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          CANINE PANCREATITIS          

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Canine Pancreatitis
Pancreatitis
THE PET HEALTH LIBRARY
By Wendy C. Brooks, DVM, DipABVP
Educational Director, VeterinaryPartner.com
http://www.VeterinaryPartner.com

Canine Pancreatitis

The Normal Pancreas and What It Does
We eat food, chew it up into a slurry, and swallow it. It travels down the esophagus to the stomach where it is ground up further and enzymes are added to begin protein break-down (digestion). When the food particles are small enough, they are propelled into the small intestine for further digestive treatment and ultimately nutrient absorption. The small intestine has three portions: the duodenum that connects to the stomach, and the jejunum and ileum below. The jejunum and ileum are mostly involved in absorption but the duodenum, being so close to the stomach, is the site of further digestion.

There are two ducts that enter the duodenum near where the stomach contents enter. One duct is for bile, squirted in directly from the liver’s gall bladder. The bile serves to neutralize the acid that the stomach had added, to emulsify (or dissolve) dietary fats for absorption later in the tract, and also to excrete some toxins. The other duct is the pancreatic duct, which squirts in more digestive enzymes so as to break down starches and more protein.

The pancreas is a pale pink glandular organ that nestles cozily just under the stomach and along the duodenum. As a glandular organ, the pancreas is all about secretion, and it has two main jobs: the first job is the secretion of digestive enzymes to help us break down the food we eat, the second job being secretion of insulin and glucagon (to regulate sugar metabolism). The digestive enzymes are the part of the story that concerns us in pancreatitis.

Pancreatitis Is Inflammation of the Pancreas
In pancreatitis, inflammation disrupts the normal integrity of the pancreas. Digestive enzymes that are normally safely stored in granules are released prematurely where they digest the body itself. The result can be a metabolic catastrophe. The living tissue becomes further inflamed and the tissue damage quickly involves the adjacent liver. Toxins released from this orgy of tissue destruction are released into the circulation and can cause a body-wide inflammatory response. If the pancreas is affected so as to disrupt its ability to produce insulin, diabetes mellitus can result; this diabetes can be either temporary or permanent.

Special disasters include the disruption of “surfactants” in the lung tissue that normally keep the tiny air-filled alveoli from collapsing after each exhaled breath. Without surfactants, the alveoli close up and respiratory failure results.

Also, there is a syndrome called Weber-Christian syndrome in which fats throughout the body are destroyed.

Pancreatitis is one of the chief risk factors for the development of what is called disseminated intravascular coagulation, or DIC, which is basically a massive uncoupling of normal blood clotting and clot dissolving mechanisms. This leads to abnormal simultaneous bleeding and clotting of blood throughout the body.

Pancreatic encephalopathy (brain damage) can occur if the fats protecting the central nervous system become digested.

The good news is that most commonly the inflammation is confined to the area of the liver and pancreas but even with this limitation, pancreatitis can be painful and life-threatening.

Pancreatitis can be acute or chronic, mild or severe.

What Causes Pancreatitis
In most cases we never find out but we do know some events that can cause pancreatitis:

• Reflux of duodenal contents into the pancreatic duct. The pancreas has numerous safety mechanisms to prevent self-digestion. One of these mechanisms is the fact that the enzymes it creates are stored in an inactive form. They are harmless until they are mixed with activating enzymes. The strongest activating enzymes are made by duodenal cells, which means that the digestive enzymes do not actually activate until they are out of the pancreas and mixing with food in the duodenum. If duodenal fluids backwash up the pancreatic duct and into the pancreas, enzymes are prematurely activated and pancreatitis results. This is apparently the most common pancreatitis mechanism in humans, though it is not very common in veterinary patients.

• Concurrent hormonal imbalance predisposes a dog to pancreatitis. Such conditions include: diabetes, hypothyroidism, and hypercalcemia. The first two conditions are associated with altered fat metabolism that predisposes to pancreatitis, and the latter condition involves elevated blood calcium that activates stored digestive enzymes.

