Pancreatitis in dogs and cats
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Pancreatitis in Dogs and Cats. Two Different Animals Wendy Blount, DVM Nacogdoches, TX. Wendy Blount, DVM [email protected] www.wendyblount.com. DVM TAMU 1992 Private Practice Houston 2 years Small Animal Residency TAMU 1994-1997 Small Animal Internal Medicine

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Pancreatitis in dogs and cats

Pancreatitis in Dogs and Cats

Two Different Animals

Wendy Blount, DVM

Nacogdoches, TX


Wendy blount dvm drblount@vonallmen net www wendyblount com

Wendy Blount, [email protected]

  • DVM TAMU 1992

  • Private Practice Houston 2 years

    • Small Animal

  • Residency TAMU 1994-1997

    • Small Animal Internal Medicine

  • Private Practice Nacogdoches, TX

    • 75% Referrals – Internal Medicine and Herbal Medicine/Nutrition

    • 25% General Practice


Pancreatitis introduction

Pancreatitis:Introduction


Two types of pancreatitis

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


Pancreatitis

Pancreatitis

Clinical Presentation

Diagnosis

Treatment

Prognosis


Pancreatitis clinical presentation

Pancreatitis:ClinicalPresentation


Pancreatitis predispositions

Pancreatitis - Predispositions

Chronic liver Disease – Why?

Bile reflux into the pancreas

Especially in cats – why?

Because bile & pancreatic duct merge

Diabetes mellitus

Intestinal disease


Pancreatitis predispositions1

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


Pancreatitis predispositions2

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


Pancreatitis predispositions3

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


Pancreatitis predispositions4

Pancreatitis - Predispositions

Drugs

Corticosteroids

Chemotherapeutics/immunosuppressives

L-asparaginase

Azathioprine (Imuran)

Estrogens

Others


Pancreatitis predispositions5

Pancreatitis - Predispositions

Toxins

Organophosphates

Scorpion stings

Uremic toxins

Vaccines


Pancreatitis predispositions6

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


Pancreatitis predispositions7

Pancreatitis - Predispositions

Hyperadrenocorticism

both

Hypothyroidism

dogs

High fat meal

dogs

Refeeding after anorexia

dogs

Pancreatic neoplasia

both

Dog vs. Cat - Quiz

Chronic Liver Disease

both

Diabetes mellitus

both

Intestinal disease

both

Hyperlipidemia

dogs

Hypercalcemia

both


Pancreatitis predispositions8

Pancreatitis - Predispositions

Trauma to the pancreas

dogs >> cats

Ischemia

both

Bile duct obstruction

cats > dogs

Protracted severe vomiting

cats > dogs

Vaccines

?????

Toxoplasma gondii

cats

Corticosteroids

dogs

Organophosphates

both

Scorpion sting

both

Uremia

both


Breed predisposition

Breed Predisposition

Dogs

Miniature Schnauzer

Sheltie

Briard

Small dogs (yorkies, poodles)

Cats

Siamese

Himalayan


Common concurrent diseases especially in cats

Common Concurrent Diseasesespecially in cats

Cholangiohepatitis

Inflammatory bowel disease

Triaditis

Nephritis

Hepatic lipidosis – cats only


Most common clinical signs

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


Clinical signs dogs and cats

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


Pancreatitis sequella

Pancreatitis - Sequella

SIRS

Systemic Inflammatory Response can Precipitate:

Thromboembolic disease

Pumonary thromboembolism

DIC

Pancreatic encephalopathy

Arrhythmia

Metabolic acidosis

Respiratory Distress (2 causes)


Pancreatitis diagnosis

Pancreatitis:Diagnosis


Diagnosis clues in the bloodwork

Diagnosis: Clues in the Bloodwork

CBC – nonspecific

Thrombocytopenia

Neutrophilia with left shift

Anemia

Serology – Dogs only

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


Diagnosis clues in the bloodwork1

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


Diagnosis clues in the bloodwork2

Diagnosis: Clues in the Bloodwork

Lipase – non-specific – why?

Digestive lipases

Intestinal lipase

Lipoprotein lipase and hepatic lipase

Hormone-sensitive lipase (adipocytes)

Lysosomal acidic lipase


Diagnosis clues in the bloodwork3

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?


