Pancreatitis & EPI Flashcards
Obj: Contrast how normal exocrine pancreatic physiology prevents pancreatitis and how disruptions cause acute pancreatitis
Obj: Based on different risk factors of pancreatitis in dog and cats, develop species’ specific treatment plans
Obj: Based on species’ differences in clinical signs and concurrent disease in both acute and chronic pancreatitis, formulate appropriate diagnostic plans to obtain an accurate diagnosis and exclude concurrent conditions
Obj: Given clinical signs, lab work, and imaging detect local (pancreatic/biliary) and systemic consequences of acute pancreatitis
Obj: Based on sensitivities and specificities of tests for pancreatitis and an individual patient, recommend the best test and/or interpret whether results rule-in/out pancreatitis
Obj: Explain the differences in pathophysiology and clinical signs of EPI between dogs and cats
Obj: Interpret diagnostic tests for EPI and recommend an individualized treatment and monitoring plan
Obj: Explain the prognosis of acute/chronic pancreatitis and EPI to owners, particularly duration of treatment, recurrence, and negative prognostic indicators
What are the exocrine pancreatic enzymes
- Synthesized, stored, and secreted in inactive form
- Trypsinogen
- Chymotrypsinogen
- Procarboxypolypeptidase
- Proelastase
- Prophospholipase A2
How is early activation of pancreatic enzymes prevented?
- Activation by cleavage of pro-peptide within the duodenum
- Packaged with pancreatic secretory trypsin inhibitor
- Lysosomes and zymogens needed for activation stored as separate granules
What is the pathophysiology of Acute pancreatitis?
- Intra-pancreatic trypsin activation
- Concentration of activated trypsin overwhelms local trypsin inhibitor
- Trypsin activates self and other pancreatic enzymes within the pancreas
- Concentration of activated pancreatic proteases overwhelms local protease inhibitors
- Auto-digestion of pancreas
What are the net results of Acute Pancreatitis
- Net Results:
- Intra-pancreatic cell membrane injury by free-radicals
- Systemic inflammatory response:
- systemic free radical formation
- activation of coagulation cascade
- activation of complement cascade
- bradykinin response → increased systemic inflammation by cytokines and chemokines (positive feedback)
- → multi-organ failure and death
In dogs what are the clinical signs of Acute Pancreatitis?
- Vomiting >90%
- Anorexia 90%
- Lethargy 90%
- Abdominal pain 60%
- Diarrhea 30%
- Fever 30%
In cats what are the clinical signs for Acute Pancreatitis
- Lethargy 100%
- Anorexia 97%
- Hypothermia 70%
- Vomiting 40%
- Abdominal pain 25%
- Diarrhea 15%
- Fever <10%
What are the risk factors for Acute Pancreatitis in Dogs?
- Terrier/non-sporting breeds
- Yorkshire terriers, Min Schnauzers, Shetland Sheepdogs
- Middle-aged to older
- Obesity
- High-fat diet / dietary indiscretion
- Hypertriglyceridemia
- Ischemia
- Pancreatic duct obstruction
- Drugs/toxins
- Azathioprine, potassium bromide, L-asparaginase, cisplatin…..etc.
What are the risk factors for Acute Pancreatitis in Cats?
- Less common
- High fat diet is NOT a risk factor
- Possible factors:
- Ischemia
- abdominal trauma
- infection (flukes, toxoplasma, virulent calicivirus)
- hypertriglyceridemia
- drugs (organophosphates
How is Acute Pancreatitis Diagnosed? (Broad Tests)
- CBC
- Chemistry - may be normal
- UA - May be normal
- Abdominal Imaging
- Additional Bloodwork
- Serum amylase and lipase conc
- SNAP canine pancreatic lipase
- Spec cPL or fPL
- Cytology
- Biopsy
What CBC findings are common with Acute Pancreatitis?
- inflammatory leukogram
- thrombocytopenia 60%
What Chemistry results are common with Acute Pancreatitis
- Chemistry - may be normal
- +/- Elevated ALP, GGT, t-bilirubin due to post-hepatic bile duct obstruction
- elevated ALT secondary to hepatocellular damage from inflammation
- +/- Hypoalbuminemia due to acute inflammation or systemic inflammation/vasculitis
- +/- Hypocalcemia
- Cats: hyperbilirubinemia 60%, hypocalcemia 50%
What UA results are common with Acute Pancreatitis?
