Pancreatitis

Question 1

Is the endocrine or exocrine pancreas mainly affected with regards to pancreatitis?

Answer 1

Exocrine pancreas

Question 2

What is the difference between the anatomy of dogs and cats pancreatic ducts?

Answer 2

Cat tends to have 1 common duct that joints the biliary system and pancreatic system as it goes into duodenum

Dog – separates out bile duct and pancreatic ducts

Question 3

What are the locations of the pancreatic ducts in dogs (in most cases)?

Answer 3

• Accessory duct = largest duct
  
  • –> minor duodenal papilla
• Pancreatic duct
  
  • –> major duodenal papilla
  • more cranial
  • close to the bile duct
• Pancreatic ducts don’t join the bile duct before emptying in to the duodenum

Question 4

What are the locations of the pancreatic ducts in cats (in most cases)?

Answer 4

• Pancreatic duct: usually only one duct
  
  • joins the bile duct before entering the duodenum
• 20% of cats have a 2ry minor or accessory duct à direct to duodenum

Question 5

What happens during acute pancreatitis?

Answer 5

• Acute pancreatitis:
  
  • variable neutrophilic inflammation, oedema & necrosis – these cases are very unwell, high mortality rate, but can be completely reversible and things go quite well and they can be a one off isolated event
  • severe disease
  • high mortality
  • reversible
  • dogs>cats?

Question 6

Is acute or chronic pancreatitis reversible?

Answer 6

Acute pancreatitis is reversible

Question 7

What happens during chronic pancreatitis?

Answer 7

• Chronic pancreatitis:
• inflammation more likely to be mononuclear or mixed
• –> fibrosis & acinar loss
• permanent & irreversible – lose some pancreatic function with each ongoing event, get progressive loss of pancreatic function – big deal is that we might get CSs associated but might also start to get additional problems due to pancreatic enzyme insufficiency, so they cannot digest or absorb food that is taken in!
• might –> EPI and/or diabetes
• Definition based on histopathology

Question 8

Why is chronic pancreatitis permanent and irreversible?

Answer 8

permanent & irreversible – lose some pancreatic function with each ongoing event, get progressive loss of pancreatic function – big deal is that we might get CSs associated but might also start to get additional problems due to pancreatic enzyme insufficiency, so they cannot digest or absorb food that is taken in!

Question 9

What form of pancreatitis do English Cocker Spaniels sometimes get?

Answer 9

English Cocker Spaniels have a form of CP which shows similarities to human type I autoimmune pancreatitis. A predominance of IgG4+ plasma cells has been found in pancreatic and renal histology. Associated with a multi systemic immune mediated disease affecting pancreas, kidney, liver and tear ducts.

Question 10

What is the pathophysiology of acute pancreatitis?

Answer 10

Question 11

Describe what can be seen here

Answer 11

Multifocal extensive areas of necrosis and haemorrhage

Question 12

Describe what can be seen here

Answer 12

• Fibrosis and parenchymal atrophy
• Not uncommon in old cats
• Usually no clinical relevance

Question 13

What breed dispositions are there for acute pancreatitis disease?

Answer 13

acute disease: terrier breeds (Yorkie, JRT), cocker spaniel

Question 14

What are some breed dispositions for chronic pancreatic disease?

Answer 14

chronic disease: CKCS, boxers, cocker spaniels, Border collies

Question 15

What are some risk factors for pancreatitis in dogs?

Answer 15

Breed predisposition

• acute disease: terrier breeds (Yorkie, JRT), cocker spaniel
• chronic disease: CKCS, boxers, cocker spaniels, Border collies
• Schnauzers: likely due to hypertriglyceridaemia syndrome

Obesity

Sex predisposition: being male or FN?

Previous surgery

Drug treatment?

• many drugs listed
• studies are very underpowered – i.e. we don’t really have good evidence

Endocrine disease: diabetes mellitus, hyperadrenocorticism

•Ischaemia (hypotension, haemolysis)

Question 16

What are some risk factors for pancreatitis in cats?

