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Small Animal Medicine II > Pancreas > Flashcards

Pancreas Flashcards

1
Q

How much of the pancreas is exocrine and how much is endocrine?

A 
Exocrine = 98%
Endocrine = 2%
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2
Q

Which 2 cells are exocrine?

A

Acinar cells

Ductal cells

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3
Q

What 2 products have an endocrine function?

A

Insulin

Glucagon

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4
Q

What is a major difference between dogs and cats with respect to their pancreatic ducts?

A

Dogs have two ducts into duodenum

Cats have one duct that joins the bile duct

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5
Q

What are 4 major exocrine functions of the pancreas?

A

Macronutrient digestion
Neutralise duodenum
B12 absorption
Regulate SI flora

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6
Q

How are the digestive enzymes stored to prevent autodigestion?

A

Inactive zymogen granules

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7
Q

How do the zymogen granules become activated?

A

By other lysosomal enzymes ONLY in SI

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8
Q

What hydrolizes itself?

A

Trypsin

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9
Q

What does plasma protease inhibitor inhibit?

A

Trypsin

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10
Q

What does plasma alpha-macroglobulin bind and why?

A

Binds proteases to enable macrophage uptake

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11
Q

What stimulates secretin release?

A

Gastric acid

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12
Q

What 2 things stimulate gastrin release?

A

Vagal stimulation

Protein digestion

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13
Q

What stimulates gastric acid release?

A

Gastric stretch

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14
Q

What stimulates CCK release?

A

Amino Acids and Fatty Acids in SI

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15
Q

What is acute pancreatitis?

A

Necrosis, edema and neutrophilic infiltrate

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16
Q

How does acute pancreatitis occur?

A

Activated enxymes released into local tissue causing inflammation, neutrophil migration and a cytokine storm

Basically autodigestion

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17
Q

What are 3 results of acute pancreatitis?

A

Local inflammation and necrosis
Systemic dissemination of activated enzymes
Systemic inflammatory response

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18
Q

T/F: Damage from acute pancreatitis is not reversible.

A

False, it IS reversible

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19
Q

What is the cause of pancreatitis?

A

Usually unknown

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20
Q

What are 4 general predisposing factors for pancreatitis?

A

Fat animal
High fat diet
Malnutrition
Hyperlipidemia (Schnauzers)

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21
Q

What are 2 predisposing factors for pancreatitis in cats?

A

Duct obstruction

Duodenal reflux

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22
Q

What is the typical signalment of a dog presenting with pancreatitis?

A

Small breed, overweight, middle-age females, exposed to high fat diet (either continuous OR in last 5-7 days)

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23
Q

What is the typical signalment of a cat presenting with pancreatitis?

A

Underweight, elderly, malnourished

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24
Q

What else might you see in the canine signalment of a pancreatitis case?

A

Post-ischemia - canine babesiosis

Know dog was previously ill.

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25
Q

What are the clinical signs of pancreatitis?

A 
Depression
Anorexia
V&D
Prayer position (acute abdomen)
Dever
Shock and collapse
Coagulopathy (if we get here, need to know things are looking bad, consider quality of life)
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26
Q

What does our hemogram look like with pancreatitis?

A

Left shift neutrophilia, thrombocytopenia

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27
Q

What else will we find on our blood chem?

A 
Hyperlipidemia
Increased amylase and lipase
Increased canine pancreatic lipase immunoassay (cPLI)
Increased liver enzymes
Hyper- or hypoglycemia
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28
Q

What is the reason for using imaging in cases of suspect pancreatitis?

A

To make sure there is not some other primary cause

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29
Q

What is important to remember about amylase and lipase with regard to pancreatitis?

A

Both may increase, BUT they’re not specific to pancreas

Can be normal in acute pancreatitis (not sensitive)
Can be abnormal in other diseases (not specific)

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30
Q

What is the gold standard for exocrine pancreatic insufficiency?

A

Trypsin-like Immunoreactivity (TLI)

NOTE: Species specific

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31
Q

Why is a TLI not a very good screening test for acute pancreatitis?

A

It’s not very sensitive (33%) because has a short half-life so TLI has already returned to normal.

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32
Q

What is TLI better for, screening or confirming?

A

Confirming (~70% specific)

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33
Q

What is a good screening test for pancreatitis?

A

Canine pancreatic lipase (SNAP PLI)

Sensitivity is 91%

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34
Q

What should you do with the results of your SNAP PLI?

A

If negative, not likely to have acute pancreatitis

If positive, send away for quantitative test (Spec PLI)

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35
Q

What is a Spec PLI?

A

Quantitative test, ~95% specific (dogs)

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36
Q

How do you interpret the results of a Spec PLI?

