Pancreatic disease

• Anatomy of the pancreas

  Right and left lobes.

  Closely associated with duodenum and stomach.

  Dogs - 2 ducts, one opens next to common bile duct on major duodenal papilla, other on minor duodenal papilla.

  Cats - single duct, fuses with bile duct before opening on major duodenal papilla - this is why they suffer with pancreatitis as a main problem.
• Role of the pancreas

  Exocrine tissue - pancreatic acinar cells, secrete digestive enzymes which are called zygomens in their inactive form.

  Enzyme inhibitors prevent enzymes digesting pancreatic tissue.

  Zygomens secreted into intestinal lumen - cleaved by enterokinase which activates them.

  If enzyme activation happens in pancreas can lead to pancreatitis.

  Endocrine tissue - 1-2% of the pancreas, found in islets of Langerhans.
• Pancreatic diseases associated with vomiting - acute pancreatitis

  Inflammation of the pancreas.

  Sudden onset - vary in severity

  Little or no permanent changes after recovery.
• Pancreatic diseases associated with vomiting - chronic pancreatitis

  Continuing inflammatory disease.

  Irreversible morphological changes - fibrosis and atrophy.

  Can lead to permanent impairment of function, endocrine pancreatic insufficiency and diabetes mellitus.
• Risk factors for pancreatitis - hereditary

  Hereditary - miniature schnauzers, yorkshire terrier, boxers, cocker spaniels, poodles and Daschund. Siamese and Bengal cats.

  Hyperlipidaemia - miniature schnauzers (idiopathic hypertriglyeridaemia).

  High fat meals and obesity - not cats

  Cats - GI disease/ vomiting, leading to bile reflux.

  • Triaditis - combination of pancreatitis, inflammatory bowel disease and cholangitis.
• Risk factors for pancreatitis - pancreatic ischaemia and hypoxia

  Shock, severe acute anaemia, dehydration, hypotension during GA, occlusion of venous outflow during abdominal surgery.
• Risk factors for pancreatitis - trauma

  Rare!

  Due to surgical biopsy, surgical manipulation, blunt abdominal trauma.

  Common pathway for pancreatitis - decreased secretion of pancreatic juices, premature activation of digestive enzymes, damages the pancreas, inflammation leads to pancreatitis.
• Clinical signs of pancreatitis

  Non specific

  Acute pancreatitis:

  • Lethargy/ weakness
  • Anorexia - suspect pancreatitis in any cat not eating/ behaving normally.
  • Vomiting and diarrhoea.

  Severe acute pancreatitis:

  • Shock
  • Collapse
• Clinical exam findings with pancreatitis

  Abdominal pain (only ~ 20% cats).

  Cranial abdominal mass

  Mild ascites

  Dehydration

  Fever (not all cases)

  Jaundice - uncommon.
• Laboratory abnormalities with acute and chronic pancreatitis - haemotology

  Anaemia

  Haemoconcentration

  Leukocytosis
• Laboratory abnormalities with acute and chronic pancreatitis - biochemistory

  Azotaemia (pre-renal)

  Increased liver enzymes (ALP)

  Hyperbilirubinaemia

  Hyper or Hypoglycaemia

  Hypoalbuminaemia

  Hypertriglyceridaemia

  Hypercholesterolaemia
• Laboratory abnormalities with acute and chronic pancreatitis - electrolytes

  Hypokalaemia

  Hypocholoraemia

  Hyponatraemia

  Hypocalcaemia
• Immunoassays for canine and feline pancreatic lipases

  cPL and fPL - specific and sensitive tests for pancreatitis.

  Spec PL (canine and feline specific)

  • ELISA from IDEXX
  • Quantitative result.
  • Abnormal >400mcg/l

  Snap PL (canine and feline specific)

  • In-practice snap test
  • Normal or abnormal result.
  • Abnormal >200mcg/l
• Laboratory abnormalities with acute and chronic pancreatitis - cTLI and fTLI

  Trypsin like immunoreactivity.

