Pancreatitis Flashcards
Why do cats typically have more obstructive disease associated with the pancrease than dogs?
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
What comprises most of the paranchyma of the pancreas?
Exocrine acinar cells and ducts arranced in clusters
What do exocrine pancreatic cells secrete?
Digestive enzymes
What is the flow from the exocrine cells to the duodenum?
Intralobar ducts–> major pancreatic duct–> duodenum
What are the Islets of Langerhans?
Contain the endocrine cells (insulin, glucagon, etc) and are between the acini of the pancreas
What do trypsin, chymotrypsin, and carboxypeptidase do?
Enzymes that digest proteins (proteases)
What does amylase do?
Digestion of carbohydrates
What do lipases, cholesterol lipase, and phospholipase do?
Digest fats
What else does the pancreas produce?
Ribonuclease, deoxyribonuclease, gelatinase, elastase, intrinsic factor, bicarbonate, water
What does intrinsic factor do?
Facilitates B12 absorption in the ileum
What are zymogens?
Digestive enzymes that are released in inactive forms
Why are zymogens important?
They are necessary to prevent enzymes from digesting origin cells
Where are zymogens activated?
Mostly in the small intestine for pancreatic enzyme
What happens if zymogens become active in the pancreas? Which enzyme is most commonly prematurely activated?
Autohydrolysis of the pancreatic tissues; Trypsin most often
T/F: Digestive enzymes are secreted and released constitutively so the gut is always ready to digest food.
False- there is little release of enzymes between digestive periods controlled by the Vagus nerve in response to cephalic phase of digestion
What are other things that control the secretion of digestive enzymes?
Mechanoreceptors in response to food distension
Endocrine in response to luminal contents of food (cholecytokinin, secretin, gastrin)
Is pancreatitis a disease of the exocrine or endocrine pancreas?
Exocrine
What is the usual severity of pancreatitis?
Can be anywhere from mild to fatal
Acute disease more associated with fatal disease than chronic but both ca be very serious
What are some other exocrine pancreatic diseases?
EPI and neoplasia
What is the pathology of pancreatitis?
Zymogen activation in pancreatic tissue leading to inflammation and necrosis of pancreatic cells
What are clinical signs caused by?
Death and inflammation of the pancreatic tissues and severe systemic inflammatory effects of cytokine release
What are the mechanisms of disease of pancreatitis?
- Decreased of secretion of enzymes
- Development of vacuoles in cytoplasm of acinar cells
- Zymogens combine and activate
- Premature activation of zymogens and trypsin
- Overwhelming of natural defenses
What is a result of the pathophysiology of pancreatitis on the pancreas?
Auto-digestion of the pancreas
- Edema
- Hemorrhage
- Necrosis/ fat necrosis
- Local and systemic inflammation
What is the usual infiltrate in acute pancreatitis?
Neutrophilic
What is the usual infiltrate in chronic pancreatitis?
Lymphocytic
What is the usual infiltrate in acute on chronic pancreatitis?
Neutrophil and lymphocyte
T/F: The damage caused by pancreatitis usually reversible.
True
What are the usual conical signs of pancreatitis?
Vomiting, diarrhea, abdominal pain, lethargy, inappetence
T/F: Systemic effects are seen with all animals with pancreatitis.
False- usually only severe cases
ARDS, SIRS, MODS, or PTE all possible
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
What are signs of acute pancreatitis?
ADR, vomiting, diarrhea, abdominal pain (prayer position), fever, lethargy, inappetence/anorexia
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
What is the usual cause of pancreatitis in the dog?
Eating “human” food
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
What are some causes of pancreatitis in the cat?
- Infectious disease (FIV, FIP, Toxo, parasites)
- Neoplasia
- Organophosphate toxicity
- Concurrent GI disease
- Concurrent liver disease
What is Amphimerus pseudofelineus?
Parasite of the bile ducts that can migrate to the pancreas
Tx: praziquantel
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
Are there usually specific UA and fecal findings in pancreatitis?
Nope
May possibly find fluke eggs in fecal
What are some common chemistry findings in a patient with pancreatitis?
Increased: cholesterol, triglycerides, liver enzymes, amylase and lipase
Decreased: calcium
Variable: glucose, electrolytes
Why are pancreatitis patients typically hypocalcemia?
Lipolytic products from the pancreas chelate calcium
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
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
What does TLI stand for?
