Pancreatitis in Dogs and Cats
Two Different Animals
Wendy Blount, DVM
Nacogdoches, TX
Wendy Blount, DVM
drblount@vonallmen.net
talkoftheinternet.com/etvma4
• DVM TAMU 1992
• Private Practice Houston 2 years
– Small Animal
• Residency TAMU 1994-1997
– Small Animal Internal Medicine
• Private Practice Nacogdoches, TX
– General Practice, Internal Medicine,
Herbal Medicine/Nutrition
Pancreatitis:
Introduction
Two types of pancreatitis
Acute Pancreatitis Chronic Pancreatitis
•Abrupt onset •Continuing inflammatory
•often reversible after disease
treatment •Irreversible pathology
•May lead to chronic •Relapsing acute pancreatitis
pancreatitis •Exocrine pancreatic
•Acute necrotizing (cell insufficiency (EPI)
death) pancreatitis is a life- •Diabetes mellitus
threatening condition
Acute Chronic
2/3 1/3 4
Pancreatitis
Clinical Presentation
Diagnosis
Treatment
Prognosis
Pancreatitis:
Clinical
Presentation
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
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
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
Hypothyroidism
Dog vs. Cat - Quiz dogs
Hyperlipidemia
High fat meal
dogs
dogs
Hypercalcemia
Refeeding after anorexia
Both
dogs
Hyperadrenocorticism
Pancreatic neoplasia
both
both
Pancreatitis - Predispositions
Corticosteroids Trauma to the pancreas
dogs dogs >> cats
Organophosphates Bile duct obstruction
both cats > dogs
Uremia Protracted severe vomiting
both 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
•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 – why?
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
–Pumonary thromboembolism
•DIC
•Pancreatic encephalopathy
•Arrhythmia
•Metabolic acidosis
•Respiratory Distress (2 causes)
Pancreatitis:
Diagnosis
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 – why?
–Azotemia
–Hyperglycemia (cause or effect)
–Hypoglycemia – why?
–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
–concurrent proximal small intestinal disease
•Folate may be low if distal intestinal disease
–Folate is absorbed in the ileum
–REMEMBER: “B” comes before “F”
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)
–Much more sensitive and specific for pancreatitis
than any blood test or imaging
–Antech and IDEXX
–TAMU GI Lab (TVMDL sends to TAMU)
Diagnostic tools: A comparison
R TM
SNAP cPL
Features
• 2 results: Normal or Abnormal Reference Sample
• Read time: 10 minutes
• Storage: Refrigeration
• Sample type: Serum
• Read: Visual; semi-quantitative
•400 ug/L pancreatitis
• Correlation to cPLI >95%
• 96% of interpretations are correct
Comparing Spec cPL values to
SNAP results
SNAP cPL for Screening
Dog w/ Vomiting, Anorexia,
Abdominal pain
CBC
Profile/lytes
UA
SNAP cPL SNAP
SNAP Abnormal
Normal >400
200-399
Treat for pancreatitis,
Baseline cPLI
Abdominal radiographs
Abdominal US
Pancreatitis is
unlikely – pursue Baseline cPLI
monitor w/ cPLI
other differential
diagnoses
US/Rads confirm
US/Rads equivocal
pancreatitis
Treat, Monitor, Retest;
Continue to rule out
Treat for pancreatitis, other differential
diagnoses
Monitor with cPLI
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
–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
•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
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 (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 or fPLI
–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?
–45% protein and <8%
carbs
•Innova EVO (California Naturals)
•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
Nutritional Content 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
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
Things associated with poor prognosis:
•Shock
•Oliguria
•Icterus
•Hypocalcemia
•Hypoglycemia
•Hypoproteinemia
•Acidosis
•Falling hematocrit
Pancreatitis: Prognosis
Things associated with poor prognosis:
•Thrombocytopenia
•DIC
Thanks
Y’All!!