5/21/2013
1
TAMU #203505
Sig: 14 yr M(n) Shih Tzu
CC: Abdominal pain
HPI: Began two days ago, has vomited
once
PU-PD for one week
Normal appetite/body weight
PE: No significant abnormalities
TAMU #203505
PCV = 24% (35-55)
WBC = 23,300/ul (6,-14,000)
Segs = 17,475/ul (4,-12,000)
Bands = 0/ul (< 500)
Lymphs = 4,660/ul (1,- 4,000)
Platelets = 498,000/ul (200,- 500,000)
TAMU #203505
Creatinine = 0.78 mg/dl (< 2.0)
Calcium = 9.7 mg/dl (9.3-11.8)
Sodium = 153 mEq/L (138-148)
Potassium = 3.8 mEq/L (3.8-5.1)
Albumin = 2.7 gm/dl (2.5-4.4)
ALT = 8,258 IU/L (< 130)
SAP = 2,354 IU/L (< 147)
Bilirubin = 0.3 mg/dl (0-0.8)
5/21/2013
2
TAMU #203505
Snap PL: positive
Your best next step is:
1 Repeat cPLI and ultrasound
2 Abdominal CT (pancreas)
3 Tx for acute pancreatitis
4 Diagnostic laparoscopy
5 Hepatic lobectomy
8
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3
WHEN DO YOU SUSPECT
AND HOW DO YOU
DIAGNOSE CANINE ACUTE
PANCREATITIS?
History
• Signalment
• Diet
• Prior episodes
• Vomiting
• Diarrhea
Physical Examination
• Anterior abdominal pain
• Less common findings:
– icterus
– profuse ascites
– fever
– SQ abscesses
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WHICH CBC(S) IS/ARE
FROM DOG(S) WITH ACUTE
PANCREATITIS?
147033 147198 90524 159796
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 none
Clinical Pathology
• Amylase/Lipase
– Sensitivity ~ 50%
– Specificity ~ 50%
• TLI
– Sensitivity ~ 35%
• cPLI
– Sensitivity ~ 80-85%
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Your best next step is:
1 Repeat cPLI and ultrasound
2 Abdominal CT (pancreas)
3 Tx for acute pancreatitis
4 Diagnostic laparoscopy
5 Hepatic lobectomy
8
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PANCREATITIS
versus
CLINICALLY IMPORTANT
PANCREATITIS
Sig: 7 yr M Boxer X
CC: Anorexia/Vomiting
HPI: Started 1 week ago
Lipase > 6,000 U/L
snap PLI : pancreatitis
Dog died despite therapy:
Everything looks normal on
gross necropsy and histopath
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Diagnostics
• cPLI
– Sensitivity ~ 80%
• Abdominal ultrasound
– Sensitivity probably ranges from 40%
to about 65%
– Findings can change within hours ...
Find evidence suggestiveof pancreatitis
Eliminate otherabdominal diseases
RadiographsUltrasound
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WHAT IS THE BEST WAY
TO DIAGNOSE CANINE
ACUTE PANCREATITIS?
Imaging (ultrasound)
Find evidence suggestiveof pancreatitis
Chemistry panelAbdominal imaging
cPLI
Eliminate diseasesmimicking pancreatitis
Patient with possible acute pancreatitis
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
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10
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 = 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
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TAMU #183550 12/2008Fluid: “... large numbers of nucleated
cells and small numbers of erythrocytes in a thick proteinaceous background with many lipid droplets. ... nucleated cells are composed almost exclusively of neutrophils with only rare macrophages observed. The neutrophils are poorly preserved and degenerate in appearance ...”
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TAMU #183550 4/2009Fluid: TP = 5 gm/dlCytology: “... large amounts of
granular and ropy necrotic and proteinaceous material. No intact nucleated cells are found ... scattered bright yellow needles and globular material that is either bilirubin or a form of hematoidin. In addition, more typical, rhomboidal hematoidin crystals are found.”
5/21/2013
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TAMU #159796
Sig: 9 yr M(c) Pug
CC: Vomiting, feeling bad, yellow
HPI: Began feeling bad 12 days ago
Started vomiting, responded to
fluid therapy, but became ill
again when started feeding it
Dog 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 = 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)
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You hope this is something that you do not see during surgery because ...
Trying to resect the mass is the WORST thing you can do
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Should you decompress the biliary system?
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
Making a “visual” diagnosis of pancreatic carcinoma is a BAD idea
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PANCREATITIS IS MUCH
MORE COMMON THAN
PANCREATIC CANCER
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
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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)
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TAMU #152494
Referral abdominal ultrasound:
“… Small amount of anechoic
effusion between liver lobes and
around urinary bladder. FNA 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”
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TAMU #152494
“Chronic necrotizing and fibrosing
interstitial pancreatitis with
multifocal ... suppuration and
hemorrhage and peritonitis
Duodenum: Subacute, eosinophilic,
fibrohistiocytic and plasmacytic
superficial enteritis with multifocal
ulceration, villous fusion ...”
Abdominal fluid
147260 152494 152485 109612
TP gm/dl 5.1 4.6 1.3 3.6
WBC/ul 15,059 153,000 700 18,200
RBC/ul 91,112 0 30,000 83,700
PANCREATITIS CAN:
a) make no abdominal effusion
b) make a little abdominal effusion
c) make a massive abdominal
effusion
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WHAT IS THE FIRST THING
THAT COMES TO YOUR
MIND?
