Pancreatitis in Dogs and Cats

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Pancreatitis in Dogs and Cats

• Two Different Animals
• Wendy Blount, DVM
• Nacogdoches, TX

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Wendy Blount, DVMdrblount_at_vonallmen.netwww.wendy
blount.com

• DVM TAMU 1992
• Private Practice Houston 2 years
• Small Animal
• Residency TAMU 1994-1997
• Small Animal Internal Medicine
• Private Practice Nacogdoches, TX
• 75 Referrals Internal Medicine and Herbal
  Medicine/Nutrition
• 25 General Practice

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PancreatitisIntroduction
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Two types of pancreatitis

• Acute Pancreatitis
• Abrupt onset
• often reversible after treatment
• May lead to chronic pancreatitis
• Acute necrotizing (cell death) pancreatitis is a
  life-threatening condition

• Chronic Pancreatitis
• Continuing inflammatory disease
• Irreversible pathology
• Relapsing acute pancreatitis
• Exocrine pancreatic insufficiency (EPI)
• Diabetes mellitus

Acute
Chronic
2/3
1/3
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Pancreatitis

• Clinical Presentation
• Diagnosis
• Treatment
• Prognosis

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PancreatitisClinicalPresentation
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Pancreatitis - Predispositions

• Chronic liver Disease Why?
• Bile reflux into the pancreas
• Especially in cats why?
• Because bile pancreatic duct merge
• Diabetes mellitus
• Intestinal disease

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Pancreatitis - Predispositions

• Hyperlipidemia Why?
• Blood sludging - pancreatic ischemia
• Lipase and other enzymes released
• Hydrolysis of TG in ECF by lipase releases free
  fatty acids (FFA)
• FFA cause microthrombi and bind to calcium to
  cause further damage (saponification)
• More lipase is released
• Positive feedback vicious cycle

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Pancreatitis - Predispositions

• Obesity
• Hypercalcemia
• Hyperadrenocorticism
• Hypothyroidism
• High fat meal How much is too much?
• gt50 calories as fat
• Careful of U/D in Schnauzers
• Refeeding after prolonged anorexia

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Pancreatitis - Predispositions

• Pancreatic neoplasia
• If you are treating one of the worst cases of
  pancreatitis you have ever seen, rule out
  pancreatic adenocarcinoma
• Infectious
• Toxoplasma gondii
• Feline liver flukes Amphimerus pseudofelinus
• Feline pancreatic flukes Eurytrema procyonis
• FIP

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Pancreatitis - Predispositions

• Drugs
• Corticosteroids
• Chemotherapeutics/immunosuppressives
• L-asparaginase
• Azathioprine (Imuran)
• Estrogens
• Others

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Pancreatitis - Predispositions

• Toxins
• Organophosphates
• Scorpion stings
• Uremic toxins
• Vaccines

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Pancreatitis - Predispositions

• Trauma to the pancreas
• Abdominal surgery
• Ischemia (post-GDV, anesthesia, hypotension,
  shock)
• Bile duct obstruction
• Protracted and severe vomiting why?
• Bile reflux into the pancreatic duct
• Especially in the cat

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Pancreatitis - Predispositions
Hyperadrenocorticism both Hypothyroidism dogs High
fat meal dogs Refeeding after anorexia dogs Pancr
eatic neoplasia both

• Dog vs. Cat - Quiz
• Chronic Liver Disease
• both
• Diabetes mellitus
• both
• Intestinal disease
• both
• Hyperlipidemia
• dogs
• Hypercalcemia
• both

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Pancreatitis - Predispositions
Trauma to the pancreas dogs gtgt cats Ischemia both
Bile duct obstruction cats gt dogs Protracted
severe vomiting cats gt dogs Vaccines ?????

