Pancreatic Conditions

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Pancreatic Conditions IVSA Standing Committee of Veterinary Education

Normal function of Pancreas: 1. Exocrineà Acinar cells produce digestive enzymes. Duct cells make pancreatic juice.

2. Endocrineà beta cells produce insulin to decrease blood glucose levels after a meal and alpha cells produce glucagon to increase blood glucose levels. Pancreas also produces pancreatic polypeptide and Somatostatin.

Exocrine Pancreatic Insufficiency (EPI) Aetiology: 1. Pancreatic Acinar Atrophy Most common type! Occurs most commonly in 6 month- 5 year old dogs. Occurs in German Shepherd Dogs, Rough Collies, Spaniels, Chows or mixed breeds. It is a heritable trait and cause is unknown and it may be preceded by lymphocytic infiltration of pancreas. It is potentially immune mediated but does not respond to immunosuppressant’s.

2. Pancreatic hypoplasia Rare! A congenital condition at less than 6 months of age and leads to poor growth. It maybe associated with juvenile diabetes mellitus.

3. Chronic pancreatitis Associated with repeated bouts of acute pancreatitis that eventually destroys all functional reserve.

EPI is very rare in cats and if it does occur it usually is associated with chronic pancreatitis.

JAN 2016 THE LOREM IPSUMS

SCoVE FALL 2016

Clinical signs: 1. Foul smelling greasy faeces (steatorrhoea) 2. Weight loss 3. Increased appetite (polyphagia) 4. Coprophagia 5. Vomiting

Diagnosis: Diagnosis can not be made on clinical signs alone.

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Serum Trypsin-like immunoreactivity (TLI)

Naturally the pancreas leaks trypsinogen (pancreatic enzyme) into the blood, but in EPI it is not produced and thus little to none leaks out into the blood. This test measures trypsinogen in the blood. More details on the test are detailed on the link attached: http://vetmed.tamu.edu/gilab/service/assays/tli

Treatment: Ø Oral Pancreatic extract- pancreatic enzyme supplements, fresh frozen pancreas. Ø Diet- highly digestible low fat and high non-complex carbohydrate food fed in small frequent amounts. Ø Vitamin Supplements- vitamin B12 and vitamin E Ø Antibiotics- only if secondary bacterial growth suspected!

Pancreatic Neoplasia Uncommon in dogs and very rare in cats! Ø Ductular and acinar adenocarcinoma Uncommon but occurs in old dogs and is clinically silent until advanced diseases, which has a grave prognosis. The pancreatic tumour blocks the bile ducts and leads to metastatic spread with concurrent signs of pancreatitis. Ø Islet cell tumour •

Insulinomaà high levels of insulin and hypoglycaemia

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Gastrinoma à gastrin à excess gastric acid à gastric ulcers (Zollinger-Ellison syndrome 2

SCoVE FALL 2016

JAN LOREM 2016 THE IPSUMS Treatment: o Surgical excision o Frequent feeding of complex carbohydrates o Glucocorticoids to antagonize insulin o Diazoxide to block insulin release.

Acute Pancreatitis Clinical details: Fairly common in dogs and high in obese middle aged female dogs. Rare in cats.

Aetiology: •

Idiopathic- ‘fat’ which is frequently associated with high fat diets, obesity and lack of exercise and hyperlipidaemia

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Pancreatic ischaemia- e.g. hypovolaemia, Anaesthesia etc.

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Trauma

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Iatrogenic (drugs- e.g. Potassium Bromide)

Pathogenesis: Experimentally, evidence shows it is caused by intracellular activation of trypsin (protease) within pancreas. This leads to antiprotease defence overwhelmed and local release of pancreatic enzymes.

This leads to auto-digestion and enzymatic destruction of pancreas from mild interstitial to severe hemorrhagic pancreatitis. Local effects include localized peritonitis and peri-pancreatic fat necrosis.

Systemic effects include: renal failure, cardiac arrhythmia, pleural effusion and shock.

Case Study A 3 year old Mixed breed dog comes into the vets and has lost weight dramatically the past week and is always very hungry and has pale white faeces 1. History and Physical Examination 2. In practice TLI test. Most likely pancreatic acinar atrophy due to young age and it is the most common pancreatic disorder.

3. Prescribe oral pancreatic enzymes, vitamin supplements and low fat and high carbohydrate diet (feed small frequent meals).

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SCoVE FALL 2016

JANLOREM 2016 THE IPSUMS Clinical signs:

Ultrasound Image

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Depression, anorexia

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Vomiting

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Lethargy

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Right cranial abdominal pain- leads to apparent back pain

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Dehydration

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Tachycardia and Tachypnoea

Diagnosis: 1. History and physical examination 2. Radiography and ultrasound 3. Pancreas- specific proteins- pancreatic lipase immune-reactivity (canine and feline specific test) used to rule out pancreatitis. High test sensitivity and low test specificity. The VET Talks video explains test sensitivity and test specificity: http://ivsascove.wix.com/ivsascove#!vettalks/c7e4 4. Routine Blood work Dog

Cat

Leukocytosis- neutrophilia

Leukocytosis/leukopenia

Hyperglycaemia

Hyperglycaemia

Hyperlipaemia

Azotaemia

Hypocalcaemia

Hypocalcaemia- poor prognostic sign

High serum activity of liver enzymes- AST and Hypokalaemia, hypercholesterolaemia ALT

Treatment: 1. Feed within 48 hours of low fat highly digestible diet. Early feeding associated with better prognosis. Feed either via oral/tube feeding after anti-emetics or parenteral IV nutrition is patient is vomiting.

2. Parenteral fluids- crystalloid fluids to maintain extra-cellular fluid volume and/or whole blood to provide circulating anti-proteases.

3. Analgesia- opioids 4. Anti-emetics 5. Antibiotics if abscess develops. Can do surgery but worsens hypotension.

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SCoVE FALL 2016

JAN 2016 THE LOREM IPSUMS Long-term therapy:

Frequent small amounts of water once vomiting stops and can take up to 2 weeks. The slowly introduce high-carbohydrate low fat diet and long-term dietary control and weight reduction.

Prognosis: Guarded and most acute cases die and hypocalcaemia in cats is a poor prognostic sign. Recurrence is common. Possible squealae include: chronic pancreatitis, exocrine pancreatic insufficiency and/or diabetes mellitus.

Chronic Pancreatitis Aetiology in Dogs: Repeated attacks of acute pancreatitis Chronic low grade pancreatitis à Causes progressive destruction of glandular tissue and fibrosis and may results in EPI and/or diabetes mellitus.

Aetiology in Cats: Usually have chronic low grade persistent interstitial pancreatitis, causing no or vague clinical signs.

It is associated with lyphocytic cholangitis and inflammatory bowel diseaseà TRIADITIS Sometimes associated with hepatic lipidosis (excess fat accumulation in liver).

Diagnosis and Treatment: Pancreatic mass and calcification can be palpated or seen radiographically. Can also do Trypsin like immunoreactivity test.

Treatment Plan: dietary control, weight reduction and oral pancreatic enzymes for long-term management.

Here is a short video on pancreatitis: https://www.youtube.co m/watch?v=Z3LGWAKE ECY

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