Diagnosis clues in the bloodwork4

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”


Diagnosis clues in the bloodwork5

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


Diagnosis clues in the bloodwork6

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)


Diagnostic tools a comparison

Diagnostic tools: A comparison


Spec cpl tm

Spec cPLTM

  • cPLI Developed by Drs. Jörg Steiner and David Williams at the Gastrointestinal Laboratory at Texas A&M University

  • IDEXX collaborated with Drs. Steiner and Williams to develop the Spec cPL

  • IDEXX renamed it Spec cPL

    • For better name recognition

    • To trademark the name

  • Available only at IDEXX Labs


Introducing snap r cpl tm

Introducing 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

  • Same technology as Spec cPL®

  • Correlation to Spec cPL >95%

  • 96% of interpretations are correct

Sample

Reference


Comparing spec cpl values to snap results

Comparing Spec cPL values to SNAP results


Snap cpl for screening

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


Diagnosis clues in the bloodwork7

Diagnosis: Clues in the Bloodwork

Urinalysis – nonspecific

Ketones

think diabetic with ketoacidosis (if glucosuria)

Or prolonged fasting/starvation

Transient proteinuria

Enzyme mediated glomerular damage


Diagnosis clues in the bloodwork8

Diagnosis: Clues in the Bloodwork

Coagulation panel

Thrombocytopenia

Vasculitis (enzyme mediated)

DIC

PT, PTT, ACT

Elevated

Antithrombin III

Low

FDP, d-Dimers

high


Diagnosis clues in the bloodwork9

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


Diagnosis abdominal ultrasound

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


Diagnosis abdominal ultrasound1

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


Diagnosis abdominal ultrasound2

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

Cost $1714 per year

3 US a week x $150 x 50 weeks = $22.5K

Subject to user experience

No more subjective than x-rays


Diagnosis radiographs

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


Diagnosis radiographs1

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)


Diagnosis abdominocentesis thoracocentesis

Diagnosis: Abdominocentesis, Thoracocentesis

Usually modified transudate

Occasionally exudative (suppurative)

Rarely hemorrhagic


Diagnosis exploratory laparotomy

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


Diagnosis exploratory laparotomy1

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


Pancreatitis treatment

Pancreatitis:Treatment


Pancreatitis treatment dogs and cats

Pancreatitis Treatment: Dogs and Cats

PRIMARY THERAPIES

Fluid therapy

Colloids

Antibiotics

Analgesia

Antioxidants


Pancreatitis treatment dogs and cats1

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


Pancreatitis treatment dogs and cats2

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


Pancreatitis treatment dogs and cats3

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

Avoid LRS if severe liver disease and needs alkalinizing – why??

Liver must transform lactate to bicarbonate


Pancreatitis treatment dogs and cats4

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


Pancreatitis treatment dogs and cats5

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


Pancreatitis treatment dogs and cats6

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)


Pancreatitis treatment dogs and cats7

Pancreatitis Treatment:Dogs and Cats

“Flop” - treatment

IV fluids – of course – 45 ml/lb/day

Rehydrates and corrects acidosis – which fluids?

Buffered – LRS, Ringers, Normosol, Plasmalyte, etc.

Potassium chloride – no disadvantage

Potassium phosphates – no disadvantage

(sliding scale) (IV drip rate calculator)

Insulin

Advantage – corrects ketoacidosis

Disadvantage – makes hypokalemia and hyposphatemia worse

Bicarbonate (handout)

Advantage – corrects acidosis

Disadvantage – will make hypokalemia worse

Cefazolin 100 mg IV TID, cimetidine 25 mg IV TID


Pancreatitis treatment dogs and cats8

Pancreatitis Treatment:Dogs and Cats

“Flop” – reassess in 4 hours

Glucose - 99 (1 unit NPH SC)

PCV – 23%

pH 7.228, HC03 10, TCO2 11

pC02 23.9,

iCa++ 1.07, Na+ 130, K+ 2.3

Phosphorus 0.7

Red tinged urine, serum icteric

Hydration normal, general condition slightly improved, no vomiting, not eating


Pancreatitis treatment dogs and cats9

Pancreatitis Treatment:Dogs and Cats

“Flop” – 2 days later

Glucose - 325

PCV – 20%

pH 7.403, HC03 18.8, TCO2 20

pC02 30

iCa++ 0.92, Na+ 134, K+ 3.7

Phosphorus 3.4

Urine clear, serum slightly icteric

Hydration normal, general condition greatly improved, eating small amounts, no vomiting