A

400ug/L = positive (abnormal)

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37
Q

What is it very important to do when your SNAP and Spec PLI and positive?

A

Check if acute pancretitis is the main cause of clinical signs

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38
Q

What are 3 radiographics signs of peritonitis?

A

Loss of contrast
Gastric-duodenal angle widening
Gastric displacement

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39
Q

What do you need to remember about RADs in pancreatitis?

A

Not sensitive or specific test

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40
Q

Even though it’s not sensitive or specific, why is it still imporant to do abdominal RADs in a case of acute abdomen?

A

Rule out other causes of acute abdoment

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41
Q

What is a Murphy sign?

A

Pain in the cranial abdomen.

NOTE: Usually consistent with acute pancreatitis

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42
Q

What 3 signs might you see on abdominal US?

A

Hypoechoic pancreas (edema)
Enlarged pancreas
Hyperechoic peri-pancreatic fat (saponification)

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43
Q

Roughly how sensitive is US in screening for pancreatitis?

A

~68% sensitives

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44
Q

What is the gold standard for diagnosing acute pancreatitis?

A

Biopsy

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45
Q

What is important to remember when taking pancreas biopsies?

A

Pathology is unevenly distributed

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46
Q

Why are pancreas biopsies rarely collected in acute dz?

A

Anesthetic risk and biopsy risk

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47
Q

When should you consider gathering a pancreas biopsy?

A

If otherwise performing surgery

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48
Q

In cats, we biopsy commonly, what extra do we do in this case?

A

Take biopsies of liver and GI as well (triaditis)

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49
Q

What is the most diagnostic combo of tests for acute pancreatitis?

A

Abdominal US and SNAP or spec

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50
Q

How do you treat acute pancreatitis?

A

Remove inciting cause if possible, support (IV fluids)

NO DEFINITIVE TREATMENT

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51
Q

What can help minimize the patients hospital stay?

A

Aggressive treatment with LRS

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52
Q

What electrolyte are a lot of the acute pancreatitis dogs deficient in?

A

Potassium, supplement with KCl

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53
Q

If you have a marked hypoalbuminemia, what colloids are the best choice?

A

Hetastarch/synthetic colloids because they stay around for days (vs. plasma products)

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54
Q

What is your first choice analgesic for acute pancreatitis?

A

Buprenorphine/methadone

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55
Q

Why should you not use morphine in acute pancreatitis?

A

Can aggravate bile duct and pancreatic duct obstruction

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56
Q

Why should you avoid NSAIDs in acute pancreatitis?

A

Animals are already hypovolemic and hypotensive, since NSAIDs inhibit Prostaglanding E, we can get colitis and gastric ulcers.

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57
Q

What 3 medications can you give as an anti-emetic in acute pancreatitis?

A

Maropitant (Anti-emetic and analgesic)
Metoclopramide (Anti-emetic and prokinetic)
Ondansetron (Anti-emetic and prokinetic)

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58
Q

Why do we want prokinetics with acute pancreatitis?

A

Because we are also battling ileus

59
Q

Why is it also a godo idea to treat pancreatitis with a gastric protectant?

A

Acute pancreatitis predisposes to gastric ulceration

60
Q

What is the “old fashioned” way to handle the diet of a pancreatitis patient?

A

“Rest” the pancreas by fasting

61
Q

How do we handle the nutrition in acute pancreatitis cases now?

A

Enteral feeding within 24hrs
Control vomiting/nausea
Offer food
Consider feeding tube

62
Q

What is thought to be the best form of enteral nutrition and why?

A

Jejunostomy because no neuroendocrine response

63
Q

How much nutrition should you give enterally initially?

A

1mL/kg/hr

64
Q

As you increase amounts of enteral nutrition, what volume do you not want to go past?

A

5-10mL/kg/hr

65
Q

When should you institute enteral feeding?

A

As soon as you can

66
Q

When would you use n pancreatic extract?

A

For dogs that are in post-prandial pain, NOT in acute pancreatitis

67
Q

What 3 things would you treat Abx with during pancreatitis?

A

Cats
Pyrexia
GI ulceration

68
Q

Can you use corticosteroids to treat acute pancreatitis?

A

No! Stay away.

69
Q

When monitoring an acute pancreatitis case, what are we watching for?

A

Clinical improvement/deterioration

Make sure you are addressing the nausea and pain

70
Q

What sort of mortality rates do we see with acute pancreatitis?

A

27-58%

71
Q

If acute pancreatitis can recur, how do we try to prevent that?

A

Feed low-fat diet for life

72
Q

What complications can occur with acute pancreatitis that may cause death?

A

DIC

73
Q

What are poor prognostic indicators?

