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Pancreatitis Flashcards

1
Q

Why do cats typically have more obstructive disease associated with the pancrease than dogs?

A

Cats have a single pancreatic duct that feeds into the duodenum at the same place as the common bile duct

Dogs have two entrances into the duodenum that are both separate from the bile duct

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2
Q

What comprises most of the paranchyma of the pancreas?

A

Exocrine acinar cells and ducts arranced in clusters

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3
Q

What do exocrine pancreatic cells secrete?

A

Digestive enzymes

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4
Q

What is the flow from the exocrine cells to the duodenum?

A

Intralobar ducts–> major pancreatic duct–> duodenum

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5
Q

What are the Islets of Langerhans?

A

Contain the endocrine cells (insulin, glucagon, etc) and are between the acini of the pancreas

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6
Q

What do trypsin, chymotrypsin, and carboxypeptidase do?

A

Enzymes that digest proteins (proteases)

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7
Q

What does amylase do?

A

Digestion of carbohydrates

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8
Q

What do lipases, cholesterol lipase, and phospholipase do?

A

Digest fats

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9
Q

What else does the pancreas produce?

A

Ribonuclease, deoxyribonuclease, gelatinase, elastase, intrinsic factor, bicarbonate, water

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10
Q

What does intrinsic factor do?

A

Facilitates B12 absorption in the ileum

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11
Q

What are zymogens?

A

Digestive enzymes that are released in inactive forms

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12
Q

Why are zymogens important?

A

They are necessary to prevent enzymes from digesting origin cells

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13
Q

Where are zymogens activated?

A

Mostly in the small intestine for pancreatic enzyme

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14
Q

What happens if zymogens become active in the pancreas? Which enzyme is most commonly prematurely activated?

A

Autohydrolysis of the pancreatic tissues; Trypsin most often

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15
Q

T/F: Digestive enzymes are secreted and released constitutively so the gut is always ready to digest food.

A

False- there is little release of enzymes between digestive periods controlled by the Vagus nerve in response to cephalic phase of digestion

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16
Q

What are other things that control the secretion of digestive enzymes?

A

Mechanoreceptors in response to food distension

Endocrine in response to luminal contents of food (cholecytokinin, secretin, gastrin)

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17
Q

Is pancreatitis a disease of the exocrine or endocrine pancreas?

A

Exocrine

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18
Q

What is the usual severity of pancreatitis?

A

Can be anywhere from mild to fatal

Acute disease more associated with fatal disease than chronic but both ca be very serious

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19
Q

What are some other exocrine pancreatic diseases?

A

EPI and neoplasia

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20
Q

What is the pathology of pancreatitis?

A

Zymogen activation in pancreatic tissue leading to inflammation and necrosis of pancreatic cells

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21
Q

What are clinical signs caused by?

A

Death and inflammation of the pancreatic tissues and severe systemic inflammatory effects of cytokine release

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22
Q

What are the mechanisms of disease of pancreatitis?

A
  1. Decreased of secretion of enzymes
  2. Development of vacuoles in cytoplasm of acinar cells
  3. Zymogens combine and activate
  4. Premature activation of zymogens and trypsin
  5. Overwhelming of natural defenses
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23
Q

What is a result of the pathophysiology of pancreatitis on the pancreas?

A

Auto-digestion of the pancreas

  • Edema
  • Hemorrhage
  • Necrosis/ fat necrosis
  • Local and systemic inflammation
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24
Q

What is the usual infiltrate in acute pancreatitis?

