History Signalment Diet Vomiting Prior episodes Diarrhea History

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History • Signalment • Diet • Vomiting • Prior episodes • Diarrhea

History • Signalment • Diet • Vomiting • Prior episodes • Diarrhea

History • Signalment • Diet • Vomiting • Prior episodes • Diarrhea

History • Signalment • Diet • Vomiting • Prior episodes • Diarrhea

Physical Examination • Anterior abdominal pain • Icterus • Profuse ascites • Fever •

Physical Examination • Anterior abdominal pain • Icterus • Profuse ascites • Fever • SQ abscesses

Physical Examination • Anterior abdominal pain • Icterus • Profuse ascites • Fever •

Physical Examination • Anterior abdominal pain • Icterus • Profuse ascites • Fever • SQ abscesses

WHICH CBC(S) IS/ARE FROM DOG(S) WITH ACUTE PANCREATITIS?

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,

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 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

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

Clinical Pathology • Amylase/Lipase – Sensitivity ~ 50% – Specificity ~ 50% • TLI – Sensitivity ~ 35%

Clinical Pathology • c. PLI – Sensitivity ~ 80 -85%

Clinical Pathology • c. PLI – Sensitivity ~ 80 -85%

Sig: 7 yr M Boxer X CC: Anorexia/Vomiting HPI: Started 1 week ago snap

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

PANCREATITIS versus CLINICALLY IMPORTANT PANCREATITIS

Diagnostics • c. PLI – Sensitivity ~ 80% • Abdominal ultrasound – Sensitivity probably

Diagnostics • c. PLI – Sensitivity ~ 80% • Abdominal ultrasound – Sensitivity probably ranges from 40% to about 65%

Diagnostics • c. PLI – Sensitivity ~ 80% • Abdominal ultrasound – Sensitivity probably

Diagnostics • c. PLI – Sensitivity ~ 80% • Abdominal ultrasound – Sensitivity probably ranges from 40% to about 65% because clinicians rarely repeat the ultrasound

Diagnostics • c. PLI – Sensitivity ~ 80% • Abdominal ultrasound – Sensitivity probably

Diagnostics • c. PLI – 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?

WHAT IS THE BEST WAY TO DIAGNOSE CANINE ACUTE PANCREATITIS?

All things being equal, try to avoid surgery

All things being equal, try to avoid surgery

THE REAL PROBLEM IS THAT ACUTE PANCREATITIS CAN PRESENT IN SO MANY DIFFERENT WAYS

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

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)

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

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

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)

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 =

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 m. Eq/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

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. 8 2. 6 4/16 1. 2

TAMU #152494 Sig: 9 yr F(s) Dalmation CC: Vomiting/diarrhea HPI: Vomiting food/bile 6 -8

TAMU #152494 Sig: 9 yr F(s) Dalmation CC: Vomiting/diarrhea HPI: Vomiting food/bile 6 -8 X 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,

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 m. Eq/L (138 -148) Potassium = 4. 1 m.

TAMU #152494 Sodium = 152 m. Eq/L (138 -148) Potassium = 4. 1 m. Eq/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

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 = RBC = 153, 000/ul Total protein = 4.

TAMU #152494 Abdominal fluid: WBC = RBC = 153, 000/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

TAMU #152494 “Chronic necrotizing and fibrosing interstitial pancreatitis with multifocal. . . suppuration and hemorrhage and peritonitis. . . ”

Sterile pancreatitis versus Septic peritonitis

Sterile pancreatitis versus Septic peritonitis

Abdominal fluid 147260 152494 TP gm/dl 5. 1 4. 6 152485 109612 1. 3

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)

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

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 – used to be called “Septic shock”

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME – inadequate perfusion of the body tissues because of an

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

WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic circulation

Courtesy of Dr. Katrina Mealey

Courtesy of Dr. Katrina Mealey

WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic

WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic circulation

WHAT CAN HAPPEN Inflammatory cytokines Lymph nodes Systemic circulation

WHAT CAN HAPPEN Inflammatory cytokines Lymph nodes Systemic circulation

EARLY -- SIRS Mild uneven vasodilatation “High output” shock Bright red mucus membranes Fast

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

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

THERAPY FOR PANCREATITIS Only supportive and symptomatic • NPO versus early feeding • Fluid

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 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 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 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 – “Regular” pancreatitis – SIRS

OTHER POSSIBILITIES • Antibiotics • Heparin

OTHER POSSIBILITIES • Antibiotics • Heparin

OTHER POSSIBILITIES • Antibiotics • Heparin • Steroids – Critical Care Medicine 36: 296

OTHER POSSIBILITIES • Antibiotics • Heparin • Steroids – Critical Care Medicine 36: 296 -327, 2008