Pancreatitis in Dogs and Cats
Two Different Animals
Wendy Blount, DVM
Nacogdoches, TX
Two types of pancreatitis
Acute Pancreatitis
•Abrupt onset
•often reversible after
treatment
•May lead to chronic
pancreatitis
•Acute necrotizing (cell
death) pancreatitis is a lifethreatening condition
Acute
1/2
Chronic Pancreatitis
•Continuing inflammatory
disease
•Irreversible pathology
•Relapsing acute pancreatitis
•Exocrine pancreatic
insufficiency (EPI) can result
•Diabetes mellitus can result
•Triaditis can result in cats
Chronic
1/2
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 - 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 - Predispositions
Pancreatitis - Predispositions
Obesity
Hypercalcemia
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 - 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 - Predispositions
Drugs
•Corticosteroids
•Chemotherapeutics/immunosuppressives
–L-asparaginase
–Azathioprine (Imuran)
•Estrogens
•Others
Pancreatitis - Predispositions
Toxins
•Organophosphates
•Scorpion stings
•Uremic toxins
Vaccines
Pancreatitis - Predispositions
Toxins
•Organophosphates
•Scorpion stings
•Uremic toxins
Vaccines
Gerald Crump
Lufkin TX
Pancreatitis - Predispositions
Toxins
•Organophosphates
•Scorpion stings
•Uremic toxins
Vaccines
Pancreatitis - Predispositions
Toxins
•Organophosphates
•Scorpion stings
•Uremic toxins
Vaccines
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 - Predispositions
Dog vs. Cat - Quiz
Hyperlipidemia
dogs
Hypercalcemia
Both
Hyperadrenocorticism
both
Hypothyroidism
dogs
High fat meal
dogs
Refeeding after anorexia
dogs
Pancreatic neoplasia
both
Pancreatitis - Predispositions
Corticosteroids
dogs
Organophosphates
both
Uremia
both
Trauma to the pancreas
dogs >> cats
Bile duct obstruction
cats > dogs
Protracted severe vomiting
cats > dogs
Vaccines
?????
Breed Predisposition
Dogs
•Miniature Schnauzer
•Sheltie
•Briard
•Small dogs (yorkies, poodles)
Cats
•Siamese
•Himalayan
Common Concurrent Diseases
especially in cats
Cholangiohepatitis
Inflammatory bowel disease
Triaditis
Nephritis
Hepatic lipidosis – cats only
Most Common Clinical Signs
Dogs
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%
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
Lethargy
Icterus
Diarrhea – with or without blood
Fever (hypothermia more common in cats – 68%)
Abdominal pain, cranial abdominal mass
Hunched stance or praying position
Clinical Signs – Dogs and Cats
Lethargy
Icterus
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
SIRS
Systemic Inflammatory Response can
Precipitate:
•Thromboembolic disease
–Pulmonary thromboembolism
•DIC
•Pancreatic encephalopathy
•Arrhythmia
•Metabolic acidosis
•Respiratory Distress
Diagnosis: Clues in the Bloodwork
CBC – nonspecific
•Thrombocytopenia
•Neutrophilia with left shift
•Anemia
Serology
•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 Bloodwork
Serology – Dogs and Cats
•Nonspecific changes
–Elevated liver enzymes
–Elevated bilirubin
–Azotemia
–Hyperglycemia (cause or effect)
–Hypoglycemia
–Hypophosphatemia – why?
–Hypochloridemia – why?
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 Bloodwork
GI Serology – Dogs and Cats
•B12 may be low – why?