  Less sensitive and less specific.

  Increase rapidly in early stages of pancreatitis but decline quickly.

  Limited diagnostic utility.
• Laboratory abnormalities with acute and chronic pancreatitis - amylase and lipase

  Non-specific assay.

  Influenced by hepatic, renal or intestinal disease and neoplasia.

  Don’t use to confirm pancreatitis.
• Diagnosis of pancreatitis - radiography.

  Evidence of pancreatitis rarely seen.

  Useful to rule out other differentials.

  Decreased detail/ ground glass appearance cranial abdomen.

  Displacement of abdominal organs.
• Diagnosis of pancreatitis - abdominal ultrasound

  Enlargement of pancreas.

  Localised peritoneal effusion.

  Decreased echogenecity - pancreatic necrosis.

  Hyperechogenicity - pancreatic fibrosis, chronic pancreatitis.

  Pancreatic duct dilation.

  User-dependant.
• Treatment plan for pancreatitis - overview

  Correct underlying fluid and electrolyte abnormalities.

  Treat underlying cause.

  Analgesia (buprenorphine, methadone, morphine, fentanyl patch or ketamine or lidocaine CRI).

  Antiemetics (maropitant, Ondastron, Metoclopramide (CRI)

  Antibiotics - if infectious cause identified (trimethoprim/sulphonamide, marbofloxacin, clindamycin).

  Steroids
• Treatment plan for pancreatitis - start feeding once vomiting controlled

  Dogs - high carb, rice, pasta, potato then low fat commercial diet.

  Cats - diet less important in cats - base on any concurrent disease.
• Treatment plan for pancreatitis - enteral feeding for anorexic

  Naso-oesophageal tube.

  Oesophagostomy tube
• Treatment plan for pancreatitis - outpatient support of cats

  Sub-cutaneous fluids - 8-100ml Hartmann’s.

  Administer via butterfly cannula (from bag or via syringe).

  Maropitant 1mg/kg s/c or oral (off-license).

  Mirtazapine - 2mg/cat transdermal or PO (off-license).

  Buprenorphine 0.01-0.03mg/kg q6-8 hours (sub-lingual (off-license) or in-clinic IM injection).
• Treatment plan for pancreatitis - long term

  Avoid high fat meals.

  Fat restricted diet - if recurrent bouts of pancreatitis.

  Oral pancreatic enzyme supplements help with abdominal pain in humans with pancreatitis.

  Cats with recurrent episodes - trial Prednisolone 1mg/kg q12-24 hours for 1 week tapering to 0.5mg/kg EOD as needed.
• Prognostic factors for pancreatitis

  Unpredictable and varies in severity mild-moderate cases tend to recover quite well but the more severe cases have quite a bad prognosis and can be fatal.

  Difficult to give accurate prognosis. Most cases give supportive care respite spontaneously and do well long term.

  Acute pancreatitis can be life-threatening.

  Poor prognosis if continue to refuse food or can’t tolerate food. Hypocalcaemia with acute necrotising pancreatitis in cats has poor prognosis.
• Pancreatic neoplasia - pancreatic adenomas

  Benign

  Singular

  Incidental finding

  Can obstruct pancreatic duct and cause EPI.
• Pancreatic neoplasia - pancreatic adenocarcinoma

  More common than adenoma, but still infrequent.

  Usually originate from duct system.

  Can originate from acinar tissue.

  Tumour necrosis can abuse pancreatic inflammation and can cause signs of pancreatitis.

  Can spread to neighbouring or distant organs.
• Pancreatic neoplasia - pancreatic sarcomas

  Few cases have been reported.
• Pancreatic neoplasia - Clinical signs

  Similar to chronic pancreatitis:

  • Vomiting, anorexia, diarrhoea, weight loss.

  May have signs associated with metastatic lesions e.g. lameness, dyspnoea, bone pain.

