5/21/2013 TAMU # TAMU # TAMU #203505

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1 TAMU # Sig: 14 yr M(n) Shih Tzu CC: Abdominal pain HPI: Began two days ago, has vomited once PU-PD for one week Normal appetite/body weight PE: No significant abnormalities TAMU # PCV = 24% (35-55) WBC = 23,300/ul (6,-14,000) Segs = 17,475/ul (4,-12,000) Bands = 0/ul (< 500) Lymphs = 4,660/ul (1,- 4,000) Platelets = 498,000/ul (200,- 500,000) TAMU # Creatinine = 0.78 mg/dl (< 2.0) Calcium = 9.7 mg/dl ( ) Sodium = 153 meq/l ( ) Potassium = 3.8 meq/l ( ) Albumin = 2.7 gm/dl ( ) ALT = 8,258 IU/L (< 130) SAP = 2,354 IU/L (< 147) Bilirubin = 0.3 mg/dl (0-0.8) 1

2 TAMU # Snap PL: positive Your best next step is: 1 Repeat cpli and ultrasound 2 Abdominal CT (pancreas) 3 Tx for acute pancreatitis 4 Diagnostic laparoscopy 5 Hepatic lobectomy 8 2

3 WHEN DO YOU SUSPECT AND HOW DO YOU DIAGNOSE CANINE ACUTE PANCREATITIS? History Signalment Diet Prior episodes Vomiting Diarrhea Physical Examination Anterior abdominal pain Less common findings: icterus profuse ascites fever SQ abscesses 3

4 WHICH CBC(S) IS/ARE FROM DOG(S) WITH ACUTE PANCREATITIS? PCV WBC 30,000 45,500 9,800 11,500 Segs 26,100 33,670 4,606 9,890 Bands 900 2,730 2,450 0 Plat 87, , , ,000 Toxic mod mod none none Clinical Pathology Amylase/Lipase Sensitivity ~ 50% Specificity ~ 50% TLI Sensitivity ~ 35% cpli Sensitivity ~ 80-85% 4

5 Your best next step is: 1 Repeat cpli and ultrasound 2 Abdominal CT (pancreas) 3 Tx for acute pancreatitis 4 Diagnostic laparoscopy 5 Hepatic lobectomy 8 5

6 PANCREATITIS versus CLINICALLY IMPORTANT PANCREATITIS Sig: 7 yr M Boxer X CC: Anorexia/Vomiting HPI: Started 1 week ago Lipase > 6,000 U/L snap PLI : pancreatitis Dog died despite therapy: Everything looks normal on gross necropsy and histopath 6

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8 Diagnostics cpli Sensitivity ~ 80% Abdominal ultrasound Sensitivity probably ranges from 40% to about 65% Findings can change within hours... Radiographs Ultrasound Find evidence suggestive of pancreatitis Eliminate other abdominal diseases 8

9 WHAT IS THE BEST WAY TO DIAGNOSE CANINE ACUTE PANCREATITIS? Patient with possible acute pancreatitis Find evidence suggestive of pancreatitis Imaging (ultrasound) Eliminate diseases mimicking pancreatitis Chemistry panel Abdominal imaging cpli All things being equal, try to avoid surgery THE REAL PROBLEM IS THAT ACUTE PANCREATITIS CAN PRESENT IN SO MANY DIFFERENT WAYS THAT YOU DON T EVEN SUSPECT IT INITIALLY 9

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

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12 TAMU # /2008 Fluid:... large numbers of nucleated cells and small numbers of erythrocytes in a thick proteinaceous background with many lipid droplets.... nucleated cells are composed almost exclusively of neutrophils with only rare macrophages observed. The neutrophils are poorly preserved and degenerate in appearance... 12

13 TAMU # /2009 Fluid: TP = 5 gm/dl Cytology:... large amounts of granular and ropy necrotic and proteinaceous material. No intact nucleated cells are found... scattered bright yellow needles and globular material that is either bilirubin or a form of hematoidin. In addition, more typical, rhomboidal hematoidin crystals are found. 13

14 TAMU # Sig: 9 yr M(c) Pug CC: Vomiting, feeling bad, yellow HPI: Began feeling bad 12 days ago Started vomiting, responded to fluid therapy, but became ill again when started feeding it Dog turned yellow PE: Scleras yellow TAMU # 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) TAMU # BUN = 4 mg/dl (8-29) Creatinine = 0.7 mg/dl (< 2.0) Glucose = 95 mg/dl (75-133) Potassium = 3.6 meq/l ( ) Cholesterol = 597 mg/dl ( ) Albumin = 2.9 gm/dl ( ) ALT = 1,691 IU/L (< 130) SAP = 3,134 IU/L (< 147) Bilirubin = 4.5 mg/dl (0-0.8) 14

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16 You hope this is something that you do not see during surgery because... Trying to resect the mass is the WORST thing you can do 16

17 Should you decompress the biliary system? TAMU # /9 4/11 4/13 4/15 4/16 ALT 1,691 2,108 1,275 SAP 3,134 3,753 3,633 Bili Making a visual diagnosis of pancreatic carcinoma is a BAD idea 17

18 PANCREATITIS IS MUCH MORE COMMON THAN PANCREATIC CANCER TAMU # 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 = F, HR = 102/min 18

19 TAMU # 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) TAMU # Sodium = 152 meq/l ( ) Potassium = 4.1 meq/l ( ) Glucose = 107 mg/dl (60-120) Albumin = 2.7 gm/dl ( ) ALT = 123 IU/L (< 110) SAP = 2,174 IU/L (< 130) Creatinine = 1.3 mg/dl (< 2.0) 19