–Intrinsic factor from the pancreas is required for
absorption (cats)
–concurrent distal small intestinal disease (ileum)
–Concurrent dysbiosis
–Concurrent EPI
–SUBNORMAL B12 NOT DUE TO DIETARY
INSUFFICIENCY
Diagnosis: Clues in the Bloodwork
GI Serology – Dogs and Cats
•B12 therapy – once weekly for 6 weeks, then
every 30 days
–<10 lbs – 250 mcg
–10-20 lbs – 400 mcg
–20-40 lbs – 600 mcg
–60-80 lbs – 1000 mcg
–80-100 lbs – 1200 mcg
–>100 lbs – 1500 mcg
Diagnosis: Clues in the Bloodwork
GI Serology – Dogs and Cats
•Folate may be high if dysbiosis
•Folate may be low if proximal small intestinal
disease
•Not usually supplemented
•More of an indicator for further diagnostics
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 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)
–Low confidence in this test amongst feline specialists
–Much more sensitive and specific for pancreatitis
than any blood test or imaging in dogs
–Antech and IDEXX
–TAMU GI Lab (TVMDL sends to TAMU)
Diagnostic tools: A comparison
Susan Little, DVM
Longview TX
Diagnostic tools: A comparison
R
SNAP cPL
TM
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
• Correlation to cPLI >95%
• 96% of interpretations are correct
Reference
Sample
Comparing Spec cPL values to
SNAP results
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,
Abdominal radiographs
Baseline cPLI
Abdominal US
Pancreatitis is
unlikely – pursue
other differential
diagnoses
Baseline cPLI
US/Rads confirm
pancreatitis
Treat for pancreatitis,
Monitor with cPLI
monitor w/ cPLI
US/Rads equivocal
Treat, Monitor, Retest;
Continue to rule out
other differential
diagnoses
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 Bloodwork
Coagulation panel
•Thrombocytopenia
–Vasculitis (enzyme mediated)
•DIC
–PT, PTT, ACT
–Elevated
–FDP, d-Dimers (Cornell Coag Lab)
–high
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
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 and stored
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
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
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
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
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
–Hyperechoic ring around the fluid
–Pancreatic duct may be tortuous and dilated
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 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 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 Ultrasound
•Duodenum
–Dilated and hypomotile (<5 waves per minute)
–Sometimes “corrugated”
•Common Bile Duct
–Dilated and tortuous
Diagnosis: Abdominal Ultrasound
•Duodenum
–Dilated and hypomotile (<5 waves per minute)
–Sometimes “corrugated”
•Common Bile Duct
Ronnie Nye, DVM
–Dilated and tortuous
Floresville TX
Diagnosis: Abdominal Ultrasound
•Duodenum
–Dilated and hypomotile (<5 waves per minute)
–Sometimes “corrugated”
•Common Bile Duct
–Dilated and tortuous
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
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
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
Diagnosis: Abdominal Ultrasound
•Duodenum
–Dilated and hypomotile (<5 waves per minute)
–Sometimes “corrugated”
•Common Bile Duct
–Dilated and tortuous
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
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
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
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 (fluid analysis chart)
•Peripancreatic fat and omentum
–hyperechoic
Diagnosis: Abdominal Ultrasound
•Ultrasound truly IS for everyone
•
Time-consuming
–30 minutes to warm up reagants
–10 minutes to run the test
•
Expensive
–Diagnostic Quality US $12K-15K
–3 US a week x $150 x 50 weeks = $22.5K
•
Subject to user experience
–No more subjective than x-rays
–Oncura can provide help if your buy their ultrasound
–GCVS does telemedicine with your US
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
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
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
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: 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: 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: Radiographs
Upper GI Barium Series
•Delayed emptying of stomach and duodenum
•Corrugation of duodenal wall
Thoracic radiographs
•Can be normal
•Pleural effusion
Diagnosis: Radiographs
Upper GI Barium Series
•Delayed emptying of stomach and duodenum
•Corrugation of duodenal wall
Thoracic radiographs
•Can be normal
•Pleural effusion
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
Usually modified transudate
Occasionally exudative (suppurative)
Rarely hemorrhagic
Diagnosis: Diagnostic Laparotomy
Pancreas
•Edematous, hemorrhagic, abscesses, cysts
Diagnosis: Exploratory Laparotomy
Pancreas
•Edematous, hemorrhagic, abscesses, cysts
John Wood
Lufkin TX
Diagnosis: Exploratory Laparotomy
Pancreas
•Edematous, hemorrhagic, abscesses, cysts
Diagnosis: Exploratory Laparotomy
Pancreas
•Edematous, hemorrhagic, abscesses, cysts
•Enlarged if acute
•Very small, wasted, fibrotic if chronic
•Can appear grossly normal in cats
Diagnosis: Exploratory Laparotomy
Pancreas
•Edematous, hemorrhagic, abscesses, cysts
•Enlarged if acute
•Very small, wasted, fibrotic if chronic
•Can appear grossly normal in cats
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 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 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
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
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
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:
Dogs and Cats
PRIMARY THERAPIES
•Fluid therapy
•Colloids
•Antibiotics
•Analgesia
•Antioxidants
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 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 serum potassium precipitously, causing
arrhythmia, weakness or even respiratory paralysis
–Most common culprits are DKA and RTA
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 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
•LRS won’t work if severe liver disease and needs
alkalinizing – why??
–Liver must transform lactate to bicarbonate
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
•LRS won’t work if severe liver disease and needs
alkalinizing – why??
–Liver must transform lactate to bicarbonate
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 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 Cats
“Flop” - diagnostics
•CBC – granulocytes 16,000
•Profile – glucose 200, BUN 41
Jeremy Finch
–TG 500, Chol 297
–Bili 4.2, ALT 148, ALP normal
LaGrange TX
–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 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 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
–Advantage – corrects acidosis
–Disadvantage – will make hypokalemia worse
•Cefazolin 100 mg IV TID, famotidine 5 mg IV BID
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 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 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
–Provides antiproteases and alpha-macroglobulins
•Whole blood if significantly anemic (hemolysis)
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 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
–Fentanyl injectable or patch
•Intraperitoneal lidocaine or bupivocaine
•Cerenia (maropitant)
•Be careful of NSAIDs – Why?
