Irving-Pancreatitis-for pdf.ppt - Beckman Laser Institute€¢ icterus (biliary tract obstruction)...

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5/21/2013 1 TAMU #203505 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 #203505 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 #203505 Creatinine = 0.78 mg/dl (< 2.0) Calcium = 9.7 mg/dl (9.3-11.8) Sodium = 153 mEq/L (138-148) Potassium = 3.8 mEq/L (3.8-5.1) Albumin = 2.7 gm/dl (2.5-4.4) ALT = 8,258 IU/L (< 130) SAP = 2,354 IU/L (< 147) Bilirubin = 0.3 mg/dl (0-0.8)

Transcript of Irving-Pancreatitis-for pdf.ppt - Beckman Laser Institute€¢ icterus (biliary tract obstruction)...

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TAMU #203505

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 #203505

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 #203505

Creatinine = 0.78 mg/dl (< 2.0)

Calcium = 9.7 mg/dl (9.3-11.8)

Sodium = 153 mEq/L (138-148)

Potassium = 3.8 mEq/L (3.8-5.1)

Albumin = 2.7 gm/dl (2.5-4.4)

ALT = 8,258 IU/L (< 130)

SAP = 2,354 IU/L (< 147)

Bilirubin = 0.3 mg/dl (0-0.8)

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TAMU #203505

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

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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

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WHICH CBC(S) IS/ARE

FROM DOG(S) WITH ACUTE

PANCREATITIS?

147033 147198 90524 159796

PCV 28.5 28.8 30 40

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 87,000 407,000 679,000 470,000

Toxic mod mod none none

Clinical Pathology

• Amylase/Lipase

– Sensitivity ~ 50%

– Specificity ~ 50%

• TLI

– Sensitivity ~ 35%

• cPLI

– Sensitivity ~ 80-85%

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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

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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

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Diagnostics

• cPLI

– Sensitivity ~ 80%

• Abdominal ultrasound

– Sensitivity probably ranges from 40%

to about 65%

– Findings can change within hours ...

Find evidence suggestiveof pancreatitis

Eliminate otherabdominal diseases

RadiographsUltrasound

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WHAT IS THE BEST WAY

TO DIAGNOSE CANINE

ACUTE PANCREATITIS?

Imaging (ultrasound)

Find evidence suggestiveof pancreatitis

Chemistry panelAbdominal imaging

cPLI

Eliminate diseasesmimicking pancreatitis

Patient with possible acute pancreatitis

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

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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 (5.5-7.5)

Albumin = 1.7 gm/dl (2.5-4.4)

ALT = 10 U/L (< 130)

SAP = 31 U/L (< 147)

Bilirubin = 0.4 mg/dl (< 1.0)

Urine: 1.015 with 4+ protein

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TAMU #183550 12/2008Fluid: “... 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 ...”

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TAMU #183550 4/2009Fluid: TP = 5 gm/dlCytology: “... 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.”

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TAMU #159796

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 #159796

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 #159796

BUN = 4 mg/dl (8-29)Creatinine = 0.7 mg/dl (< 2.0)Glucose = 95 mg/dl (75-133)Potassium = 3.6 mEq/L (3.8-5.1)Cholesterol = 597 mg/dl (120-247)Albumin = 2.9 gm/dl (2.5-4.4)ALT = 1,691 IU/L (< 130)SAP = 3,134 IU/L (< 147)Bilirubin = 4.5 mg/dl (0-0.8)

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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

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Should you decompress the biliary system?

TAMU #159796

4/9 4/11 4/13 4/15 4/16

ALT 1,691 2,108 1,275

SAP 3,134 3,753 3,633

Bili 4.5 4.5 4.8 2.6 1.2

Making a “visual” diagnosis of pancreatic carcinoma is a BAD idea

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PANCREATITIS IS MUCH

MORE COMMON THAN

PANCREATIC CANCER

TAMU #152494

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 = 102.5 F, HR = 102/min

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TAMU #152494

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 #152494

Sodium = 152 mEq/L (138-148)

Potassium = 4.1 mEq/L (3.5-5.0)

Glucose = 107 mg/dl (60-120)

Albumin = 2.7 gm/dl (2.5-4.4)

ALT = 123 IU/L (< 110)

SAP = 2,174 IU/L (< 130)

Creatinine = 1.3 mg/dl (< 2.0)

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TAMU #152494

Referral abdominal ultrasound:

“… Small amount of anechoic

effusion between liver lobes and

around urinary bladder. FNA reveals

turbid yellow tan fluid.”

