Pancreatitis Help.

Re: Pancreatitis Help.

Claire Godfrey — Tue, 31 Jul 2012 15:28:20 GMT

Thanks all, will double chck re the diet and poss try changing. Think will ignore the heart for now unless we start seeing problems!

Was just checking there wasn't anything glaringly obvious should be doing that I wasn't.

Thanks Claire

Re: Pancreatitis Help.

Rob Davis — Tue, 31 Jul 2012 12:20:40 GMT

[quote user="Martin Atkinson"]don't under-estimate the ability of little old ladies to give titbits to their companion despite strict instructions on feeding and lie about it. You must emphasise the importance of not even giving a tiny bit of chicken or tea with milk on pain of death. [/quote]

Some years ago I had a patient with recurrent bouts of pancreatitis. Despite insisting repeatedly that he was only fed what I had advised, his owners eventually admitted that he did get a bowl of cornflakes with full fat milk on every morning......"we didn't think that counted!"

Re: Pancreatitis Help.

Kate Richardson — Mon, 30 Jul 2012 21:48:27 GMT

Agree with above posts- would be worth a PLI to be certain you are dealing with pancreatitis, that's where I would spend my money at this stage. Personally am not a fan of the SNAP test, I prefer a quantitative result. However conversely if it comes back as normal you still can't rule pancreatitis out! so in this case, debatable if worth spending the money or to go with your gut feeling of diagnosis and assess response to treatment- low fat diet really important, these guys often have significant pain after eating any fat- Chappie is another good low fat choice especially if costs are an issue, plus pain relief as mentioned above- if tramadol works stick with it, but continue it bid for a period, don't stop and start it.

Re: Pancreatitis Help.

Christopher Saul — Mon, 30 Jul 2012 18:28:25 GMT

[quote user="David Mills"]I wouldn't worry about the heart at the moment at all [/quote]

[quote user="David Mills"]Care with cerenia and heart disease and it has calcium channel antagonistic properties, so care where HR may be low. [/quote]

slightly contradictory statements there!

[quote user="David Mills"]so the ECG would essentially be a waste of money at this stage[/quote]

Depends how much an ECG costs really. Agreed it's not likely to change treatment plan (other than to avoid cerenia which David himself pointed out!) though. Also depends how much you want to determine the rhythm... you could let the owners decide.

Re: Pancreatitis Help.

Martin Atkinson — Mon, 30 Jul 2012 16:45:21 GMT

[quote user="claire godfrey"]He is owned by a lovely lady who is house bound and struggles for money but does take out loans when necessary[/quote] I would go along with all that has been said before but don't under-estimate the ability of little old ladies to give titbits to their companion despite strict instructions on feeding and lie about it. You must emphasise the importance of not even giving a tiny bit of chicken or tea with milk on pain of death.

Re: Pancreatitis Help.

David Mills — Mon, 30 Jul 2012 15:21:46 GMT

I wouldn't worry about the heart at the moment at all - it's not causing the clinical signs (or any signs) and heart rhythm can do all sorts of things with systemic illness, especially inflammatory, so the ECG would essentially be a waste of money at this stage because it won't affect your treatment plan even if it was unrelated to underlying illness (e.g. SSS)

Care with cerenia and heart disease and it has calcium channel antagonistic properties, so care where HR may be low. Its analgesic properties are not well documented presently and initial studies have proved disappointing (according to BSAVA congress this year).

An alternative for GI pain is buscopan tablets or injection, very useful in colicking horses and believed to have similar analegisa, spasmolytic, anti-pyretic effects on dogs; hell of a lot cheaper than cerenia too.

If you're using ranitidine then use twice the formulary dose (i.e. you require 4-5mg/kg) to produce significant drop in gastric pH.

Re: Pancreatitis Help.

Christopher Saul — Mon, 30 Jul 2012 14:54:16 GMT

Hi Claire,

We are making assumptions about the diagnosis here; lipase as a standalone test has a fairly low specificity for pancreatitis - about 43% according to a recent study. PLI is somewhat superior in this respect though there is no single gold standard test (other than histopathology). In the ideal world you'd need to eliminate other causes for the clinical signs. That said, the liklihood is that the dog does suffer with pancreatitis if the clincial sigs are consistent, so if the owners really have no money there's not alot you can do.

The cornerstone of chronic pancreatitis would be a low fat diet - RCW GI low fat has the lowest % fat per KCal of all the commercially available diets. Ideally fed in more frequent, smaller meals.

Though there is no firm evidence to support its use, there is thearoetical justification to use pancreatic enzyme supplementation in these patients.There is a CCK mediated negative feedback loop on pancreatic secretion that we may be able to utilise by supplementing with enzymes, and there is some anecdotal evidence that it may work. I use tryplase but whatever supplement you prefer is fine - lypex, panzyme, whatever.

Analgesia is very important too; if tramadol works well then maybe stick with that. Pardale V is another option (I use paracetamol 10mg/Kg TID). I have used NSAIDs but only in patients which are not vomiting or anorexic and are adequately hydrated, and even then only if other options dont' seem to work. You mention this patient is wretching so maybe best avoided.

With regards the heart rythm, it could be pain but there are other explanations; pancreatitis itself can alter vagal tone and cause arrythmias. Westies can get sick sinus syndrome. Can you run an ECG and post it on here?

hope this helps

Chris

Re: Pancreatitis Help.

Rajat — Mon, 30 Jul 2012 14:25:45 GMT

Several issues here so tough caser esp with no money

First- the missed beats/arrhythmia CAN be secondary to severe pancreatitis but from the sounds of it he is getting mild flareups, and unlikely he has severe inflammation causing VPCs so it is more likely to another issue whether secondary or primary myocardial.

The bloods- well lipase is fairly non specific for pancreatitis, why not try the inhosue snap CPLIs and you can always send them out for quantitiative analysis ro confirmation to IDexx if u want. Not expensive to run and much much better at dx the disease.

Also if he has been off steroids the ALP is mod high, again non specific but GI/biliary system may be involved. Also isoenzyme from bone/kidney also worth bearing in mind. On the scan,did the biliary tree look normal? Did the adrenals look normal ? any other signs of adrenal disease? Pancreas normal on US? Altho pancreas can look normal with a mild flareup, my experience in dogs is some abnormalities will be seen on US in most cases- at least mild swelling/enlargement is usually present, if not more obvious changes seen with more severe cases

Endocrine disease can increase the fat levels and hypertriglyceridemia may predispose to flareups of pancreatitis..cushingoid dogs certainly can get pancreatitis this way, but I'd want to see clinical signs of cushings not just biochemical changes to be more certain

Meds you can use:

Tramadol as you are +/- paracetamol.

Cerenia - anti nausea + anti inflammatory and analgesic effects in the GI

pancrex- seems to help some dogs with chronic pancreatitis

Trial low fat diet if fasting Triglycerides are high

Best of luck!

Raj

Re: Pancreatitis Help.

Mark Hedberg — Mon, 30 Jul 2012 13:44:52 GMT

Might consider z/d, it's an ultra low allergen food, i find for severe cases can be more useful than d/d.