Cat with acute pancreatitis not getting better - options??

Re: Cat with acute pancreatitis not getting better - options??

Rajat — Tue, 03 Jul 2012 09:18:21 GMT

I was going to say something along the lines of what Eleanor said but in a far less eloquent fashion, especially about ab choices.. nice posting Eleanor!

Re: Cat with acute pancreatitis not getting better - options??

Eleanor Raffan — Tue, 03 Jul 2012 09:05:03 GMT

Hi Emma,

Thanks for filling in the gaps and keeping us updated. It sounds like you had a sensible tx plan in place and (who'd have thought it?) it worked! Fingers crossed the cat keeps on improving, but nice to know referral for more work-up is an option.

Encouraging re WBC - though normal total neuts in pyrexic animal often flags up as a warning sign to me - what right does it have not to have some kind of inflammatory white cell picture?! I wonder if the normal temp was physiologic (less of whatever caused it in the first place) or a consequence of NSAID tx.

The debate re whether pancreatitis has a bacteriological origin is ongoing. Those who claim is sterile can quote this paper where neutrophilic inflammation not frequently associated with bacteria. http://vet.sagepub.com/content/44/1/39.long . Those who say yes point out that bacteria are sometimes found in inflamed pancreas samples, and that the anatomy is such that reflux of bugs from gut is possible (particularly where GI stasis or vomiting). But wether it is causal or secondary to the primary disease process is difficult to know.

Assuming you fall into the 'there's a risk and treatment is relatively benign' camp, I'm not sure there is much to support hitting them hard with a fluoroquinolone, particularly as anaerobes predominate in the duodenum of cats (http://info.theclinics.com/mdconsult/pdf/Veterinary_Clinics_Small_Animal_sample_article.pdf). But, as usual, there's little evidence as to whether abx will actually affect outcome. Because of the common association with GI inflammation (+ bile duct = 'triaditis'), a common choice is metronidizole which is not only good for GI anaerobes likely to be there, but also is thought to have an immunomodulatory effect.

Interesting stuff! Thanks for sparking some interesting comments, Eleanor.

Re: Cat with acute pancreatitis not getting better - options??

Andrew Kent — Mon, 02 Jul 2012 20:13:16 GMT

[quote user="Emma Middleton"]

Forgot to say - I put it on amoxyclav when I admitted it because of the WBC, even though apparently feline pancreatitis is rarely bacterial. So it has had broad spec cover. Temp has been back to normal (37-38ish) last few days. Result on admission was:

WBC    = 5.19   x10^9/L 5.5-19.5

Neuts and lymphs were WNLs. Biochem and potassium were checked over the weekend and these were all OK. The fPL has come back normal today, and my colleague has just informed me the cat did eat over the weekend (even though it is not recorded anywhere!) so I've agreed to let the owner take it home and see if being at home makes any different to it's appetite (It's a very antisocial cat). I did give it a shot of dex before discharging it.

We have got ultrasound but I was reluctant to spend more of the owner's money when I wasn't confident I'd even be able to visualise the pancreas. But have mentioned referral to her, as I guess a scan would be one of the first things they'd do. After discussing it with her husband she may spend the money on referral if there's no improvement in 24hours, as she would like to get a definitive diagnosis. It turns out money is not so much short, she just only wants to spend it if there's a good chance the cat's going to get better. On that basis, I think referral is a good option.

Great help all of you, thank you for your useful and thorough replies.

[/quote] I believe a reasonable proportion of pancreatitis cases is cats will be bacterial due to the anatomy of the pancreatic duct and the high risk of ascending infection from vomiting etc. for this reason I would put the cat on a fluoroquinolone to penetrate well into this region. Andy

Re: Cat with acute pancreatitis not getting better - options??

Emma Middleton — Mon, 02 Jul 2012 17:56:46 GMT

WBC    = 5.19   x10^9/L 5.5-19.5

Great help all of you, thank you for your useful and thorough replies.

Re: Cat with acute pancreatitis not getting better - options??

Eleanor Raffan — Mon, 02 Jul 2012 16:59:13 GMT

Hi Emma,

Tricky case! I'd be worried you are missing something as fPLI is not 100% specific and pancreatitis could be secondary or concurrent with another dz. I am particularly concerned about your mention of 'low WBC'. Was this low total or neutropenia (worrying in a cat with pyrexia) or just lymphopenia (common response to physiological stress in sick animals)? A smear would be good - left shift?

I find it easiest to go back to basics and make a problem list in cases like this (abdo pain, anorexia, pyrexia, ?low WBC) and considering ddx and likely things in order.