A

Neutrophilic

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25
What is the usual infiltrate in chronic pancreatitis?
Lymphocytic
26
What is the usual infiltrate in acute on chronic pancreatitis?
Neutrophil and lymphocyte
27
T/F: The damage caused by pancreatitis usually reversible.
True
28
What are the usual conical signs of pancreatitis?
Vomiting, diarrhea, abdominal pain, lethargy, inappetence
29
T/F: Systemic effects are seen with all animals with pancreatitis.
False- usually only severe cases ARDS, SIRS, MODS, or PTE all possible
30
What are some other potential sequelae to pancreatitis?
Bile duct obstruction, hypotension, acute renal failure, pulmonary edema, DIC, hepatic dysfunction, diabetes mellitus, EPI, severe gastroenteritis, death
31
What are signs of acute pancreatitis?
ADR, vomiting, diarrhea, abdominal pain (prayer position), fever, lethargy, inappetence/anorexia
32
What will you find on the physical exam of a patient with pancreatitis?
Weakness, dehydration, abdominal pain, hypersalivation, hyper/hypothermia, hypovolemic shock, abdominal mass effect, icterus, petechia/ecchymosis
33
What is the usual cause of pancreatitis in the dog?
Eating "human" food
34
What are other causes of pancreatitis in the dog?
- High fat diet/hypertriglyceridemia - Schnauzers predisposed to idiopathic - Organophosphate toxicity - Drugs - Trauma or hypoperfusion - Neoplasia - Hypercalcemia - Immune mediated disease
35
What are some causes of pancreatitis in the cat?
- Infectious disease (FIV, FIP, Toxo, parasites) - Neoplasia - Organophosphate toxicity - Concurrent GI disease - Concurrent liver disease
36
What is Amphimerus pseudofelineus?
Parasite of the bile ducts that can migrate to the pancreas Tx: praziquantel
37
What are common CBC findings of an animal with pancreatitis?
Dog: leukocytosis with a lift shift or leukopenia, thrombocytosis or thrombocytopenia Cat: anemia especially with heinz bodies
38
Are there usually specific UA and fecal findings in pancreatitis?
Nope May possibly find fluke eggs in fecal
39
What are some common chemistry findings in a patient with pancreatitis?
Increased: cholesterol, triglycerides, liver enzymes, amylase and lipase Decreased: calcium Variable: glucose, electrolytes
40
Why are pancreatitis patients typically hypocalcemia?
Lipolytic products from the pancreas chelate calcium
41
What will coags typically look like in a patient with pancreatitis?
Prolonged PT/PTT due to consuption Elevated fibrinogen due to inflammation Elevated d-dimers confirming blood clots and lysis
42
What is the sensitivity/specificity status for lipase and amylase for diagnosing pancreatitis in the dog and cat?
LOW Elevated values support pancreatitis but are NOT diagnostic for it
43
What does TLI stand for?
Trypsin like immunoreactivity
44
What is TLI used for?
Reflection of amount of functional pancreatic tissue Used to support pancreatitis and diagnose EPI
45
What does PLI stand for?
Pancreati lipase immuunoreaticity
46
What are the quantitiative PLI tests?
Spec cPL of fPL on fasted serum- gold standard to support pancreatitis in the CAT
47
What are the non-quantitative tests for PLI levels?
Snap cPL done table side Positives are indicative of pancreatitis but confirm with other tests
48
What increases PLI?
Inflammation and necrosis of the pancreas
49
What is the sensitivity of PLI in canine and feline patients?
64% in mild canine cases | 54-100% in feline cases (more accurate in advanced disease)
50
T/F: PLI gives you an accurate idea of the histological severity of the disease.
False
51
What is imaging useful for in pancreatitis patients?
Thoracic: aspiration pneumonia and pleural effusion Abdominal: loss of detail cranial with a ground glass appearance, effusion detection, r/o other causes
52
What is the classic appearance of pancreatitis on abdominal US?
Hypoechoic pancreas with hyperechoic surrounding mesentery May also see pseudocyts, ascesses, or mass lesions
53
What are some normal abdominal US findings in an animal with pancreatitis?
Peritoneal, peripancreatic fluid Enlarged regional LNs Echogenicity changes in liver with bile duct distension Pain - Intestinal changes (hypomotility, thickened/corrugated wall)
54
What test is most definitive for diagnosing pancreatitis?
Pancreatic biopsy though it's not routinely performed as pathology often is not evenly distributed Helps to rule out neoplasia
55
T/F: There is a specific treatment protocol for pancreatitis.
False- treatment is supportive and symptomatic No direct treatment for pancreatic inflammation and necrosis
56
What is an important aspect of pancreatitis treatment?
Early aggressive therapy to prevent permanent damage
57
T/F: Patients that present with pancreatitis often require shock doses in order to correct fluid imbalances.