Answer 16

• No breed predisposition therefore no clear genetic link
• Association with inflammatory bowel disease +/- inflammatory liver disease à “triaditis” – something that seems real, multisystemic inflammatory syndrome,
• Chronic pancreatitis more likely than acute?
• Duodenal reflux (vomiting, trauma)
• Less likely to have trigger facts for acute, but more likely they have inflammatory disease in liver and gut – more likely to have inflammatory disease in the pancreas

Question 17

What are some non-specific signs of pancreatitis?

Answer 17

• mild intermittent abdominal pain- can be difficult to detect/assess
  
  • pain after eating?
• anorexia and weakness
• can be a prolonged subclinical phase à extensive pancreatic destruction

Question 18

What are the most common presenting signs with regards to pancreatitis?

Answer 18

• More common presenting signs include
  
  • vomiting
  • cranial abdominal discomfort
• Most common things – abdominal pain and vomiting. Pain usually in cranial abdomen, but often painful all over

Question 19

What are some additional clinical signs of pancreatitis?

Answer 19

• Additional signs include
  
  • Dehydration – from V+
  • Icterus – biliary obstruction, post hepatic jaundice
  • praying posture – not exclusive for pancreatitis, but might happen – signs for cranial abdomen pain
  • diarrhoea
  • increased tendency to bleed (coagulopathy) – if going down SIRS route, bleeding into gut etc.
  • cardiac arrhythmia – because they are becoming the critical care patients where everything is going wrong as fast as it can and heart is irritable because of those factors. Spiralling out of control. Same end point for many diseases
• In pancreatitis 2ry to other disease signs such as PD/PU, polyphagia and lethargy can be seen
  
  • Try to identify any concurrent disease if it gives you something you can treat!

Question 20

How can there be a wide variation of clinical signs on a physical exam in a patient with pancreatitis?

Answer 20

Wide variation….

• Hyperthermia –> hypothermia – variation, very sick patients
• Cranial abdominal pain +/- cranial abdominal mass effect (esp cats)
  
  • tachycardia
  • Tachypnoea
• Ascites
• Signs of dehydration –> circulatory shock –> DIC –> collapsed
  
  • skin tent
  • oral mucous membrane changes
• Icterus
  
  • obstruction of the common bile duct

Question 21

What are some clinical signs of acute feline pancreatitis?

Answer 21

• Really ill cat
• Anorexia, lethargy rather than more obvious GI signs
• Collapsed
• Tachycardia/pnoea
• hypothermia
• ?pulmonary oedema
• ?jaundice

Question 22

What are some clinical signs of chronic feline pancreatitis?

Answer 22

• ‘Triaditis’
• Think about the anatomy
• Anorexia
• Vomiting, weightloss, V&D
• Jaundice
• Abdominal pain

Question 23

Define triaditis

Answer 23

Feline triaditis is the concurrent presence of inflammatory disease of the liver, the pancreas, and the intestines in a cat.

Question 24

What would you see on a biochemistry profile in a patient with pancreatitis?

Answer 24

• Mild hepatobiliary enzyme elevations – ALT and ALP
• Hyperbilirubinaemia
  
  • could suggest obstruction of the bile duct due to oedema/swelling
• Azotaemia (­creatinine and urea)
  
  • usually secondary to dehydration ie pre renal azotaemia, urine SG would be >1.035
• Hypokalaemia is common in acute pancreatitis
• Hypocalcaemia has been reported secondary to pancreatitis (cats>dogs?)
• Hyperglycaemia
  
  • 2ry to diabetogenic hormones?
    
    • catecholamines/cortisol/glucagon/hypoinsulinism
  • true diabetes 2ry to progressive chronic pancreatitis?
• Hypercholesterolaemia and hypertriglyceridaemia
  
  • associated with concurrent endocrine disease or lipid disorders
• Amylase and lipase: non specific
  
  • in renal disease, dehydration because renally excreted
  • lipases secreted from multiple organs including liver and stomach

Question 25

What would you see on a haematology profile with pancreatitis?

