Surgical or medical?? Pancreatitis only??

Re: Surgical or medical?? Pancreatitis only??

Julieg — Sat, 24 Nov 2012 19:23:57 GMT

The diagnosis they made was cholecystitis, when he was discharged his liver parameters were still elevated but much brighter in himself. I saw him yesterday to take further bloods at their request - demeanor wise he is back to his normal self.

Re: Surgical or medical?? Pancreatitis only??

Anthony Todd — Sat, 24 Nov 2012 17:18:23 GMT

[quote user="Rajat"]Anthony, it sounds like you are wedded to the exploratory laparotomy as a diagnostic tool to a pathological degree![/quote]

I must admit I was surprised by the plethora of diagnostic possibilities offered by indirect methods.

All the other diagnostic tools haven't exactly been unequivocal and a more definite diagnosis would have been obtained during the ex. lap on day one and, as I said, definitely eliminated the FB possibility.

See my previous summary, so yes, I still think a quick ex.lap seems to offer the best chance of an instant diagnosis quicker and more definitely than other methods.

Re: Surgical or medical?? Pancreatitis only??

Rajat — Sat, 24 Nov 2012 16:42:55 GMT

[quote user="Anthony Todd"]

[quote user="Julieg"]

He went home on Friday apparently much improved, they were treating him for cholangiohepatitis following FNAs of the liver, also giving vit K as the PT was increased. The gall bladder apparently was very oedematous on us scan so didn't FNA this. cPLi when it came back to us was >600 (0-200)

Thanks again for all your advice

[/quote]

I assume the dog has made an uneventful recovery?

But I'm not very impressed with the diagnostic approach or the results of same.

Xray bloods and subsequent multiple posts were equivocal at best and contradictory at worst.

We have obvious indications of pancreatic involvement on bloods [with some liver involvement?]

Ultrasound says it's the liver, pancreas normal!

Biopsy results of the liver are unknown?

The dog apparently gets better but over what period? [and don't mention the cost]

Although the amylase made me say I wouldn't ex.lap. I'm beginning to wonder, particularly bearing in mind the spectre of a FB.

Is the amylase incidental and/or labile and or spurious and seen in other pathology?

Would not an exlap given a more definitive diagnosis quicker and more definitely [apart from totally eliminating the FB possibility?]

Sorry, nothing to do until Qually.;-)

[/quote]

Anthony, it sounds like you are wedded to the exploratory laparotomy as a diagnostic tool to a pathological degree!

Re: Surgical or medical?? Pancreatitis only??

Anthony Todd — Sat, 24 Nov 2012 12:27:38 GMT

[quote user="Julieg"]

Thanks again for all your advice

[/quote]

I assume the dog has made an uneventful recovery?

But I'm not very impressed with the diagnostic approach or the results of same.

Xray bloods and subsequent multiple posts were equivocal at best and contradictory at worst.

We have obvious indications of pancreatic involvement on bloods [with some liver involvement?]

Ultrasound says it's the liver, pancreas normal!

Biopsy results of the liver are unknown?

The dog apparently gets better but over what period? [and don't mention the cost]

Although the amylase made me say I wouldn't ex.lap. I'm beginning to wonder, particularly bearing in mind the spectre of a FB.

Is the amylase incidental and/or labile and or spurious and seen in other pathology?

Would not an exlap given a more definitive diagnosis quicker and more definitely [apart from totally eliminating the FB possibility?]

Sorry, nothing to do until Qually.;-)

Re: Surgical or medical?? Pancreatitis only??

Julieg — Mon, 19 Nov 2012 19:28:10 GMT

Thanks again for all your advice

Re: Surgical or medical?? Pancreatitis only??

Julieg — Mon, 19 Nov 2012 14:57:58 GMT

Frustratingly i am still waiting to hear back from them . . . . . . . . .

Re: Surgical or medical?? Pancreatitis only??

Anthony Todd — Sun, 18 Nov 2012 17:20:29 GMT

[quote user="Anthony Todd"]Don't forget to tell us please.[/quote]

Like to know, did they end up doing an ex-lap??

