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History. Not sensitive Not specific. Signalment Diet Vomiting Prior episodes Diarrhea. Identify diseases that MIMIC pancreatitis. History. Signalment Diet Vomiting Prior episodes Diarrhea. Physical Examination. Not sensitive Not specific. Anterior abdominal pain Icterus

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History
History

Not sensitive

Not specific

  • Signalment

  • Diet

  • Vomiting

  • Prior episodes

  • Diarrhea


History1

Identify diseases

that MIMIC pancreatitis

History

  • Signalment

  • Diet

  • Vomiting

  • Prior episodes

  • Diarrhea


Physical examination
Physical Examination

Not sensitive

Not specific

  • Anterior abdominal pain

  • Icterus

  • Profuse ascites

  • Fever

  • SQ abscesses


Physical examination1

Identify diseases

that MIMIC pancreatitis

Physical Examination

  • Anterior abdominal pain

  • Icterus

  • Profuse ascites

  • Fever

  • SQ abscesses



147033 147198 90524 159796
147033 PANCREATITIS?147198 90524 159796

Non-discriminatory

PCV 28.528.830 40

WBC 30,00045,5009,800 11,500

Segs 26,10033,6704,606 9,890

Bands 9002,7302,450 0

Plat 87,000407,000679,000 470,000

Toxic modmodnone none


Clinical pathology
Clinical Pathology PANCREATITIS?

  • An anorexic, vomiting dog with fasting hyperlipidemia probably has acute pancreatitis


Clinical pathology1
Clinical Pathology PANCREATITIS?

  • An anorexic, vomiting dog with fasting hyperlipidemia probably has acute pancreatitis

  • Most dogs with pancreatitis DO NOT have fasting hyperlipidemia


Clinical pathology2
Clinical Pathology PANCREATITIS?

Garbage

  • Amylase/Lipase

    • Sensitivity ~ 50%

    • Specificity ~ 50%

  • TLI

    • Sensitivity ~ 35%


Clinical pathology3
Clinical Pathology PANCREATITIS?

  • cPLI

    • Sensitivity ~ 80-85%


Sig: 7 yr M Boxer X PANCREATITIS?

CC: Anorexia/Vomiting

HPI: Started 1 week ago

snap PLI = pancreatitis

Dog died despite therapy:

Everything normal on

gross necropsy


PANCREATITIS PANCREATITIS?

versus

CLINICALLY IMPORTANT PANCREATITIS


Diagnostics
Diagnostics PANCREATITIS?

  • cPLI

    • Sensitivity ~ 80%

  • Abdominal ultrasound

    • Sensitivity probably ranges from 40% to about 65%


Diagnostics1
Diagnostics PANCREATITIS?

  • cPLI

    • Sensitivity ~ 80%

  • Abdominal ultrasound

    • Sensitivity probably ranges from 40% to about 65% because clinicians rarely repeat the ultrasound


Diagnostics2
Diagnostics PANCREATITIS?

  • cPLI

    • Sensitivity ~ 80%

  • Abdominal ultrasound

    • Sensitivity probably ranges from 40% to about 65%

    • Findings can change within hours ...




THE REAL PROBLEM IS THAT ACUTE PANCREATITIS CAN PRESENT IN SO MANY DIFFERENT WAYS THAT YOU DON’T EVEN SUSPECT IT INITIALLY


Tamu 88267
TAMU #88267 PRESENT IN

Sig: 7 yr M Sheltie

CC: Vomiting

HPI: Began 5 weeks ago

Partial anorexia, vomits phlegm or

bile once daily

Dog otherwise pretty healthy

PE: No significant abnormalities


Tamu 882671
TAMU #88267 PRESENT IN

PCV = 37% (35-55)

WBC = 21,800/ul (6,-16,000)

Segs = 20,274/ul (4,-14,000)

Lymphs = 840/ul (1,000 - 4,000)