- UA - May be normal
- mild proteinuria (systemic inflammation)
- increased bilirubin if hyperbilirubinemia
- Dilute USG is secondary acute kidney injury
What radiography findings are common for Acute Pancreatitis
- Radiographs - non specific
- decreased serosal detail, especially in right cranial abdomen
- Right and ventral displacement of the duodenum
- left displacement of the gastric axis
- Gastric and proximal duodenal gas dilation
- functional ileus due to inflammation
What Ultrasound findings are common with Acute Pancreatitis
- US - can be normal Sensitivity 70%
- Enlarged, hyperechoic pancreas with surrounding hyperechoic mesentery
- Abdominal effusion due to inflammation
- +/- mineralization in surrounding mesentery
- +/- Common bile duct and gallbladder distention if extrahepatic biliary obstruction
- Cats:
- 85% pancreatic enlargement
- 25% extrahepatic biliary dilation
How reliable are serum amylase and lipase concentrations for diagnosing Acute Pancreatitis?
- Not specific
- no useful in dogs/cats for diagnosis of pancreatitis
- 50% of dogs with increased lipase do NOT have pancreatitis
- 50% of dogs with pancreatitis do NOT have elevated lipase/amylase
How reliable is the SNAP canine pancreatic lipase test for diagnosing Acute Pancreatitis
- High sensitivity 94%
- A negative test can help rule out pancreatitis
- Low specificity 70-75%
- many false positives
How can results of a SNAP canine pancreatic lipase test be confirmed?
- Confirmatory test
- Spec cPL or fPL (pancreatic specific lipase) test
- High sensitivity 80-94%
- high specificity 90% if >400mcg/dL
- Spec cPL or fPL (pancreatic specific lipase) test
What cytology findings are common with Acute Pancreatitis?
- Acinar cell necrosis and neutrophilic inflammation
- Not ruled out by normal cytology
- samples difficult to obtain
What is the treatment for Acute Pancreatitis
- Treat predisposing cause if known
- Supportive Care
- IV fluids
- Antiemetic and anti-nausea drugs
- Early enteral nutrition
- Analgesia
- Steroids
Why are IV fluids part of Acute Pancreatitis treatment?
- Correct:
- hypervolemia
- hypotension
- electrolyte abnormalities
- acid-base abnormalities
- Pancreatic hypoperfusion can worsen pancreatitis
- decreased perfusion of other organs increases risk for multi-organ dysfunction
What fluids can be used for IV fluid therapy for Acute Pancreatitis
- Crystalloids
- Plasmalyte
- Normosol
- Lactated Ringers
- Colloids
What are the pros/cons of using Crystalloids for Acute Pancreatitis?
- Pro:
- widely available
- Balanced electrolytes
- Acid-buffering
- Con:
- Low oncotic pull
- may easily leak through vascular
- worsening of tissue edema and cavitary fluids
What are the pros/cons of colloids for Acute Pancreatitis
- Pro:
- Improved microcirculation
- low-volume resuscitation
- Cons:
- Dose-dependent coagulopathy
- questionable clinical significance
- Dose-dependent coagulopathy
What parameters can be measured to adjust fluid rate based on need
- Urine output
- Body weight
- blood pressure
- improvement or worsening of effusion/edema
- Biochemical changes
- PCV/TS
- lactate
Why would potassium need to be supplemented while treating Acute Pancreatitis?
- Hypokalemia common:
- GI/urinary losses
- decreased intake
- iatrogenic diuresis form fluid therapy
- K+max = 0.5 mEq/kg/h
What Antiemetic and anti-nausea drugs are commonly used for Acute Pancreatitis? pros of each
- Maropitant
- additional visceral pain-relieving properties
- Ondansetron
- Low oral bioavailability
- Good intravenous efficacy
- Consider multi-modal approach
What early enteral nutrition is recommended for Acute Pancreatitis?
