Pancreatitis in Dogs and Cats Two Different Animals Wendy Blount, DVM Nacogdoches, TX Wendy Blount, DVM email@example.com www.wendyblount.com • DVM TAMU 1992 • Private Practice Houston 2 years – Small Animal • Residency TAMU 1994-1997 – Small Animal Internal Medicine • Private Practice Nacogdoches, TX – 75% Referrals – Internal Medicine and Herbal Medicine/Nutrition – 25% General Practice 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 Dog vs. Cat - Quiz Hyperadrenocorticism Chronic Liver Disease both both Hypothyroidism Diabetes mellitus dogs both High fat meal Intestinal disease dogs both Refeeding after anorexia Hyperlipidemia dogs dogs Pancreatic neoplasia Hypercalcemia both both Pancreatitis - Predispositions Toxoplasma gondii Trauma to the pancreas cats dogs >> cats Corticosteroids Ischemia dogs both Organophosphates Bile duct obstruction both cats > dogs Scorpion sting Protracted severe vomiting both cats > dogs Uremia Vaccines both ????? 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 – Dogs only •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 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 Lipase – non-specific – why? –Digestive lipases –Intestinal lipase –Lipoprotein lipase and hepatic lipase –Hormone-sensitive lipase (adipocytes) –Lysosomal acidic lipase 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 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 TM Spec cPL ♦ cPLI Developed by Drs. Jörg Steiner and David Williams at the Gastrointestinal Laboratory at Texas A&M University ♦ IDEXX collaborated with Drs. Steiner and Williams to develop the Spec cPL ♦ IDEXX renamed it Spec cPL For better name recognition To trademark the name ♦ Available only at IDEXX Labs R TM Introducing SNAP cPL Features • 2 results: Normal or Abnormal Reference Sample • 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 • Same technology as Spec cPL® • Correlation to Spec cPL >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 –Antithrombin III –Low –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 (<5 waves per minute) –Sometimes “corrugated” •Common Bile Duct –Dilated and tortuous •Gall bladder –Enlarged, wall edema/hyperechoic, sludge •Ascites •Peripancreatic fat and omentum –hyperechoic Diagnosis: Abdominal Ultrasound •Ultrasound truly IS for everyone • Time-consuming –time to warm up reagants –10 minutes to run the test • Expensive –Used Toshiba Analog $12k in 2000 –Cost $1714 per year –3 US a week x $150 x 50 weeks = $22.5K • Subject to user experience –No more subjective than x-rays 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 •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: 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 Culture/Cytology any abscesses •Usually sterile (do cytology first) •Bacterial infection is not very common in dogs and cats Pancreatitis: Treatment 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 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 •Avoid LRS 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” - 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 (handout) –Advantage – corrects acidosis –Disadvantage – will make hypokalemia worse •Cefazolin 100 mg IV TID, cimetidine 25 mg IV TID 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 when incubated with heparin 35-75 U/kg for 30 minutes prior to administration –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 –Meperidine* –Fentanyl injectable or patch •Intraperitoneal lidocaine or bupivocaine •Be careful of NSAIDs – Why? Pancreatitis Treatment: Dogs and Cats Antioxidants •Milk thistle •SAMe •VetriScience Cell Advance •Vitamin E/selenium 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 - controversial –Definitely make the patient more comfortable –May prevent death from vagal surge –Some would rather not cover up their vomiting –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, Cimetidine, (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 –Already discussed IV therapy –Some cats with severe chronic pancreatitis need oral HC03 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 in notes) 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 CONTROVERSIAL THERAPIES •Drugs to inhibit pancreatic secretion •Seem to work with experimental pancreatitis •Little effect in spontaneous pancreatitis –Glucagon –Gabexate mesylate, nafamostat mesylate –Atropine –Acetazolamide –Somatostatin –calcitonin 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 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, AT3 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 •At least 48 hours •Offer water after no vomiting for 24 hours •Offer food when no vomiting for 24 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 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 •Avoid turkey – why? –Tryptophan potently stimulates the pancreas Treatment: Canine Pancreatitis Nutrition •Suitable commercial diets –Hill’s I/D canned and dry –Medi-Cal Canine Gastro Formula canned and dry –Leo Specific Digest (CIW canned CID dry) –Purine CNM EN canned and dry –Select Care Canine Sensitive Formula canned and dry •Home made food –Fat free cottage cheese and white rice is ideal 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 –If dog can’t be fed PO within 5-7 days, consider TPN, or PPN –Requires a central line, and monitoring multiple times daily –Probably should not be administered while dog is unattended (extravasation is bad) –Excellent catheter care is a must –Nutrients are expensive – hundreds of dollars to mix up a batch –Needs to be mixed aseptically, under a laminar flow hood –Gut atrophy continues TPN Resource Handout After Recovery –2 weeks or more after recovery, consider switching to low fat, high fiber diet –May or may not eventually be able to go back to a maintenance type diet Treatment: Canine Pancreatitis Nutrition Suitable High Fiber Low Fat foods for long term –Hill’s R/D and W/D –Leo Specific CRW (canned) and CRD (dry) –Medi-Cal Canine Fibre Formula canned and dry –Medi-Cal Canine Weight Control/Geriatric canned and dry –Purina CNM OM canned and dry –Purina CNM DCO dry, Purina CNM GL dry –Select Care Canine HiFactor Formula canned and dry –Waltham/Pedigree Canine High Fiber canned and dry 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 0.1 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 metoclopramide (1-2 mg per cat) by tube 30 minutes prior to feeding –If that doesn’t work, try cisapride (2.5 mg per cat) –Or Cerenia, Anzemet, Zofran –If all else fails, consider a jejunostomy tube handouts: Tube Feeding Tube Diets 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 is only one dry diet with >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 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 -- dogs •Hypoglycemia •Hypoproteinemia •Acidosis •Falling hematocrit Pancreatitis: Prognosis Things associated with poor prognosis: •Thrombocytopenia •DIC Thanks Y’All!!
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