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Devastating pancreatitis and duodenal necrosis in a dog
Case advisors: Dr K Murphy, Dr J BrownProgram advisor: Dr K Mathews
Signalment and history‘Kita’ 6 y.o NF HuskyIdiopathic epilepsy since 1
y.o, on phenobarbGot into garbage 5 days
prior to admissionVomiting 48 hours laterGeneralised seizures X 2Hospitalised on IV fluids
for last 2 days, no improvement
Physical examGeneralised weakness, mentally dullPyrexic at 40.1°CHR=200bpm, normotensiveAbdominal pain, abdominal free fluidInjected m.membs
Assessment: Hypovolemic +/- distributive shock DDx- severe acute pancreatitis vs septic peritonitis
Treatment: IV fluid bolus 20ml/kg PLA Hydromorphone
Lab findingsAbdominal fluid cytology-
degenerate neutrophils +++, no bacteria
Severe mixed metabolic and respiratory acidosis
PvCO2=30mmHg (27.9 )BE=-13.3Hyperchloremic (-9 of
BE)Lactate=2.7
Lab findingsCoagulopathic- PT and
aPTT 2X high normalPlatelet count 154,000Albumin=26g/LCreatinine=297umol/lTBIL=68umol/lLipase=11,620Leukocytosis + left shift
9% bands
Assessment?early DICrenal insultsuspect biliary
obstruction
Imaging
Imaging
Assessment
Severe acute pancreatitis+SIRS+/- DIC
Global perfusion compromise, acute renal insult, at risk for ARF
Suspect common bile duct obstruction
?? SepsisSuspect duodenal FB
Mechanisms of renal insult in acute pancreatitis
Renal injury
Loss of protective autoregulation
Microthrombus, ischemia, tissue damage
Cytokines
Endotoxins
Bilirubinemia
↑Blood viscosity, ↓RBC deformation
↓Glucagon
Hypovolemia
Vomiting, 3rd space losses, vasodilation
Stabilisation planCrystalloids 50ml/kg+ pentastarch 5ml/kg to achieve
adequate volume status- HR↓ 124bpmU-cath- monitor urine output as @ risk for ARFFentanyl analgesiaFFP 10ml/kg vs coagulopathyNG tube passed, aspirated 1500mls gastric fluidAmpicillin 22mg/kg Q6 pending cultures
Surgical plan‘Seek and destroy’ FBView pancreas- biopsy for
histo+ cultureVisualise biliary systemLavage abdomen and
place abdominal drainsPlace e-tubePlace central line
Blood supplyExocrine ducts
• 68% dogs have pancreatic duct and accessory pancreatic duct
• Accessory duct >>pancreatic duct
• 32% have accessory duct alone, or 3 ducts
Biliary ducts
Options?Duodenum necrotic from
pylorus to 20cm distallyEntire right limb of the
pancreas necroticCommon bile duct
occludedLeft limb of the pancreas
inflamed
Literature reviewNo case series or formal case reports xTechnique of canine total
pancreatectomy for generating a human diabetes research model
Anecdotal reports- EPI+DM
Human literature reviewSakorafas GH Experience with duodenal necrosis- A rare
complication of acute necrotizing pancreatitis International J Pancreatology 1999
Kingham TP Management and spectrum of complications in patients undergoing surgical debridement for pancreatic necrosis The American Surgeon 2008
Heidt DG Total and partial pancreatectomy: Indications, Operative technique, Postoperative sequelae J Gastrointest Surg 2007
Kahl S Exocrine and endocrine pancreatic insufficiency after pancreatic surgery Clinical Gastroenterology 2004
Pancreatic surgery in acute pancreatitisIndications in humans...
Bacteria on cytology or culture from aspirates of peripancreatic fluid
- manifests lateCT signs of abscess or wide area
failing to enhance→necrosisPersistent sepsis manifesting as
hemodynamic instability without identifiable source
Failure to improve after> 14 days
Key points...Anticipate staged approach and need for
several proceduresConservative technique
Retain all tissues/ structures until inflammation ↓ Place drains to
Remove local fluid collections Achieve temporary biliary bypass- flank cystostomy tubes Evacuate intraluminal duodenal /gastric secretions
Manage small duodenal perforations with local drainage until later definitive repair
Achieve enteral feeding
InsulinHormone of energy
storageInsulin dependency
likely post pancreatectomy > 50% (pancreatitis) >80% neoplasia
‘Brittle’ diabetesGlargine insulin of
choice
GlucagonHormone of energy releaseDeficit results in
↑insulin sensitivity ↑hypoglycemic crises ↓ketosis ↓catecholamine
response to hypoglycemia
hepatic lipidosisDog has some enteric
sources of glucagon
Pancreatectomy- impact on endocrine function
Pancreatectomy- impact on exocrine functionEPI inevitable in TP or if pancreatic duct and accessory
pancreatic ducts lost↓ HCO3 in GI→ chronic ulcersMalabsorbtion compounded by concurrent gastrectomyLong term therapy with
Pancreatic enzymes Proton pump inhibitors Multivitamins
Surgical re-routing of exocrine secretions possible
Duodenectomy and partial pancreatectomyAdvantages
Lower risk of insulin dependency vs TP (30-50% vs 100%)
Some glucagon secretion maintained →↓hepatic lipidosis
Disadvantages Exocrine duct ligation → EPI+
acute/ chronic pancreatitis in pancreatic remnant
Pancreaticojejunostomy?
Partial pancreatectomy , choleduodenostomy and pancreaticojejunostomy
Total pancreatectomyInsulin dependency, ‘brittle’
diabetes inevitableEPI inevitableBiliary re-routing requiredSplenectomy may be requiredPancreatic pain reducedInflammatory focus removed
High complication rate20-40% mortality with severe
pancreatic necrosis80-100% mortality with infected pancreatic necrosis
managed non-surgicallyMedian ICU stay 20 days15-20% incidence of ARF40-60% incidence ARDS requiring mechanical ventilation20% incidence significant intra-abdominal hemorrhage
Outcome for Kita......euthanasia in surgery
Questions?