A 
Cardiac abnormalities
Respiratory bnormalities
Altered oncotic/hydrostatic preassure
Anorexia for 3+ days
Low calcium
Hyperkalemia
74
Q

What are 3 potential sequelae of acute pancreatitis?

A

Could recur
Extrahepatic bile duct obstruction
Abscess/pseudocysts

75
Q

What is important to remember with cats and pancreatitis?

A

Cats are not small dogs

76
Q

What signs of pancreatitis do we see in cats?

A

Lethargy, anorexia, icterus

Very non-specific

Only 35% vomit, and only 25% show pain

77
Q

What is the most common cause of pancreatitis in cats?

A

Cause often unknown

78
Q

What is considered “unimportant” in the cat?

A

High fat diets etc

79
Q

What do we often see pancreatitis in association with?

A

Other diseases… Triaditis (Pancreatitis, Hepatitis, Irritable Bowl Dz)

80
Q

What are diagnostic in feline pancreatitis?

A

Celiotomy and biopsy

81
Q

T/F: Cats rarely develop chronic pancreatitis.

A

False, cats often develop chronic pancreatitis

82
Q

What are the sensitivities of the new SNAP fPL?

A

Poor in mild dz

More specific in severe dz

83
Q

How do you treat pancreatitis in cats?

A

Similar to dogs, DO NOT STARVE CATS, provide Abx

Often cats rapidly develop Heinz body anemia, will need transfusions.

84
Q

Why can cat with pancreatitis often become icteric?

A

Because pancreas is right next to common bile duct

85
Q

What is more common in cats that with dogs with regards to their temperature during pancreatitis?

A

Hypothermia (vs. pyrexia in dogs)

86
Q

What are 8 ways you can investigate possible pancreatitis in a cat?

A 
Hematology & biochem
Amylase & lipase
Feline TLI
Feline Spec PL
RADs
US
FNA
Biopsy
87
Q

What is the most accurate blood test for diagnosing pancreatitis in a cat?

A

Feline Spec PL

88
Q

What is a negative to blood work to diagnose pancreatitis in a cat?

A

Highly variable

89
Q

What is a negative to using amylase and lipase to diagnose pancreatitis in a cat?

A

Often normal, or can increase with other things like intestinal dz and renal dz

90
Q

What is a negative to using Feline TLI to diagnose pancreatitis in a cat?

A

Short half-life so lacks sensitivity

91
Q

When might a FNA be necessary to do in a cat with signs of pancreatitis?

A

To rule out neoplasia

92
Q

How do you treat a cat with pancreatitis?

A

Similar to dogs

Analgesia important (remember that cats are stoic)
May need NE tube
More indication for Abx
Corticosteroids more ok in cats

93
Q

Why are corticosteroids considered when treating a cat with pancreatitis?

A

Because they commonly get chronic lymphocytic form of pancreatitis.

94
Q

What is chronic pancreatitis?

A

Permanent histological change with chronic non-suppurative pancreatitis and progressive loss of function

95
Q

What type of cellular infiltrates do you see with chronic pancreatitis?

A

Mononuclear (Lymphocytes) with fibrosis

96
Q

How might chronic pancreatitis present?

A

As an acute flare up (acute-on-chronic)

97
Q

How might an animal develop chronic pancreatitis?

A

Progression from acute dz

Start as chronic dz

98
Q

What are 4 dog breeds predisposed to chronic pancreatitis?

A

Cavalier King Charles Spaniels
English Cocker Spaniels
Boxers
Collies

99
Q

What is interesting about Boxers and chronic pancreatitis?

A

Resistant to end-stage dz (EPI & DM), good regenerative capacity

100
Q

What clinical signs will you see with chronic pancreatitis?

A

Intermittent, low-grade CS OR
Acute signs OR
Older, non-GSD with EPI OR
DM

101
Q

How do you diagnose chronic pancreatitis?

A

Bipsy, US, PLI

NOTE: Insensitive d/t loss of pancreatic mass

102
Q

What is treatment for chronic pancreatitis?

A

Supportive
If acute presentation, manage as acute case
If chronic, Analgesia, low-fat diet, B12, corticosteroids (in cats and cockers)

103
Q

What is exocrine pancreatic insufficiency (EPI)?

A

Pancreatic malfunction, seen when 80-90% loss of fxn

104
Q

What 2 breeds have autosomal recessive pancreatic acinar atrophy?

A

GSD

Rough Collie

105
Q

What causes pancreatic acinar insufficiency in young dogs?

A

Cell aplasia

106
Q

In what species is chronic pancreatitis the cause of EPI?

A

Cats, geriatric dogs (yorkies, min schnauzers)

107
Q

What happens in exocrine pancreatic insufficiency?

A

Loss of acinar cells -> loss of digestive enzymes -> loss of digestion and absorption -> malassimilation -> steatorrhea

Can develop into severe malnutrition

108
Q

What is a complication of severe malassimilation and malabsorption?