• Use of certain drugs can predispose to pancreatitis (sulfa-containing antibiotics such as trimethoprim sulfa or chemotherapy agents such as azathioprine).

• Trauma to the pancreas as from a car accident or even surgical manipulation can cause inflammation and thus pancreatitis.

Miniature Schnauzers are predisposed to pancreatitis as they commonly have altered fat metabolism.

Signs of Pancreatitis
The classical signs in dogs are appetite loss, vomiting, diarrhea, painful abdomen, and fever.

Making the Diagnosis
A reliable blood test has been lacking for this disease. Traditionally, blood levels of amylase and lipase (two pancreatic enzymes) have been used. When their levels are especially high, this is felt to be a reasonable sign of pancreatitis, but still these tests are not as sensitive or specific as we would prefer. They can elevate dramatically with corticosteroid use, with intestinal perforation, kidney disease, or even dehydration. Some experts advocate measuring lipase and amylase on fluid from the belly rather than on blood but this has not been fully investigated and is somewhat invasive.

A newer test called the PLI or pancreatic lipase immunoreactivity test has come to be important. Lipase is one of the pancreatic digestive enzymes and small traces are normally present in the circulation. These levels jump dramatically in pancreatitis and the diagnosis can be confirmed with a less expensive and non-invasive test. A regular lipase level measures all forms of lipase, not just those of a pancreatic source; this is test is specific for pancreatic lipase. The problem is that technology needed to run this test is unique and the test can only been run in certain facilities on certain days. Results are not necessarily available rapidly enough to help a very sick patient.

More recently a new test called the SPEC cPL (specific canine pancreatic lipase) test has come to be the test of choice. This test is a newer generation immunological test for canine pancreatic lipase and can be run overnight by a reference lab. This test is able to detect 83% of pancreatitis cases (the test is 83% sensitive) and excludes other possible diseases in 98% of cases (i.e., the test is 98% specific for pancreatitis). There is no comparable test for cats at this time.

Radiographs can show a widening of the angle of the duodenum against the stomach, which indicates a swelling of the pancreas. Most veterinary hospitals have the ability to take radiographs but this type of imaging is not very sensitive in detecting pancreatitis and only is able to find 24% of cases.

Ultrasound, on the other hand, detected 68% of cases and provides the opportunity to image other organs and even collect fluid from the belly easily. When one balances rapid results and accuracy, this test may be the best.

In some cases, surgical exploration is the only way to make the correct diagnosis.

Treatment
The passage of food through the duodenum is a strong stimulus to the pancreas. In the treatment of canine pancreatitis we do not want any stimulation of the pancreas; we want the pancreas to rest. This means no food and no water for 2 to 3 days (IV fluid support prevents dehydration).

Fluid support will generally require potassium supplementation as potassium depletes in pancreatitis. Blood pH must be tracked as well. A critical patient with pancreatitis will need 24 hour care and blood test monitoring several times a day. A plasma transfusion represents a special type of fluid therapy and helps provide special proteins that inhibit pancreatic enzymes. Whether or not the protection afforded by plasma is real or theoretical is still being worked out but since it is difficult to go wrong with a plasma transfusion, do not be surprised if your veterinarian uses this approach.

Pancreatitis is a painful condition and pain management is not only humane but important in recovery. Untreated pain affects the immune system and increases mortality. Injectable pain medications, fentanyl patches, and even continuous drips can be used effectively to control pain. Additional medications to control nausea are also commonly used in the management of this condition. Antibiotics are often used because even though pancreatitis is not a bacterial disease, bacterial invasion from the diseased intestine is a common occurrence.

Once the patient has started to eat again, a low fat diet (such as one of the prescription high fiber diets) is important to minimize pancreatic stimulation. Since there is potential for the pancreas to always have a chronic smoldering bit of inflammation, long-term use of a low-fat diet is likely to be recommended.