- Appetite stimulation once vomiting controlled
- NG-tube support once vomiting controlled
- Low-fat diet (dogs)
What Analgesia options are there for Acute Pancreatitis?
- Opioids
- Buprenorphine
- Mild - moderate pain
- Expensive for large dogs
- Butorphanol
- Mild - moderate pain
- Better for visceral pain than buprenorphine
- Anti-emetic effects
- Short-acting unless given as CRI
- Hydromorphone
- Good analgesia
- Risk of Vomiting, ileus
- Methadone
- Excellent Analgesia
- Best option as CRI for moderate - severe pain
- Risk of ileus
- Fentanyl
- Excellent analgesia
- Best option as CRI for moderate - severe pain
- Risk of ileus
- Buprenorphine
- Adjunctive:
- Lidocaine CRI
- Ketamine CRI
- Maropitant
What is the benefit of early enteral nutrition in Acute Pancreatitis?
- Improved GI mucosal barrier
- Decreased vomiting
What food can be provided to patients with Acute Pancreatitis?
- Liquid diet
- CRI
- 25-30% RER on day 1
- Increase caloric intake25-30% per day
- Facilitate feeding with anti-emetics and prokinetics
- Nutrient profile
- Dogs: Low fat
- 2.5-5 g/100kcal fat
- Cats: High Protein
- 9-12g/100kcal protein
- Dogs: Low fat
When could steroids benefit patients with Acute Pancreatitis?
- Cases with extra-hepatic biliary obstruction
- may benefit from decreased peripancreatic inflammation
What treatments do not work for Acute Pancreatitis?
- Plasma - in absence of SIRS/DIC
- Antibiotics - in absence of sepsis
When would antibiotics be indicated for use in Acute Pancreatitis cases?
- Biochemical evidence of sepsis/GI mucosal translocation
- Documented systemic infection
- Documented infected pancreatic abscess
What are the possible complications of Acute Pancreatitis?
- Vasodilatory or hypovolemic shock
- Hypovolemia
- DIC
- Thrombosis
- Acute kidney injury
- Diabetes mellitus
- Pancreatic abscess/pseudocyt formatoin
- Extrahepatic biliary obstruction
- Systemic inflammatory response
- → multiorgan failure → Death
What in chronic pancreatitis
- associated with pancreatic fibrosis and atrophy
- Most common presentation of pancreatitis in cats
- uncommon in dogs
What are the clinical signs of chronic pancreatitis in dogs?
- Lethargy 80%
- Decreased appetite
- Vomiting 60%
- 35% chronic vomiting
- Diarrhea 40%
What concurrunt conditions affect dogs with Chronic Pancreatitis
- Endocrine
- Diabetes mellitus
- hypothyroidism
- Hepatobiliary diseae
- IBD
How is Chronic Pancreatitis diagnosed in dogs?
- Blood work - usually normal
- 70% spec cPL elevation
- Abdominal US
- Hyperechoic pancreas with increased/heterogenous echotexture
- No peri-pancreatic changes
- Normal in 50%
How is Chronic Pancreatitis treated in Dogs?
- Long term, low-fat diet
- Avoid dietary indiscretion
- Avoid predisposing drugs/risk factors
- Treatment of concurrent GI or endocrine disease
What are the clinical signs of Chronic Pancreatitis in Cat?
- Chronic, intermittent vomiting/diarrhea
- Chronic, intermittent dysrexia
- Intermittent lethargy
- Weight loss
How is Chronic Pancreatitis diagnosed in cats?
- Histopathology
- rarely performed
- Rule out other causes of Chronic Gi signs
- Spec fPL
What are common disease concurrent with Chronic Pancreatitis in cats?
- Pancreatitis + Cholangitis + IBD
- Triaditis
- Pancreatitis + IBD
- Pancreatitis + Cholangitis
What is the treatment for Chronic Pancreatitis in Cats?
- Supportive:
- Anti-emetic/anti-nausea medications
- fluid therapy
- appetite stimulants
- Avoid risk factors for exacerbation
- Treatment of IBD and cholangitis if present
What is a Pancreatic abscess? Etiologies?
- Circumscribed collection of purulent material associated with the pancreas
- Etiologies:
- Complication of acute pancreatitis
- Usually Sterile
What are the clinical signs of a Pancreatic Abscess?