• Toxoplasma gondii
• cats
• Corticosteroids
• dogs
• Organophosphates
• both
• Scorpion sting
• both
• Uremia
• both

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Breed Predisposition

• Dogs
• Miniature Schnauzer
• Sheltie
• Briard
• Small dogs (yorkies, poodles)
• Cats
• Siamese
• Himalayan

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Common Concurrent Diseasesespecially in cats

• Cholangiohepatitis
• Inflammatory bowel disease
• Triaditis
• Nephritis
• Hepatic lipidosis cats only

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Most Common Clinical Signs

• Dogs
• 95 of dogs with pancreatitis vomit
• Anorexia (91)
• Abdominal pain (58)
• Cats
• Anorexia/weight loss 97
• Only 35 of cats with pancreatitis vomit
• Dehydration 92
• Constipation

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Clinical Signs Dogs and Cats

• Lethargy
• Icterus why?
• Diarrhea with or without blood
• Fever (hypothermia more common in cats 68)
• Abdominal pain, cranial abdominal mass
• Hunched stance or praying position
• Elevated respiratory rate
• Necrotic skin lesions or red skin why?
• Ascites

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Pancreatitis - Sequella

• SIRS
• Systemic Inflammatory Response can Precipitate
• Thromboembolic disease
• Pumonary thromboembolism
• DIC
• Pancreatic encephalopathy
• Arrhythmia
• Metabolic acidosis
• Respiratory Distress (2 causes)

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PancreatitisDiagnosis
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Diagnosis Clues in the Bloodwork

• CBC nonspecific
• Thrombocytopenia
• Neutrophilia with left shift
• Anemia
• Serology Dogs only
• Lipemia after a prolonged fast (TG, chol)
• Can present for opaque eyes or anterior uveitis
• Hypocalcemia why?
• Calcium consumed by saponification of fat
• Hypoalbuminemia why?
• Massive inflammation, vasculitis, sepsis

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Diagnosis Clues in the Bloodwork

• Serology Dogs only
• Amylase
• normal in 47
• Lipase
• Normal in 61
• Serology Cats only
• Elevated cholesterol (not as often triglycerides)
• Amylase and lipase not at all useful

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Diagnosis Clues in the Bloodwork

• Lipase non-specific why?
• Digestive lipases
• Intestinal lipase
• Lipoprotein lipase and hepatic lipase
• Hormone-sensitive lipase (adipocytes)
• Lysosomal acidic lipase

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Diagnosis Clues in the Bloodwork

• Serology Dogs and Cats
• Nonspecific changes
• Elevated liver enzymes
• Elevated bilirubin why?
• Azotemia
• Hyperglycemia (cause or effect)
• Hypoglycemia why?
• Hypophosphatemia why?
• Hypochloridemia why?

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Diagnosis Clues in the Bloodwork

• GI Serology Dogs and Cats
• B12 may be low why?
• Intrinsic factor from the pancreas is required
  for absorption
• concurrent proximal small intestinal disease
• Folate may be low if distal intestinal disease
• Folate is absorbed in the ileum
• REMEMBER B comes before F

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Diagnosis Clues in the Bloodwork

• GI Serology Dogs and Cats
• TLI (trypsin like immunoreactivity)
• Highly specific for EPI
• Increased in SOME dogs and cats with pancreatitis

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Diagnosis Clues in the Bloodwork

• GI Serology Dogs and Cats
• What is the BEST blood test to diagnose
  pancreatitis??
• cPLI (canine Pancreatic Lipase Immunoreactivity)
• 97 sensitive for pancreatitis
• 82 specific for pancreatitis
• fPLI (feline Pancreatic Lipase Immunoreactivity)
• Much more sensitive and specific for pancreatitis
• than any blood test or imaging
• Antech and IDEXX
• TAMU GI Lab (TVMDL sends to TAMU)

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Diagnostic tools A comparison
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Spec cPLTM

• cPLI Developed by Drs. Jörg Steiner and David
  Williams at the Gastrointestinal Laboratory at
  Texas AM University
• IDEXX collaborated with Drs. Steiner and Williams
  to develop the Spec cPL
• IDEXX renamed it Spec cPL
• For better name recognition
• To trademark the name
• Available only at IDEXX Labs

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Introducing SNAPR cPLTM
Features

• 2 results Normal or Abnormal
• Read time 10 minutes
• Storage Refrigeration
• Sample type Serum
• Read Visual semi-quantitative
• lt200 ug/L normal
• 200-400 ug/L borderline
• gt400 ug/L pancreatitis
• Same technology as Spec cPL
• Correlation to Spec cPL gt95
• 96 of interpretations are correct