Answer 25

• CBC changes are also poorly specific
  
  • Mild leucocytosis or leucopaenia?
  • Mild anaemia or haemoconcentration (if dehydrated)
  • Thrombocytopaenia
    
    • can be indicator of consumptive stage of DIC
    • secondary phenomenon à ? immune mediated
• Sometimes just showing us what the systemic signs

Question 26

What is the pancreatic lipase immunoreactivity test

How specific and sensitive is it?

How is it performed?

Answer 26

• Improved sensitivity and specificity compared with traditional lipase (and amylase) tests
  
  • good but not perfect
    
    • the best we have?
    • what is our gold standard test for comparison (histopathology)
  • sensitivity:
    
    • 72-78%
    • lower for dogs and cats with mild disease or chronic pancreatitis
    • the test will miss some dogs/cats with pancreatitis
  • specificity: varies according to the cut off taken for an abnormal result
    
    • 78-98%
  • Qualitative in-house snap test:
    
    • -ve likely to rule out pancreatitis
    • +ve should be followed up with a quantitative test

Question 27

Why would serum B12 be useful as a diagnotic indicator for pancreatitis?

Answer 27

• Dogs and cats with chronic pancreatitis are at risk of progressive hypocobalaminaemia due to
  
  • Gradual onset EPI?
  • +/- concurrent disease in the ileum especially in cats
  • If we don’t supplement B12 in dogs and cats where it is low, then the gut wont be happy

Question 28

What is the role of diagnostic imaging with regards to diagnosing pancreatitis?

Answer 28

Abdominal Radiography

• Helpful to rule out important differentials such as intestinal FB
• Might provide support for clinical suspicion of acute pancreatitis:
  
  • focal loss of contrast in cranial abdomen (localised peritonitis)
• VD view:
  
  • proximal duodenum
    
    • dilated and fixed
    • displaced laterally by inflamed pancreas
  • transverse colon displaced caudally
• Could have all biochem changes and positive snap test, but could be a duodenal FB and pancreatitis is secondary. If they get SIRS and MODS – they could die. Should be finding FB – so radiographs often indicated to help rule out other underlying causes such as a FB

Question 29

What do you notice about the duodenum is this image?

Answer 29

Duodenum pushed to lateral aspect slightly due to inflammed pancreas

Question 30

What is the role of abdominal ultrasound with regards to diagnosing pancreatitis?

Answer 30

Abdominal Ultrasound

• Reasonable specificity ie few false +ve
• Sensitivity depends on experience, machine quality: ie can appear normal even if patient has pancreatitis
• Findings depend on the degree of
  
  • oedema
  • pancreatic swelling and
  • peripancreatic fat necrosis
  • peritonitis
• Useful for
  
  • assessing concurrent disease
    
    • GI disease
    • biliary tract disease
  • ruling out a pancreatic mass/abscess
• Much less useful for chronic pancreatitis

Question 31

What is the gold standard for pancreatitis diagnosis?

Answer 31

Pancreatic biopsy – gold standard but rare performed

• Remains the gold standard however is rarely performed
  
  • Patient stability and post-biopsy complications
  • Often too sick to manage a biopsy
  • More likely in a cat as might want to know exactly what is going on
• Studies have shown limited correlation between ultrasound findings and biopsy findings
• Various pathologies identified
  
  • Some seem to be breed related
  • Some animals have mixed neutrophilic and lymphocytic disease
• Difficulties over interpretation
  
  • Normal animals often have chronic pancreatic changes
  • Difficult to interpret in clinical context
  • No current criteria that distinguish clinically relevant changes
  • Some pathology is focal and therefore can be missed if biopsies are from a different region

Question 32

How can you manage low grade/mild chronic pancreatitis?

Answer 32

• Short period of “self starve” acceptable
• Low fat diet
  
  • decreased post prandial pain
  • decreased risk of acute flare ups (acute-on-chronic disease)
  • *check treats are not being fed*
• Analgesia? Often needed even if they seem mild
• Metronidazole?
  
  • if bacterial overgrowth associated with disruption to normal gut motility/pancreatic function
• Cobalamin/B12 supplement if low?