10 year old, INTACT FEMALE, miniature poodle
TAMU #159077 2/05
Sig: 10 F Miniature poodle
CC: Bloody diarrhea
HPI: Acute bloody stool & vomiting
white foam Friday night
Dog goes to vet on Saturday
Monday dog comes to TAMU
PE: T = 102.1 F, P = 120, R = 36
Icteric, depressed, bloody stool
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TAMU #159077
PCV = 25% (35-55)
WBC = 8,300/ul (6,-14,000)
Segs = 5,976/ul (4,-12,000)
Bands = 415/ul (< 300)
Metas = 83/ul (0)
Platelets = 15,400/ul (200,-500,000)
Toxic WBC = many toxic, plus a
moderate # of severe toxic
TAMU #159077
BUN = 10 mg/dl (8-20)Sodium = 149 mEq/L (138-148)Potassium = 2.7 mEq/L (3.8-5.1)TCO2 = 15 mmol/L (21-28)Glucose = 69 mg/dl (75-133)Albumin = 1.8 gm/dl (2.5-4.4)ALT = 50 IU/L (<130)SAP = 324 IU/L (<147)Bilirubin = 6.3 mg/dl (< 0.8)
TAMU #159077
Abdominal US: “... fluid filled tubular
structure consistent with a uterine
horn. The remainder of the
abdomen was unremarkable.
Sonographic Impression: Pyometra,
right follicular cyst, inactive right
ovary.”
5/21/2013
24
TAMU #152117
Sig: 8 yr M Chow
CC: Acute renal failure
HPI: Anorexia, vomiting, excessive
drinking for last 3 days
Vomiting pale yellow fluid
Now unable to stand
PE: Can stand only if helped
T = 101.5, P = 56, R = 68
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TAMU #152117
PCV = 42% (35-55)
WBC = 4,100/ul (6,-14,000)
Segs = 2,050/ul (4,-12,000)
Bands = 492/ul (< 300)
Metas = 41/ul (0)
Lymphs = 1,189/ul (1,-4,000)
Platelets = 291,000/ul (200,-500,000)
TAMU #152117
BUN = 40 mg/dl (8-29)Creatinine = 2.6 mg/dl (< 2.0)Glucose = 67 mg/dl (75-133)Potassium = 4.1 mEq/L (3.8-5.1)Magnesium = 1.2 mg/dl (1.7-2.1)Calcium = 7.5 mg/dl (9.3-11.8)Albumin = 1.9 gm/dl (2.5-4.4)ALT = 10 IU/L (< 130)SAP = 491 IU/L (< 147)
TAMU #152117
U/S: “Serosal surfaces were bright
and there was a large amount of gas
in the stomach ... moderate volume of
hypoechoic fluid ... in the abdomen
... generalized mild distention of
small bowel with no peristalsis
visualized ... suggestive of peritonitis
with ileus.”
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TAMU #152117
Abdominal fluid:
RBCs = 34,855/ul
WBCs = 5,362/ul
70% neutrophils
30% mononuclear
mild to moderate degeneration
3.8 gm/dl total protein
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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
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Courtesy of Dr. Katrina Mealey
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WHAT IS SUPPOSED TO HAPPEN
Bacterial toxin, inflammatory cytokines
Lymph nodes, hepatic macrophages
Systemic circulation
Inflammatory cytokines
Lymph nodes
Systemic circulation
WHAT CAN HAPPEN
EARLY -- SIRSMild uneven vasodilatation
“High output” shock
Bright red mucus membranesFast capillary refill timeBounding pulsesTachycardia
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LATE -- SIRSSevere peripheral vasodilatation + poor cardiac contractility
“Low output” shock
Pale mucus membranesWeak pulsesSlow refill time
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
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THERAPY FOR PANCREATITISOnly supportive and symptomatic
• NPO versus early feeding
THERAPY FOR PANCREATITISOnly supportive and symptomatic
• NPO versus early feeding
• Fluid therapy
Crystalloids
Plasma
Colloids
Jejunostomy feeding
(PEG-J, Nasal J, regular J)
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THERAPY FOR PANCREATITISOnly supportive and symptomatic
• NPO versus early feeding
• Fluid therapy
Crystalloids
Plasma
Colloids
Nutrition
• Analgesics
THERAPY FOR PANCREATITISOnly supportive and symptomatic
• NPO versus early feeding
• Fluid therapy
• Analgesics
• Anti-emetics: primarily if vomiting makes it hard to maintain hydration
• Proton-pump inhibitors: the same
OTHER POSSIBILITIES
• Antibiotics
– “Regular” pancreatitis
– SIRS
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OTHER POSSIBILITIES
• Antibiotics
• Heparin
OTHER POSSIBILITIES
• Antibiotics
• Heparin
• Steroids – Critical Care Medicine 36: 296-327, 2008
COMMON MISTAKES IN DOGS WITH ACUTE PANCREATITIS
Request amylase, lipase or TLI
Not obtain radiographs/ultrasound
Not repeat ultrasound
Expect “classic” presentation
“Complacent” medical therapy
Inappropriately aggressive surgery
Watch lab/ultrasound instead of patient