Pancreatitis treatment dogs and cats10

Pancreatitis Treatment:Dogs and Cats

Colloids – why so crucial

Low albumin + vasculitis + fluid therapy = pulmonary edema

Hetastarch 5-10 ml/lb/day

Plasma 10 ml/lb/day, over 2-3 hours

Premedicate with diphenhydramine

Can repeat daily until improved

Also treats DIC when incubated with heparin 35-75 U/kg for 30 minutes prior to administration

Provides antiproteases and alpha-macroglobulins

Whole blood if significantly anemic (hemolysis)


Pancreatitis treatment dogs and cats11

Pancreatitis Treatment:Dogs and Cats

Antibiotics – controversial

Increased survival in people with pancreatitis who are treated with antibiotics

But bacterial pancreatitis is much less common in dogs and cats

Should prevent systemic infection from bacterial translocation across the gut

Treat concurrent infection, of course (UTI*)

Penicillins (avoid Clavamox – it causes vomiting)

Cephalosporins

Quinolones alone aren’t the best choice – why?


Pancreatitis treatment dogs and cats12

Pancreatitis Treatment:Dogs and Cats

Analgesia – THIS IS A PAINFUL DISEASE

Butorphanol (1 mg/10 lbs q2-4hrs PRN for pain)

Buprenorphine (0.015 mg/kg q6-12hrs)

Opiate pure agonists – what’s the catch?

Oxymorphone

Morphine

Hydromorphone

Meperidine*

Fentanyl injectable or patch

Intraperitoneal lidocaine or bupivocaine

Be careful of NSAIDs – Why?


Pancreatitis treatment dogs and cats13

Pancreatitis Treatment: Dogs and Cats

Antioxidants

Milk thistle

SAMe

VetriScience Cell Advance

Vitamin E/selenium

Free radical damage is rampant in pancreatitis

People with recurring pancreatitis have fewer episodes when they take daily antioxidants


Pancreatitis treatment dogs and cats14

Pancreatitis Treatment: Dogs and Cats

SECONDARY THERAPIES - As indicated

Heparin

Questionable efficacy in cats

Some think it is primary therapy for dogs – why?

Even if not in DIC, they are hypercoagulable

May promote pancreatic microcirculation

Preventing a thromboembolism is

Way better than treating one


Pancreatitis treatment dogs and cats15

Pancreatitis Treatment:Dogs and Cats

SECONDARY THERAPIES - As indicated

Antiemetics - controversial

Definitely make the patient more comfortable

May prevent death from vagal surge

Some would rather not cover up their vomiting

Metoclopramide, Cisapride

Ondansetron (Zofran), dolasetron (Anzemet) - 5HT3 antagonists – 0.3-0.6 mg/kg SID to BID

Maropitant (Cerenia) - neurokinin-1 receptor antagonist – 1 mg/kg SID

Careful of phenothiazines – why?

don’t want hypotension


Pancreatitis treatment dogs and cats16

Pancreatitis Treatment:Dogs and Cats

SECONDARY THERAPIES - As indicated

B vitamins (especially B12)

H2 blockers/H+ pump blockers, sucralfate/barium

if blood in the stool or vomit

May prevent reflux esophagitis if vomiting

is severe

Famotidine, Ranitidine, Cimetidine, (omeprazole)

There is some evidence cimetidine

and ranitidine might aggravate

pancreatitis in people


Pancreatitis treatment dogs and cats17

Pancreatitis Treatment:Dogs and Cats

SECONDARY THERAPIES - As indicated

Treat hyperlipidemia

Handout

Hyperlipidemia predisoposes to pancreatitis

Calcium

Therapy rarely needed

Only if clinical signs, and calcium < 6.5 mg/dl

Bicarbonate

Already discussed IV therapy

Some cats with severe chronic

pancreatitis need oral HC03


Pancreatitis treatment dogs and cats18

Pancreatitis Treatment: Dogs and Cats

SECONDARY THERAPIES - As indicated

Surgery/laparoscopy

Biopsy to diagnose neoplasia in dogs and cats

Biopsy to diagnose pancreatitis in cats

Debridement

Restore bile flow (stent)

To treat abscesses or pseudocysts

That recur after US guided

drainage


Pancreatitis treatment dogs and cats19

Pancreatitis Treatment:Dogs and Cats

SECONDARY THERAPIES - As indicated

Antihelminthics

In the rare case of liver flukes or pancreatic flukes in cats

Fenbendazole

Praziquantel (high dose in notes)


Pancreatitis treatment dogs and cats20

Pancreatitis Treatment:Dogs and Cats

CONTROVERSIAL THERAPIES

Dopamine CRI

Protective effect when administered to cats with experimental pancreatitis within 12 hours

