Thyroid replacement hormone levothyroxine sodium by MikeJenny

VIEWS: 2 PAGES: 59

									    EDUCATION
Education is learning what you didn’t
    even know you didn’t know.
                -Daniel J. Boorstin
DISEASES OF THE PARATHYROID GLANDS


     HYPERPARATHYROIDISM
     HYPOPARATHYROIDISM
Thyroid/Parathyroid glands


                                   2 glands for each
                                   thyroid lobe




       1=normal thyroid gland
       2 and 3=parathyroid gland
       4=enlarged thyroid gland
       Parathyroid gland
• Secretion: Parathyroid hormone (PTH,
  Parathormone)
• Function: ↑ plasma Ca2+ concentration
   – 1. ↑ osteoclast activity
   – 2. ↑ Ca++ absorption from GI tract
   – 3. ↑ Ca++ reabsorption from kidney tubules
• Hyperparathyroidism → ________________
• Hypoparathyroidism → __________________
    Hyperparathyroidism
• Causes:
   – 1º hyperparathyroidism— ___________________________
   – 2º hyperparathyroidism—poor diet; low Ca intake
• Clinical signs:
   – Many animals show __________________________
   – signs occur as organ dysfunction occurs
       • urinary/renal calculi (high plasma Ca++)
       • cardiac arrhythmias, tremors (Ca++ necessary
         for normal muscle contraction)
       • Anorexia, vomiting, constipation
       • weakness
Signalment: 7-11 yrs; Keeshoondren
               Hyperparathyroidism

Dx:
• Routine chemistry panel
   – ↑ blood Calcium (normal: ~ _____________ mg/dl))
   – +/- ↓ blood Phosphorus (normal: ~2-6 mg/dl)
• PTH assay
   – normal PTH: dogs ~20 pg/ml, cats ~17 pg/ml
   – In a normal animal: if blood Ca++ is high, PTH is low (neg feedback)
   – 1º Hyperparathyroidism: ______________________________
• Ultrasound of neck – enlarged glands, abdomen -
  uroliths
Dff: neoplasia (LSA), Addison’s, rodenticide
  toxicosis, ARF
                 Hyperparathyroidism

Tx:
    1. _________________________ of diseased parathyroid (generally
   4 lobes are imbedded in thyroid gland)
Other options:
   2. Ultrasound-guided chemical (ethanol)
    3. Ultrasound-guided heat (laser) ablation
Post-Op Care:
    1. Hospitalize for 1 wk; ↓PTH may predispose animal to
    hypocalcemia
    2. _____________________ (oral tabs, liquid)
    3. Vit D supplements (promotes Ca intestinal absorption)
       Hyperparathyroidism
Client Info
1. Most hyperparathyroid animals show no
    signs when first diagnosed
2. Run _____________ chem panels on all
    normal, older animals
Hypercalcemia: Other causes

 • Causes
   – Neoplasia (lymphoma, perianal gland
     tumors)
   – Renal failure
   – Hypoadenocorticism
   – Vitamin D rodenticide
   – Drugs or artifacts (ex lipemia)
 • Clinical signs vary with cause
   – PU/PD, anorexia, lethargy, vomiting,
     weakness, stupor/coma (severe), uroliths
             Hypercalcemia
• Tests
  – Elevated serum calcium levels
  – Low to low-normal phosphorus concentrations
               Hypercalcemia
• Treatment
  – Fluids: 0.9% NaCl
     • No Ca2+ containing fluids
  – Diuretics (furosemide): dilute urine
  – Steroids
• Complications
  – Irreversible renal failure
  – Soft tissue calcifications
                         Hypocalcemia
Causes:
1.     Parathyroid disease
     a.   Inadvertent removal of ____________________ during thyroidectomy (most
          common cause
     b.   1º Hypoparathyroidism (uncommon in animals)

2.     Chronic renal failure—
     a.   may cause ↑ serum P, which can result in ↓ serum Ca (Ca:P __________________)
     b.   Vit D normally activated in kidney
     c.   Protein-losing nephropathy results in loss of albumin-bound Ca

