Pancreatitis and PLN

Re: Pancreatitis and PLN

Christopher Saul — Tue, 25 Jun 2013 11:40:34 GMT

You're most welcome.

[quote user="Thomas Ward"]It seems I may have ended up the wrong track.[/quote]

Possibly you have but NOT for sure; though Andy and I are sceptical about it being aPLN, we haven't completely eliminated it.

Re: Pancreatitis and PLN

Tom Ward — Mon, 24 Jun 2013 23:12:11 GMT

Hi Chris, Many thanks for your message, that is really useful. It seems I may have ended up the wrong track. There are some cost issues (especially as the clients are 'insured' through the practice but do not get external lab fees included), but I'll try to steer the case towards some more diagnostics (and stop the steroid!).

Re: Pancreatitis and PLN

Christopher Saul — Mon, 24 Jun 2013 22:26:38 GMT

Hi Thomas,

With those renal parameters I can understand how a PLN sprung to mind, but to be honest I still think with a U P:CR of only 1.5 you need more to go on before you can call it that (esp if you have haematuria which ail artificially elevate U P:CR ). I don't think it is a PLN but I may be wrong

In general the differentials for hypoalbuminaemia can be grouped into the following categories:-

-GI ( direct loss, malassimilation/mababsorbtion)

-renal loss

-hepatic failure

-3rd spacing/exudative disease (e.g.peritonitis, vasculitis)

-starvation (can rule this out from the history)

So:-

As Andy says, any history of GI signs e.g. diarrhoea?

I would be inclined to do a bile acid stim test, B12/folate,TLI. and repeat urinalysis also. - remember steroids will artificially increase U P:Cr - to be honest I agree with Andy, I wouldn't use them just yet.

We really need a sample of the ascitic fluid for analysis - is it a pure transudate? or could it be an exudate - could we have a peritonitis secondary to the pancreatitis?

Imaging is really the way forward- survey radiography of thorax and abdomen as well as ultrasound of the abdomen - you can use ultrasound to have a good look at the GI tract, pancreas, kidney, lymph nodes etc. You can also use the ultrasound to guide a needle to sample any remaining fluid.

Hope this helps

Chris

PS Emy is right, with a PLN you want to restrict dietary protein. In honesty until we have a diagnosis I would be inclined to use a highly digestible diet such as sensitivity ...

Re: Pancreatitis and PLN

Andrew Kent — Mon, 24 Jun 2013 22:15:49 GMT

Did you characterise the abdominal fluid? It is unlikely an albumin of 16 would lead to massive ascites so it would be helpful to know what the fluid was to determine the aetiology.

I would agree that if this were a PLN then high protein diet won't help, but I'm not sure this is a PLN.

Re: Pancreatitis and PLN

emy — Mon, 24 Jun 2013 20:52:33 GMT

Although it's not sure if this hypoalbuminemia is due to renal loss, i've read that protein restriction is recommended for protein-losing nephropathies. Apparently if you increase proteins in the diet, it increases albuminuria, and leads to decreased albumin concentration in the serum.

Re: Pancreatitis and PLN

Tom Ward — Mon, 24 Jun 2013 18:16:02 GMT

I've sent the blood of for a quantitative cPLI today to ascertain what the pancreas is doing. Initial bloods were as follows, today ALB is 13, ALT is 134, CRE 190, BUN 20.9 and the amylase is down to 1650, everything else much the same. His urine sample is now showing up blood ++++ on the dipstick, though initially a sediment (done by the lab) was normal!

ALB (25-44) 16 *lo

ALP (20-150) 100

ALT (10-118) 79

AMY (200-1200) 2478 *hi

TBIL (2-10) 6

BUN (2-9) 19.5 *hi

CA++ (2.15-2.95) 2.44

PHOS (0.93-2.13) 1.64

CRE (27-124) 217 *hi

GLU (3.3-6.1) 5.7

NA+ (138-160) 139

K+ (3.7-5.8) 4.0

TP (54-82) 49 *lo

GLOB (23-52) 32

Thanks for all your help! I can't quite decipher why the ALB levels are worse but the ascites is resolved - perhaps there is another cause...

Re: Pancreatitis and PLN

Andrew Kent — Mon, 24 Jun 2013 10:34:56 GMT

As Chris says I am not sure that UPC accounts for such severe hypoalbuminaemia so it would be worth looking for other causes of this - is there any history of chronic GI disease? Could you do a bile acid stim? And has any analysis been performed on the abdominal fluid? All of these things could help you characterise further where the problem is.

I am also not sure that I would use steroids yet as we don't really know what we are treating.

Re: Pancreatitis and PLN

Kate Richardson — Mon, 24 Jun 2013 10:22:39 GMT

How low is the albumin? It needs to be pretty low to cause ascites and the UPC whilst elevated isn't that high- was a urine sediment examined as well to make sure not due to urinary tract infection/inflammation? Is there any sign of other body cavity effusions or oedema? I would be cautious about diagnosing panccreatitis at this stage- amylase could be elevated due to reduced renal clearance which you have evidence of with azotaemia. I agree that some abdominal imaging would be a good step; you need to determine for certain the cause of the ascites. Probably worth some good sedation, repeat bloods and abdominal ultrasound/xrays, and if funds allow checking the thoracic cavity as well for signs of free fluid/abnormalities. I would also be cautious about using prednisolone until you have more information. As the dog is young and bright, definitely worth investigating further to get to the bottom of this.

Re: Pancreatitis and PLN

Christopher Saul — Mon, 24 Jun 2013 10:14:23 GMT

Can you past any figures Thomas.... how low are the albumin and globulins? Have you done a BAST? True PLNs causing hypoalbuminaemia often have higher prot: creat than 1.5 to be honest ( I've seen 11 before now)

Re: Pancreatitis and PLN

Tom Ward — Mon, 24 Jun 2013 09:48:15 GMT

No, no haematology sadly. Managed to get another sample today, looks much the same as before, amylase has come down from 2400 u/l to 1650 u/l (ref 200-1200) but still azotaemic and hypoalbuminaemia has worsened. Still very bright, eating/drinking fine; think I need to up the dietary protein intake... What would you be looking for on imaging?

Re: Pancreatitis and PLN

Martin Atkinson — Mon, 24 Jun 2013 09:37:52 GMT

Can't see how you can make any decisions until you repeat the bloods for a progress report, then some imaging. Did you do haematology? I wouldn't be happy with just a SNAP SpecPL, I like some numbers to compare so usually send a sample to Idexx as well.