Pancreas: new conceps
J. Pastor, DVM, PhD, Dipl ECVCP
Veterinary Faculty
Autonomous University of Barcelona
08193-Bellaterra (Spain)
Clinical case: PomaMiniature schnauzer, femalle, 9 y
old, spayed.
Client complaint
• Doing well since yesterday.
• Started to vomiting and diarrhea.
• Now, she is vomiting 7-8 times x day, she
is unable to stand or walk, very weak.
Physical examination
• Body score 4/5
• Tachycardia 120 ppm
• Weak femoral pulse.
• Slow capillary refill time ( over 2 secs).
• Tachypnea: 40 bpm
• Abdominal painfull palpation.
Key pointAlthough pancreatitis symptoms may be very unspecific, dogs with severe
pancreatitis usually present with vomiting and cranial abdominal pain. Pancreatitis
should be suspected in animals presenting with these clinical signs. Milder cases of
pancreatitis may not necessarily present with vomiting or abdominal pain.
Clinical signs in animals with
pancreatitis
• Vomiting: 90%
• Weakness: 79%
• Abdominal pain: 58%
• Dehydration: 46%
• Diarrhea: 33%
• Fever: 21%
• Hess et al. Clinical, clinicopathologic, radiographic, and ultrasonographic abnormalities in dogs with fatal acute pancreatitis: 70 cases (1986-1995). J Am Vet
Med Assoc. 1998 Sep ;213(5):665-70.
Differential diagnosis
• Gastrointestinal:
– Foreign bodies, neoplasia, IBD, alimentary...
• Extra-gastrointestinal:
– Pancreas.
– Liver.
– Kidney.
– Metabolic / Endocrine diseases.
– Other…
Diagnostic plan
• CBC.
• Biochemistry.
• Acid-base status.
• UA.
• Abdominal x-ray.
• Abdominal ultrasound.
CBC
• RBC (x10^6/µL): 8.22
• HCT (%): 45
• VCM (fl): 62.1
• CHCM (g/dl): 32,5
• WBC (/µL): 21470
– Lymp: 3006
– Mono: 429
– Band: 215
– Segm: 17391
– Eosin: 429
• PLT (x 10^3/µL): 120
• Coagulation profile:
– PT: 12 sec (6-8 sec)
– aPTT: 30 ( 8-16 sec)
– Fibrinogen: 150 mg/dl
(200-400)
– D-dimer: > 2000 (<200)
Biochemistry
• Creat (mg/dl): 3.1 (0.5-1.5)
• Urea (mg/dl): 120 (20-60)
• Cholesterol (mg/dl): 535 (135-270)
• Tryglicerides (mg/dl): 350 (50-100)
• Glucose (mg/dl): 150 (6-118)
• Total proteins (g/dL): 5.24
– Alb: 1.6 (2.6-3.3)
– Alfa 1: 0,15 (0,2-0,5)
– Alfa 2: 1.31 (0,3-1,1)
– Beta: 1,86 (0,9-1,6)
– Gamma: 0,33 (0,3-0,8)
• Total bil (mg/dl): 0.09 (0,1-0,5)
• ALP (UI/L): 2400 (20-156)
• GGT (UI/L): 21 (1,2-6,4)
• ALT (UI/L): 800 (21-102)
• Ca (mg/dl): 9.1 (9-11,3)
• K (mmol/L): 3,74 (4,37-5,35)
• NA (mmol/L): 138 (141-152)
• Cl (mmol/L): 107,8 (105-115)
• Phosphorus (mg/dl): 5,09 (2,6-6,2)
• Lipasa (UI/l): 577 (13-200)
Laboratory changes in animals with
pancreatitis
• ALP: 79%
• ALT: 61%
• Azotemia: 59%
• Bilirrubin: 53%
• Hipoalbuminemia: 50%
• Hipercholesterolemia: 48%
• Bleeding disorders: 68%
• Hess et al. Clinical, clinicopathologic, radiographic, and ultrasonographic abnormalities in dogs with fatal acute pancreatitis: 70 cases (1986-1995). J Am Vet Med Assoc. 1998 Sep ;213(5):665-
70.
Pancreatitis
Steiner, 2003, 2009
Key points
• The degree of elevations of lipase and amylase
do not correlate with severity of pancreatitis.