TAMU #152494

Abdominal fluid:

WBC = 153,000/ul

RBC = 0/ul

Total protein = 4.6 gm/dl

90% nondegenerate neutrophils

8% macrophages, vaculated

“Suppurative exudate”

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TAMU #152494

“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

147260 152494 152485 109612

TP gm/dl 5.1 4.6 1.3 3.6

WBC/ul 15,059 153,000 700 18,200

RBC/ul 91,112 0 30,000 83,700

PANCREATITIS CAN:

a) make no abdominal effusion

b) make a little abdominal effusion

c) make a massive abdominal

effusion

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WHAT IS THE FIRST THING

THAT COMES TO YOUR

MIND?

10 year old, INTACT FEMALE, miniature poodle

TAMU #159077 2/05

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 = 102.1 F, P = 120, R = 36

Icteric, depressed, bloody stool

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TAMU #159077

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 #159077

BUN = 10 mg/dl (8-20)Sodium = 149 mEq/L (138-148)Potassium = 2.7 mEq/L (3.8-5.1)TCO2 = 15 mmol/L (21-28)Glucose = 69 mg/dl (75-133)Albumin = 1.8 gm/dl (2.5-4.4)ALT = 50 IU/L (<130)SAP = 324 IU/L (<147)Bilirubin = 6.3 mg/dl (< 0.8)

TAMU #159077

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.”

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TAMU #152117

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

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TAMU #152117

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 #152117

BUN = 40 mg/dl (8-29)Creatinine = 2.6 mg/dl (< 2.0)Glucose = 67 mg/dl (75-133)Potassium = 4.1 mEq/L (3.8-5.1)Magnesium = 1.2 mg/dl (1.7-2.1)Calcium = 7.5 mg/dl (9.3-11.8)Albumin = 1.9 gm/dl (2.5-4.4)ALT = 10 IU/L (< 130)SAP = 491 IU/L (< 147)

TAMU #152117

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.”

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TAMU #152117

Abdominal fluid:

RBCs = 34,855/ul

WBCs = 5,362/ul

70% neutrophils

30% mononuclear

mild to moderate degeneration

3.8 gm/dl total protein

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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

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Courtesy of Dr. Katrina Mealey

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WHAT IS SUPPOSED TO HAPPEN

Bacterial toxin, inflammatory cytokines

Lymph nodes, hepatic macrophages

Systemic circulation

Inflammatory cytokines

Lymph nodes

Systemic circulation

WHAT CAN HAPPEN

EARLY -- SIRSMild uneven vasodilatation

“High output” shock

Bright red mucus membranesFast capillary refill timeBounding pulsesTachycardia

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LATE -- SIRSSevere peripheral vasodilatation + poor cardiac contractility

“Low output” shock

Pale mucus membranesWeak pulsesSlow 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

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THERAPY FOR PANCREATITISOnly supportive and symptomatic

• NPO versus early feeding

THERAPY FOR PANCREATITISOnly supportive and symptomatic

• NPO versus early feeding

• Fluid therapy

Crystalloids

Plasma

Colloids

Jejunostomy feeding

(PEG-J, Nasal J, regular J)

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THERAPY FOR PANCREATITISOnly supportive and symptomatic

• NPO versus early feeding

• Fluid therapy

Crystalloids

Plasma

Colloids

Nutrition

• Analgesics

THERAPY FOR PANCREATITISOnly 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

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OTHER POSSIBILITIES

• Antibiotics

• Heparin

OTHER POSSIBILITIES

• Antibiotics

• Heparin

• Steroids – Critical Care Medicine 36: 296-327, 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