3.     Puerperal Tetany (Eclampsia)—late gestation thru post-partum period
     a.   Improper prenatal ______________________________________
     b.   Heavy lactation
     c.   Inappropriate Ca++ supplementation
     d.   Post-partum and late gestaion


     http://www.thepetcenter.com/gen/eclampsia.html#The_video
                  Hypocalcemia
Clinical Signs:
1.   Restlessness, muscle tremors, tonic-clonic contractions,
     seizures
2.   ______________________ with excitement;
     __________________ in severe cases (Ca++ is necessary
     for proper muscle contractions)
3.   Hyperthermia
4.   Stiffness, ataxic
            Hypocalcemia

Dx:
Total serum < ______________ mg/dl
Tx:
1.    IV infusion of _______________________
      solution (monitor HR and rhythm during infusion)
2.    ___________________ (IV) to control seizures
3.    Oral supplements of Ca (tabs, caps, syrup)
4.    Improve nutrition
             Hypocalcemia
Client info:
1. Well-balanced diet; increase volume as
    pregnancy progresses
2. Signs in pregnant animal is _____________;
    call vet immediately
3. May recur with subsequent pregnancies
4. Early weaning is recommended
                   LIFE
―Nobody can go back and start a new
beginning, but anyone can start today
      and make a new ending.‖
                  -Maria Robinson
DISEASES OF THE
   PANCREAS
 DIABETES MELLITUS (DM)
       INSULINOMA
  EXOCRINE PANCREATIC
   INSUFFICIENCY (EPI)
Review of pancreas functions

 • Long flat organ near
   _________________ and stomach
 • Exocrine function (the majority of the
   pancreas):
   – ________________ enzymes
 • Endocrine function – islets of
   Langerhans
   – Alpha cells => _______________
   – Beta cells => ___________________
   – Delta cells => ___________________
Pancreas
Pancreas:
beta cells
                  Review

• Insulin
   – Moves glucose into ___________ to be used for energy
     (glycolysis)
   – _______________ blood glucose
• Glucagon
   – _________________ blood glucose
       • Stimulates liver to release glucose
       • Stimulates gluconeogenesis
   – Other hormones from other glands perform similar
     functions (hyperglycemic effect)
       • Growth hormone
       • Glucocorticoids
Insulin/Glucagon Balance
   Endocrine Pancreas

• Hyperglycemia
  – Definition: Excessively high blood glucose
    levels
     • Normal in dogs: _________________ mg/dl
     • Normal in cats: __________________ mg/dl
      Diabetes Mellitus

• Definition: Disorder of carbohydrate, fat
  and protein metabolism caused by an
  absolute or relative ___________
  deficiency
• Type I – Insulin Dependent DM – very
  low or absent insulin secretory ability
• Type II – Non insulin dependent DM
  (insulin insensitivity) – inadequate or
  delayed insulin secretion relative to the
  needs of the patient
          Diabetes mellitus
Incidence:
     Dogs: ~100% Type I (Insulin dependent)
     Cats: ~ 50% Type I and 50% Type II
            -non-insulin dependent cats
            can sometimes be managed with
            diet and drug therapy
Causes:
     Chronic pancreatitis
     _______________________________
      -beta cell destruction
Predisposing/risk factors:
     Cushing’s Disease
     Acromegaly
     Obesity
     Genetic predisposition
     Drugs (steroids)
       Diabetes mellitus
• Age/sex:
  – Dogs: 4-14 yrs, females 2x more likely to
    be affected
  – Cats: all ages, but 75% are 8-13yrs,
    neutered males most affected
• Breeds: Poodles, Schnauzers, Keeshonds,
  Cairn Terriers, Dachshunds, Cockers, Beagles
                               DM
• Pathophysiology
   – Insulin deficiency => impaired ability to use glucose from
     ______________, __________________ and _______________
   – Impaired glucose utilization + gluconeogenesis => hyperglycemia
   – Clinical signs develop when:
       • Exceeds capacity of renal tubular cells to reabsorb
       • Dogs – BG > ________________ mg/dl
       • Cats - BG > __________________mg/dl
   – Glycosuria develops
       • Osmotic diuresis
       • Polyuria/polydipsia
                      DM
• SYSTEMS AFFECTED:
   – Endocrine/metabolic: electrolyte depletion
     and metabolic _________________
   – Hepatic: liver failure 2° to hepatic lipidosis
     (mobilization of free fatty acids to liver
     leads to hepatic lipidosis and ketogenesis)
   – Ophthalmic: __________ (dogs) from
     glaucoma
   – Renal/urologic: UTI, osmotic diuresis
   – Nervous: peripheral neuropathy in cats
   – Musculoskeletal: Compensatory weight
     loss
            Diabetes Mellitus
• Clinical Signs:
  – ____________________
  – ____________________
  – Weight loss (esp. cats)
  – Dehydration
  – Cataract formation-dogs
  – Plantigrade stance-cats
 Diabetes in Cats:
Plantigrade posture


