Pancreas Flashcards
Anatomy
- Central body with two limbs
- Exocrine (98%) & endocrine (2%) cells
Excocrine Pancreatic Function (4)
Enzymes: - amylase - phospholipase - chymotrypsin - trypsin - lipase these initiate protein, CHO and lipid dgestion
- bicarbonate chloride and water: neutralises duodenum
- intrinsic factor: facilitates cobalamine (vit B12 absorption)
- antibacterial proteins: regulates SI bacterial flora
Acute pacreatitis CS in dogs(8)
- Vomiting
- Anorexia
- Depression
- Abdominal pain
- Diarrhoea
- Shock
- Jaundice
- Dehydration
Normal defence against autodigestion
- locally (7)
- systemically (1)
Locally:
- Proteolytic enzymes are synthesised as inactive zymogens (eg trypsinogen)
- These are Zymogens packaged in granules
- Granules also contain pancreatic secretory trypsin inhibitor (PSTI)
- Granules lie far away from enzymes
- When required, zymogen granules are released by exocytosis
- trypsinogen is activated to trypsin in SI by enterkinase
- trypsin then activates other granules
Systemically:
Plasma contains molecules that will scavenge free enzymes (eg. α-1 antitrypsin, α-2 macroglobulin)
so MANY processes are required to activate and fast deactivation to prevent autodigestion
Acute Pacreatitis pathogenesis (6)
- Initiating event thought to be premature activation of digestive zymogens within the pancreatic cell
- Lysosomes & zymogen granules fuse to form vacuoles
Lysosomal enzymes activate trypsinogen –> trypsin - Vacuoles rupture releasing active enzymes into cell
- Other zymogens then activated
- Causes cell necrosis & pancreatic autodigestion
- Inflammatory mediators & cytokines etc cause cell necrosis & inflammation
Acute pancreatitis
- results (3)
- histologically (3)
Result is:
- Local inflammation & necrosis
- Systemic dissemination of activated enzymes
- Systemic inflammatory response
histologically:
- necrosis
- oedema
- neutrophilic infiltrate
Acute pancreatitis
- aetiology
- Dietary factors: hyperlipideaemia, scavenging from bin
- Drugs/Toxins
- Trauma
- Reduced pancreatic perfusion: shock, addisons
- Genetics
- Hypercalcaemia
- Duodenal/biliary reflux
Acute pacreatitis clin path
- haematology (2)
- biochem (70
- additional (2)
Non-specific changes due to inflammation & hypovolaemia
Haematology:
- Leucocytosis
- (Thrombocytopenia)
Biochemistry:
- Increased liver enzymes
- Azotaemia – pre-renal (renal)
- Hypokalaemia
- Hypocalcaemia
- Hyperlipaemia (cause or effect ?)
- (Hyperbilirubinaemia)
- (Hyperglycaemia)
Additional tests:
- increase in amylase
- increase in lipase
Trypsin-Like Immunoreactivity (TLI)
- measures trypsin and trypsinogen in blood
- quite specific: if high likely to be due to pancratitis
- not very sensitive: short t1/2, increase early in decrease but rapidly decreases
- delayed results
- meh
Canine Pancreatic Lipase
SNAP© cPLTM
- In house test
- Negative, intermediate, positive
- Sensitivity 91% ; specificity 77% so positive should be confirmed
- If negative, unlikely to have acute pancreatitis
- If positive, should send away for quantitative test
Spec PLI
- Needs to be sent away
- Quantitative test
--> >400 ug/L – positive
- ~85% sensitive, ~95% specific (dogs)
- Potential false +ve if renal disease or steroid administration
Expensive
Acute pancreatitis Rx
- radiographs (4)
- US (5)
Radiographs:
- need to rule out other causes
- Signs - peritonitis
- -> Loss of contrast
- -> Gastric-duodenal angle widening
- -> Gastric displacement
US
- Subjective
- Hypoechoic pancreas
- Enlarged pancreas
- Hyperechoic peri-pancreatic fat
- Pain in cranial abdomen?