Abdo pain - broadly due to any infection/inflammation/visceral stretch but in reality consider: pancreatitis (confirm if poss by abnormal imaging, repeat test, presence of other signs such as vomiting); peritonitis (particularly given low WBC, young age); pyelonephritis (rare but azotemia from start and important to identify - you don't mention UA in this cat - cheap and easy test, worth making effort to look at sediment if anything not normal on dipstick); cystitis (presumably no signs); enlarged liver or spleen (lymphoma, uncommon infectious); enteritis (any d+?); don't forget abdo wall pain (abcess) and spinal pain too.
pyrexia - broadly inflammation or infection, but where? Quite marked on presentation and not incompatible with pancreatitis but also flags worries re other infectious foci (abscess, peritonitis, FIV/FIP) or inflammatory foci (neoplasia, though young so unlikely).
anorexia - likely 2y to others. Any sign of active food aversion as you see with peritonitis sometimes? Whatever the cause, remember that prolonged (>3d) anorexia is a real worry and try to get some food on board. Since I started writing, Rajat has put some helpful ocmments on that up.
low WBC. If not just lymphopenia, you should be concerned where the neuts are in this cat with a clear clinical picture of inflammation. 1y leukopenia so vulnerable to infection, and what process (bone marrow dz)? 2y to another process - pooling in a pancreatic abscess, peritoneal cavity? Repeat WBC count and blood smear essential to answer these questions.

So, where next? I would prioritise feeding, abdominal imaging (scanning likely your most sensitive modality but survey rads likely helpful too). Don't be put off by finding it hard to track down the pancreas - if it's really severe you are likley to find a hypoechoic abscess in the right place. If the fPLI is a red herring, you will be able to pick up free fluid, or abnormalities in other organs. It sounds silly, but I always go back and do a really thorough rpt clinical examination, looking for other body systems involved when I have a puzzle like this.

Consider the meds in this cat: if painful still, increase to full mu agonist. I worry about NSAID effects on a starved GIT so consider adding in H2 antagonist +/- sucralfate (especially if you get a feeding tube in). You could even try missing a dose and seeing what happens (allows you to see what temp doing, opiates should be good enough for pain). I would be very worried about using steroids: steroids + NSAIDs = very efficient way to ulcerate the gut; contraindicated if infection; will muck up future diagnostics eg of IBD/triaditis; not indicated in pancreatitis; blah...! You don't mention antibiotics - commendable not to use when no clear indication but I would be considering some broad spectrum antibiosis (clavamox?) in case occult infection and because of suggestion of ascending bact infection in feline pancreatitis.

I do appreciate the money worries as this cat clearly (by now) has a serious problem and no guarantee of success, but in a young cat the odds are you can find something fixable if you look hard enough.

Good luck and keep us posted!

Eleanor

Re: Cat with acute pancreatitis not getting better - options??

Rajat — Mon, 02 Jul 2012 16:12:43 GMT

Hi Emma

Always the way with funds and difficult cases

tough to say re prognosis, many will turn around and do well, sometimes with ats they need to be reminded re food, and so I like your idea fo tube feeding. A naso-oesophageal tube can be placed in conscious patients with local eye drops placed in both nostrils couple of minutes prior to tubing so doesnt require GA or major costs and allows short term enteral nutrition. I'd try and add a glutamine source eg glutalyte for the enterocytes- the villi will prob be suffering after so many days of anorexia.

Are you monitoring electrolytes especially K+? Bet it will be low after this duration of anorexia and supplementing it aggressively till its normal can make these guys feel much better.

I'd be more aggressive with the analgesia, and use a mu opioid if available if only bupe available then add a ketamine CRI. Cerenia can have analgesic and anti inflammatory products along with providing anti nausea benefits in these patients. Mirtazapine can also have some anti nausea properites (serotonergic) along with appetite stimulation.

A naso-oesophageal tube can be placed in conscious patients with local eye drops placed in both nostrils couple of minutes prior to tubing so doesnt require GA or major costs and allows short term enteral nutrition

Is the cat voume replete and fully hydrated as the high urea may indicate pre renal issues or GI bleeding. Another vote for abdo US.

I see hypocalcemia cf hyper I take it thats what you meant?

I read some interesting stuff about how they are finding bacteria in cat'spancreas' recently I think it was IFSM, so thes emay not be completely sterile, abs may not be such a bad idea especially if time and money are limited.

And finally dexamethasone is useful where time and/or money is running out, especially as many of these kitties as I am sur eyou know also have triaditis. Doesn't seem like it from your bloods but Tbil is high (can be anorexia/full GB)

Best of luck

Raj

Re: Cat with acute pancreatitis not getting better - options??

James Laidlaw — Mon, 02 Jul 2012 15:24:46 GMT

Is it still pyrexic? Has it had antibiotics, cause I would have personally been concerned with the potential for a bacterial infection with a temp of 40.2 and then 39.7 AFTER NSAID as well?

Other than the fPL has there been anything to suggest pancreatitis?

Is imaging the abdomen an option at all - ultrasound may be helpful not only with looking at the pancreas, but with evaluating motility and the rest of the abdomen as well.

Good luck - always these cases that run out of money when the path isn't crystal clear!!!

Re: Cat with acute pancreatitis not getting better - options??

Mark Holmes — Mon, 02 Jul 2012 15:04:59 GMT

Change melixicam to dex, may well make a dramatic improvement. Feeding tube if funds are available.