature schnauzers more predisposed.
What are the clinical signs of acute pancreatitis?
There may be history of ingestion of a very high fat meal or dietary indiscretion in dogs. Clinical signs can vary from very mild to quite severe and can include abdominal pain, anorexia, dehydration, vomiting and diarrhoea. More severe cases have signs of SIRS, DIC or multi organ disease: collapse, shock, tahcycardia.
How is acute pancreatitis diagnosed?
Minimum database may show hemoconcentration with dehydration, neutrophilia and left shift or neutropenia with SIRS/sepsis, pre renal or renal azotaemia, elevated liver enzymes, hypokalaemia, concentrated or isothenuric USG and possibly prooteinuria. Abdominal radiographs are typically unhelpful but may show decreased cranial abdominal detail and an air filled duodenum. PLI should be performed to confirm diagnosis.
What is the treatment for Acute pancreatitis?
Remove any inciting cause if possible. Supportive care, iv fluids, electrolyte supplementation. Pain management usually necesasry, with an opioid. NUtritional support should be provided, trickle feed of very small amounts. a bland easily digestible diet should be fed. Multiple anti emetics may be required. Gastroprotectants often indicated. Antibiotic therapy given in severe cases.
What is the prognosis for acute pancreatitis?
Mild cases of pancreatitis may be treated supportively as for acute gastroenteritis and self resolves in a couple of days. Severe cases may require extensive supportive care and are high risk for developing severe life threatening complications.
How can chronic pancreatitis develop?
It can develop as an extension of acute inflammation that leads to permanent impairment of function or impairment of function or persistent low levels of inflammation. Inflammatory infiltrates are usually mononuclear. Chronic pancreatitis may occur as a primary autoimmune disease in English cocker spaniels.
What is the signalment for chronic pancreatitis?
Generally middle aged to older dogs and cats. More frequently seen in cockers and CKCS though siberian husky, collies and boxers are overrepresented.
What are the clinical signs of chronic pancreatitis?
Generally waxing/waning or intermittent. Signs can include bouts of anorexia vomiting and abdominal pain, cats are often just anorexic. Chronic pancreatitis can eventually lead to enough fibrosis to cause EPI or DM so patients could also present with corresponding clinical signs.
How do you diagnose chronic pancreatitis?
Over all findings is similar to acute disease though changes are usually less pronounced. PLI is still the test with highest sensitivity. Cobalamin should be measured in all cases because decreased intrinsic factor production with chronic pancreatitis can cause hypocobalaminaemia. Biopsy needed for definitive diagnoses.
What is the treatment for chronic pancreatitis?
Most dogs and cats with chronic pancreatitis will have intermittent flare ups or bouts of acute disease. These can be managed as acute pancreatitis. Long term management on a low fat diet may reduce acute episodes in dogs. Cobalamin should be supplemented if indicated. Periods of anorexia should be managed with feeding tube supplementation if necessary.
What is exocrine pancreatic insufficiency?
Loss of exocrine pancreatic function may occur secondary to chronic pancreatitis or pancreatic acinar atrophy (dogs only). With pancreatitis, chronic inflammation and fibrosis leads eventually to loss of enough exocrine pancreeatis tissue that maldigestion occurs. With pancreatic acinar atrophy there is an autoimmune reaction against pancreatic acini.
What is the signalment for exocrine pancreatic insufficiency?
EPI from pancreatic acinar atrophy is seen in young german shepherd dogs, rough coated collies and chow chows primarily. Average ate at time of diagnosis is 2-3 years. EPI from chroonic pancreatitis can be any age/breed, though middle aged to lder at risk for pancreatitis (Cocker CKcS) are more frequently affected. Average age onset - 6 years.
What are the clinical signs of Exocrine pancreatic insufficiency?
Weight loss, which may be severe, diarrhoea is often present ay be small bowel due to maldigestion or large bowel due to bacterial overgrowth. Appetite is classically increased but may also be decreased. Steatorrhea may be present if over 90% lipase production is lost. With chronic pancreatitis EPI, DM may also be present.
How is exocrine pancreatic insufficiency diagnosed?
The minimum database is usually unremarkable unless concurrent diseases are present. EPI can cause mild hypoproteinaemia, mildly increase LE, low cholesterol and triglycerides and mild lymphopaenia. TLI is the diagnostic of choice with high sensitivity and specificity. A fasted sample should be used to reduce the likellihood of false negatives. Cobalamin and folate should also be measured.
What is the treatment for exocrine pancreatic insufficiency?
Medical management consists primarily of pancreatic enzyme replacement, typically with pancreazyme or something similar. Patients should be co administered an H2 antaonist or PPI so that enzymes are not degraded by gastric acid. Over time, pancreatic enzymes may be weaned to lowest effective dose. Diet should consist of moderate fat, highly digestible diet that is not high in fibre. Tylosin or metranidazole can help bacterial overgrowth. Cobalamin should be spuplemented.
What are Pancreatic Cysts/pseudocysts?
Pancreatic cysts occur congenitally in some breeds (persians) or Ocassionally in association with neoplastic disease. A pancreatic pseudocyst is a cyst like structure filled with pancreatic enzymes that is seen uncommonly with pancreatitis. They are both Important for differential for pancreatic abscess.
What are the clinical signs of pancreatic cysts/ pseudocysts?
Usually none. Ocassionally cysts could cause EHBO and corresponding signs.
How are cysts/pseudocysts diagnosed?
Aspirate of fluid from structure will be modified transudate in the case of a cyst or pseudocyst versus exudate with abscess
What is the treatment for cysts/pseudocysts?
None - unless there is biliary tract compression in which case it may be drained with ultrasound guidance or surgery.
What are the clinical signs of pancreatic disease?
Anorexia, vomiting, diarrhoea, abdominal pain, weight loss. systemic signs: lethargy, depression, dehydration, signs of systemic inflammatory response syndome, bleeding with DIC.
What will be the results of Haematology with pancreatic disease?
RBC count - increased with dehydration, decreased with anaemia
WBC - stress or inflammatory leukogram causing neutrophilia, sepsis/SIRS causing neutropenia
Platelets - thrombocytopaenia with severe pancreatitis/DIC.
What will be the results of biochemistry with pancreatic disease?
Elevated liver enzymes - primarily hepatocellular with neighbouring inflammation or cholestatic with biliary obstruction.
Azotaemia - pre renal from dehydratioon. Renal with concurrent acute kidney injury from pancreatitis.
Bilirubin and bile acids - may be elevated from biliary obstruction from pancreatitis.
Amylase/lipase are NOT helpful in diagnosing pancreatic disease.
What will be the results of urinalysis for pancreatic disease?
USG - concentrated with dehydration
Isothenuric with concurrent acute kidney injury.
Proteinuriea - can occur with severe systemic inflammation.
What will be the result for pancreatic lipase immunoreactivity (PLI) test with pancreatic disease?
Available as canine or feline specific quantitive test, or SNAP PLI (canine). Highly sensitive and specific for pancreatitis. Diagnostic of choice.
What is the Trypsin like immunoreactivity (TLI) test?
Quantification of trypsinogen and trypsin in systemic circulation - a small amount normally leaks from pancreas to blood. Decreased with exocrine pancreatic insufficiency. Must be on a fasted sample or may get falsely elevated reading. Diagnostic of choice for EPI. May be increeased with pancreatitis. Less sensitive than PLI.