Sample
Reference
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Comparing Spec cPL values to SNAP results
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SNAP cPL for Screening
Dog w/ Vomiting, Anorexia, Abdominal pain
CBC Profile/lytes UA SNAP cPL
SNAP Abnormal
SNAP Normal
gt400
200-399
Treat for pancreatitis, Baseline cPLI
Abdominal radiographs Abdominal US Baseline cPLI
Pancreatitis is unlikely pursue other
differential diagnoses
monitor w/ cPLI
US/Rads confirm pancreatitis
US/Rads equivocal
Treat, Monitor, Retest Continue to rule out
other differential diagnoses
Treat for pancreatitis, Monitor with cPLI
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Diagnosis Clues in the Bloodwork

• Urinalysis nonspecific
• Ketones
• think diabetic with ketoacidosis (if glucosuria)
• Or prolonged fasting/starvation
• Transient proteinuria
• Enzyme mediated glomerular damage

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Diagnosis Clues in the Bloodwork

• Coagulation panel
• Thrombocytopenia
• Vasculitis (enzyme mediated)
• DIC
• PT, PTT, ACT
• Elevated
• Antithrombin III
• Low
• FDP, d-Dimers
• high

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Diagnosis Clues in the Bloodwork

• Electrolyte panel/blood gases (venous is fine)
• HCO3,TC02, pH, pC02
• Low - Metabolic acidosis
• What clue will your patient give you to check
  venous blood gases?
• Panting
• Potassium
• Low why?
• H outside the cell exchanged for K inside the
  cell
• K lost in the urine
• Especially a problem with diabetics why?
• Insulin is required to get potassium into the
  cell where it is needed

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Diagnosis Abdominal Ultrasound

• BEFORE PLI, WAS THE BEST TEST FOR DIAGNOSIS OF
  PANCREATITIS
• Highly specific, but not that sensitive
• 60 of cats with pancreatitis have normal US
• Pancreatitis (gt 1 cm thick)
• Enlarged pancreas
• Hypoechoic
• May have cavitary lesions
• Fluid accumulation around the pancreas
• Pancreatic duct may be tortuous and dilated

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Diagnosis Abdominal Ultrasound

• Duodenum
• Dilated and hypomotile (lt5 waves per minute)
• Sometimes corrugated
• Common Bile Duct
• Dilated and tortuous
• Gall bladder
• Enlarged, wall edema/hyperechoic, sludge
• Ascites
• Peripancreatic fat and omentum
• hyperechoic

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Diagnosis Abdominal Ultrasound

• Ultrasound truly IS for everyone
• Time-consuming
• time to warm up reagants
• 10 minutes to run the test
• Expensive
• Used Toshiba Analog 12k in 2000
• Cost 1714 per year
• 3 US a week x 150 x 50 weeks 22.5K
• Subject to user experience
• No more subjective than x-rays

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Diagnosis Radiographs

• Abdominal radiographs
• Often normal (sensitivity 24)
• Ascites generalized or localized
• Peritonitis loss of detail ground glass
• Stomach displaced left, dilation
• Duodenum displaced caudal and right, gas
• Dilated, thickened, corrugated
• Colon displaced caudal
• Calcification of fat

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Diagnosis Radiographs

• Upper GI Barium Series
• Delayed emptying of stomach and duodenum
• Corrugation of duodenal wall
• Thoracic radiographs
• Can be normal
• Pleural effusion
• Pulmonary edema
• Severe vasculitis
• if severe hypoalbuminemia
• 25-50 of cats have either pleural effusion or
  ascites
• Sometimes pneumonitis (interstitial pattern)

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Diagnosis Abdominocentesis, Thoracocentesis

• Usually modified transudate
• Occasionally exudative (suppurative)
• Rarely hemorrhagic

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Diagnosis Exploratory Laparotomy

• Pancreas
• Edematous, hemorrhagic, abscesses, cysts
• Enlarged if acute
• Very small, wasted, fibrotic if chronic
• Can appear grossly normal in cats
• Peripancreatic tissues
• Saponification of fat
• Inflammation
• Adhesions

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Diagnosis Exploratory Laparotomy

• Histopathology - pancreas
• Definitive diagnosis in cats
• Chronic pancreatitis fibrosis, inflammation,
  nodular hyperplasia
• Acute pancreatitis edema, hemorrhage, necrosis,
  inflammation
• Few side effects after Bx of cat pancreas
• Culture/Cytology any abscesses
• Usually sterile (do cytology first)
• Bacterial infection is not very common in dogs
  and cats

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PancreatitisTreatment
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Pancreatitis Treatment Dogs and Cats

• PRIMARY THERAPIES
• Fluid therapy
• Colloids
• Antibiotics
• Analgesia
• Antioxidants