Re: Surgical or medical?? Pancreatitis only??

Anthony Todd — Wed, 14 Nov 2012 15:48:39 GMT

[quote user="Julieg"]Had an update today,[/quote]

Don't forget to tell us please.

Re: Surgical or medical?? Pancreatitis only??

Julieg — Tue, 13 Nov 2012 20:58:40 GMT

Had an update today, he had an ultrasound scan this morning and they are thinking along the lines of liver disease, apparently the gall bladder was very oedematous and they have taken FNAs from the liver. The pancreas looked normal, no other problems seen, no evidence of a FB. Small amount fluid accumulated around cranial edge of liver. He is slightly brighter this morning apparently but still pretty poorly.

Re: Surgical or medical?? Pancreatitis only??

Anthony Todd — Mon, 12 Nov 2012 15:40:32 GMT

[quote user="Julieg"]I referred him first thing this morning, there was no change in him.[/quote]

Yes, please let us know.

Re: Surgical or medical?? Pancreatitis only??

Julieg — Mon, 12 Nov 2012 13:49:03 GMT

I referred him first thing this morning, there was no change in him. I will let you all know when i hear the outcome - hope he does well, he's a lovely dog and lovely owners too. Thanks to everyone for the advice.

Re: Surgical or medical?? Pancreatitis only??

james herriot lied — Mon, 12 Nov 2012 13:14:04 GMT

How did you get on overnight, julie?

Re: Surgical or medical?? Pancreatitis only??

claire power — Sun, 11 Nov 2012 22:25:52 GMT

Hi Julieg,

Also if his heart rate is low at 60 despite abdo pain etc would be worth checking his elecs, particularly potassium if you haven't already. It might be worth repeating all the bloods from yesterday and checking acid/base if you have an istat.

Good luck

Claire

Re: Surgical or medical?? Pancreatitis only??

Julieg — Sun, 11 Nov 2012 21:47:05 GMT

Have had him on cerenia for 48h, i think to give him the best chance i will refer him first thing tomorrow as we do not have 24h nursing which i think we are now at the point of needing plus better analgesia / equipment etc

Re: Surgical or medical?? Pancreatitis only??

james herriot lied — Sun, 11 Nov 2012 21:44:31 GMT

Sorry, that last bit was meant to have the word 'ketamine' in it....

Re: Surgical or medical?? Pancreatitis only??

james herriot lied — Sun, 11 Nov 2012 21:41:45 GMT

Possible +1 for cerenia also - can really help to reduce discomfort (provided of course you're happy there's no FB); also potentially for paracetamol, although some of your liver parameters are up. I would personally take the view that a decent dose of metacam - with stomach protectants and plenty of fluids - will help. Pain is the first and last enemy here.

Would you also have the option of a CRI?

Re: Surgical or medical?? Pancreatitis only??

Andrew Kent — Sun, 11 Nov 2012 21:34:50 GMT

And I would avoid NSAIDs as he is likely to be hypovolaemic and have GI ulceration already. As suggested maropitant may have some analgesic properties in pancreatitis (at least this has been shown in rats!)

Re: Surgical or medical?? Pancreatitis only??

Andrew Kent — Sun, 11 Nov 2012 21:33:17 GMT

If the dog is deteriorating and that painful then it sounds like he has an acute abdomen and should be investigated as such. At the least you can see if there is free fluid within his abdomen and tap it to aid in diagnosis but it sounds like he needs more aggressive pain and nutritional mamagement in addition to investigations. If this isn't possible then I would suggest referral may be a good option sooner rather than later as his prognosis is likely to be worsened by a time delay in getting to the bottom of his condition. It sounds like he has malaena which certainly needs gastro-protectant medication in addition to investigation. And again be careful in over interpreting cPLI results, they don't tell you a lot in these kind of cases. He may also have a marked ileus which needs appropriate treatment to resolve. Ultrasound is likely to give you many of the indications you need in this case but I suggest doing this tonight rather than in 12 hours time. Andy

Re: Surgical or medical?? Pancreatitis only??