Acute pancreatitis Tx (5)
- IVFT: Improve & maintain pancreatic perfusion
- Analgesia
- -> Buprenorphine/methadone 1st choice
- -> Morphine/ketamine/lidocaine (MLK) or butorphanol CRI
- -> opioids are fine with pancreatic duct but not NSAIDs
Anti-emetics
- Maropitant
- -> Blocks NK-1 receptor
- -> Peripheral & centrally acting - Metoclopramide
- -> Dopamine antagonist
- -> Centrally acting & pro-kinetic action - Ondansetron
- -> 5-HT3 antagonist
- -> Peripherally & centrally acting
Gastric protectants
- Acute pancreatitis predisposes to gastric ulceration
- Cimetidine, Ranitidine, Famotidine, Omeprazole
Nutrition: do NOT rest pancreas! Feed the enterocytes, give low fat food in small ammounts
Acute Pancreatitis Prognosis and Outcome
- complete recovery
- recurring acute pancreatitis
- chronic pancreatitis
- death
- complications (SIRS, abscess/psuedocyst, DIC, multi-organ failure, extra hepatic bile duct obstruction_
Acute Pancreatitis in Cats CS (7)
- Often non-specific – anorexia, lethargy
- Vomiting rare
- Hypothermia more common than fever
- Sometimes cranial abdominal mass
- Dehydration
- Pale mucous membranes
- Dyspnea
- (Diarrhoea)
- (Icterus)
- (PUPD)
- (Polyphagia)
Acute Pancreatitis in Cats
- investigation (4)
- Tx
Haematology & biochemistry
- Highly variable, non-specific
Amylase & lipase
- Often normal
- Increased with intestinal disease & renal disease
- Not useful
Feline TLI
- Not useful for pancreatitis
SNAP© fPLTM
- In house
- Normal/abnormal
Tx:
- similar to dogs
- more indication for ABs
- consider corticosteroids
Chronic Pancreatitis pathogenesis (5)
- may present acutely but progress to chronic or start as chronic
- Permanent histological change
- Non-suppurative
- Mononuclear infiltrate with fibrosis
- Progressive loss of exocrine & endocrine function
Chronic Pancreatitis
- CS (4)
- Dx (3)
CS
- Intermittent, low-grade clinical signs OR
- Acute signs OR
- Exocrine pancreatic insufficiency OR
- -> Older, non-GSD - Diabetes mellitus (PUPD, weight loss, polyphagia)
Dx:
- biopsy
- US
- PLI
Chronic pancreatitis Tx (8)
- Supportive
- Analgesia
- Low-fat diet
- Vitamin B12 injections - if low
- Consider appetite stimulants (cats)
- Treat EPI if present or if chronic weight loss
- Treat DM if present
- Consider corticosteroid therapy (cats & Cocker spaniels)
Exocrine Pancreatic Insufficiency (EPI)
- what
- CS (6)
- Clin path (2)
- decreased pancreatic secretory capacity
CS:
- Weight loss
- Diarrhoea
- Flatulence
- Increased appetite
- Poor hair coat
- Steatorrhoea
Clinical pathology
- TLI is low
- serum cobalamin is low
EPI causes (4)
Can be caused by:
Pancreatic acinar atrophy
- End stage autoimmune process
- GSDs and Rough collies – autosomal recessive
Aplasia
- Young dogs
Chronic pancreatitis
- main cause in cats
- increasingly recognised in dogs
- May have concurrent diabetes mellitus
Pancreatic neoplasia
EPI management (3)
Enzyme supplementation
- Powder or granules (not unopened capsules)
- Give with every meal – mix with food
- Can be unpalatable for cats
Diet
- Individual variation
- May be able to continue original diet
- No single best diet
- Highly digestible, low fiber, moderate fat diet may help?
- Little & often?
cobalamin injections if it’s low
EPI: poor response (5)
Enough enzyme in correct form?
Dysregulation of GI flora
- Antibiotic responsive diarrhoea
- Metronidazole, tylosin, tetracyclines
- For 1-3 weeks
The effect of gastric pH
- Consider H2-antagonists or proton pump inhibitors
Diet change
- Fat restriction?
Concurrent SI disease
- Food responsive diarrhoea, IBD
- May need further investigations
Pancreatic Neoplasia
- Differentiation (3)
- Most common: dogs (2), cats (1)
- Exocrine or endocrine
- Primary or secondary
- Benign (adenomas) or malignant (adenocarcinomas
Dogs - Pancreatic lymphoma, haemangiosarcoma etc - Pancreatic adenocarcinoma Cats - Pancreatic adenocarcinoma
Pancreatic Neoplasia
- CS (4)
- Dx (3)
CS:
- May be incidental finding
- Can be non-specific (hyperglycaemia if beta cells destroyed)
- Can obstruct duct leading to secondary atrophy & EPI
- Can lead to pancreatitis (local inflammation secondary to tumour necrosis)
Dx:
- Imaging: similar to pancreatitis + mass
- Try FNA but do not exfoliate well
- Often diagnosed at exploratory laparotomy or post-mortem
Pancreatic Neoplasia
- Metastasis
- Tx (3)
- Profnosis
Metastatic spread common
- liver, local lymph nodes, mesentery, intestines & lungs
Tx:
- Surgical resection –> Margins rarely achieved
- Chemotherapy –> Little effect
- Radiation therapy –> Not used
Prognosis: grave