A

Bacterial overgrowth and B12 malabsorption

109
Q

What are the clinical signs of EPI?

A 
Weight loss
Poor hair coat
Increased appetitie
Coporophagia *Main owner complaint
Steatorrhea
Diarrhea
Flatulence
110
Q

What is the most sensitive and specific test for EPI?

A

Species specific TLI

NOTE: Gather sample after 12hr fast

111
Q

What are 2 things you can do to treat EPI?

A 
Supplement enzymes (powdered)
Frozen beef or pork pancreas fed raw
112
Q

How do you manage EPI (2 ways)?

A

Enzyme supplementation
***Enteric coated is best!!!
Cobalamin (injectable, can sting a bit)

NOTE: Give vit. K is required as well

113
Q

What are 5 things to consider with treatment failure of EPI?

A 
Enough enzyme in correct form?
Effect of gastric pH
     Consider H2 agonists or PPIs
Dysregulation of GI flora
     Abx responsive diarrhea
     Metronidazole, tylosin, tetracyclines
Concurrent dz
     Food responsive, IBD, diabetes
Fat restriction
114
Q

If gastric pH is causing your EPI treatment to fail, what 2 things could you try to help?

A

H2 agonists

PPIs

115
Q

If dysregulation of GI flora is occurring, how would you know and what 3 options do you have to treat?

A

Abx responsive diarrhea

Metronidazole
Tylosin
Tetracyclines

116
Q

What are 2 ways that EPI can develop?

A

Pancreatic acinar atrophy

Chronic pancreatitis

117
Q

What 2 diseases often happen concurrently to chronic pancreatitis?

A

DM

EPI

118
Q

What does EPI usually result from in cats?

A

Chronic pancreatitis

119
Q

What are 2 major signs of EPI in cats?

A

Weight loss

Greasy coat

120
Q

What cats should you screen for EPI?

A

Chronic diarrhea cases

121
Q

How do you screen cats for EPI?

A

Feline TLI

122
Q

What 2 ways can you treat EPI in cats?

A

1/2 to 1 tsp of enzyme powder per meal

25-50g raw pancreas per meal

123
Q

What must you always supplement cats with EPI?

A

Cobalamin

124
Q

How common are pancreatic neoplasias?

A

Rare

125
Q

What are the 2 types of exocrine pancreatic neoplasia?

A

Adenoma

Adenocarcinoma

126
Q

Is adenocarcinoma malignant or benign and what is the prognosis?

A

Malignant

Poor prognosis

127
Q

Is an insulinoma endocrine or exocrine in nature?

A

Endocrine

128
Q

How do we diagnose an insulinoma?

A

See Hypoglycemia and high insulin

Not often seen on US, rely on surgeon to palpate pancreas.

129
Q

Are adenomas malignant or benign?

A

Benign

130
Q

Why is it difficult to make a diagnosis on an FNA of a pancreatic neoplasia?

A

Because the ells don’t slough very well.

Usually have to rely on invasive tests.

131
Q

What is the most common pancreatic neoplasia in the cat?

A

Pancreatic adenocarcinoma

132
Q

What is a pancreatic adenocarcinoma in a cat also called?

A

Ductular carcinoma

133
Q

How does a cat with a ductular carcinoma/adenocarcinoma usually present?

A

With pancreatitis, abdominal pain, possibly vomiting

134
Q

What will you see if you do an US on a cat with ductular carcinoma/adenocarcinoma?

A

Cystic lesions because of pancreatic duct obstruction

135
Q

What is the prognosis for a cat with ductular carcinoma/adenocarcinoma?

A

Good. Don’t usually need chemotherapy either

136
Q

How are pancreatic neoplasias often found?

A

Incidental finding or post-mortem

137
Q

What are the signs of a pancreatic neoplasia?

A

Non-specific

138
Q

Is metastatic spread of pancreatic neoplasias common?

A

Yes

139
Q

Why are pancreatic neoplasia mets difficult to address in the dog?

A

Because at time of dx, already have a very high stage of dz.

140
Q

Where do pancreatic neoplasias metastasize to?

A

Locoregional (liver, l.n., mesentery, intestines, lungs)

141
Q

Why is surgical resection of pancreatic neoplasias usually impossible?

A

Margins are rarely achieved

142
Q

Why do we not use radiation or chemotherapy on pancreatic neoplasias?

A

Both had little effect, and radiation is difficult to do on the abdomen without side effects.

143
Q

Why is it important to distinguish between pancreatic hyperplasia and granulomas?

A

Because hyperplasia is benign, granulomas have a grave prognosis.

Small Animal Medicine II (8 decks)

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