History
• Signalment
• Diet
• Vomiting
• Prior episodes
• Diarrhea
History
• Signalment
• Diet
• Vomiting
• Prior episodes
• Diarrhea
Physical Examination
• Anterior abdominal pain
• Icterus
• Profuse ascites
• Fever
•
SQ abscesses
Physical Examination
• Anterior abdominal pain
• Icterus
• Profuse ascites
• Fever
•
SQ abscesses
WHICH CBC(S) IS/ARE
FROM DOG(S) WITH ACUTE
PANCREATITIS?
147033 147198
90524
PCV
28.5
28.8
30
40
WBC
30,000
45,500
9,800
11,500
Segs
26,100
33,670
4,606
9,890
Bands
900
2,730
2,450
0
Plat
87,000
407,000 679,000 470,000
Toxic
mod
mod
none
159796
none
Clinical Pathology
• An anorexic, vomiting dog with
fasting hyperlipidemia probably has
acute pancreatitis
Clinical Pathology
• An anorexic, vomiting dog with
fasting hyperlipidemia probably has
acute pancreatitis
• Most dogs with pancreatitis DO NOT
have fasting hyperlipidemia
Clinical Pathology
• Amylase/Lipase
– Sensitivity ~ 50%
– Specificity ~ 50%
• TLI
– Sensitivity ~ 35%
Clinical Pathology
• cPLI
– Sensitivity ~ 80-85%
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
PANCREATITIS
versus
CLINICALLY IMPORTANT
PANCREATITIS
Diagnostics
• cPLI
– Sensitivity ~ 80%
• Abdominal ultrasound
– Sensitivity probably ranges from 40%
to about 65%
Diagnostics
• cPLI
– Sensitivity ~ 80%
• Abdominal ultrasound
– Sensitivity probably ranges from 40%
to about 65% because clinicians rarely
repeat the ultrasound
Diagnostics
• cPLI
– Sensitivity ~ 80%
• Abdominal ultrasound
– Sensitivity probably ranges from 40%
to about 65%
– Findings can change within hours ...
WHAT IS THE BEST WAY
TO DIAGNOSE CANINE
ACUTE PANCREATITIS?
Patient with possible acute pancreatitis
Find evidence suggestive
of pancreatitis
Eliminate diseases
mimicking pancreatitis
Imaging (ultrasound)
Chemistry panel
Abdominal imaging
cPLI
Patient with possible acute pancreatitis
Find evidence suggestive
of pancreatitis
Eliminate diseases
mimicking pancreatitis
Imaging (ultrasound)
Chemistry panel
Abdominal imaging
cPLI
All things being equal, try
to avoid surgery
THE REAL PROBLEM IS
THAT ACUTE PANCREATITIS
CAN PRESENT IN SO MANY
DIFFERENT WAYS THAT
YOU DON’T EVEN SUSPECT
IT INITIALLY
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 #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 #88267
Creatinine =
BUN =
Total protein =
Albumin =
ALT =
SAP =
Bilirubin =
Urine:
2.0 mg/dl (< 2.0)
36 mg/dl (8-29)
4.7 gm/dl (5.5-7.5)
1.7 gm/dl (2.5-4.4)
10 U/L (< 130)
31 U/L (< 147)
0.4 mg/dl (< 1.0)
1.015 with 4+ protein
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 #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 #159796
BUN =
Creatinine =
Glucose =
Potassium =
Cholesterol =
Albumin =
ALT =
SAP =
Bilirubin =
4 mg/dl (8-29)
0.7 mg/dl (< 2.0)
95 mg/dl (75-133)
3.6 mEq/L (3.8-5.1)
597 mg/dl (120-247)
2.9 gm/dl (2.5-4.4)
1,691 IU/L (< 130)
3,134 IU/L (< 147)
4.5 mg/dl (0-0.8)
TAMU #159796
4/9
4/11
4/13
4/15
ALT 1,691
2,108
1,275
SAP 3,134
3,753
3,633
Bili
4.5
4.5
4.8
2.6
4/16
1.2
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 #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 #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 #152494
Abdominal ultrasound:
“… Small amount of anechoic
effusion between liver lobes and
around urinary bladder. Fine Needle
Aspirate reveals turbid yellow tan
fluid.”
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 #152494
“Chronic necrotizing and fibrosing
interstitial pancreatitis with
multifocal ... suppuration and
hemorrhage and peritonitis ...”
Sterile pancreatitis
versus
Septic peritonitis
Abdominal fluid
147260 152494
TP gm/dl 5.1
4.6
152485
109612
1.3
3.6
WBC/ul
15,059 153,000 700
18,200
RBC/ul
91,112 0
83,700
30,000
PANCREATITIS CAN:
a) make no abdominal effusion
b) make a little abdominal effusion
c) make a massive abdominal
effusion
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
SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME –
used to be called “Septic
shock”
SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME –
inadequate perfusion of the
body tissues because of an
exaggerated inflammatory
response
WHAT IS SUPPOSED TO
HAPPEN
Bacterial toxin, inflammatory cytokines
Lymph nodes, hepatic macrophages
Systemic
circulation
Courtesy of Dr. Katrina Mealey
WHAT IS SUPPOSED TO
HAPPEN
Bacterial toxin, inflammatory cytokines
Lymph nodes, hepatic macrophages
Systemic
circulation
WHAT CAN HAPPEN
Inflammatory cytokines
Lymph nodes
Systemic
circulation
EARLY -- SIRS
Mild uneven vasodilatation
“High output” shock
Bright red mucus membranes
Fast capillary refill time
Bounding pulses
Tachycardia
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 symptomatic
• NPO versus early feeding
THERAPY FOR PANCREATITIS
Only supportive and symptomatic
• NPO versus early feeding
• Fluid therapy
Crystalloids
Plasma
Colloids
Total/partial parenteral nutrition
THERAPY FOR PANCREATITIS
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 symptomatic
• NPO versus early feeding
• Fluid therapy
Crystalloids
Plasma
Colloids
Nutrition
• Analgesics
THERAPY FOR PANCREATITIS
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
• Antibiotics
– “Regular” pancreatitis
– SIRS
OTHER POSSIBILITIES
• Antibiotics
• Heparin
OTHER POSSIBILITIES
• Antibiotics
• Heparin
• Steroids – Critical Care Medicine 36: 296-327, 2008