Trypsin like immunoreactivity
What is TLI used for?
Reflection of amount of functional pancreatic tissue
Used to support pancreatitis and diagnose EPI
What does PLI stand for?
Pancreati lipase immuunoreaticity
What are the quantitiative PLI tests?
Spec cPL of fPL on fasted serum- gold standard to support pancreatitis in the CAT
What are the non-quantitative tests for PLI levels?
Snap cPL done table side
Positives are indicative of pancreatitis but confirm with other tests
What increases PLI?
Inflammation and necrosis of the pancreas
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)
T/F: PLI gives you an accurate idea of the histological severity of the disease.
False
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
What is the classic appearance of pancreatitis on abdominal US?
Hypoechoic pancreas with hyperechoic surrounding mesentery
May also see pseudocyts, ascesses, or mass lesions
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)
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
T/F: There is a specific treatment protocol for pancreatitis.
False- treatment is supportive and symptomatic
No direct treatment for pancreatic inflammation and necrosis
What is an important aspect of pancreatitis treatment?
Early aggressive therapy to prevent permanent damage
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
What needs to be supplemented once patients are stable and on a CRI of fluids?
Potassium supplementation 20mEq/L
What fluids are typically used in pancreatitis patients?
Crystalloids
Colloids can be used
What is a concern when using colloids in a pancreatitis patient?
Overhydration
Which colloids are used in pancreatitis patients?
Vetstarch/hetastarch and fresh frozen plasma
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
What drugs do you NOT use in pancreatitis for pain control?
NSAIDS or steroids
What drugs are used in pancreatitis to control pain?
Methadone, fentanyl, lidocaine, ketamine, dexmed, buprenorphine, cerenia, tramamdol
What antacids are used in pancreatitis patients?
H2 receptor antagonists- famotidine and ranitidine
Proton pump inhibitors- pantoprazole and omeprazole
What antiemetics are used in pancreatitis patients?
Cerenia, ondansetron and dolasetron, metoclopramide
What prokinetics are used?
metolopramide ranitidine, erythromycin, cisapride
What anti-clot therapy can be used with pancreatitis patients?
Low molecular weight heparin, clopidogrel (dogs and cats)
Rivaroxaban- dogs only
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)
What antibiotics can be used in the cat with pancreatitis?
Unasyn, enrofloxacin, metronidazole
Are vasopressors used in pancreatitis?
Yes, if hypovolemic/tenisve
MUST have adequate hydration
Norepi or dopamine
T/F: Gastric atony or hypomotility is not uncommon with pancreatitis patients.
True
What does gastric decompression help with?
Response to medications
Recovery times
Patient comfort
What is the ideal way to dcompress a stomach?
Nasogasttric tube ideal as you can also use this for nutritional supplementation
Is there scientific support that supplementing pancreatic enzymes has a positive effect on prognosis?
No- some empirical evidence though
Why do a lot of patients with pancreatitis present hyperglycemic?
A lot of pancreatitis patients are also in DKA
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
T/F: Surgery is useful for pancreatitis patients.
False-usually not done except in cases of non-resolving obsrution or neoplasia
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
What diets are recommended to keep dogs on? Cat?
Dogs: low fat foods
Cats: whatever they will eat
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
What is the prognosis of mild acute pancreatitis?
Typically recoverr well with brief hospitalization and outpatient monitoring
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
What breed is predisposed to chronic pancreatitis and why?
Miniature schnauzer due to a gene abnormality in SPINK1 protease inhibitor
Test with an ELISA
What conditions are chronic pancreatitis patients predisposed to?
EPI and diabetes mellitus
When is steroid therapy appropriate for pancreatitis patients?
Concurrent inflammatory disease (IBD or inflammatory liver disease) or chronically elevated PLI with NO clinical signs
What concurrent illnesses are found in cats with pancreatitis?
- Hepatic lipidosis
- IBD
- Cholangitis
- Cholangiohepatitis
- Diabetes mellitus
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
What are some poor prognostic indicators ffor pancreatitis?
- Cardiac or respiratory abnormalities
- Altered oncotic/hydrostatic pressures
- Anorexia for 3+ days
- Low calcium
- Hyperkalemia
What pancreatic neoplasms exist?
Rare: carcinomas or insulinomas
Adenomas are highly malignant and carry a poor prognosis