Beware of Diabetes Mellitus
When the inflammation subsides in the pancreas, some scarring is inevitable. When 80% of the pancreas is damaged, insulin cannot be produced, and diabetes mellitus results. This may or may not be permanent depending on the capacity for the pancreas’ tissue to recover. See more information on the management of diabetes mellitus.
Copyright 2006 - 2007 by the Veterinary Information Network, Inc. All rights reserved.
This work was originally published by Veterinary Information Network, Inc. (VIN)
 and is republished with VIN's permission.

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PANCREATITIS

http://www.provet.co.uk

This information is provided by Provet for educational purposes only.
You should seek the advice of your veterinarian if your pet is ill as only he or she can correctly advise on the diagnosis and recommend the treatment that is most appropriate for your pet.
Note for Pet Owners:
If you have an animal diagnosed as having pancreatitis there are some important guidelines that you should follow:   Always give the medications that your veterinarian has prescribed at the correct dose and at the correct times.Contact your veterinary practice if you are concerned that your animal is having a relapse, or if it appears to react abnormally following treatment.
Keep your animal on the strict diet that your veterinarian recommends and AVOID feeding high fat foods because fat intake can make the condition much worse. If your pet is a bin scrounger or likely to steal food - stop him/her . Many "snacks" are relatively high in fat - so cut them out !!

Topics on this Page:

Description
Cause
Breed Occurrence
Signs
Complications
Diagnosis
Treatment
Prognosis
Long-term problems
 
Description
Pancreatitis literally means inflammation of the pancreas. If the condition is sudden in onset it is called acute pancreatitis, whereas chronic pancreatitis is a continuing inflammatory process with sub-acute recurrence's of the disease. Both forms of the disease can lead to permanent damage and reduced functionality of the pancreas with serious consequences for the animal. When the pancreas is inflamed local release of enzymes occurs including trypsin , kallikrein, elastase, lipase, phospholipase A, amylase and lysosymes. These cause local problems in adjacent tissues and affect the range of clinical signs that develop including causing peritonitis.

Cause
In many cases of pancreatitis the initiating cause is unknown. However, several specific associations have been reported:

Nutritional changes - Extremely high fat content diets (60% fat) can cause acute pancreatitis in some dogs , if they are kept on it for 14-38 weeks. High fat, high protein diets cause increased pancreatic enzyme synthesis and storage and lead to acute pancreatitis, whereas a protein-deficient diet can cause pancreatic atrophy.

Drugs - several drugs have been implicated in the development of pancreatitis - one of the most common being corticosteroids. Others include diuretics (thiazides and frusemide), antibiotics (sulphonamides and tetracycline) azothiaprin, L-asparaginase and exposure to cholinesterase inhibitors in insecticides and cholinergic agonists.

Injury to the brain or spinal cord. Trauma to the central nervous system has been associated with the onset of actue pancreatitis in humans and in dogs. In dogs the significance of the trauma itself is often difficult to determine because many patients (e.g. following acute intervertebral disc protrusion) are treated routinely with corticosteroids which have also been implicated in causing pancreatitis.

Hypercalcaemia - increased blood calcium concentrations in parathyroid disease (hyperparathyroidism), and after the administration of excess calcium.

Other - proposed (but unproven) causes might include - Infectious agents -bacteria and viruses, Immune diseases, obstruction of the pancreatic duct, reflux of intestinal contents up the pancreatic duct, uraemia, impaired blood supply to the pancreas (ischaemia), and hereditary factors.

For a list of risk factors CLICK HERE

Breed Occurrence
There is no reported breed prevalence for primary pancreatitis although some breeds do have a predisposition to develop other conditions which may then lead to pancreatitis for example:

 Miniature Schnauzers develop hyperlipidaemia which can result in secondary pancreatitis.
Briards

Shelties
 
Himalayan cats

Signs
Acute Pancreatitis - Shock, collapse, dehydration (can lead to prerenal failure), high body temperature, depression, inappetance, vomiting. In some cases diarrhoea and/or acute abdominal pain in the right cranial region of the abdomen. Swelling of the abdomen (due to gas accumulation in the intestine) and adoption of a "praying" position* at rest are also seen. (* front legs and chest down - bottom up !)