– At least 3 folds increase in lipase are needed to
suspect pancreatitis.
• At present, pancreatic lipase (cPLI) is the most
sensitive biochemistry test for diagnosing canine
pancreatitis.
• Laboratory changes in animals with pancreatitis
depend on the severity of the condition, and vary
greatly between one animal and another.
Normal 200 400
Pancreatic inflammation Pancreatitis
Pancreatitis
• Small number of animals.
• Retrospective study.
• Need a blinded study
Steiner, 2003, 2009
A Multi-Institutional Study Evaluating Diagnostic Utility of
Spec cPLI in the Diagnosis of Acute Pancreatitis in DogsACVIM 2009
K. McCord; J. Davis; F. Leyva; P.J. Armstrong; K.W. Simpson; M. Rishniw; M.A. Forman
• Multi-institutional blinded study.
– Cases:• with an initial differential diagnosis that included acute pancreatitis
(APS)
• did not include acute pancreatitis (CO)
– Information:• dog history, physical examination, laboratory findings (including total
amylase and lipase), abdominal ultrasound and the clinical course.
• Cases were categorized to one of five pre-defined groups (0-4): 0--not pancreatitis, 1--not primary pancreatitis, 2--possibly pancreatitis, 3--probably pancreatitis or 4--pancreatitis.
Conclusions ACVIM 2009
• Amylase and lipase activities did not differ
between groups.
• Spec cPL sensitivity and specificity for
cases with clinical score 0 (no
pancreatitis), and 2,3,4 (pancreatitis),
calculated using current cut off values of <
200µg/L as negative and >400 µg/L
positive:– 93% sensitivity and 78% specificity.
How we use spec cPLI
• If spec cPLI is < 200 µg/L is highly unlikely
to have acute pancreatitis.
• If spec cPLI is > 400 µg/L pancreatitis may
be present (could be pancreatitis).
Why a pancreatic lipase can be
increased without primary
pancreatitis?
Non pancreatic disease
Hypoxia
Cytokines
Endotoxins
Loss membrane permability
Increase enzimes
Other causes increase cPLI
• Gastritis.
• Chronic inflammatory bowel disease.
• Chronic renal failure.
• Drugs: bromide and phenobarbital.
Penninck, D. (2008). Atlas of Small
Animal Ultrasound. Blackwell publicing
Penninck, D. (2008). Atlas of Small
Animal Ultrasound. Blackwell publicing
Definitive diagnostic tool
• Pancreatic biopsy.
– Best technique.
– Animals with pancreatitis and many complications
have high anesthetics risks.
Poma
• Spec cPLI: 1800 µg/L
• Multiple organ compromise:
– Coagulation
– Liver
– Kidney
– Hematology
– Shock and hypotension
• PROGNOSIS
Poma
• Bad prognosis.
• Treatment
Treatment• 5 Strong evidence, 0 no evidence for its use.
Steiner, J.M. Y Rozanski, E.
Rationale treatment of
pancreatitis in small animals.
ACVIM 2006, pp 628-630
IV fluids (5) and plasma
• Fluidos: 5
– Crystalloid
– Colloids.
• Plasma: 2-4
– Colloids: 2
– Inhibitors Proteases: 2-1
– Coagulation factors: 4
Systemic inflammation
Analgesia (5)
• Evidence 5.
– Butrophanol: 0.1-1 mg/kg/SC/qid
– Fentanyl:
• 2-5 µg/kg/h CRI
– Ketamine (alone or with fentanyl):
• 0.2-0.6 mg/kg/h CRI
– Morphine + lidocaine+ketamine
• 0.24 mg/kg/h, 3 mg/kg/h and 0.6 mg/kg/h
Antiemetic treatment (4)
• Vomiting due to:– Local stimulus.
– Central.
• Metoclopramide: – central
• Dolansetron/ondansetron:– Central and peripheral.
• Maropitant (Cerenia):– Central and peripheral
– 1 mg/kg/SQ/24h
Nutrition (3-4)
• Parenteral nutrition (2-3):
– high cost, complications.
• Enteral feeding:
– free acces or using nasogastric tubes...
• New concept: start nutrition as soon as
possible it will improves survival.