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Pancreatitis Treatment Dogs and Cats

• Fluid therapy why so crucial
• Need to support pancreatic perfusion
• Pancreatitis pancreatic ischemia bad things
• 35-45 ml/lb/day until eating well
• less if low albumin, until colloids restored
• Supplement potassium according to the sliding
  scale
• One scale for animals with severe acidosis
• One scale for animals with normal venous blood
  gases

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Pancreatitis Treatment Dogs and Cats

• Fluid therapy why so crucial
• Why do pets with acidosis need more potassium?
• In a state of acidosis, there are excess hydrogen
  ions (H) in the extracellular fluid
• As the acidosis is corrected by therapy,
  potassium that had left the cells in exchange for
  H goes quickly back into the cells
• This can drop potassium precipitously, causing
  arrhythmia, weakness or even respiratory
  paralysis
• Most common culprits are DKA and RTA

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Pancreatitis Treatment Dogs and Cats

• Fluid therapy why so crucial
• Add glucose if hypoglycemic
• Add bicarbonate if
• Acidosis is immediately life threatening
• Acidosis will not be corrected by treating other
  problems
• See handout
• Avoid LRS if severe liver disease and needs
  alkalinizing why??
• Liver must transform lactate to bicarbonate

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Pancreatitis Treatment Dogs and Cats

• Flop
• Chief Complaint Not doing well since treating
  abscess on a toe 1 week ago, vomiting blood
• 3 days ago regular vet did a UA and blood glucose
• UA showed ketones and glucose , blood
  glucose 296
• Has been treating with IV fluids since, getting
  worse
• Did not start insulin because cat not eating
• Exam - Dehydrated, lethargic, icteric, RR 56
• vomited coffee grounds and collapsed on abdominal
  palpation, HR 65/bpm
• Responded to atropine IV and fluid bolus

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Pancreatitis Treatment Dogs and Cats

• Flop - diagnostics
• CBC granulocytes 16,000
• Profile glucose 200, BUN 41
• TG 500, Chol 297
• Bili 4.2, ALT 148, ALP normal
• Ca 7.0, Phos 1.6
• UA SG 1.027, ketones , glucose , inactive
  sediment
• Electrolytes K lt2.0, Na 133, iCa 1.08
• pH 7.032, BE -24, HCO3 7, TCO2 8
• pCO2 26.5,
• No chest rads or abdominal US done
• Urine culture pending

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Pancreatitis Treatment Dogs and Cats

• Flop - diagnosis
• Initial life threatening problems
• Severe ketoacidosis
• treatment insulin, bicarbonate, IV fluids
• Severe hypokalemia
• treatment IV KCl or K-phosphates
• Severe hypophosphatemia
• treatment IV K-phosphates
• (pancreatitis, hematemesis, abscess on toe)
• (treatment feed, antacids, sucralfate,
  antibiotics)

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Pancreatitis Treatment Dogs and Cats

• Flop - treatment
• IV fluids of course 45 ml/lb/day
• Rehydrates and corrects acidosis which fluids?
• Buffered LRS, Ringers, Normosol, Plasmalyte,
  etc.
• Potassium chloride no disadvantage
• Potassium phosphates no disadvantage
• (sliding scale) (IV drip rate calculator)
• Insulin
• Advantage corrects ketoacidosis
• Disadvantage makes hypokalemia and
  hyposphatemia worse
• Bicarbonate (handout)
• Advantage corrects acidosis
• Disadvantage will make hypokalemia worse
• Cefazolin 100 mg IV TID, cimetidine 25 mg IV TID

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Pancreatitis Treatment Dogs and Cats

• Flop reassess in 4 hours
• Glucose - 99 (1 unit NPH SC)
• PCV 23
• pH 7.228, HC03 10, TCO2 11
• pC02 23.9,
• iCa 1.07, Na 130, K 2.3
• Phosphorus 0.7
• Red tinged urine, serum icteric
• Hydration normal, general condition slightly
  improved, no vomiting, not eating

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Pancreatitis Treatment Dogs and Cats

• Flop 2 days later
• Glucose - 325
• PCV 20
• pH 7.403, HC03 18.8, TCO2 20
• pC02 30
• iCa 0.92, Na 134, K 3.7
• Phosphorus 3.4
• Urine clear, serum slightly icteric
• Hydration normal, general condition greatly
  improved, eating small amounts, no vomiting