Chronic pancreatitis - Recurrent less severe bouts of diarrhoea, depression, weight loss.

Complications
Include : jaundice, dyspnoea or increased respiratory rate (tachypnoea), bleeding disorders and heart arrhythmias.

Apart from the clinical signs, diagnosis depends upon the following laboratory tests:
Plasma amylase - in dogs plasma amylase concentrations greatly increase (to over 5000U/L), but it's an unreliable in affected dogs because amylase concentrations can increase due to other causes. In cats with pancreatitis plasma amylase concentrations DECREASE.

Plasma lipase - is the best test for evaluation of pancreatic disease in dogs. Plasma concentrations of lipase D increases greatly in dogs with pancreatitis to over 500U/L - with a sensitivity of over 98%, so most cases will be detected. A few positive cases will have other causes (liver disease, kidney disease or cancer).In cats there is no direct correlation between lipase concentrations and pancreatitis and normal results do not rule out the diagnosis.

Other tests -the following tests may prove helpful in some cases:

Blood glucose - increased in some dogs and cats

High blood cholesterol or triglyceride concentrations - seen in cats and may be causative factor in dogs.

High enzymes (Alanine aminotransferase (ALT) and alkaline phosphatase (ALP) - if liver disease present, and high bilirubin if the bile duct is obstructed.

Protein in the urine. Prerenal increase in blood urea concentrations.

Low blood calcium.
Xray - Increased radiodensity and sometimes calcification in the right cranial abdomen adjacent to the duodenum which, because of gut stasis might, be filled with air and also the position of the duodenum remains static on sequential Xray films. Xray examination can be normal in some cases.

Examination during exploratory surgery and Biopsy
Examination of the pancreas during exploratory surgery - reveals various abnormal appearances from inflammation and loss of pancreatic tissue, to localised fat necrosis in surrounding tissue. Sometimes adhesions form. Fine needle biopsy can be performed quite easily, although excessive handling of the pancreas should be avoided.

Treatment
One objective of treatment is to minimise the stimuli that cause secretion of pancreatic enzymes.

Diet - Some authors advise no food by mouth for 2-5 days. During this period parenteral nutrition should be given if the facilities are available. Small volumes of glucose solution can then be given by mouth, followed by the gradual introduction of a bland starch-based diet e.g. boiled rice. Carbohydrate sources are chosen because they cause the least stimulation of pancreatic enzyme secretion. Other authors recommend the oral feeding of small amounts of a special diet that has the following characteristics :

Low fat

Highly digestible

Corticosteroids - the use of corticosteroids is controversial because of their known association with causing pancreatitis. However, they may have an important beneficial role in controlling shock when it is present.

Blood transfusion - should be performed in very severe cases because recent evidence suggests that plasma protease inhibitors are used up in pancreatitis leading to saturation of a -macroglobulins which can result in life-threatening intravascular coagulation. Transfusion replaces the macroglobulins.

The other objective is to reverse any complications :
Replace fluid and electrolyte losses.

Antibiotics - bacteria have been found circulating in the blood of dogs with pancreatitis even though the bacteria were not involved as a cause of the disease.

Insulin is required if diabetes mellitus is a complication due to loss of Islets of Langerhans.

Prognosis
Good in most cases except in severe cases with widespread intravascular coagulation, or severe cardiac complications.

Long term problems
If significant tissue damage has occurred exocrine pancreatic insufficiency and/or diabetes mellitus may result.   
Copyright (c) 1999 - 2007 Provet. All rights reserved. mailto:info@provet.co.uk  
reprinted with kind permission from Mike Davies Provet Limited

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The above information is simply informational. It's intent is not to replace the advice of a veterinarian nor to assist you in making a diagnosis of your pet. Please consult with your own veterinarian for confirmation of any diagnosis. Your pets life may depend on it.