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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
147033147198 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
  • An anorexic, vomiting dog with fasting hyperlipidemia probably has acute pancreatitis
clinical pathology1
Clinical Pathology
  • An anorexic, vomiting dog with fasting hyperlipidemia probably has acute pancreatitis
  • Most dogs with pancreatitis DO NOT have fasting hyperlipidemia
clinical pathology2
Clinical Pathology

Garbage

  • Amylase/Lipase
    • Sensitivity ~ 50%
    • Specificity ~ 50%
  • TLI
    • Sensitivity ~ 35%
clinical pathology3
Clinical Pathology
  • cPLI
    • Sensitivity ~ 80-85%
slide13
Sig: 7 yr M Boxer X

CC: Anorexia/Vomiting

HPI: Started 1 week ago

snap PLI = pancreatitis

Dog died despite therapy:

Everything normal on

gross necropsy

slide17
PANCREATITIS

versus

CLINICALLY IMPORTANT PANCREATITIS

diagnostics
Diagnostics
  • cPLI
    • Sensitivity ~ 80%
  • Abdominal ultrasound
    • Sensitivity probably ranges from 40% to about 65%
diagnostics1
Diagnostics
  • cPLI
    • Sensitivity ~ 80%
  • Abdominal ultrasound
    • Sensitivity probably ranges from 40% to about 65% because clinicians rarely repeat the ultrasound
diagnostics2
Diagnostics
  • cPLI
    • Sensitivity ~ 80%
  • Abdominal ultrasound
    • Sensitivity probably ranges from 40% to about 65%
    • Findings can change within hours ...
slide31

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

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

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

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

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

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

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

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

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

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

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

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

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

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

slide53
Sterile pancreatitis

versus

Septic peritonitis

abdominal fluid
Abdominal fluid

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

slide55

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

slide56
Pancreatitis can present as:
  • 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
slide57
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME –

used to be called “Septic shock”

slide58
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME – inadequate perfusion of the body tissues because of an exaggerated inflammatory response
what is supposed to happen
WHAT IS SUPPOSED TO HAPPEN

Bacterial toxin, inflammatory cytokines

Lymph nodes, hepatic macrophages

Systemic circulation

what is supposed to happen1
WHAT IS SUPPOSED TO HAPPEN

Bacterial toxin, inflammatory cytokines

Lymph nodes, hepatic macrophages

Systemic circulation

slide64

WHAT CAN HAPPEN

Inflammatory cytokines

Lymph nodes

Systemic circulation

early sirs
EARLY -- SIRS

Mild uneven vasodilatation

“High output” shock

Brightred mucus membranes

Fast capillary refill time

Bounding pulses

Tachycardia

late sirs
LATE -- SIRS

Severe peripheral vasodilatation + poor cardiac contractility

“Low output” shock

Pale mucus membranes

Weak pulses

Slow refill time

therapy for pancreatitis only supportive and symptomatic1
THERAPY FOR PANCREATITISOnly 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 PANCREATITISOnly 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 PANCREATITISOnly supportive and symptomatic
  • NPO versus early feeding
  • Fluid therapy

Crystalloids

Plasma

Colloids

Nutrition

  • Analgesics
therapy for pancreatitis only supportive and symptomatic4
THERAPY FOR PANCREATITISOnly 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
  • Antibiotics
    • “Regular” pancreatitis
    • SIRS
other possibilities1
OTHER POSSIBILITIES
  • Antibiotics
  • Heparin
other possibilities2
OTHER POSSIBILITIES
  • Antibiotics
  • Heparin
  • Steroids – Critical Care Medicine 36: 296-327, 2008
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