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Pancreatitis Treatment Dogs and Cats

• Colloids why so crucial
• Low albumin vasculitis fluid therapy
  pulmonary edema
• Hetastarch 5-10 ml/lb/day
• Plasma 10 ml/lb/day, over 2-3 hours
• Premedicate with diphenhydramine
• Can repeat daily until improved
• Also treats DIC when incubated with heparin 35-75
  U/kg for 30 minutes prior to administration
• Provides antiproteases and alpha-macroglobulins
• Whole blood if significantly anemic (hemolysis)

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Pancreatitis Treatment Dogs and Cats

• Antibiotics controversial
• Increased survival in people with pancreatitis
  who are treated with antibiotics
• But bacterial pancreatitis is much less common in
  dogs and cats
• Should prevent systemic infection from bacterial
  translocation across the gut
• Treat concurrent infection, of course (UTI)
• Penicillins (avoid Clavamox it causes vomiting)
• Cephalosporins
• Quinolones alone arent the best choice why?

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Pancreatitis Treatment Dogs and Cats

• Analgesia THIS IS A PAINFUL DISEASE
• Butorphanol (1 mg/10 lbs q2-4hrs PRN for pain)
• Buprenorphine (0.015 mg/kg q6-12hrs)
• Opiate pure agonists whats the catch?
• Oxymorphone
• Morphine
• Hydromorphone
• Meperidine
• Fentanyl injectable or patch
• Intraperitoneal lidocaine or bupivocaine
• Be careful of NSAIDs Why?

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Pancreatitis Treatment Dogs and Cats

• Antioxidants
• Milk thistle
• SAMe
• VetriScience Cell Advance
• Vitamin E/selenium
• Free radical damage is rampant in pancreatitis
• People with recurring pancreatitis have fewer
  episodes when they take daily antioxidants

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Pancreatitis Treatment Dogs and Cats

• SECONDARY THERAPIES - As indicated
• Heparin
• Questionable efficacy in cats
• Some think it is primary therapy for dogs why?
• Even if not in DIC, they are hypercoagulable
• May promote pancreatic microcirculation
• Preventing a thromboembolism is
• Way better than treating one

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Pancreatitis Treatment Dogs and Cats

• SECONDARY THERAPIES - As indicated
• Antiemetics - controversial
• Definitely make the patient more comfortable
• May prevent death from vagal surge
• Some would rather not cover up their vomiting
• Metoclopramide, Cisapride
• Ondansetron (Zofran), dolasetron (Anzemet) - 5HT3
  antagonists 0.3-0.6 mg/kg SID to BID
• Maropitant (Cerenia) - neurokinin-1 receptor
  antagonist 1 mg/kg SID
• Careful of phenothiazines why?
• dont want hypotension

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Pancreatitis Treatment Dogs and Cats

• SECONDARY THERAPIES - As indicated
• B vitamins (especially B12)
• H2 blockers/H pump blockers, sucralfate/barium
• if blood in the stool or vomit
• May prevent reflux esophagitis if vomiting
• is severe
• Famotidine, Ranitidine, Cimetidine, (omeprazole)
• There is some evidence cimetidine
• and ranitidine might aggravate
• pancreatitis in people

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Pancreatitis Treatment Dogs and Cats

• SECONDARY THERAPIES - As indicated
• Treat hyperlipidemia
• Handout
• Hyperlipidemia predisoposes to pancreatitis
• Calcium
• Therapy rarely needed
• Only if clinical signs, and calcium lt 6.5 mg/dl
• Bicarbonate
• Already discussed IV therapy
• Some cats with severe chronic
• pancreatitis need oral HC03

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Pancreatitis Treatment Dogs and Cats

• SECONDARY THERAPIES - As indicated
• Surgery/laparoscopy
• Biopsy to diagnose neoplasia in dogs and cats
• Biopsy to diagnose pancreatitis in cats
• Debridement
• Restore bile flow (stent)
• To treat abscesses or pseudocysts
• That recur after US guided
• drainage

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Pancreatitis Treatment Dogs and Cats

• SECONDARY THERAPIES - As indicated
• Antihelminthics
• In the rare case of liver flukes or pancreatic
  flukes in cats
• Fenbendazole
• Praziquantel (high dose in notes)

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Pancreatitis Treatment Dogs and Cats