No effect after 12 hours

Can cause vomiting, nausea, seizures in cats

Peritoneal dialysis

To remove chemical irritants from the abdomen

When ascites (especially exudative)


Pancreatitis treatment dogs and cats21

Pancreatitis Treatment:Dogs and Cats

CONTROVERSIAL THERAPIES

Oral pancreatic enzymes

Reported to reduce pain in people with pancreatitis

Less likely to be effective in dogs because they do not have a protease negative feedback

Some have observed clinical benefits

in dogs who have pain associated

with chronic pancreatitis


Pancreatitis treatment dogs and cats22

Pancreatitis Treatment:Dogs and Cats

CONTROVERSIAL THERAPIES

Drugs to inhibit pancreatic secretion

Seem to work with experimental pancreatitis

Little effect in spontaneous pancreatitis

Glucagon

Gabexate mesylate, nafamostat mesylate

Atropine

Acetazolamide

Somatostatin

calcitonin


Pancreatitis treatment dogs and cats23

Pancreatitis Treatment:Dogs and Cats

Patient Monitoring

TPR, blood pressure BID or more

Low body temp indicates big trouble

High fever spikes might indicate infection

Increased heart rate??

Pain

Hypovolemia (need more fluids)

Increased respiratory rate??

Pain

Pulmonary edema, pleural effusion, pneumonitis

acidosis


Pancreatitis treatment dogs and cats24

Pancreatitis Treatment:Dogs and Cats

Patient Monitoring

Electrolytes/blood gases, lactate

SID-BID when critical

QOD when stable

Weigh BID when concerned about kidney function

Why?

Increase in body weight 10% is the first sign

of fluid retention

If you catch this early, you can prevent

pulmonary edema, and give your patient

more time to start making urine


Pancreatitis treatment dogs and cats25

Pancreatitis Treatment:Dogs and Cats

Patient Monitoring

HCT

SID if stable

BID if phosphorus low, especially if DKA

Albumin

daily if <1.5

QOD if >2.0, as long as on fluid therapy

Monitor for DIC

Platelets

If decreasing, do PT, PTT, FDP/d-dimers, AT3


Pancreatitis treatment dogs and cats26

Pancreatitis Treatment:Dogs and Cats

Patient Monitoring

Glucose

Every 2 hours when unstable

Give insulin ONLY as needed

Glucose can be very erratic in DKA

When stable enough, can do every 2 hours during the day, and not overnight

If you MUST spot check, then do so 6 hours

after insulin (glucose low)

Insulin nadir is much more important

than peak when deciding dose


Pancreatitis treatment dogs and cats27

Pancreatitis Treatment:Dogs and Cats

Patient Monitoring

Urine ketones if diabetic – daily until stable

cPLI or fPLI

Long term, to monitor resolution of pancreatitis, and need for ongoing dietary therapy and antioxidant supplementation

Abdominal US

To follow resolution of pancreatic abscesses or cysts


Treatment canine pancreatitis

Treatment: Canine Pancreatitis

Glucocorticoids contraindicated

NPO

At least 48 hours

Offer water after no vomiting for 24 hours

Offer food when no vomiting for 24 hours with free choice water

2-3 very small meals the first day (2 teaspoons to 2 tablespoons)

Gradually work up to full feed over 3-5 days

If any vomiting, start over at the top


Treatment canine pancreatitis1

Treatment: Canine Pancreatitis

Nutrition

Low fat – Why?

<15-20% of calories

Low fiber, at first – Why?

Can go to higher fiber later

Low protein – Why?

<25% of calories

Avoid turkey – why?

Tryptophan potently stimulates the pancreas


Treatment canine pancreatitis2

Treatment: Canine Pancreatitis

Nutrition

Suitable commercial diets

Hill’s I/D canned and dry

Medi-Cal Canine Gastro Formula canned and dry

Leo Specific Digest (CIW canned CID dry)

Purine CNM EN canned and dry

Select Care Canine Sensitive Formula canned and dry

Home made food

Fat free cottage cheese and white rice is ideal


Treatment canine pancreatitis3

Treatment: Canine Pancreatitis

Nutrition

Monomeric (elemental food)

Water soluble liquid foods in their simplest nutritional state

Should in theory minimally stimulate the pancreas

Some have added glutamine to support enterocyte recovery from disuse atrophy

Can cause diarrhea, as many are hyperosmolar


Treatment canine pancreatitis4

Treatment: Canine Pancreatitis

3-5-7 Rule

If dog can’t be fed PO within 5-7 days, consider TPN, or PPN

Requires a central line, and monitoring multiple times daily

Probably should not be administered while dog is unattended (extravasation is bad)

