Pancreatitis in Dogs and Cats by AmnaKhan

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									Pancreatitis in Dogs and Cats

 Two Different Animals

  Wendy Blount, DVM
   Nacogdoches, TX
        Wendy Blount, DVM
        drblount@vonallmen.net
         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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