Microsoft word - pancreatitis.docm

Pancreatitis is defined as inflammation of the pancreas and can be caused by a number of inciting factors. The pancreas is responsible for tasks such as glucose regulation and aids in the digestion of food. Accordingly, two separate parts are responsible for these functions: the endocrine portion, which produces insulin for glucose regulation and the exocrine portion, which produces enzymes for food digestion. While the origin of most cases remains unknown, several predisposing factors have been identified. Inciting factors for dogs and cats include high fat meals, such as table scraps and other “people food,” physical trauma to the organ, and concurrent systemic disease (diabetes, Cushing’s disease, high triglycerides) or local disease involving the liver or gastrointestinal tract. History, Signs, and Physical Examination Dogs and cats with pancreatitis can have a wide variety of signs, which include, but are not limited to the following:  Vomiting  Diarrhea  Decreased appetite  Visibly painful abdomen; abnormal or hunched posture  Lethargy, playing less, depression  Weight loss  Hiding more or becoming more clingy  Other signs related to concurrent disease The course of the disease can be acute or chronic, depending on inciting factors. Dogs most commonly present for vomiting, while cats most commonly present for decreased appetite. In chronic cases, signs may wax and wane, worsening in times of stress. Cats commonly present with concurrent disease related to liver and gastrointestinal tract Some dogs and dog breeds are also more genetically predisposed to pancreatitis than others. Miniature Schnauzers are considered at higher risk for pancreatitis. No age or sex predilection has been identified. Unfortunately, pancreatitis can be difficult to diagnose. The gold standard for diagnosing it is obtaining biopsies (wedges) of tissue to be evaluated by a pathologist (histopathology); this requires surgery to obtain the sample of the pancreas. While this is the only way to say 100% that pancreatitis is present, there are other tests that are supportive of a diagnosis of pancreatitis.  Amylase and lipase: These are fairly non-specific blood tests to evaluate for pancreatitis in dogs. A portion of patients with pancreatitis will have increased amylase and lipase concentrations. Other diseases can elevate these values, too. There is no correlation between elevation of these values and pancreatitis in cats.  Radiographs (x-rays): Some patients with pancreatitis will show changes on abdominal radiographs. Decreased detail may be seen due to fluid build-up in the abdomen secondary to the inflammation with pancreatitis. You may also see slight change in the positioning of the gastrointestinal loops. Abdominal radiographs are also used to rule out non-pancreatitis diseases that can cause similar signs such as gastrointestinal foreign bodies. Pancreatitis can also cause fluid accumulation around the lungs (pleural effusion). Therefore, chest radiographs are sometimes recommended.  Abdominal ultrasound: This test allows us to see within the abdominal organs in much more detail than radiographs. We can see the pancreas to see if there is enlargement, thickening, masses within the pancreas, or changes in brightness of the pancreas (often darker with acute pancreatitis and brighter with chronic pancreatitis). The area around the pancreas (mesentery) can also be evaluated for changes (often bright with acute pancreatitis)  Pancreatic lipase immunoreactivity assay (PLI): This is a blood test that looks at a more specific type of lipase that comes from the pancreas. It is more sensitive and specific than the basic lipase test, although there are still false positives and negatives with this test. For dogs, there is an in-house version of the test. For cats and for some cases in dogs, we send out the blood for a PLI test to be run at an outside laboratory (usually Texas A&M).  Serum biochemistry: Patients with pancreatitis may have changes in some of their liver enzymes (increase with inflammation or irritation of the liver) and even bilirubin. Bilirubin is processed by the liver and excreted by the gall bladder through the bile duct. The bile duct runs right by the pancreas and with severe inflammation of the pancreas, this duct can become partially obstructed, leading to high bilirubin. Albumin, one of the main proteins in the blood, can decrease secondary to inflammation or ulceration within the gastrointestinal tract. Globulin, another protein within the blood, can also become low with a gastrointestinal ulceration. Pancreatitis can also lead to electrolyte abnormalities. No test is 100% diagnostic for pancreatitis. Linking laboratory abnormalities with the history and clinical signs helps us to arrive at a tentative diagnosis, as well as rule out other causes. A high PLI (pancreatic lipase immunoreactivity) test result, along with concurrent clinical signs, helps to rule in pancreatitis. An abdominal ultrasound may show inflammation associated with the pancreas and possibly effusion if severe. No specific cure for pancreatitis exists; accordingly, treatment is symptomatic and supportive. Intravenous fluids, pain relief, anti-nausea medications, and nutritional support are commonly administered. Feeding is controversial, but helps to maintain the integrity of the gastrointestinal tract. Other, more specific, treatments are also given for the inciting cause, if identified. Serial blood tests may also be necessary. o Metoclopramide (Reglan) – This medication helps to decrease nausea and can increase the motility of the stomach and upper intestines. It can be given in hospital as a continuous infusion. We can give it as a pill or liquid every 8 hours at home. Side effects are rare with this medication. o Anzemet/Zofran: These are two medications that can be used to decrease nausea. Typically, Anzemet is given injectibly in the hospital. Zofran, a similar medication, comes as a pill that can be given at home. Usually, we give Zofran (ondasetron) every 12 hours. Side effects are rare with these medications. o Cerenia: This medication can be used to decrease nausea. It can be given under the skin in the hospital or as a pill at home. Unfortunately, you can only give this medication for 5 days in a row and then have to stop giving it for several days to ensure that the blood levels do not become too high. We used this medication in both dogs and cats, although it is considered “off label” in cats at this time. This medication can also be used to treat motion sickness in dogs.  