Академический Документы
Профессиональный Документы
Культура Документы
Darren Merrett
BVSc (Hons) CertSAC MVS FANZCVS
29/07/2019
Acute Canine
Pancreatitis
Why talk about acute
Darren Merrett pancreatitis?
BVSc (Hons) CertSAC MVS FANZCVS
1 2
3 4
Normal Pancreas
• Potent digestive enzymes secreted and stored in
granules as inactive zymogens OR active enzymes
but lacking co-factor
• Pancreatic secretory trypsin inhibitor (PSTI) inhibits
5 6
1
29/07/2019
Normal Pancreas
Pancreatic secretory trypsin inhibitor = SERINE PROTEASE INHIBITOR,
KAZAL-TYPE, 1
PSTI = SPINK1
https://veteriankey.com/pancreas-2/
7 8
https://courses.washington.edu/conj/bess/zymogens/zymogens.html
9 10
11 12
2
29/07/2019
13 14
15 16
17 18
3
29/07/2019
19 20
21 22
23 24
4
29/07/2019
25 26
27 28
29 30
5
29/07/2019
Signalment
• Middle aged + (few mths – 15+yr)
• Min schnauzer, Terriers, Cocker spaniels, CKCS,
31 32
33 34
35 36
6
29/07/2019
37 38
Aim of diagnostics
1. Find evidence to SUPPORT the diagnosis of pancreatitis
Diagnosing Pancreatitis •
•
Rupture
Torsion
• Perforation
• GDV
• Biliary mucocoele
• Vascular occlusion
39 40
41 42
7
29/07/2019
43 44
Histopathology Histopathology
151 dogs (originally 200 dogs but 49 with autolysis) 73 dogs post mortem
No record of cause of death No record of cause of death
• Chronic pancreatitis 34% • Abnormalities in 64.3% (47/73)
• Acute pancreatitis 2.6% • Suppurative inflammation 32.9%
• Pancreatic neoplasia 3% • Pancreatic necrosis 31.5%
• No abnormalities 22% • Lymphocytic inflammation 46.6%
• Significant fibrosis 23% • Of the 47 dogs with abnormalities 28/47 with fibrosis
• Other changes 16%
45 46
47 48
8
29/07/2019
49 50
Sensitivity is the proportion of patients who tested positive for the disease
amongst those who are sick
A very sensitive test will detect LOTS of the patients that have the problem
Disease Present Disease Absent
51 52
Specificity
TEST POSITIVE TEST NEGATIVE Low specificity
SICK True Positive False Negative High specificity
HEALTHY False Positive True Negative
Specificity is the proportion of patients who tested negative for the disease
amongst those who are healthy
High sensitivity
Specificity = True Negative
Total number of healthy (false positives + true negatives) Low sensitivity
A very specific test will mainly give positive results only in those patients that
have the problem
53 54
9
29/07/2019
Amylase/Lipase Amylase/Lipase
55 56
Amylase/Lipase Amylase/Lipase
• Generally speaking in DOGS . . . • Elevations of amylase/lipase may be seen in:
• Sensitivity for any increase in pancreatitis cases ~30-70% • intestinal disease
• If you apply >3x cut-off sensitivity ~15% • renal disease
• hepatic disease
• prostatic disease
• post abdominal surgery
• Amylase/lipase are not particularly sensitive in the detection of • corticosteroid administration lipase up to 5x
acute pancreatitis in dogs!
• Amylase/lipase are not particularly specific in the detection of acute
pancreatitis
57 58
59 60
10
29/07/2019
61 62
Acute Abdomen Spec cPL <200 Spec cPL >200 Spec cPL >400
Sensitivity Specificity ug/L ug/L ug/L
63 64
Sensitivity Specificity Spec cPL <200 ug/L 200-400 ug/L >400 ug/L
65 66
11
29/07/2019
67 68
69 70
71 72
12
29/07/2019
73 74
75 76
Aim of diagnostics
1. Find evidence to SUPPORT the diagnosis of pancreatitis
77 78
13
29/07/2019
79 80
Imaging - Ultrasound
• How good is it?
• sensitivity and specificity of ~70-80%
81 82
83 84
14
29/07/2019
Imaging - CT Imaging - CT
J Vet Intern Med 2019;33:79–88
J Vet Intern Med 2015;29:97-103
85 86
Imaging - CT Imaging - CT
J Vet Intern Med 2019;33:79–88 J Vet Intern Med 2019;33:79–88
• 26 dogs with pancreatitis
• CT visualised the entire pancreas in 26/26 vs 19/26 with ultrasound
• Dogs with heterogenous contrast enhancement (indicates pancreatic
• CT and ultrasonography similar to detect signs of inflammation necrosis) had:
• CT slightly better pancreatic enlargement and gastric/intestinal thickening • Longer hospitalisation
• US slightly better peripancreatic fat/mesentery changes and detecting free • Higher cPL
fluid • More portal vein thrombosis
• Similar for extra-hepatic biliary obstruction
• CT did much better visualising portal vein thrombosis (10/26 vs 1/26)
87 88
Imaging - MR Imaging - MR
• MRI detected
• Pancreatic abnormalities in 9/10 cats
• Scant data
• Peripancreatic abnormalities 1/10
• US detected
• Pancreatic abnormalities in 9/10 cats
• Peripancreatic abnormalities in 3/10
• Many of the changes were mild and only affected limited sections
and authors suggest the experience of the ultrasonographer was
very influential in detection
89 90
15
29/07/2019
91 92
• 73 cats with pancreatitis and FNA vs 63 cats with FNA of another • Of the 73 cats with pancreatitis that had FNA
abdominal organ vs 61 cats with NO FNA • 24/73 non diagnostic
• No difference in rate of survival to discharge or length of hospital stay • ONLY 9 had histopathology for comparison and of these 6/9 there
between groups was agreement between cytology and histopathology (3 with
carcinoma, 3 with lymphocytic inflammation)
. . . So it is a safe procedure
93 94
95 96
16
29/07/2019
97 98
99 100
101 102
17
29/07/2019
Diagnosing Pancreatitis
• If you believe you have achieved a diagnosis of pancreatitis OR if you
have ruled out surgical differentials treatment will be similar and
supportive
• MONITOR your patient and QUESTION your diagnosis
• If patient stable or improving
• Continue supportive care Treatment
• If patient deteriorating
• Reassess diagnosis, repeat diagnostics
103 104
105 106
107 108
18
29/07/2019
109 110
111 112
• NOT recommended
113 114
19
29/07/2019
115 116
117 118
119 120
20
29/07/2019
• 1 mth survival
• Pred: 38/45 (88.7%)
• NO pred: 11/20 (57.9%)
• Study NOT blinded or randomised
• Relied on in-clinic test of lipase based on DGGR assay and did not
assay pancreatic specific lipase
121 122
123 124
Follow up
• At discharge
• Low fat diet
• Avoid any known triggers (e.g. drug therapy)
• ?Pancreatic enzyme supplementation
• Check triglycerides +1-2 wks
• If ongoing hyperlipidaemia then investigate for causes and use low fat diet
• If not hyperlipidaemic then transition back to original diet
125 126
21
29/07/2019
127
22