20 TAMU # Referral abdominal ultrasound: Small amount of anechoic effusion between liver lobes and around urinary bladder. FNA reveals turbid yellow tan fluid. TAMU # Abdominal fluid: WBC = 153,000/ul RBC = 0/ul Total protein = 4.6 gm/dl 90% nondegenerate neutrophils 8% macrophages, vaculated Suppurative exudate 20

21 TAMU # Chronic necrotizing and fibrosing interstitial pancreatitis with multifocal... suppuration and hemorrhage and peritonitis Duodenum: Subacute, eosinophilic, fibrohistiocytic and plasmacytic superficial enteritis with multifocal ulceration, villous fusion... Abdominal fluid TP gm/dl WBC/ul 15, , ,200 RBC/ul 91, ,000 83,700 PANCREATITIS CAN: a) make no abdominal effusion b) make a little abdominal effusion c) make a massive abdominal effusion 21

22 WHAT IS THE FIRST THING THAT COMES TO YOUR MIND? 10 year old, INTACT FEMALE, miniature poodle TAMU # /05 Sig: 10 F Miniature poodle CC: Bloody diarrhea HPI: Acute bloody stool & vomiting white foam Friday night Dog goes to vet on Saturday Monday dog comes to TAMU PE: T = F, P = 120, R = 36 Icteric, depressed, bloody stool 22

23 TAMU # PCV = 25% (35-55) WBC = 8,300/ul (6,-14,000) Segs = 5,976/ul (4,-12,000) Bands = 415/ul (< 300) Metas = 83/ul (0) Platelets = 15,400/ul (200,-500,000) Toxic WBC = many toxic, plus a moderate # of severe toxic TAMU # BUN = 10 mg/dl (8-20) Sodium = 149 meq/l ( ) Potassium = 2.7 meq/l ( ) TCO 2 = 15 mmol/l (21-28) Glucose = 69 mg/dl (75-133) Albumin = 1.8 gm/dl ( ) ALT = 50 IU/L (<130) SAP = 324 IU/L (<147) Bilirubin = 6.3 mg/dl (< 0.8) TAMU # Abdominal US:... fluid filled tubular structure consistent with a uterine horn. The remainder of the abdomen was unremarkable. Sonographic Impression: Pyometra, right follicular cyst, inactive right ovary. 23

24 TAMU # Sig: 8 yr M Chow CC: Acute renal failure HPI: Anorexia, vomiting, excessive drinking for last 3 days Vomiting pale yellow fluid Now unable to stand PE: Can stand only if helped T = 101.5, P = 56, R = 68 24

25 TAMU # PCV = 42% (35-55) WBC = 4,100/ul (6,-14,000) Segs = 2,050/ul (4,-12,000) Bands = 492/ul (< 300) Metas = 41/ul (0) Lymphs = 1,189/ul (1,-4,000) Platelets = 291,000/ul (200,-500,000) TAMU # BUN = 40 mg/dl (8-29) Creatinine = 2.6 mg/dl (< 2.0) Glucose = 67 mg/dl (75-133) Potassium = 4.1 meq/l ( ) Magnesium = 1.2 mg/dl ( ) Calcium = 7.5 mg/dl ( ) Albumin = 1.9 gm/dl ( ) ALT = 10 IU/L (< 130) SAP = 491 IU/L (< 147) TAMU # U/S: Serosal surfaces were bright and there was a large amount of gas in the stomach... moderate volume of hypoechoic fluid... in the abdomen... generalized mild distention of small bowel with no peristalsis visualized... suggestive of peritonitis with ileus. 25

26 TAMU # Abdominal fluid: RBCs = 34,855/ul WBCs = 5,362/ul 70% neutrophils 30% mononuclear mild to moderate degeneration 3.8 gm/dl total protein 26

27 SYSTEMIC INFLAMMATORY RESPONSE SYNDROME used to be called Septic shock SYSTEMIC INFLAMMATORY RESPONSE SYNDROME inadequate perfusion of the body tissues because of an exaggerated inflammatory response WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic circulation 27

28 Courtesy of Dr. Katrina Mealey 28

29 WHAT IS SUPPOSED TO HAPPEN Bacterial toxin, inflammatory cytokines Lymph nodes, hepatic macrophages Systemic circulation WHAT CAN HAPPEN Inflammatory cytokines Lymph nodes Systemic circulation EARLY -- SIRS Mild uneven vasodilatation High output shock Bright red mucus membranes Fast capillary refill time Bounding pulses Tachycardia 29

30 LATE -- SIRS Severe peripheral vasodilatation + poor cardiac contractility Low output shock Pale mucus membranes Weak pulses Slow refill time 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 30

31 THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Crystalloids Plasma Colloids Jejunostomy feeding (PEG-J, Nasal J, regular J) 31

32 THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Crystalloids Plasma Colloids Nutrition Analgesics THERAPY FOR PANCREATITIS Only supportive and symptomatic NPO versus early feeding Fluid therapy Analgesics Anti-emetics: primarily if vomiting makes it hard to maintain hydration Proton-pump inhibitors: the same OTHER POSSIBILITIES Antibiotics Regular pancreatitis SIRS 32

33 OTHER POSSIBILITIES Antibiotics Heparin OTHER POSSIBILITIES Antibiotics Heparin Steroids Critical Care Medicine 36: , 2008 COMMON MISTAKES IN DOGS WITH ACUTE PANCREATITIS Request amylase, lipase or TLI Not obtain radiographs/ultrasound Not repeat ultrasound Expect classic presentation Complacent medical therapy Inappropriately aggressive surgery Watch lab/ultrasound instead of patient 33