- Abdominal pain
- Anorexia
- Fever
- Vomiting/diarrhea
- Lethargy/depression
- Palpable abdominal mass
How is a Pancreatic Abscess diagnosed?
- Abdominal ultrasound:
- circumscribed fluid-focus with hyperechoic rim
- material may be hypoechoic to hyperechoic, depending on cellularity
- circumscribed fluid-focus with hyperechoic rim
- Cytology of fluid:
- high cellularity
- non-degenerate neutrophils
What is the treatment for Pancreatic abscess?
- Pain management
- Surgical resection
- percutaneous drainage/conservative management if surgery is not possible
What is a Pancreatic Pseudocyst? Etiology?
- Sterile, focal collection of pancreatic fluid, surrounded by fibrous or granulation tissue
- Etiology:
- complication of pancreatitis
What are the clinical signs of a pancreatic pseudocyst?
- Non-specific - similar to pancreatitis
- or asymptomatic
How are Pancreatic pseudocysts diagnosed?
- Abdominal US:
- cyst-like structure associated with the pancreas
- Cytology of fluid:
- low cellularity
What is the treatment for Pancreatic pseudocysts?
- Medical: percutaneous drainage and monitoring
- Surgery if medical management is unsuccessful
What is Exocrine Pancreatic insufficiency? Etiologies?
- Insufficient synthesis and secretion of pancreatic enzymes
- Etiology:
- Lack of pancreatic acinar cells secondary to acinar atrophy (most common in dogs)
- Lack of pancreatic acinar cells secondary to chronic pancreatitis (most common in cats)
- Obstruction of pancreatic duct secretion into the SI lumen, preventing effective secretion in the face of normal production
What breeds are predisposed to acinar atrophy?
- German Shepherd
- Rough-coated collie
- Eurasian
What is the Pathogenesis of Exocrine Pancreatic insufficiency?
- Pancreatic secretory products and pancreatic enzymes crucial for food digestion
- Absence of secretory products = Maldigestion
- undigested food components in GI tract → Diarrhea, microbiome dysbiosis, weight loss
What are the clinical signs of Exocrine Pancreatic Insufficiency in Dogs?
- Weight-loss with good to increased appetite
- Diarrhea - often watery, malodorous and containing undigested food
- Flatulence
- Poor hair coat
- Coprophagia, pica
What are the clinical signs of Exocrine Pancreatic Insufficiency in Cats?
- Clinical signs for appetite and diarrhea differ from dogs
- Weight loss 90%
- Anorexia 40%
- Increased appetite 40%
- Unformed stool 60%
- Watery diarrhea 30%
- Poor haircoat
- Vomiting 20%
How is Exocrine Pancreatic Insufficiency diagnosed?
- Serum trypsin-like immunoreactivity (TLI) assay
- severely decreased or undetectable
What is the treatment for Exocrine Pancreatic Insufficiency?
- Pancreatic enzyme supplementation
- Dried pancreatic extract (porcine/bovine): Tablet, capsule, powder supplementation
- 1 tsp/10kg body weight ON food
- Enzyme activities of commercial products varies and are not strictly controlled.
- Side-effects: Oral ulceration and bleeding
- Raw, fresh pancreas
- less ideal - risk of Echinococcus transmission
- Option for pet that does not tolerate dried extract
- Dried pancreatic extract (porcine/bovine): Tablet, capsule, powder supplementation
- Check serum cobalamin or methylmalonic acid and supplement cobalamin if decreased or increased, respectively
- cobalamin deficiency in 80%
- Diet:
- no benefit to specific diet types in absence of concurrent intestinal disease
- High-quality, maintenance diets
- Avoid high fiber diets - may interfere with fat absorption
What is the prognosis of Exocrine Pancreatic Insufficiency?
- Life-long treatment needed
- If lack of response, consider:
- concurrent SI disease
- Anti-acids: decrease destruction of supplemented enzymes within the stomach and decrease steatorrhea
- Overall response in cats:
- good 60%
- partial 30%
- poor 13%
- Negative prognosis indicator: Untreated cobalamin deficiency
