Pancreatitis in Dogs and Cats

1. Pancreatitis in Dogs and Cats Two Different Animals Wendy Blount, DVM Nacogdoches, TX

2. Wendy Blount, DVMdrblount@vonallmen.nettalkoftheinternet.com/etvma4 • DVM TAMU 1992 • Private Practice Houston 2 years • Small Animal • Residency TAMU 1994-1997 • Small Animal Internal Medicine • Private Practice Nacogdoches, TX • General Practice, Internal Medicine, Herbal Medicine/Nutrition

3. Pancreatitis:Introduction

4. Two types of pancreatitis • Acute Pancreatitis • Abrupt onset • often reversible after treatment • May lead to chronic pancreatitis • Acute necrotizing (cell death) pancreatitis is a life-threatening condition • Chronic Pancreatitis • Continuing inflammatory disease • Irreversible pathology • Relapsing acute pancreatitis • Exocrine pancreatic insufficiency (EPI) • Diabetes mellitus Acute Chronic 2/3 1/3

5. Pancreatitis Clinical Presentation Diagnosis Treatment Prognosis

6. Pancreatitis:ClinicalPresentation

7. Pancreatitis - Predispositions Chronic liver Disease – Why? Bile reflux into the pancreas Especially in cats – why? Because bile & pancreatic duct merge Diabetes mellitus Intestinal disease

8. Pancreatitis - Predispositions Hyperlipidemia – Why? Blood sludging - pancreatic ischemia Lipase and other enzymes released Hydrolysis of TG in ECF by lipase releases free fatty acids (FFA) FFA cause microthrombi and bind to calcium to cause further damage (saponification) More lipase is released Positive feedback vicious cycle

9. Pancreatitis - Predispositions Obesity Hypercalcemia Hyperadrenocorticism Hypothyroidism High fat meal – How much is too much? >50% calories as fat Careful of U/D in Schnauzers Refeeding after prolonged anorexia

10. Pancreatitis - Predispositions Pancreatic neoplasia If you are treating one of the worst cases of pancreatitis you have ever seen, rule out pancreatic adenocarcinoma Infectious Toxoplasma gondii Feline liver flukes Amphimerus pseudofelinus Feline pancreatic flukes Eurytrema procyonis FIP

11. Pancreatitis - Predispositions Drugs Corticosteroids Chemotherapeutics/immunosuppressives L-asparaginase Azathioprine (Imuran) Estrogens Others

12. Pancreatitis - Predispositions Toxins Organophosphates Scorpion stings Uremic toxins Vaccines

13. Pancreatitis - Predispositions Trauma to the pancreas Abdominal surgery Ischemia (post-GDV, anesthesia, hypotension, shock) Bile duct obstruction Protracted and severe vomiting – why? Bile reflux into the pancreatic duct Especially in the cat

14. Pancreatitis - Predispositions Hypothyroidism dogs High fat meal dogs Refeeding after anorexia dogs Pancreatic neoplasia both Dog vs. Cat - Quiz Hyperlipidemia dogs Hypercalcemia Both Hyperadrenocorticism both

15. Pancreatitis - Predispositions Trauma to the pancreas dogs >> cats Bile duct obstruction cats > dogs Protracted severe vomiting cats > dogs Vaccines ????? Corticosteroids dogs Organophosphates both Uremia both

16. Breed Predisposition Dogs Miniature Schnauzer Sheltie Briard Small dogs (yorkies, poodles) Cats Siamese Himalayan

17. Common Concurrent Diseasesespecially in cats Cholangiohepatitis Inflammatory bowel disease Triaditis Nephritis Hepatic lipidosis – cats only

18. Most Common Clinical Signs Dogs 95% of dogs with pancreatitis vomit Anorexia (91%) Abdominal pain (58%) Cats Anorexia/weight loss – 97% Only 35% of cats with pancreatitis vomit Dehydration – 92% Constipation

19. Clinical Signs – Dogs and Cats Lethargy Icterus – why? Diarrhea – with or without blood Fever (hypothermia more common in cats – 68%) Abdominal pain, cranial abdominal mass Hunched stance or praying position Elevated respiratory rate Necrotic skin lesions or red skin – why? Ascites

20. Pancreatitis - Sequella SIRS Systemic Inflammatory Response can Precipitate: Thromboembolic disease Pumonary thromboembolism DIC Pancreatic encephalopathy Arrhythmia Metabolic acidosis Respiratory Distress (2 causes)

21. Pancreatitis:Diagnosis

22. Diagnosis: Clues in the Bloodwork CBC – nonspecific Thrombocytopenia Neutrophilia with left shift Anemia Serology Lipemia after a prolonged fast (TG, chol) Can present for opaque eyes or anterior uveitis Hypocalcemia – why? Calcium consumed by saponification of fat Hypoalbuminemia – why? Massive inflammation, vasculitis, + sepsis

23. Diagnosis: Clues in the Bloodwork Serology – Dogs and Cats Nonspecific changes Elevated liver enzymes Elevated bilirubin – why? Azotemia Hyperglycemia (cause or effect) Hypoglycemia – why? Hypophosphatemia – why? Hypochloridemia – why?