• CONTROVERSIAL THERAPIES
• Dopamine CRI
• Protective effect when administered to cats with
  experimental pancreatitis within 12 hours
• No effect after 12 hours
• Can cause vomiting, nausea, seizures in cats
• Peritoneal dialysis
• To remove chemical irritants from the abdomen
• When ascites (especially exudative)

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Pancreatitis Treatment Dogs and Cats

• CONTROVERSIAL THERAPIES
• Oral pancreatic enzymes
• Reported to reduce pain in people with
  pancreatitis
• Less likely to be effective in dogs because they
  do not have a protease negative feedback
• Some have observed clinical benefits
• in dogs who have pain associated
• with chronic pancreatitis

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Pancreatitis Treatment Dogs and Cats

• CONTROVERSIAL THERAPIES
• Drugs to inhibit pancreatic secretion
• Seem to work with experimental pancreatitis
• Little effect in spontaneous pancreatitis
• Glucagon
• Gabexate mesylate, nafamostat mesylate
• Atropine
• Acetazolamide
• Somatostatin
• calcitonin

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Pancreatitis Treatment Dogs and Cats

• Patient Monitoring
• TPR, blood pressure BID or more
• Low body temp indicates big trouble
• High fever spikes might indicate infection
• Increased heart rate??
• Pain
• Hypovolemia (need more fluids)
• Increased respiratory rate??
• Pain
• Pulmonary edema, pleural effusion, pneumonitis
• acidosis

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Pancreatitis Treatment Dogs and Cats

• Patient Monitoring
• Electrolytes/blood gases, lactate
• SID-BID when critical
• QOD when stable
• Weigh BID when concerned about kidney function
• Why?
• Increase in body weight 10 is the first sign
• of fluid retention
• If you catch this early, you can prevent
• pulmonary edema, and give your patient
• more time to start making urine

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Pancreatitis Treatment Dogs and Cats

• Patient Monitoring
• HCT
• SID if stable
• BID if phosphorus low, especially if DKA
• Albumin
• daily if lt1.5
• QOD if gt2.0, as long as on fluid therapy
• Monitor for DIC
• Platelets
• If decreasing, do PT, PTT, FDP/d-dimers, AT3

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Pancreatitis Treatment Dogs and Cats

• Patient Monitoring
• Glucose
• Every 2 hours when unstable
• Give insulin ONLY as needed
• Glucose can be very erratic in DKA
• When stable enough, can do every 2 hours during
  the day, and not overnight
• If you MUST spot check, then do so 6 hours
• after insulin (glucose low)
• Insulin nadir is much more important
• than peak when deciding dose

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Pancreatitis Treatment Dogs and Cats

• Patient Monitoring
• Urine ketones if diabetic daily until stable
• cPLI or fPLI
• Long term, to monitor resolution of pancreatitis,
  and need for ongoing dietary therapy and
  antioxidant supplementation
• Abdominal US
• To follow resolution of pancreatic abscesses or
  cysts

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Treatment Canine Pancreatitis

• Glucocorticoids contraindicated
• NPO
• At least 48 hours
• Offer water after no vomiting for 24 hours
• Offer food when no vomiting for 24 hours with
  free choice water
• 2-3 very small meals the first day (2 teaspoons
  to 2 tablespoons)
• Gradually work up to full feed over 3-5 days
• If any vomiting, start over at the top

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Treatment Canine Pancreatitis

• Nutrition
• Low fat Why?
• lt15-20 of calories
• Low fiber, at first Why?
• Can go to higher fiber later
• Low protein Why?
• lt25 of calories
• Avoid turkey why?
• Tryptophan potently stimulates the pancreas

76
Treatment Canine Pancreatitis

• Nutrition
• Suitable commercial diets
• Hills I/D canned and dry
• Medi-Cal Canine Gastro Formula canned and dry
• Leo Specific Digest (CIW canned CID dry)
• Purine CNM EN canned and dry
• Select Care Canine Sensitive Formula canned and
  dry
• Home made food
• Fat free cottage cheese and white rice is ideal

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Treatment Canine Pancreatitis

• Nutrition
• Monomeric (elemental food)
• Water soluble liquid foods in their simplest
  nutritional state
• Should in theory minimally stimulate the pancreas
• Some have added glutamine to support enterocyte
  recovery from disuse atrophy
• Can cause diarrhea, as many are hyperosmolar

