Feline pancreatitis (Proceedings)

Pancreatitis

     • Inflammation of the pancreas

          o Acute

          o Chronic

     • Common

Spectrum of Disease

     • Mild, edematous

          o Mild, rapid recovery

          o Interstitial edema

     • Hemorrhagic, necrotic

          o Severe, prolonged

          o Complications

          o Necrosis

Pathophysiology

     • Autodigestion of the pancreas

          o Premature activation of zymogen granules

Pancreatic Protection

          o Enzymes stored as inactive zymogens

          o Cleaved by proteases in small intestine

          o Zymogens and lysosomal enzymes separate

          o Pancreatic secretory trypsin inhibitor

Risk Factors

     • Fat!

          o Obesity

          o Hyperlipidemia

          o Dietary indiscretion

          o High fat diet

     • Endocrine diseases

          o Diabetes Mellitus

          o Cushing's Disease

     • Pancreatic factors

          o Duct obstruction

          o Trauma/ischemia

          o Neoplasia

Drugs & Toxins

     • Potassium bromide (KBr)

     • Azathioprine (Imuran™)

     • L-asparaginase (Elspar™)

     • Organophosphates

     • Furosemide (Lasix™)?

     • Corticosteroids?

Additional Risk Factors in Cats

     • Trauma (high-rise syndrome)

     • Toxoplasma ?

     • FIP ?

     • Triaditis

          o Inflammatory bowel disease

          o Cholangiohepatitis

          o Pancreatitis

Signalment

     • Cats

          o ??

Clinical Signs (Feline)

     • Lethargy

     • Anorexia

     • Dehydration

     • ± Hypothermia

     • ± Vomiting

     • ± Abdominal pain

     • ± Dyspnea

     • ± Ataxia

     • ± Diarrhea

     • ± Icterus

     • ± Weight loss

Complications

     • DIC

     • Acute Renal Failure

     • Respiratory distress

          o Pulmonary edema

          o PTE

     • Vascular collapse, shock

     • Diabetes mellitus/EPI (chronic or acute recurrent)

Diagnosis

     • No pathognomonic test!

     • Definitive diagnosis = biopsy

Baseline Bloodwork

     • CBC

          o Leukocytosis with a left shift

          o PCV elevated (dehydration)

          o Anemia

     • Chemistry

          o Azotemia (prerenal or acute renal failure)

          o Elevated LES

          o Hyperbilirubinemia

          o Hyperglycemia

          o Hypocalcemia

          o Hyperlipidemia

          o Hypertriglyceridemia

     • Amylase and lipase

          o Lack of sensitivity

          o Lack of specificity

          o If very high (3-4 x baseline) than suggestive

Urinalysis

Coagulation Screen

     • PT

     • PTT

     • FDP

     • D-dimers

Diagnosis

     • feline pancreatitic lipase immunoreactivity (fPLI)

          o Specific

          o Sensitivity

          o Chronic pancreatitis

Imaging

     • Radiographs

     • Ultrasound

     • CT scanning?

     • MRI?

Cytology?

          o FNA

          o Abdominocentesis

     • Exploratory laparotomy?

Whole clinical picture

Ultrasound imaging

Cats are tricky …

     • Vague signs

          o Anorexia

          oVomiting?

     • Ultrasound

     • May require biopsy

Treatment Objectives

     • ↓ Stimulation of pancreas

     • Manage hypovolemia

     • Supportive care

          o Pain

          o Nausea

          o Nutrition

          o Gastric hyperacidity

          o Infection

Fluids & Antiemetics

     • Maintain pancreatic perfusion

     • Give IV

     • Replace deficits quickly!

     • Use antiemetics

          o Metoclopramide

          o Dolazetron

          o Cerenia

          o Mirtazapine

     • USE ANALGESICS!

          o Buprenorphine

          o Meperidine

          o Fentanyl

Gastric Antacids

Nutritional Support

     • NPO 24 to 48 hr

     • Water first

     • OK to feed if no vomiting!

     • Parenteral nutrition

          o If NPO > 2 days

          o TPN

               PPN

     • J tube?

Antibiotics???

     • If septic or suspect necrotizing form, protect against enteric bacteria

Plasma

     • Provides

          o Protease inhibitor

          o Colloid

          o Coagulation factors

          o Protein

     • Consider if

          o Hypoalbuminemia

          o DIC

     • Pancreatic Enzymes

          o Negative feedback in humans

          o Benefit in dogs uncertain

          o Oral

     • Antioxidants

          o Benefit in humans

          o Dogs?

               • Selenium

               • Vitamin E

               • SAMe

Finally …

     • Anticoagulants, if

          o DIC

          o PTE

     • Corticosteroids?

          oCat with IBD?

          o Autoimmune pancreatitis

          o Sepsis (physiologic)

Prognosis

About Cats …

Complicated by other disease

          o IBD

          o Cholangiohepatitis

          o Hepatic lipidosis

     • Prognosis difficult