          Plantigrade posture
                 Diabetic neuropathy
  Diabetes: Cataracts




Increase in sugar (sorbitol) in lens causes an influx
of water, which breaks down the lens fibers
               Diabetic Ketoacidosis




2 metabolic crises:
↑ lipolysis in adipose tissue → fatty acids →ketone bodies →ketoacidosis →coma
           (insulin normally _________________ lipolysis)
↑ hepatic gluconeogenesis (in spite of high plasma glucose levels)
           (insulin normally ____________________ gluconeogenesis)
        Diabetic Ketoacidosis
• Definition: True medical _______________
  secondary to absolute or relative insulin
  deficiency causing hyperglycemia, ketonemia,
  metabolic acidosis, dehydration and electrolyte
  depletion
• DM causes increased lipolysis => _________
  production and _______________
             Diabetic Ketoacidosis
• Diagnosed with ketones in urine or ketones in blood
   – Can use urine dip stick with serum.
• Clinical Signs
   –   All of the DM signs
   –   Depression
   –   Weakness
   –   Tachypnea
   –   Vomiting
   –   Odor of acetone on breath
   Diabetic Ketoacidosis

• IV fluids to rehydrate 0.9% NaCl
  – K (potassium) supplement
• Regular insulin to slowly decrease BG
• Monitor BG q 2-3 hrs
• When BG close to normal and patient
  stable switch to longer acting insulin
                        DM
• DIAGNOSIS:
  – CBC: normal
  – Biochemistry panel:
      • Glucose > ________mg/dl (dogs), > _____________ (cats)
  – UA
      • ____________________!!!!
      • ______________________
      • USG – low
  – Electrolytes may be low due to osmotic diuresis
  – Blood gases (if ketoacidotic)
  – Fructosamine levels – mean glucose level for last 2-3 weeks
    (dogs)
      • Ideal to test for regulation checks
  DM Rx: INSULIN AND DIET!!!
 Table 1. Traditional insulin outline.

                           Insulin types             Concentration
Duration/onset
category
Rapid acting               Regular (Humulin R)       U-100 (100 units/ml)
(emergency)
Intermediate acting        NPH (Humulin N)           U-100

                           Lente (Vetsulin® by       U-40 (40 units/ml)
                           Intervet) NO LONGER
                           AVAILABLE*
Long acting                PZI (Idexx)               U-40

                           Ultralente NO LONGER      U-100
                           AVAILABLE*
                           Glargine insulin analog   U-100
Diabetes: Insulin therapy
        DM: Insulin therapy
• INSULIN
   – Beef-origin insulin is biologically similar to cat
     insulin
   – Porcine-origin insulin is biologically similar to dog
     insulin
   – Dogs and cats have responded well to human
     insulin products
• INSULIN ADMINISTRATION:
   – ALWAYS USE THE ______________________
     INSULIN SYRINGE! (U-40 vs. U-100)
       • Insulin is given in units (insulin syringes are
         labeled in units, not mL)
DM: dietary management
• DIET
  – DOGS: high _____________-, complex carbohydrate diets
     • Slows digestion, reduces the post-prandial glucose spike,
       promotes weight loss, reduces risk of pancreatitis
     • Hill’s R/D or W/D
  – CATS: high _______________, low carbohydrate diets
     • Cats use protein as their primary source of energy – blood
       glucose is maintained primarily through liver metabolism
       of fats and proteins
     • Purina DM, Hill’s M/D
     • Often a diet change in cats can dramatically reduce or
       eliminate the need for insulin
          – This is particularly true for type II
                          DM
• Oral hypoglycemics (cats NIDDM)
  o Sulfonylureas – Glipizide
     o Direct stimulation of insulin secretion from the pancreas
  o Alpha-Glucosidase Inhibitors – Acarbose (dogs)
     o Delays digestion of complex carbohydrates and delays
       absorption of glucose from the intestinal tract.
Diabetes Mellitus: Monitoring