Pancreatitis Treatment:
Dogs and Cats
Antioxidants
•Milk thistle
•SAMe (Denosyl), Denamarin
•VetriScience Cell Advance
Free radical damage is rampant in pancreatitis
People with recurring pancreatitis have fewer
episodes when they take daily antioxidants
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 Cats
SECONDARY THERAPIES - As indicated
•Antiemetics
–Definitely make the patient more comfortable
–May prevent death from vagal surge
–Early return to alimentation
Pancreatitis Treatment:
Dogs and Cats
SECONDARY THERAPIES - As indicated
•Antiemetics
–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 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, omeprazole
–There is some evidence cimetidine and ranitidine
might aggravate pancreatitis in people
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
–Some cats with severe chronic pancreatitis need long
term oral HC03
–these cats also tend to have EPI
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 Cats
SECONDARY THERAPIES - As indicated
•Antihelminthics
–In the rare case of liver flukes or pancreatic
flukes in cats
–Fenbendazole
–Praziquantel (high dose)
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 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 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 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 Cats
Royce Smathers
Patient Monitoring Kirbyville TX
•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 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 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 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
–No need for BMBT
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 Cats
Patient Monitoring
•Urine ketones if diabetic – daily until stable
•cPLI
–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
Glucocorticoids contraindicated
NPO
•Offer water after no vomiting for 24 hours
•Offer food when no vomiting for 8-12 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
•Use antiemetics for early alimentation
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
•Carbs stimulate amylase which has little to
do with pathology of pancreatitis
Treatment: Canine Pancreatitis
Nutrition
•Suitable commercial diets
–Hill’s I/D low fat canned and dry
–Royal Canine GI Low Fat
–Natura Ultra Low Fat
•Home made food
–Fat free cottage cheese and white rice is ideal
–Turkey breast (without skin) and potatoes
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 Pancreatitis
3-5-7 Rule
–3 days with no food, and you should be formulating a
nutritional plan
–Never let a patient go more than 5 days without
nutrition
–7 days without nutrition has serious implications
After Recovery
–2 weeks or more after recovery, consider switching to
low fat, high fiber diet (use cPLI, fPLI)
–May or may not eventually be able to go back to a
maintenance type diet (use cPLI)
Treatment: Canine Pancreatitis
Nutrition
Suitable High Fiber Low Fat foods for long term
–Hill’s R/D and W/D
–Purina CNM OM canned and dry
–Purina CNM DCO dry, Purina CNM GL dry
–Select Care Canine HiFactor Formula canned and dry
–Royal Canin Canine High Fiber canned and dry
–Royal Canin Gastrointestinal Low Fat
Dogs with persistently high triglycerides
will probably have to stay on this type diet
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 0.2 mg/kg every other day
•Wean to lowest effective dose over 2-4 months,
after clinical response
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 Pancreatitis
Nutrition
•If vomiting becomes difficult to control:
–Drip liquid diet CRI if bolus feeding is not
tolerated
–Try Cerenia, Anzemet, Zofran
–If all else fails, consider a jejunostomy tube
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 are very few dry diets with >45% protein and
<8% carbs
•Innova EVO (California Naturals), Wellness CORE
•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
Binky’s Page Dry Cat Foods Canned Cat Foods
Percent Calories Calculator
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
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: 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: Prognosis
Cats - variable
•Tend to take longer than dogs to respond
•Some cats can begin eating in days
Mary Marble
•Some have to be fed by tube for months
Frankston TX
•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: 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: Prognosis
Things associated with poor prognosis:
•Shock
•Oliguria
•Icterus
•Hypocalcemia
•Hypoglycemia
•Hypoproteinemia
•Acidosis
•Falling hematocrit
Pancreatitis: Prognosis
Things associated with poor prognosis:
•Thrombocytopenia
•DIC
Handouts
•PowerPoint Presentation – behind the
yellow tab
•Bicarbonate Administration
•Fluid Analysis Diagnostic Chart
•Hyperlipidemia
•IV Potassium Supplementation
•Cornell Comparative Coagulation Lab
Instructions, Submission Form and test list
Handouts
•Client Information Handouts
•Canine Pancreatitis
•Feline Pancreatitis
•Canned Cat Food Content
•Dry Cat Food Content
•Fish Oil
•Web Resources
•Cat Food Percent Calories Calculator
•IV Fluid Rate Calculator