24. Diagnosis: Clues in the Bloodwork Serology – Dogs only Amylase normal in 47% Lipase Normal in 61% Serology – Cats only Elevated cholesterol (not as often triglycerides) Amylase and lipase not at all useful

25. Diagnosis: Clues in the Bloodwork GI Serology – Dogs and Cats B12 may be low – why? Intrinsic factor from the pancreas is required for absorption concurrent proximal small intestinal disease Folate may be low if distal intestinal disease Folate is absorbed in the ileum REMEMBER: “B” comes before “F”

26. Diagnosis: Clues in the Bloodwork GI Serology – Dogs and Cats TLI (trypsin like immunoreactivity) Highly specific for EPI Increased in SOME dogs and cats with pancreatitis

27. Diagnosis: Clues in the Bloodwork GI Serology – Dogs and Cats What is the BEST blood test to diagnose pancreatitis?? cPLI (canine Pancreatic Lipase Immunoreactivity) 97% sensitive for pancreatitis 82% specific for pancreatitis fPLI (feline Pancreatic Lipase Immunoreactivity) Much more sensitive and specific for pancreatitis than any blood test or imaging Antech and IDEXX TAMU GI Lab (TVMDL sends to TAMU)

28. Diagnostic tools: A comparison

29. SNAPRcPLTM Features • 2 results: Normal or Abnormal • Read time: 10 minutes • Storage: Refrigeration • Sample type: Serum • Read: Visual; semi-quantitative • <200 ug/L normal • 200-400 ug/L borderline • >400 ug/L pancreatitis • Correlation to cPLI >95% • 96% of interpretations are correct Sample Reference

30. Comparing Spec cPL values to SNAP results

31. SNAP cPL for Screening Dog w/ Vomiting, Anorexia, Abdominal pain CBC Profile/lytes UA SNAP cPL SNAP Abnormal SNAP Normal >400 200-399 Treat for pancreatitis, Baseline cPLI Abdominal radiographs Abdominal US Baseline cPLI Pancreatitis is unlikely – pursue other differential diagnoses monitor w/ cPLI US/Rads confirm pancreatitis US/Rads equivocal Treat, Monitor, Retest; Continue to rule out other differential diagnoses Treat for pancreatitis, Monitor with cPLI

32. Diagnosis: Clues in the Bloodwork Urinalysis – nonspecific Ketones think diabetic with ketoacidosis (if glucosuria) Or prolonged fasting/starvation Transient proteinuria Enzyme mediated glomerular damage

33. Diagnosis: Clues in the Bloodwork Coagulation panel Thrombocytopenia Vasculitis (enzyme mediated) DIC PT, PTT, ACT Elevated FDP, d-Dimers high

34. Diagnosis: Clues in the Bloodwork Electrolyte panel/blood gases (venous is fine) HCO3,TC02, pH, pC02 Low - Metabolic acidosis What clue will your patient give you to check venous blood gases? Panting Potassium Low – why? H+ outside the cell exchanged for K+ inside the cell K+ lost in the urine Especially a problem with diabetics – why? Insulin is required to get potassium into the cell where it is needed

35. Diagnosis: Abdominal Ultrasound BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF PANCREATITIS Highly specific, but not that sensitive 60% of cats with pancreatitis have normal US Pancreatitis (> 1 cm thick) Enlarged pancreas Hypoechoic May have cavitary lesions Fluid accumulation around the pancreas Pancreatic duct may be tortuous and dilated

36. Diagnosis: Abdominal Ultrasound Duodenum Dilated and hypomotile (<5 waves per minute) Sometimes “corrugated” Common Bile Duct Dilated and tortuous Gall bladder Enlarged, wall edema/hyperechoic, sludge Ascites Peripancreatic fat and omentum hyperechoic