Platelets = 255,000/ul (200, - 500,000)


Tamu 882672
TAMU #88267 PRESENT IN

Creatinine = 2.0 mg/dl (< 2.0)

BUN = 36 mg/dl (8-29)

Total protein = 4.7 gm/dl (5.5-7.5)

Albumin = 1.7 gm/dl (2.5-4.4)

ALT = 10 U/L (< 130)

SAP = 31 U/L (< 147)

Bilirubin = 0.4 mg/dl (< 1.0)

Urine: 1.015 with 4+ protein


Tamu 159796
TAMU #159796 PRESENT IN

Sig: 9 yr M(c) Pug

CC: Vomiting, yellow scleras

HPI: Feeling bad 12 days ago

Started vomiting, responded to

fluid therapy, but became ill

again when started feeding it

Dog’s eyes turned yellow

PE: Scleras yellow


Tamu 1597961
TAMU #159796 PRESENT IN

PCV = 40% (35-55)

WBC = 11,500/ul (6,-14,000)

Segs = 9,890/ul (4,-12,000)

Lymphs = 460/ul (1,-4,000)

Eos = 230/ul (100-1,250)

Platelets = 470,000/ul (200,-500,000)


Tamu 1597962
TAMU #159796 PRESENT IN

BUN = 4 mg/dl (8-29)

Creatinine = 0.7 mg/dl (< 2.0)

Glucose = 95 mg/dl (75-133)

Potassium = 3.6 mEq/L (3.8-5.1)

Cholesterol = 597 mg/dl (120-247)

Albumin = 2.9 gm/dl (2.5-4.4)

ALT = 1,691 IU/L (< 130)

SAP = 3,134 IU/L (< 147)

Bilirubin = 4.5 mg/dl (0-0.8)


Tamu 1597963
TAMU #159796 PRESENT IN

4/9 4/11 4/13 4/15 4/16

ALT 1,691 2,108 1,275

SAP 3,134 3,753 3,633

Bili 4.5 4.5 4.8 2.6 1.2


Tamu 152494
TAMU #152494 PRESENT IN

Sig: 9 yr F(s) Dalmation

CC: Vomiting/diarrhea

HPI: Vomiting food/bile 6-8X in 2 weeks

Diarrhea constantly for 2 weeks

Decreased appetite for 10 days,

anorexia for 5 days

PE: T = 102.5 F, HR = 102/min


Tamu 1524941
TAMU #152494 PRESENT IN

PCV = 35.5% (35-55)

WBC = 21,700/ul (6,-14,000)

Segs = 15,200/ul (4,-12,000)

Bands = 630/ul (< 500)

Lymphs = 1,400/ul (1,-4,000)

Platelets = 568,000/ul (200,-500,000)


Tamu 1524942
TAMU #152494 PRESENT IN

Sodium = 152 mEq/L (138-148)

Potassium = 4.1 mEq/L (3.5-5.0)

Glucose = 107 mg/dl (60-120)

Albumin = 2.7 gm/dl (2.5-4.4)

ALT = 123 IU/L (< 110)

SAP = 2,174 IU/L (< 130)

Creatinine = 1.3 mg/dl (< 2.0)


Tamu 1524943
TAMU #152494 PRESENT IN

Abdominal ultrasound:

“… Small amount of anechoic effusion between liver lobes and around urinary bladder. Fine Needle Aspirate reveals turbid yellow tan fluid.”


Tamu 1524944
TAMU #152494 PRESENT IN

Abdominal fluid:

WBC = 153,000/ul

RBC = 0/ul

Total protein = 4.6 gm/dl

90% nondegenerate neutrophils

8% macrophages, vaculated

“Suppurative exudate”


Tamu 1524945
TAMU #152494 PRESENT IN

“Chronic necrotizing and fibrosing interstitial pancreatitis with multifocal ... suppuration and hemorrhage and peritonitis ...”


