Pancreatic Disease

What duct drains left lobe?

Pancreatic duct

Where does the pancreatic duct open at in the dog?

Opens at major duodenal

papilla, adjacent to bile duct

What makes the cat's pancreatic duct different than other animals?

Pancreatic ducts merges with CBD prior to entry into intestine

What duct drains the right lobe and opens at minor duodenal papilla?

Accessory duct

T/F Accessory duct may be absent in the cat

True

What are the THREE cells that make up the Exocrine: duct system?

- Acinar cells

- Centroacinar cells

- Intercalated ducts

Just read:

Endocrine: Islets of Langerhans

- Alpha cells: glucagon

- Beta cells: insulin

- Delta cells: gastrin, somatostatin

- PP cells: pancreatic polypeptide

okay

What cells digestive enzymes: initiate

digestion of protein, carbohydrate, lipid, and nucleic acid?

acinar cells

What THREE things are secreted by ductal cells?

-Bicarbonate & water

- Intrinsic factor

-Antibacterial proteins

What does the HCO3 and water do? (2)

• Neutralize duodenal pH

• Protect intestinal mucosa

What is important about intrinsic factor?

• facilitate cobalamin (vitamin B12) absorption in distal ileum

What is important to know about the pancreatic secretion of Intrinsic factor for cats?

relies on pancreatic IF for cobalamin

Why doesn't the pancreas digest itself? (2)

- Synthesis of inactivated zymogens

- Packaging of zymogens into granules

What in the duodenum activates trypsinogen and converts it into trypsin?

Enteropeptidase

What does trypsin do?

activates other zymogens

What is the regulator of trypsin so that sh*t doesnt go crazy?

Pancreatic secretory trypsin inhibitor

What is inflammatory infiltration of the pancreas and is relatively common?

pancreatitis

What form of pancreatitis is fully reversible and can be local or systemic infection?

Acute pancreatitis

What would you see on histology with Acute pancreatitis?

edema, neutrophils, necrosis

What would you expect to see with Chronic pancreatitis? (3)

-Lymphocytic/lymphoplasmacytic inflammation

- Irreversible changes, fibrosis

- Subclinical or recurrent episodes +/- decreased function

T/F Acute pancreatitis is typically seen in cats

False, it is sometimes seen but normally it is chronic pancreatitis

What is the pathogenesis behind pancreatitis? (3)

- Initiating event

- Premature activation of zymogen within acinar cell

- Trypsin inhibitor overwhelmed

What are some examples of initiating event of pancreatitis?

ischemia, inflammation, hypotension, oxidative stress, ductal obstruction

What is the "poster child" dog breed for pancreatitis and is thought to have genetic component?

Miniature Schnauzer

What are some breed disposition for acute pancreatitis?

Sheltie, Yorkie & other terriers, Poodle, Maltese, Bichon Frise, Samoyed,

Miniature Pinscher, Shih Tzu, Pomeranian, Miniature Dachshund

What are some breed disposition for chronic pancreatitis?

Cavalier King Charles, Boxer, Collie, English Cocker Spaniel

What is the most common cause of pancreatitis?

idiopathic

What are some other etiologies and risk factors of pancreatitis?

• Hypertriglyceridemia and Obesity

• Dietary indiscretion

• Endocrine disorders (Cushing's, Hypothyroidism, Diabetes mellitus (DKA))

• Other concurrent diseases

• Trauma, surgical manipulation

• Drugs

What are some drugs that may put dogs at risk for pancreatitis?

potassium bromide, phenobarbital, calcium, and L-asparginase

What are some complications of pancreatitis?

Chronic pancreatitis

• Ileus

• Diabetes mellitus (leading to DKA)

• Bile duct obstruction

• Exocrine pancreatic insufficiency

• Hepatic lipidosis (cats)

• Pancreatic abscess

• Pancreatic pseudocyst

• Ascites, bicavitary effusion

• Renal injury

What are the three disease that compose triaditis?