78
Treatment Canine Pancreatitis

• 3-5-7 Rule
• If dog cant be fed PO within 5-7 days, consider
  TPN, or PPN
• Requires a central line, and monitoring multiple
  times daily
• Probably should not be administered while dog is
  unattended (extravasation is bad)
• Excellent catheter care is a must
• Nutrients are expensive hundreds of dollars to
  mix up a batch
• Needs to be mixed aseptically, under a laminar
  flow hood
• Gut atrophy continues
• TPN Resource Handout
• After Recovery
• 2 weeks or more after recovery, consider
  switching to low fat, high fiber diet
• May or may not eventually be able to go back to a
  maintenance type diet

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Treatment Canine Pancreatitis

• Nutrition
• Suitable High Fiber Low Fat foods for long term
• Hills R/D and W/D
• Leo Specific CRW (canned) and CRD (dry)
• Medi-Cal Canine Fibre Formula canned and dry
• Medi-Cal Canine Weight Control/Geriatric canned
  and dry
• Purina CNM OM canned and dry
• Purina CNM DCO dry, Purina CNM GL dry
• Select Care Canine HiFactor Formula canned and
  dry
• Waltham/Pedigree Canine High Fiber canned and dry
• Dogs with persistently high triglycerides
• will probably have to stay on this type diet

80
Treatment Feline Pancreatitis

• Glucocorticoids
• Indicated for feline pancreatitis why?
• Controlling concurrent IBD and cholangiohepatitis
  will remove predisposition to pancreatitis
• Can be immune mediated per se in cats
• Prednisone 1 mg/lb/day
• Dexamethasone 0.1 mg/kg every other day
• Wean to lowest effective dose over 2-4 months,
  after clinical response

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Treatment Feline Pancreatitis

• Nutrition FEED!!!
• Place feeding tube ASAP why?
• Pancreatitis fatty liver disaster
• Place E-tube first
• Place G-tube if E-tube can not be maintained due
  to uncontrollable vomiting
• Why not place G-tube right away?
• 10-25 are dislodged even with
• proper placement
• Can result in gastric perforation

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Treatment Feline Pancreatitis

• Nutrition
• If vomiting becomes difficult to control
• Drip liquid diet CRI if bolus feeding is not
  tolerated
• Try metoclopramide (1-2 mg per cat) by tube 30
  minutes prior to feeding
• If that doesnt work, try cisapride (2.5 mg per
  cat)
• Or Cerenia, Anzemet, Zofran
• If all else fails, consider a jejunostomy tube
• handouts Tube Feeding Tube Diets

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Treatment Feline Pancreatitis

• Nutrition
• As always, cats do best on a high protein,
• low carb diet (especially diabetics)
• No need to be concerned about fat content in cats
• There is only one dry diet with gt45 protein and
  lt8 carbs
• Innova EVO (California Naturals)
• Purina DM and Hills Prescription Diet M/D have
  15 carbs (protein is fine)
• Studies used to market DM and M/D are on canned
• Nutritional Content Canned Cat Foods

84
Treatment Feline Pancreatitis

• Nutrition
• Appetite stimulants can be used
• Cyproheptadine 2 mg per cat PO BID 30 min prior
  to feeding
• Mirtazipine 3-4 mg per cat twice a week
• Diazepam is risky with concurrent liver disease

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PancreatitisPrognosis
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Pancreatitis Prognosis

• Dogs variable
• Good if response to short term therapy
• Guarded if severe pancreatitis
• Better for lean dogs than fat dogs why?
• Less necrosis of fat to deal with
• Clinical response is probably the best predictor
• 100 recovery is possible
• Some dogs are prone to repeated episodes

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Pancreatitis Prognosis

• Cats - variable
• Tend to take longer than dogs to respond
• Some cats can begin eating in days
• Some have to be fed by tube for months
• Worse if concurrent hepatic lipidosis
• Worse if suppurative pancreatitis rather than
  mononuclear
• Cats who have it once tend to get it again
• Owners learn to catch it early and intervene

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Pancreatitis Prognosis

• Things associated with poor prognosis
• Shock
• Oliguria
• Icterus
• Hypocalcemia -- dogs
• Hypoglycemia
• Hypoproteinemia
• Acidosis
• Falling hematocrit

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Pancreatitis Prognosis

• Things associated with poor prognosis
• Thrombocytopenia
• DIC

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