Excellent catheter care is a must

Nutrients are expensive – hundreds of dollars to mix up a batch

Needs to be mixed aseptically, under a laminar flow hood

Gut atrophy continues

TPN Resource Handout

After Recovery

2 weeks or more after recovery, consider switching to low fat, high fiber diet

May or may not eventually be able to go back to a maintenance type diet


Treatment canine pancreatitis5

Treatment: Canine Pancreatitis

Nutrition

Suitable High Fiber Low Fat foods for long term

Hill’s R/D and W/D

Leo Specific CRW (canned) and CRD (dry)

Medi-Cal Canine Fibre Formula canned and dry

Medi-Cal Canine Weight Control/Geriatric canned and dry

Purina CNM OM canned and dry

Purina CNM DCO dry, Purina CNM GL dry

Select Care Canine HiFactor Formula canned and dry

Waltham/Pedigree Canine High Fiber canned and dry

Dogs with persistently high triglycerides

will probably have to stay on this type diet


Treatment feline pancreatitis

Treatment: Feline Pancreatitis

Glucocorticoids

Indicated for feline pancreatitis – why?

Controlling concurrent IBD and cholangiohepatitis will remove predisposition to pancreatitis

Can be immune mediated per se in cats

Prednisone 1 mg/lb/day

Dexamethasone 0.1 mg/kg every other day

Wean to lowest effective dose over 2-4 months, after clinical response


Treatment feline pancreatitis1

Treatment: Feline Pancreatitis

Nutrition – FEED!!!

Place feeding tube ASAP – why?

Pancreatitis + fatty liver = disaster

Place E-tube first

Place G-tube if E-tube can not be maintained due to uncontrollable vomiting

Why not place G-tube right away?

10-25% are dislodged even with

proper placement

Can result in gastric perforation


Treatment feline pancreatitis2

Treatment: Feline Pancreatitis

Nutrition

If vomiting becomes difficult to control:

Drip liquid diet CRI if bolus feeding is not tolerated

Try metoclopramide (1-2 mg per cat) by tube 30 minutes prior to feeding

If that doesn’t work, try cisapride (2.5 mg per cat)

Or Cerenia, Anzemet, Zofran

If all else fails, consider a jejunostomy tube

handouts: Tube FeedingTube Diets


Treatment feline pancreatitis3

Treatment: Feline Pancreatitis

Nutrition

As always, cats do best on a high protein,

low carb diet (especially diabetics)

No need to be concerned about fat content in cats

There is only one dry diet with >45% protein and <8% carbs

Innova EVO (California Naturals)

Purina DM and Hills Prescription Diet M/D have 15% carbs (protein is fine)

Studies used to market DM and M/D are on canned

Nutritional Content Canned Cat Foods


Treatment feline pancreatitis4

Treatment: Feline Pancreatitis

Nutrition

Appetite stimulants can be used

Cyproheptadine 2 mg per cat PO BID 30 min prior to feeding

Mirtazipine 3-4 mg per cat twice a week

Diazepam is risky with concurrent liver disease


Pancreatitis prognosis

Pancreatitis:Prognosis


Pancreatitis prognosis1

Pancreatitis: Prognosis

Dogs – variable

Good if response to short term therapy

Guarded if severe pancreatitis

Better for lean dogs than fat dogs – why?

Less necrosis of fat to deal with

Clinical response is probably the best predictor

100% recovery is possible

Some dogs are prone to repeated episodes


Pancreatitis prognosis2

Pancreatitis: Prognosis

Cats - variable

Tend to take longer than dogs to respond

Some cats can begin eating in days

Some have to be fed by tube for months

Worse if concurrent hepatic lipidosis

Worse if suppurative pancreatitis rather than mononuclear

Cats who have it once tend to get it again

Owners learn to catch it early and intervene


Pancreatitis prognosis3

Pancreatitis: Prognosis

Things associated with poor prognosis:

Shock

Oliguria

Icterus

Hypocalcemia -- dogs

Hypoglycemia

Hypoproteinemia

Acidosis

Falling hematocrit


Pancreatitis prognosis4

Pancreatitis: Prognosis

Things associated with poor prognosis:

Thrombocytopenia

DIC


Thanks y all

ThanksY’All!!


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