Question 33

What is the treatment for acute pancreatitis (or acute on chronic)?

Answer 33

• Treat any underlying cause but most cases are idiopathic
  
  • stop any drugs if suspicious of adverse reaction
    
    • potassium bromide
    • azathioprine
• Manage concurrent disease especially in cats
  
  • cholangitis/hepatic lipidosis?
  • IBD?
  • DKA? Might remember pancreatitis is a trigger factor for diabetic ketoacidosis – so need to manage these cases very aggressively if they are also ketoacidotic
• Main treatment objectives are:
  
  • analgesia
  • manage fluid requirements
    
    • early enteral nutrition

Question 34

What is the management for mild acute pancreatitis?

Answer 34

• Mild: can manage at home?
  
  • 24-48 hours without food
  • water by mouth
  • anti emetics

Question 35

What is the treatment for more severe cases of acute pancreatitis?

Answer 35

• More severe cases:
  
  • hospitalise for appropriate fluid therapy
  • how will you work out fluid requirements?
  • supplement potassium if hypokalaemic
  • monitor urine output if at risk of AKI
• analgesia
  
  • opioids
  • avoid NSAIDs
  • lidocaine?

Question 36

What is the management for CRITICAL cases of pancreatitis?

Answer 36

• Critical cases:
  
  • fluid therapy is challenging and prognosis often very poor
  • often hypovolaemic associated with SIRS à MODS
  • more at risk of pulmonary oedema due to endothelial damage
  • crystalloids always first choice
    
    • plasma?
    • hypertonic saline?
  • antibiotics?
    
    • only justification really is if suspect bacterial translocation
    • rarely due to any infectious disease process
• Prognosis is worse when you get to this kind of critical

Question 37

What is the advice for management of pancreatitis with regards to nutrition in dogs?

Answer 37

• Evidence suggests early feeding is beneficial
  
  • reduces bacterial translocation
  • improves gut wall integrity
• Pre pyloric feeding is well tolerated (O tube)
  
  • no need to bypass the pancreas
• What to feed?
  
  • low fat diet
    
    • prescription diets?
    • baby rice
  • add pancreatic enzyme replacer – seems to reduce the work load on the pancreas, seems to be quite effective and used by some people
• Anti emetics:
  
  • as long as no concerns about GI obstruction

Question 38

What is the advice for management of pancreatitis with regards to nutrition in cats?

Answer 38

• No real evidence to help with decision making
• BUT…. cats at risk of hepatic lipidosis if they refuse food
• O tube feeding a sensible option
• Low fat diet less crucial
  
  • feed for IBD?
• More of a role for steroid treatment in cats with IBD

Question 39

What are some long term complications of chronic disease? I.e. what can it progress to?

Answer 39

Cna progress to EPI, Diabetes Mellitus or protein/calorie malnutrition

Question 40

What is a pancreatic psudeocyst?

Answer 40

A complication of complication

Sterile environment

Collection of enzyme rich pancreatic fluid

From autodigestion during acute necrotising pancreatitis

Can spontaneously resolve (or rupture!)

Question 41

What is the recommended management for a pancreatic pseudocyst?

Answer 41

Recommended management unclear as so rare:

• In humans these are monitored if small and non-infected
• US guided aspiration reported – caution with leakage of fluid
• Surgery if US guided techniques are unsuccessful

Question 42

What is a pancreatic abscess?

Answer 42

Complication of pancreatitis

Sterile environment

• Collection of purulent and necrotic pancreatic tissue
• In acute disease when severe pancreatitis leads to parenchymal necrosis
• Sterile abscess but may develop secondary bacterial infection
• Surgery treatment of choice (consider US guided aspiration)
• Mortality rate high, often due to severity of underlying pancreatic necrosis

Question 43

What are some poor prognostic indicators in acute pancreatitis?

Answer 43

Poor prognostic indicators in acute disease

• Rapid deterioration
• Evidence of SIRS/pulmonary oedema
• Clinical signs of bleeding/DIC
• Intractable pain/vomitingàdistressing/ expensive to manage