True- start with 1/4-1/3 dose and reassess
58
What needs to be supplemented once patients are stable and on a CRI of fluids?
Potassium supplementation 20mEq/L
59
What fluids are typically used in pancreatitis patients?
Crystalloids Colloids can be used
60
What is a concern when using colloids in a pancreatitis patient?
Overhydration
61
Which colloids are used in pancreatitis patients?
Vetstarch/hetastarch and fresh frozen plasma
62
What is a proposed benefit of plasma therapy in pancreatitis patients?
Anti-inflammatory benefit- supplementation of a2-macroglobulin Also replaces clotting factors and provides colloid support
63
What drugs do you NOT use in pancreatitis for pain control?
NSAIDS or steroids
64
What drugs are used in pancreatitis to control pain?
Methadone, fentanyl, lidocaine, ketamine, dexmed, buprenorphine, cerenia, tramamdol
65
What antacids are used in pancreatitis patients?
H2 receptor antagonists- famotidine and ranitidine Proton pump inhibitors- pantoprazole and omeprazole
66
What antiemetics are used in pancreatitis patients?
Cerenia, ondansetron and dolasetron, metoclopramide
67
What prokinetics are used?
metolopramide ranitidine, erythromycin, cisapride
68
What anti-clot therapy can be used with pancreatitis patients?
Low molecular weight heparin, clopidogrel (dogs and cats) Rivaroxaban- dogs only
69
Are antibiotics typically used in pancreatitis patients?
Not usually in veterinary medicine, often used in human med More commonly used in cats than dogs since cats usually have other organs involved that are prone to infection (GI and liver)
70
What antibiotics can be used in the cat with pancreatitis?
Unasyn, enrofloxacin, metronidazole
71
Are vasopressors used in pancreatitis?
Yes, if hypovolemic/tenisve MUST have adequate hydration Norepi or dopamine
72
T/F: Gastric atony or hypomotility is not uncommon with pancreatitis patients.
True
73
What does gastric decompression help with?
Response to medications Recovery times Patient comfort
74
What is the ideal way to dcompress a stomach?
Nasogasttric tube ideal as you can also use this for nutritional supplementation
75
Is there scientific support that supplementing pancreatic enzymes has a positive effect on prognosis?
No- some empirical evidence though
76
Why do a lot of patients with pancreatitis present hyperglycemic?
A lot of pancreatitis patients are also in DKA
77
Should you be feeding pancreatitis patients?
Yes, early enteral feeding is very important, no longer recommended to fast animals Try to get vomiting under control first
78
T/F: Surgery is useful for pancreatitis patients.
False-usually not done except in cases of non-resolving obsrution or neoplasia
79
When can pancreatitis patients be sent home?
When they are not vomiting, pain is controlled, eating on their own or tolerating a tube, fluid and electolyte imbalances are corrected Ultrasound findings will likely not be resolved
80
What diets are recommended to keep dogs on? Cat?
Dogs: low fat foods Cats: whatever they will eat
81
How long should you monitor pancreatitis patients?
2-3 weeks at ehe longest to assess any abnormalities and recheck bloodwork and PLI if any CS are persisiting
82
What is the prognosis of mild acute pancreatitis?
Typically recoverr well with brief hospitalization and outpatient monitoring
83
T/F: Chronic pancreatitis typically presents with severe clinical signs that will not resolve without intervention.
False- typically mild to moderate clinical signs but DO require treatment as they can have more generalized systemic illness
84
What breed is predisposed to chronic pancreatitis and why?
Miniature schnauzer due to a gene abnormality in SPINK1 protease inhibitor Test with an ELISA
85
What conditions are chronic pancreatitis patients predisposed to?
EPI and diabetes mellitus
86
When is steroid therapy appropriate for pancreatitis patients?
Concurrent inflammatory disease (IBD or inflammatory liver disease) or chronically elevated PLI with NO clinical signs
87
What concurrent illnesses are found in cats with pancreatitis?
- Hepatic lipidosis - IBD - Cholangitis - Cholangiohepatitis - Diabetes mellitus
88
What is the prognosis of pancreatitis?
- Mortality in 27-58% of acute cases of moderate to severe pancreatitis - Death typically results from systemic complications - Longterm prognosis good if they survive acute disease but recurrence is possible
89
What are some poor prognostic indicators ffor pancreatitis?
- Cardiac or respiratory abnormalities - Altered oncotic/hydrostatic pressures - Anorexia for 3+ days - Low calcium - Hyperkalemia
90
What pancreatic neoplasms exist?
Rare: carcinomas or insulinomas Adenomas are highly malignant and carry a poor prognosis

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