Famotidine (Pepcid) – This medication is a H2 blocker antacid. It can be given every 12 – 24 hours. You can buy it at most pharmacies. You should by the generic version of this medication, as it is the same thing as brand name Pepcid but costs significantly less.  Ranitidine (Zantac) – This medication helps to increase gastrointestinal motility and reduces the amount of acid within the stomach. It is usually given every 12 hours. This medication can be bought over the counter at pharmacies, but often needs to be specially compounded for smaller patients.  Omeprazole – This medication is a protein pump inhibitor (PPI) antacid. They have been shown to have strong antacid properties than H2 blockers. This medication can be bought over the counter at pharmacies, but often needs to be specially compounded for smaller patients. This medication is usually given once a day.  Sucralfate (Carafate) – This medication coats any ulcerations that are present to form a protective barrier, which allows the ulceration to heal faster. Sucralfate must be given on an empty stomach and cannot be given at the same time as other medications as it will decrease how well these other medications are absorbed. Rarely, this medication can cause constipation.  Barium – This medication can be used to coat ulcers in the stomach and can coat all the way down to the colon to decrease irritation that can lead to diarrhea. This medication cannot be given at the same time as food or other oral medications. This medication can cause significant lung problems if the patient vomits it and inhales it into the lungs. When barium passes in the stool, it makes the feces a chalky white color. Barium can cause constipation. o Tramadol – This is one of the most common oral pain medications on which we send canine pancreatitis home. There is a large dose range for dogs; we usually start with at least every 6-8 hours dosing. The main side effect is sedation; if the patient becomes too sedate, you should cut the amount of medication or the frequency that you administer it. o Buprenex – This medication can be given to cats or small dogs for pain relief. It is absorbed by the gum in the mouth so when you give it, you should not aim for it to go down the throat. The main side effect is sedation; if the patient becomes too sedate, you should cut the amount of medication or the frequency that you administer it. o Fentanyl patch – This medication is a patch that goes on the skin through which fentanyl (a pain medication) can absorb in a continuous manner. In general, it takes about 12 hours for this medication to start working and it tends to last 3-4 days in most dogs and cats. The main side effect of this medication is sedation. It is really important not to let your pet or any small children get ahold of this patch. If a dog, cat, or human eats the patch, it can cause a potentially fatal dose of fentanyl to be absorbed all at once. o Metronidazole (Flagyl) – This medication is an antibiotic that has anti- inflammatory properties in the gastrointestinal tract. Side effects are rare but include decrease appetite. Neurologic side effects including seizures can occur but usually only occur if higher doses (> 30 mg/kg/day) are given. o FortiFlora – This medication is a probiotic, good bacteria for the patient’s gastrointestinal tract. Human studies show that probiotics can reduce the severity and complication rate in pancreatitis and can decrease the length of hospitalization needed. FortiFlora is one type of probiotic that is specifically made to taste good to dogs and cats. It can be sprinkled on the patient’s food or mixed with a small amount of water and given via a syringe. One packet is given once a day. Prognosis for dogs and cats varies depending on severity of the disease and on the inciting causes. For example, pancreatitis resulting from dietary indiscretion typically carries a better prognosis than cases with more severe inciting causes, such as cancer. Several sequalae can occur secondary to pancreatitis.  Gastrointestinal ulceration – Ulcers within the stomach and intestines can occur secondary to the inflammatory reactions seen with pancreatitis. These ulcers can cause a patient to lose blood, be nauseous, have a decreased appetite, or have diarrhea. Often we will treat pancreatitis patients with antacids such as famotidine (Pepcid) or omeprazole (Prilosec) to decrease the amount of stomach acid and, therefore, reduce the risk of ulcers forming. If ulcers are already present, we use sucralfate (Carafate) to help bind to the ulcer as a protective layer to allow faster healing.  Low serum albumin – This is the main protein in the blood. A pet’s albumin concentration can decrease with pancreatitis secondary to the severe inflammatory or due to ulceration of the gastrointestinal tract. Albumin is responsible for keeping the fluid component of blood within the blood vessels. Therefore, when the albumin concentration falls, the fluid may leak out of the blood vessels and between the surrounding cells. This process can lead to edema under the skin (usually seen first in the feet, muzzle, and underside of the abdomen), fluid within the abdomen (peritoneal effusion), fluid around the lungs (pleural effusion), or fluid within the lungs (pulmonary edema).  Blood clots – due to the severe inflammatory response that can be seen with pancreatitis, the body may be more prone to developing blood clots. In dogs and cats, the most common location the blood clot goes to is to the lungs. If this occurs, the patient will acutely have severe difficulty breathing (increased respiratory rate and effort). Blood clots can also go to the legs (acutely not able to use that leg, very painful, often cold to the touch), gastrointestinal tract (acute worsening of severe vomiting and diarrhea), the kidneys, the heart (collapse, difficulty breathing, or acute death), or brain (seizures, coma, or acute death). Long-term monitoring of PLI for chronic pancreatitis cases is useful. If the patient has developed low albumin or high bilirubin, we usually recommend rechecking blood work to verify that these values have normalized.

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