  Cats - paraneoplastic alopecia, shiny skin disease, alopecia of ventrum, limbs and face.
• Pancreatic neoplasia - laboratory abnormalities

  Lab results may be unremarkable.

  May have Neutrophilia, anemia, hypokalaemia, bilirubinaemia, azotaemia, hyperglycaemia, increased liver enzyme activities.

  Some dogs have very high serum lipase.

  Hypercalcaemia can occur.
• Pancreatic neoplasia - imaging findings

  Radiogrpahy - tend to be non-specific.

  • Decreased contrast cranial abdomen.
  • May see mass.
  • Spleen may be caudally displaced.

  Ultrasonography:

  • Soft tissue mass in region of pancreas.
  • If peritoneal effusion present - sample it for cytology.
  • FNA of mass can be attempted - only successful in 25% of cases.
• Pancreatic neoplasia - diagnosis

  Often made at ex-lap or at post-mortem.

  Biopsy and histology required to establish definitive diagnosis.
• Pancreatic neoplasia - treatment of adenomas

  Benign - only treat if cause clinical signs.

  If find mass during ex-lap - partial pancreatectomy to establish diagnosis.
• Pancreatic neoplasia - treatment of adenocarcinomas

  Often metastatic disease present by time of diagnosis.

  Sites of metastatic disease - liver, abdominal and thoracic lymph nodes, mesentery, intestines, lungs.

  If no gross metastatic lesions, surgical resection can be attempted.

  Clean surgical margins rarely acheived.

  Overall prognosis is grave.

  Chemotherapy and radiation therapy - little success.
• Exocrine pancreatic insufficiency (EPI)

  Loss of pancreatic acinar cells.

  Causes malabsorption due to reduction in pancreatic enzymes.

  Signs don’t occur until most of exocrine tissue has been lost.

  Much more common in dogs than cats.

  Breed predispositions - GSD, rough collies, chows.
• Exocrine pancreatic insufficiency (EPI) - aetiology


  Pancreatic acinar atrophy (PAA)

  • Spontaneous
  • Most common cause in dogs.
  • Young animals.

  Chronic pancreatitis

  • Causes progressive destruction of acinar cells.
  • Common cause in cats, rare in dogs.

  Hypoplasia/aplasia and congenital abnormality:

  • Congenital absence of acinar cells - been described in English setters.
• Exocrine pancreatic insufficiency (EPI) - history 


  Weight loss with normal or increased appetite.

  Severe polyphagia (cats may be anorexic).

  Coprophagia and/or pica in dogs.

  Diarrhoea - large volume, yellow, fatty, frequent.

  May include vomiting.

  Borborygmi and flatulence.

  Water intake may be increased.
• Exocrine pancreatic insufficiency (EPI) - clinical signs


  Weight loss - can be severe.

  Muscle wastage

  Minimal body fat.

  Poor hair coat.
• Exocrine pancreatic insufficiency (EPI) - diagnosis


  Low serum trypsin-like immunoreactivity (TLI)

  • Highly sensitive and specific test.
  • Diagnostic for EPI.
  • cTLI/fTLI

  Minimum database

  • ALT mildly to moderately increased.
  • Triglycerides and cholesterol may be decreased.

  Low cobalamin:

  • If not low at time of diagnosis, often will be after 1-2 years of treatment.
• Treating Exocrine pancreatic insufficiency (EPI) - pancreatic enzyme replacement


  Most Pateints can be successfully managed.

  Add to each meal.

  Some preparations enteric coated.

  Diarrhoea, coprophagia and polyphagia improve within 4-5 days.

  Can take weeks or moths for body weight to return to normal.

  Fresh chopped pig or cow pancreas.
• Treating Exocrine pancreatic insufficiency (EPI) - dietary modification


  If not improving on normal diet, use highly digestible low fibre diet.

  Avoid low fat diets.

  Feed more than recommended initially to encourage weight gain.
• Treating Exocrine pancreatic insufficiency (EPI) - vitamin supplementation


  Often need cobalamin supplementation long term.

  Regular blood tests.