Sterile pancreatitis PRESENT IN

versus

Septic peritonitis


Abdominal fluid
Abdominal fluid PRESENT IN

Non-discriminatory

147260152494152485 109612

TP gm/dl 5.14.61.3 3.6

WBC/ul 15,059153,000700 18,200

RBC/ul 91,112030,000 83,700


PANCREATITIS CAN: PRESENT IN a) make no abdominal effusionb) make a little abdominal effusionc) make a massive abdominal effusion


Pancreatitis can present as: PRESENT IN

  • acute vomiting with abdominal pain

  • chronic, low grade vomiting/anorexia (abscess)

  • icterus (biliary tract obstruction)

  • ascites (minimal, little or lots)

  • acute abdomen (looks just like septic peritonitis)

  • SIRS (looks like septic shock)

  • any really sick animal


SYSTEMIC INFLAMMATORY RESPONSE SYNDROME PRESENT IN –

used to be called “Septic shock”


SYSTEMIC INFLAMMATORY RESPONSE SYNDROME PRESENT IN – inadequate perfusion of the body tissues because of an exaggerated inflammatory response


What is supposed to happen
WHAT IS SUPPOSED TO HAPPEN PRESENT IN

Bacterial toxin, inflammatory cytokines

Lymph nodes, hepatic macrophages

Systemic circulation



What is supposed to happen1
WHAT IS SUPPOSED TO HAPPEN PRESENT IN

Bacterial toxin, inflammatory cytokines

Lymph nodes, hepatic macrophages

Systemic circulation


WHAT CAN HAPPEN PRESENT IN

Inflammatory cytokines

Lymph nodes

Systemic circulation


Early sirs
EARLY -- SIRS PRESENT IN

Mild uneven vasodilatation

“High output” shock

Brightred mucus membranes

Fast capillary refill time

Bounding pulses

Tachycardia


Late sirs
LATE -- SIRS PRESENT IN

Severe peripheral vasodilatation + poor cardiac contractility

“Low output” shock

Pale mucus membranes

Weak pulses

Slow refill time


Therapy for pancreatitis only supportive and symptomatic
THERAPY FOR PANCREATITIS PRESENT IN Only supportive and symptomatic

  • NPO versus early feeding


Therapy for pancreatitis only supportive and symptomatic1
THERAPY FOR PANCREATITIS PRESENT IN Only supportive and symptomatic

  • NPO versus early feeding

  • Fluid therapy

    Crystalloids

    Plasma

    Colloids

    Total/partial parenteral nutrition


Therapy for pancreatitis only supportive and symptomatic2
THERAPY FOR PANCREATITIS PRESENT IN Only supportive and symptomatic

  • NPO versus early feeding

  • Fluid therapy

    Crystalloids

    Plasma

    Colloids

    Jejunostomy feeding

    (PEG-J, Nasal J, regular J)


Therapy for pancreatitis only supportive and symptomatic3
THERAPY FOR PANCREATITIS PRESENT IN Only supportive and symptomatic

  • NPO versus early feeding

  • Fluid therapy

    Crystalloids

    Plasma

    Colloids

    Nutrition

  • Analgesics


Therapy for pancreatitis only supportive and symptomatic4
THERAPY FOR PANCREATITIS PRESENT IN Only supportive and symptomatic

  • NPO versus early feeding

  • Fluid therapy

  • Analgesics

  • Anti-emetics: if vomiting makes it hard to maintain hydration or patient is really miserable

  • Proton-pump inhibitors: the same


Other possibilities
OTHER POSSIBILITIES PRESENT IN

  • Antibiotics

    • “Regular” pancreatitis

    • SIRS


Other possibilities1
OTHER POSSIBILITIES PRESENT IN

  • Antibiotics

  • Heparin


Other possibilities2
OTHER POSSIBILITIES PRESENT IN

  • Antibiotics

  • Heparin

  • Steroids – Critical Care Medicine 36: 296-327, 2008


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