pancreatitis Flashcards
what is the significant differnce in anatomy of the dog and cat pancreas?
Dogs – two ducts
‘Dorsal’ opens next to common bile duct on major duodenal papilla
‘Ventral’ or ‘Accessory’ duct opens on minor duodenal papilla
Cats – single duct
Fuses with bile duct before opening on major duodenal papilla
‘Design flaw’
what are the cells of the pancreas and what is their function?
Exocrine = acinar cells
* Secrete inactive digestive enzymes (zymogens) into intestinal lumen
◦ Zymogens activated when cleaved by enterokinase
* Enzyme inhibitors in the pancreas prevent autodigestion
◦ …But if enzyme activation happens in the pancreas, this can lead to pancreatitis
Endocrine = islets of langerhans
* Secrete insulin
* 1-2% of the pancreas
what are the two types of pancreatitis what can they cause?
Acute pancreatitis
* Sudden onset
* Variable clinical effect
◦ Some patients will require intensive and extended hospitalisation, others less severe
* Little or no permanent changes after recovery
Chronic pancreatitis
* Continuing inflammatory disease
* Irreversible morphological changes – fibrosis and atrophy
* Can lead to permanent impairment of function (exocrine pancreatic insufficiency, diabetes mellitus)
what are the risk fctors for pancreatitis in dogs?
- Hereditary/breed predisposition
◦ Acute: Terrier breeds, miniature schnauzer, cocker spaniel, miniature poodle, dachshund
◦ Chronic: Collie, boxer, Cavalier King Charles spaniel - Hypertriglyceridaema (miniature schnauzers)
- High fat meal
- Obesity
what are the risk factors for pancreatisis in cats?
- ACVIM consensus: no breed predisposition (Forman et al., 2021)
◦ Some literature suggests Siamese and Bengals – others suggest domestic shorthairs! - Gastrointestinal disease/vomiting
◦ Can lead to bile reflux - Triaditis
◦ Pancreatitis + inflammatory bowel disease + cholangitis/cholangiohepatitis
what are the ‘other’ risk factors for the developmnet of pancreatitis?
- Pancreatic ischaemia and hypoxia
◦ Shock, severe acute anaemia, dehydration, hypotension during general anaesthesia,occlusion of venous outflow during abdominal surgery - Pancreatic trauma(RARE)
◦ Surgical biopsy, surgical manipulation, blunt abdominal trauma
what is the common pathway for pancreatitis?
what are the clinical signs of acute and chronic pancreatits?
Common pathway for pancreatitis: Decreased secretion of pancreatic juices –> premature activation of digestive enzymes –> damage to the pancreas –> inflammation leads to pancreatitis
Clinical signs:
Acute pancreatitis:
* Lethargy/weakness
* Anorexia – suspect pancreatitis in any cat not eating/behaving normally
* Vomiting
* Diarrhoea
Severe acute pancreatitis:
* Shock
* Collapse
what is found on clinical exam with pancreatitis?
- Abdominal pain (only ~20% of cats)
- Cranial abdominal mass
- Mild ascites
- Dehydration
- Fever (not all cases)
- Jaundice – uncommon (extrahepatic bile duct obstruction)
Changes on complete blood count, biochemistry, and urinalysis generally non-specific and variable with pancreatitis.
Serum may be lipaemic which can lead to lipaemia interference
what biochem parameter many be associated with poorer prognosis in cats and what biochem paramenter makes cats anorexic and therefore might need treatment?
- Hypocalcaemia- May be associated with poorer prognosis in cats
- Hypokalaemia - makes cats not want to eat so might need treatment
what Immunoassays tests avalible for pancreatitis?
Canine and feline pancreas-specific lipase (cPL and fPL)
* Spec cPL/fPL
◦ Quantitative ELISA
◦ Abnormal >400μg/L (equivocal 200 to 399μg/L)
* SNAP cPL/fPL
◦ Semi-quantitative in-practice ‘SNAP’ test
◦ Abnormal >200μg/l
- Positive result with suggestive signs – probably pancreatitis
◦ SNAP should ideally be followed by Spec cPL/fPL to confirm the diagnosis - But negative result can’t truly rule out pancreatitis
◦ Cats – false negative rate of 24%
what other diagnotic tests are avalible for diagnosis of pancreatitis?
what other pancreatic condition is on eof these used to diagnose?
-
Trypsin-like immunoreactivity – specific to canine and feline (cTLIandfTLI)
◦ Less sensitive/specific and of limited diagnostic utility in pancreatitis
◦ Increases rapidly in early stages of pancreatitis but declines quickly
◦** Important test for exocrine pancreatic insufficiency** - Amylaseandlipase
◦ Non-specific – influenced by hepatic, renal, or intestinal disease and neoplasia
◦ May increase suspicion but don’t use to confirm pancreatitis
Radiography:
* Evidence of pancreatitis rarely seen
* Useful to rule out other differentials
Ultrasound:
* Pancreatic enlargement
* Localised peritoneal effusion
* Hypoechogenicity – pancreatic necrosis
* Hyperechogenicity – pancreatic fibrosis – chronic pancreatitis
* Pancreatic duct dilation
what is the treatment plan for pancreatitis?
- Correct fluid & electrolyte abnormalities
◦ Improves pancreatic perfusion
◦ Supplement potassium if hypokalaemic - Treat underlying cause (if known!)
- Analgesia
◦ Avoid non-steroidal anti-inflammatory drugs (NSAIDs)
◦ Commonly used opioids: Methadone, buprenorphine
◦ Continuous rate infusion (CRI): Ketamine, lidocaine
◦ Off license: Morphine, fentanyl patch - Anti-emetics
◦ Maropitant, metoclopramide (CRI)
◦ Off license: Ondansetron - Antibiotics - only if evidence supports infectious cause
◦ Trimethoprim/sulfonamide, clindamycin, metronidazole, marbofloxacin - Steroids?
◦ Some evidence that may be useful in acute canine pancreatitis
◦ May benefit some chronic cases e.g. feline triaditis but be cautious of side effects (diabetes mellitus)
what nutritional support is given to dogs and cats with pancreatits?
Start feeding once vomiting controlled
* Dogs: High carbohydrate (rice, pasta, potato), then low-fat commercial diet
* Cats: Diet less important – base on any concurrent disease
Enteral feeding for anorexic cats
* Naso-oesophageal tube
* Oesophagostomy tube
what treatment can be given to cats with pancreatits as outpatient support?
- Subcutaneous (SC) fluids – 80-100ml Hartmann’s
◦ Administer via butterfly cannula (from bag or via syringe) - Maropitant SC or PO (off license)
- Mirtazapine – transdermal or PO (off license)
- Buprenorphine - sublingual (off license) or in-clinic intramuscular injection
what is the long term tretment of pancreatitis?
- Avoid high-fat meals in dogs
- Fat-restricted diet – if recurrent bouts of pancreatitis
- Oral pancreatic enzyme supplements help with abdominal pain in humans with pancreatitis?
- Cats with recurrent episodes – trial prednisolone 1mg/kg q12-24h for 1 week, tapering to 0.5mg/kg every other day as needed
