2. History Signalment Diet Vomiting Prior episodes Diarrhea

3. History Signalment Diet Vomiting Prior episodes Diarrhea

4. Physical Examination Anterior abdominal pain Icterus Profuse ascites Fever SQ abscesses

5. Physical Examination Anterior abdominal pain Icterus Profuse ascites Fever SQ abscesses

6. WHICH CBC(S) IS/ARE FROM DOG(S) WITH ACUTE PANCREATITIS?

7. 147033 147198 90524159796 PCV 28.528.83040 WBC30,00045,5009,80011,500 Segs26,10033,6704,6069,890 Bands 9002,7302,4500 Plat87,000407,000679,000470,000 Toxic mod modnonenone

9. Clinical Pathology An anorexic, vomiting dog with fasting hyperlipidemia probably has acute pancreatitis

10. Clinical Pathology An anorexic, vomiting dog with fasting hyperlipidemia probably has acute pancreatitis Most dogs with pancreatitis DO NOT have fasting hyperlipidemia

11. Clinical Pathology Amylase/Lipase – Sensitivity ~ 50% – Specificity ~ 50% TLI – Sensitivity ~ 35%

12. Clinical Pathology cPLI – Sensitivity ~ 80-85%

13. Sig: 7 yr M Boxer X CC: Anorexia/Vomiting HPI: Started 1 week ago snap PLI = pancreatitis Dog died despite therapy: Everything normal on gross necropsy

17. PANCREATITIS versus CLINICALLY IMPORTANT PANCREATITIS

24. Diagnostics cPLI – Sensitivity ~ 80% Abdominal ultrasound – Sensitivity probably ranges from 40% to about 65%

25. Diagnostics cPLI – Sensitivity ~ 80% Abdominal ultrasound – Sensitivity probably ranges from 40% to about 65% because clinicians rarely repeat the ultrasound

27. Diagnostics cPLI – Sensitivity ~ 80% Abdominal ultrasound – Sensitivity probably ranges from 40% to about 65% – Findings can change within hours...

28. WHAT IS THE BEST WAY TO DIAGNOSE CANINE ACUTE PANCREATITIS?

30. All things being equal, try to avoid surgery

31. THE REAL PROBLEM IS THAT ACUTE PANCREATITIS CAN PRESENT IN SO MANY DIFFERENT WAYS THAT YOU DON’T EVEN SUSPECT IT INITIALLY

32. TAMU#88267 Sig: 7 yr M Sheltie CC: Vomiting HPI: Began 5 weeks ago Partial anorexia, vomits phlegm or bile once daily Dog otherwise pretty healthy PE: No significant abnormalities

33. TAMU#88267 PCV =37% (35-55) WBC =21,800/ul (6,-16,000) Segs =20,274/ul (4,-14,000) Lymphs =840/ul (1,000 - 4,000) Platelets =255,000/ul (200, - 500,000)

34. TAMU#88267 Creatinine =2.0 mg/dl (< 2.0) BUN =36 mg/dl (8-29) Total protein =4.7 gm/dl (5.5-7.5) Albumin =1.7 gm/dl (2.5-4.4) ALT =10 U/L (< 130) SAP =31 U/L (< 147) Bilirubin =0.4 mg/dl (< 1.0) Urine:1.015 with 4+ protein

39. TAMU#159796 Sig: 9 yr M(c) Pug CC: Vomiting, yellow scleras HPI: Feeling bad 12 days ago Started vomiting, responded to fluid therapy, but became ill again when started feeding it Dog’s eyes turned yellow PE: Scleras yellow

40. TAMU#159796 PCV =40% (35-55) WBC =11,500/ul (6,-14,000) Segs =9,890/ul (4,-12,000) Lymphs =460/ul (1,-4,000) Eos =230/ul (100-1,250) Platelets =470,000/ul (200,-500,000)

41. TAMU#159796 BUN =4 mg/dl (8-29) Creatinine =0.7 mg/dl (< 2.0) Glucose =95 mg/dl (75-133) Potassium =3.6 mEq/L (3.8-5.1) Cholesterol =597 mg/dl (120-247) Albumin =2.9 gm/dl (2.5-4.4) ALT =1,691 IU/L (< 130) SAP =3,134 IU/L (< 147) Bilirubin =4.5 mg/dl (0-0.8)