37. Diagnosis: Abdominal Ultrasound Ultrasound truly IS for everyone Time-consuming time to warm up reagants 10 minutes to run the test Expensive Used Toshiba Analog $12k in 2000 3 US a week x $150 x 50 weeks = $22.5K Subject to user experience No more subjective than x-rays

38. Diagnosis: Radiographs Abdominal radiographs Often normal (sensitivity 24%) Ascites – generalized or localized Peritonitis – loss of detail “ground glass” Stomach – displaced left, dilation Duodenum – displaced caudal and right, gas Dilated, thickened, corrugated Colon – displaced caudal Calcification of fat

39. Diagnosis: Radiographs Upper GI Barium Series Delayed emptying of stomach and duodenum Corrugation of duodenal wall Thoracic radiographs Can be normal Pleural effusion Pulmonary edema Severe vasculitis if severe hypoalbuminemia 25-50% of cats have either pleural effusion or ascites Sometimes pneumonitis (interstitial pattern)

40. Diagnosis: Abdominocentesis, Thoracocentesis Usually modified transudate Occasionally exudative (suppurative) Rarely hemorrhagic

41. Diagnosis: Exploratory Laparotomy Pancreas Edematous, hemorrhagic, abscesses, cysts Enlarged if acute Very small, wasted, fibrotic if chronic Can appear grossly normal in cats Peripancreatic tissues Saponification of fat Inflammation Adhesions

42. Diagnosis: Exploratory Laparotomy Histopathology - pancreas Definitive diagnosis in cats Chronic pancreatitis – fibrosis, inflammation, nodular hyperplasia Acute pancreatitis – edema, hemorrhage, necrosis, inflammation Few side effects after Bx of cat pancreas Culture/Cytology any abscesses Usually sterile (do cytology first) Bacterial infection is not very common in dogs and cats

43. Pancreatitis:Treatment

44. Pancreatitis Treatment: Dogs and Cats PRIMARY THERAPIES Fluid therapy Colloids Antibiotics Analgesia Antioxidants

45. Pancreatitis Treatment:Dogs and Cats Fluid therapy – why so crucial Need to support pancreatic perfusion Pancreatitis + pancreatic ischemia = bad things 35-45 ml/lb/day until eating well less if low albumin, until colloids restored Supplement potassium according to the sliding scale One scale for animals with severe acidosis One scale for animals with normal venous blood gases

46. Pancreatitis Treatment:Dogs and Cats Fluid therapy – why so crucial Why do pets with acidosis need more potassium? In a state of acidosis, there are excess hydrogen ions (H+) in the extracellular fluid As the acidosis is corrected by therapy, potassium that had left the cells in exchange for H+ goes quickly back into the cells This can drop potassium precipitously, causing arrhythmia, weakness or even respiratory paralysis Most common culprits are DKA and RTA

47. Pancreatitis Treatment:Dogs and Cats Fluid therapy – why so crucial Add glucose if hypoglycemic Add bicarbonate if: Acidosis is immediately life threatening Acidosis will not be corrected by treating other problems See handout LRS won’t work if severe liver disease and needs alkalinizing – why?? Liver must transform lactate to bicarbonate

48. Pancreatitis Treatment:Dogs and Cats “Flop” Chief Complaint – Not doing well since treating abscess on a toe 1 week ago, vomiting blood 3 days ago regular vet did a UA and blood glucose UA showed ketones++ and glucose +++, blood glucose 296 Has been treating with IV fluids since, getting worse Did not start insulin because cat not eating Exam - Dehydrated, lethargic, icteric, RR 56 vomited coffee grounds and collapsed on abdominal palpation, HR 65/bpm Responded to atropine IV and fluid bolus

49. Pancreatitis Treatment:Dogs and Cats “Flop” - diagnostics CBC – granulocytes 16,000 Profile – glucose 200, BUN 41 TG 500, Chol 297 Bili 4.2, ALT 148, ALP normal Ca 7.0, Phos 1.6 UA – SG 1.027, ketones ++, glucose +++, inactive sediment Electrolytes – K+ <2.0, Na+ 133, iCa++ 1.08 pH 7.032, BE -24, HCO3 7, TCO2 8 pCO2 26.5, No chest rads or abdominal US done Urine culture pending

50. Pancreatitis Treatment:Dogs and Cats “Flop” - diagnosis Initial life threatening problems Severe ketoacidosis treatment – insulin, bicarbonate, IV fluids Severe hypokalemia treatment – IV KCl or K-phosphates Severe hypophosphatemia treatment – IV K-phosphates (pancreatitis, hematemesis, abscess on toe) (treatment – feed, antacids, sucralfate, antibiotics)