Claire Fisher — Sun, 11 Nov 2012 21:28:26 GMT

If he's not already on it I believe Cerenia provides some visceral analgesia. If NSAIDs aren't indicated then iv paracetmol could be used as an alternative.

Re: Surgical or medical?? Pancreatitis only??

Julieg — Sun, 11 Nov 2012 21:21:44 GMT

I have him on 0.02mg/kg buprenophine q6h (we dont have anything more potent - trying to work on getting methadone into the practice but slow progress). I read somewhere that wasn't ideal to give nsaids so stopped this yesterday - should i restart? He has not eaten anything now for 5 days which concerns me. My colleagues are keen for ex-lap as next step?

Re: Surgical or medical?? Pancreatitis only??

james herriot lied — Sun, 11 Nov 2012 21:14:11 GMT

With you in spirit there, Julie

If you've got a suspect pancreas that seems to be getting worse, then pain control must be your first port of call. You said you had him on buprenorphine - how much and how often? Any NSAIDs in there too? Have you access to any more potent agonists? There is a theoretical risk that opioids will make the sphincter of odi go bananas, and so make the pain worse - it's always worth considering, but more dogs howl with under-analgesia (is that a real term?) than with SoO dysfunction. If you're concerned about this, try a short acting opioid first.

Tarry faeces? As in melaena? Stomach protectants are going to be a good idea in any case - perhaps some antepsin and omeprazole, although others will have differing views on which combos to use.

Keep those fluids running also - whilst the modern young things keep on feeding through an episode now, for years we had NPO for a good couple of days - and I'm not sure I can see any difference in outcome. Sometimes, removing both sight and smell of food (particularly with a lab) can stop the cholecystokinin and related surges, and prevent some of the pain.

Put the scanner on anyway - if you're not confident about finding the pancreas, you may surprise yourself. It would be worth having a look round the bile duct / gall bladder / bilairy tree in any case, given the bloods.

Best of luck

Re: Surgical or medical?? Pancreatitis only??

Mark Holmes — Sun, 11 Nov 2012 20:34:34 GMT

Must appologise I did not suggest my own post as the answer, that would make me a pillock.

Re: Surgical or medical?? Pancreatitis only??

AlanH — Sun, 11 Nov 2012 20:12:09 GMT

HI,

I think the opacity looks like fluid in pylorus? is it R lateral? Apprecaite 2 views not easy in conscious dog but if doing again id sedate to get 2 views, I'm going with pancreatitis still. Interested to see what happens! Good luck with this one

Alan

Re: Surgical or medical?? Pancreatitis only??

Julieg — Sun, 11 Nov 2012 19:39:36 GMT

Thanks for all the input so far:

The amylase was 3019 (200-1200) and should get cPLi results back tomorrow.

He does seem to be getting a bit worse this evening in that he's whining / groaning quite a lot now and resents abdo palp now too. HR now 60, temp normal and mm pink. Refusing any oral intake whatsoever including water. He is now passing small amounts tarry sticky faeces also.

My plan for tomorrow is rpt bloods to check whether getting worse incl platelets, if getting worse then referral i think will be best, if results better then i think i will have to sedate to place a feeding tube. What would be your suggestions for the best / simplest feeding tube for me to use (haven't had to do one before) and i am assuming i can just do barium this way if necessary (we have the liquid form). Also probably a daft question but will barium cause worsening of the pancreatitis??

Ultrasound wise, i will also try to do this tomorrow to see if can see anything obvious but will need to refer i think to be able to diagnose anything useful

Thank you

Re: Surgical or medical?? Pancreatitis only??

Anthony Todd — Sun, 11 Nov 2012 11:32:20 GMT

I know, I know ,but a blood test expunges them as any recent graduate will stress....

And an ultrasound is a stake through the heart of any internal devil; though not so good on conkers I've been led to believe.