Antibiotics (1-3)
• Evidence: 1-3
• If there are risk of sepsis or abscess
• Grave cases.
• Broad spectrum:
– Ampiciline o cefalexine + enrofloxacine
Poma• Bad prognosis
• Treatment.
Tomy, Husky, male, 7y old
• Acute presentation of vomiting.
• Not doing well for the last month.
• Physical examination:
– Abodminal pain and distensión.
• Located in craneal abdomen.
– Pale mucous membranes.
– Tachycardia and tachypnea.
– Hypotension
CBC
• RBC (x10^6/µL): 6.55
• HCT (%): 46
• VCM (fl): 70.2
• CHCM (g/dl): 36
• WBC (/µL): 20160
– Lymp: 403
– Mono: 1008
– Band: 0
– Segm: 18749
– Eosin: 0
• PLT (x 10^3/µL): 336
• Coagulation profile:
– PT: 7 sec (6-8 sec)
– aPTT: 15 ( 9-16 sec)
– Fibrinogen: 480 mg/dl
(200-400)
– D-dimer: 1000-2000 (<200)
Biochemistry
• Creat (mg/dl): 1.1 (0.5-1.5)
• Urea (mg/dl): 70 (20-60)
• Cholesterol (mg/dl): 180 (135-270)
• Trylicerides (mg/dl): 100 (50-100)
• Glucose (mg/dl): 68 (80-118)
• Total proteins (g/dL): 4.8
– Alb: 1.2 (2.6-3.3)
– Alfa 1: 0,15 (0,2-0,5)
– Alfa 2: 1.31 (0,3-1,1)
– Beta: 1,81 (0,9-1,6)
– Gamma: 0,33 (0,3-0,8)
• Total bil (mg/dl): 0.09 (0,1-0,5)
• ALP (UI/L): 250 (20-156)
• GGT (UI/L): 5 (1,2-6,4)
• ALT (UI/L): 150 (21-102)
• Ca (mg/dl): 9.1 (9-11,3)
• K (mmol/L): 4.4 (4,37-5,35)
• NA (mmol/L): 145 (141-152)
• Cl (mmol/L): 107,8 (105-115)
• Phosp (mg/dl): 5,09 (2,6-6,2)
• Lipase (UI/l): 800 (13-200)
• Spec cPLI: 850 µg/L (<100)
Is it a pancreatitis case?
• Do we need further investigation?.
Tomy
• Abdominal fluid:– Total proteins: 3 g/dl
– WBC: 127.490/µl• Lymp: 0
• Eosinop: 0
• Macropha: 14024
• Neutrop: 1134667
– Creat: 0.7 mg/dl
– Lipase: 5136 U/L
– Glucose:, 40 mg/dl
– LDH: >2800 UI/L.
DO YOU THINK IT STILL BE
A PANCREATITIS?
Acute Pancreatitis - Conclusion
• The diagnosis of pancreatitis does not only depend on laboratory test results, but also on careful interpretation of the animal's symptoms, results of physical examination, presence of predisposing factors, correct interpretation of changes in laboratory tests, and diagnostic imaging findings, especially ultrasound.
• Vomiting and cranial abdominal pain are the most common presentations for animals with acute pancreatitis. However, milder cases of pancreatitis may not necessarily present with vomiting or abdominal pain.
New conceps: acute or
chronic
Pancreatitis spectrum
Pancreatitis: classification
• Basically histopathology and clinical
course.
• Acute:
– Neutrophils, necrosis, edema. Reversible.
• Chronic:
– Mononuclear cells and fibrosis.ç
– Often subclinical phase that end with a agute
presentetion (acute on chronic)
• Chronic pancreatitis:
– 26-34%
• Acute pancreatitis:
– 2%
• Breeds:
– Cavalier king Charles,
boxer, collies (and
Cockers)
Sensitivity of test in chronic
cases• Ultrasound:
– 56%
• TLI:
– 25%
• cPLI:
– 58%
• Lipase (3x):
– 28%
• DECREASED SENSITIVY BECAUSE LESS
PANCREAS LEFT
Acute or acute on chronic is
important?• No for immediate treatment.
• Affects long term management:
– Risk of recurrence.
– Risk of diabetes or EPI.
• Get clues at history.
• Only biopsy will give the right answer.