45. TAMU #159796 4/9 4/114/13 4/15 4/16 ALT 1,691 2,108 1,275 SAP 3,134 3,753 3,633 Bili 4.5 4.5 4.8 2.6 1.2

46. TAMU #152494 Sig: 9 yr F(s) Dalmation CC: Vomiting/diarrhea HPI: Vomiting food/bile 6-8X in 2 weeks Diarrhea constantly for 2 weeks Decreased appetite for 10 days, anorexia for 5 days PE: T = 102.5 F, HR = 102/min

47. TAMU #152494 PCV =35.5% (35-55) WBC =21,700/ul (6,-14,000) Segs =15,200/ul (4,-12,000) Bands =630/ul (< 500) Lymphs =1,400/ul (1,-4,000) Platelets =568,000/ul (200,-500,000)

48. TAMU #152494 Sodium =152 mEq/L (138-148) Potassium =4.1 mEq/L (3.5-5.0) Glucose =107 mg/dl (60-120) Albumin =2.7 gm/dl (2.5-4.4) ALT =123 IU/L (< 110) SAP =2,174 IU/L (< 130) Creatinine =1.3 mg/dl (< 2.0)

49. TAMU #152494 Abdominal ultrasound: “… Small amount of anechoic effusion between liver lobes and around urinary bladder. Fine Needle Aspirate reveals turbid yellow tan fluid.”

50. TAMU #152494 Abdominal fluid: WBC =153,000/ul RBC =0/ul Total protein =4.6 gm/dl 90% nondegenerate neutrophils 8% macrophages, vaculated “Suppurative exudate”

52. TAMU #152494 “Chronic necrotizing and fibrosing interstitial pancreatitis with multifocal... suppuration and hemorrhage and peritonitis...”

53. Sterile pancreatitis versus Septic peritonitis

54. Abdominal fluid 147260152494152485109612 TP gm/dl 5.14.61.33.6 WBC/ul 15,059153,00070018,200 RBC/ul 91,112030,00083,700

55. PANCREATITIS CAN: a) make no abdominal effusion b) make a little abdominal effusion c) make a massive abdominal effusion

56. Pancreatitis can present as: acute vomiting with abdominal pain chronic, low grade vomiting/anorexia (abscess) icterus (biliary tract obstruction) ascites (minimal, little or lots) acute abdomen (looks just like septic peritonitis) SIRS (looks like septic shock) any really sick animal

57. SYSTEMIC INFLAMMATORY RESPONSE SYNDROME – used to be called “Septic shock”

58. SYSTEMIC INFLAMMATORY RESPONSE SYNDROME – inadequate perfusion of the body tissues because of an exaggerated inflammatory response

59. WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic circulation

61. Courtesy of Dr. Katrina Mealey

63. WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic circulation

64. Inflammatory cytokines Lymph nodes Systemic circulation WHAT CAN HAPPEN

65. EARLY -- SIRS Mild uneven vasodilatation “High output” shock Bright red mucus membranes Fast capillary refill time Bounding pulses Tachycardia

67. LATE -- SIRS Severe peripheral vasodilatation + poor cardiac contractility “Low output” shock Pale mucus membranes Weak pulses Slow refill time

68. THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding

69. THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Crystalloids Plasma Colloids Total/partial parenteral nutrition

70. THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Crystalloids Plasma Colloids Jejunostomy feeding (PEG-J, Nasal J, regular J)

71. THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Crystalloids Plasma Colloids Nutrition Analgesics

72. THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Analgesics Anti-emetics: if vomiting makes it hard to maintain hydration or patient is really miserable Proton-pump inhibitors: the same

73. OTHER POSSIBILITIES Antibiotics – “Regular” pancreatitis – SIRS

74. OTHER POSSIBILITIES Antibiotics Heparin

75. OTHER POSSIBILITIES Antibiotics Heparin Steroids – Critical Care Medicine 36: 296-327, 2008