Find an ear vein   Prick the ear to get   Place drop of blood
                   blood sample           on green tip; readout in
                                          a few seconds
Diabetes Rx: Urine glucose
Diabetes monitoring: Urine
         glucose
DM: monitoring
                            DM
• Client Education
   – ______________________ insulin replacement therapy
   – Insulin administered by _______________________________
   – _____________________ insulin, mix _____________ (no
     bubbles), single use syringes
   – Cataracts common, permanent
   – Consistent diet and exercise
   – Recheck BG or curve regularly or fructosamine levels
   – Progressive
   – If animal _________________- NO INSULIN
            Endocrine Pancreas
• Hypoglycemia
  – Definition: Low blood glucose levels
  – Causes
     •   Neonatal and juvenile
     •   Septicemia
     •   Neoplasia
     •   Starvation
     •   Iatrogenic – insulin overdose
     •   Portosystemic shunt
     •   Many others
             Insulin Shock
Causes:
1. Insulin overdose (____________ syringe)
2. Too much exercise
3. Anorexia
Signs:
Weakness, incoordination,_______________,
   coma
              Insulin Shock
Prevention
1. ________________ diet (type and
   amount)/consistent exercise (less insulin with
   exercise)
2. Monitor urine/blood glucose at same time each
   day
3. Feed 1/3 with insulin; the rest 8-10 h later (at
   insulin peak)
4. Have sugar supply handy
                   Insulinoma
• CAUSE:
  ______________ of beta
  cells, secreting an excess
  of insulin
• SIGNS: prolonged
  ______________________
  →weakness, ataxia,
  muscle fasciculations,
  posterior paresis, brain
  damage, seizures, coma,
  death,
                 Insulinoma: Dx
• Chem Panel
   – ↓blood glucose
   – Simultaneous glucose and insulin tests
     ____________ glucose, __________________ insulin =>
     insulinoma


• Observations
   – Symptoms occur after _______________ or _________________
   – when symptomatic, blood glucose< ______________ mg/dl
   – symptoms corrected with sugar administration
                        Insulinoma: Rx
Surgical Rx: removal of tumor
Medical Rx:
Acute, at home:
  administer glucose (Karo); keep animal quiet, seek vet care
Acute, in Hosp
  adm. glucose (50% Dextrose)
Chronic care
  feed 3-6 small meals/day (high protein, low fat)
  limited exercise
  glucocorticooid therapy (antagonizes insulin effect at cellular
  level)
  Diazoxide (↓insulin secretion, tissue use of glucose, ↑blood
  glucose)
  Octreotide (Sandostatin) injections—inhibits synthesis and release
  of insulin by both normal and neoplastic beta cells
           Insulinoma: Client info
•   1. Usually, by the time insulinoma is diagnosed, metastasis has occurred
    so prognosis is ______________________
•   2. With proper medical therapy, survival may be 12-24 mo
•   3. Always limit _____________ and _________________
•   4. Feed __________ , ________________meals throughout day; keep
    sugar source close during exercise
•   5. _________________________ on mm provides for rapid absorption
    of glucose into blood stream
•   6. Avoid placing hand into dog’s mouth during seizure to avoid being
    bitten
Exocrine Pancreas Insufficiency (EPI)

• Inability to process nutrients efficiently due
  to ____________ of production of enzymes
  from pancreas.
  – Pancreatic acinar atrophy
• Found most commonly in German
  Shepherds and Rough Collies through a
  recessive gene.
  – In cats, EPI is primarily the result of chronic
    pancreatitis
            Diagnosis of EPI
• Not usually evident until ____________ % of
  pancreas is unable to secrete enzymes.
  – _________________ although no change in diet or
    appetite (appetite often increases)
  – Persistent tarry diarrhea.
  – Flatulence
  – Poor haircoat
   Testing and treatment for EPI
• TLI (trypsin-like immunoreactivity)
   – Detects trypsin and trypsinogen
   – Usually want ____________________ in dogs to be diagnostic
      • Canine 5.7-45.2
      • Feline 12-82
• Treatment includes enzymatic supplement
   – ___________________ powder (Amylase, protase, lipase)
   – Raw ox or pig pancreas
          Client considerations
•   Usually life long treatment.
•   Can be very expensive.
•   Can be well controlled.
•   Should not breed animal that has EPI.

								
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