- Inflammatory Bowel Disease

- Pancreatitis

- Cholangitis

In cats, ____ ____ is a common channel at the duodenal papilla

Pancreaticobiliary sphincter

What can cause mechanical or functional obstruction to the common bile duct permits bile reflux into the pancreatic ductal system in cats?

Cholangitis ( this is commonly seen with pancreatitis)

What are some clinical signs of Pancreatitis in dogs?

- Vomiting

- Diarrhea

- Abdominal pain

- Dehydration

- Anorexia

- Regurgitation

- Depression/Lethargy

- Pyrexia

- Weakness

- Peritoneal effusion

- Icterus

What are the common clinical signs of pancreatitis in cats?

- Vomiting

- Dehydration

- Anorexia

- Depression/Lethargy

T/F Pancreatitis requires a combination of

diagnostics for diagnosis

True

What are some diagnostics that you would maybe do to help you diagnose pancreatitis?

• MINIMUM DATABASE

- CBC

- Chemistry

- Urinalysis

Imaging

- Radiographs

- Abdominal Ultrasound

T/F With pancreatitis, the WBC are variable

True

What would you expect to see on PCV with pancreatitis?

- Hemoconcentration

- Anemia

What would you see on serum chemistry with pancreatitis?

• Azotemia: pre-renal or renal

• Hypoalbuminemia (mild)

• Hypocalcemia in severe cases

- Secondary to hypoalbuminemia

- Formation of calcium soaps - saponification of fat

• Electrolyte abnormalities

• Liver enzyme (ALP> ALT) and bilirubin increase

• Hyperlipidemia

• Metabolic acidosis

• Amylase and lipase

T/F Amylase and lipase are diagnostic for pancreatitis

false, they are nonspecific, insensitive, not recommended

Pancreatitis is the most common cause of what that involves the liver?

extrahepatic biliary

duct obstruction

T/F Ultrasounds is dependent on operator skill and equipment

True

What would you expect to see on ultrasound with acute pancreatitis?

• Enlargement of the pancreas

- Hypoechoic pancreas

- Hyperechoic mesentery/fat

What does the Hypoechoic pancreas indicative of?

inflammation

What would you expect to see on ultrasound with chronic pancreatitis?

Hyperechoic (bright) pancreas: fibrosis

What marker of pancreatitis in dogs measures pancreatic lipase exclusively, increased in disease and specific for exocrine function and

pancreatitis?

Canine pancreatic lipase

(cPLI / Spec cPL)

T/F Canine pancreatic lipase

(cPLI / Spec cPL) has the highest sensitivity (70%) and specificity (77%)

True

What should you use to diagnose pancreatitis in cats?

Feline pancreatic lipase (fPLI /

Spec fPL)

T/F Feline pancreatic lipase has Highest sensitivity (40-60%) and specificity (68-100%)

True

If you get a positive on a cPL or fPL, what does this mean?

Positive is likely to be a true positive but

cannot rule out disease

If you want to get a DDX, then you can do cytology. What would see on cytology for Acute pancreatitis?

Acute: acinar cell necrosis with neutrophilic inflammation

What does cytology really help with more than an actual diagnosis?

R/O neoplasia, abscess, pseudocyst

Why is a pancreatic biopsy questionable for a gold standard diagnosis?

Normal does not rule out pancreatitis

What is the treatment for pancreatitis?

- Fluid therapy: Balanced isotonic crystalloids

What antiemetic NK1 antagonist can you give to treat pancreatitis?

Maropitant (Cerenia)

What antiemetic 5-HT3 antagonists can you give to treat pancreatitis?

• Ondansetron (Zofran)

What antiemetic D2 antagonist + prokinetic can you give to treat pancreatitis?

Metoclopramide

If a dog has pancreatitis, what diet should you be feeding them?

Dog: Low fat

If a cat has pancreatitis, what diet should you be feeding them?

Novel protein / hypoallergenic

What drugs can you use for pain control of pancreatitis?

Opioids

Why are Antimicrobials not recommended for treatment of pancreatitis?

- Pancreatitis mostly sterile process

- Keep in mind possibility of bacterial translocation

Why are steroid not recommended for treatment of pancreatitis?

No benefits with acute pancreatitis

Why are NSAIDS not recommended for treatment of pancreatitis?

can cause/enhance pancreatitis

Why are acid suppressants not recommended for treatment of pancreatitis?

- Not indicated unless evidence of ulceration is present

Why are Plasma transfusion not recommended for treatment of pancreatitis?

Controversial, often not indicated unless bleeding from DIC

Why are Surgical intervention not recommended for treatment of pancreatitis?

- Not indicated unless pancreatic abscess is present

How do you prevent pancreatitis?

• Low-fat diet for life

• Avoid treats (mainly high fat) as much as possible

What do you need to keep in mind with the diet if the owner cannon afford a prescription diet?

Fat just needs to be lower than previous diet

T/F There is no real way to prevent 100% ultimately

True

What disease process has insufficient synthesis and secretion of digestive enzymes from the exocrine pancreas?

Exocrine pancreatic insufficiency

What is the MAIN etiology of EPI?

• Pancreatic acinar atrophy (PAA)

What are some other causes of EPI?

• Chronic pancreatitis (it causes destruction of PAA)

• Occluded pancreatic duct

• Congenital hypoplasia / aplasia

What is the posterchild for EPI?

Young German Shepherd Dog

What are some other breeds that are predisposed to EPI?

- Rough Coated Collie*

- Eurasian*

- Chow Chow

- Cavalier King Charles Spaniel

What is the pathogenesis of EPI?

• Lack of pancreatic acinar cells → maldigestion

↓ Bicarbonate, which buffers gastric acid

What substance is made in the exocrine pancreatitis and is is the main/only source of intrinsic factor in the dog/cat

cobalamin

Would you expect to see high or low cobalamin with EPI?

low

What are the clinical signs of EPI?

Weight loss

• Stool - Steatorrhea

-Polyphagia, pica, coprophagia

• Borborygmus, flatulence

• Poor hair coat

What is a common associated condition that is due to the lack of pancreatic intrinsic factor?

obalamin deficiency

add other conditions later

slide 54

What are some DDX of EPI?

– Hyperthyroidism

– Diabetes mellitus

– Inflammatory bowel disease

– GI neoplasia

– Some GI parasites

– Pythiosis/histoplasmosis

– Other infiltrative bowel disease

What is the gold standard, highly species specific, that measures concentrations of Cationic trypsinogen, trypsin and is used to diagnose EPI?

Trypsin-like immunoreactivity (TLI)

Why is the Fecal pancreatic elastase not recommended as a test by itself but is used to verify + result with cTLI/fTLI?

- Plasma turbidity test

- Para-amino benzoic acid test

- Fecal proteolytic activity

- X-ray film digestion

What are the TWO ways that you can treat using replacement of digestive enzymes?

1. Dried extract from beef or pork pancreas -

Powder preferred

2. Fresh raw pancreas (beef, pork, sheep, game)

What a concern of using raw pancreas?

risk of parasites and infectious disease

What is like super de duper important that you do with the replacement of digestive enzymes?

• Mix with food immediately before serving! (wait 15 min)

T/F With EPI you may need to change the diet to low faw and low fiber-may interfere with fat absorption

False, low fat diet isn't necessary and you want to avoid high fiber things

What may need to be supplemented SQ and may need to be lifelong supplementation in EPI patients?

Cobalamin

What is the main reason that treatment of EPI fails?

there is a concurrent disease present (Inflammatory bowel disease, diabetes mellitus, small intestinal dysbiosis)

What are some things that you can do if the treatment of EPI fails?

• Antacids (gastric acid destroys many of the enzymes)

• Hypoallergenic diet

• Glucocorticoid: if concurrent IBD and/or cholangiohepatitis

What is the LAST resort for treatment of EPI and why is that?

lower fat diet because there is a risk of fat-soluble vitamin deficiency and EFA deficiency

T/F EPI dogs most have a normal quality and quantity of life!

True

the last 17 slides are case examples <3

love you girl