GI JRT

Re: GI JRT

Alan Tevendale — Thu, 05 Sep 2013 14:50:20 GMT

Good thought Hanna. The big positive is that the dog went home today. We even gave her a squeaky toy to play with she was so bright! Back in for a check up tomorrow as a precaution. I'll post some info about the lab results as they come in.

Thanks everyone.

Re: GI JRT

Hanna Bennett — Wed, 04 Sep 2013 21:41:32 GMT

sorry Alan. i'm skipping reading thru the replies as it's late - we've found recently some sci cases need emeprid cri and cerenia just doesn't work - thought it was worth mentioning sorry if i'm repeating stuff

Re: GI JRT

Alan Tevendale — Wed, 04 Sep 2013 18:54:22 GMT

The dog is currently on metronidazole and noroclav. On IV fluids as well. Body temp was 39.1C when last taken today. May well ultrasound again tomorrow depending on progress.

Re: GI JRT

Richard Carter — Wed, 04 Sep 2013 18:17:38 GMT

body temp? still on drip? - I would put in some i.v. abs, check for post op peritonitis by ultrasound if you have it. If no i.v. abs available then penicillin/ metronidazole combination pretty good for most intestinal bugs until your results come back.

Re: GI JRT

Alan Tevendale — Wed, 04 Sep 2013 16:13:14 GMT

Well I don't think we've released all the bad spirits unfortunately. The dog continues to improve clinically. It has now started to show more interest in food and is becoming more it's normal self - i.e. difficult.

We repeated the biochem and haematology today. Biochemistry is again unremarkable. The WBC count is now 44.04 (5.5-16.9). Is this an indication of further problems or down to the fact that we operated on her only 3 days ago. Her PCV has dropped from 48.4% to 37.6% - ongoing GI losses?. We're still waiting on our histology and faecal analysis results from the weekend and have also sent blood for TLI, folate & cobalamin today.

Re: GI JRT

Richard Carter — Wed, 04 Sep 2013 09:43:29 GMT

statistically however recovery could be directly attributable to the inserting of a thermometre

Re: GI JRT

Richard Carter — Wed, 04 Sep 2013 09:33:06 GMT

naw - its the releasing of blood and bad spirits. Haven't you noticed that after taking blood samples, some animals start to recover???

Re: GI JRT

Mark Hedberg — Tue, 03 Sep 2013 20:39:32 GMT

[quote user="Richard Carter"]

let those bad spirits out....

[/quote]

Rubbish - it's the reoxygenation of the hypoxaemic omentum that provides the impetus for successful recovery!

Re: GI JRT

Richard Carter — Tue, 03 Sep 2013 18:30:56 GMT

let those bad spirits out....

Re: GI JRT

Linda Filshie — Tue, 03 Sep 2013 16:35:46 GMT

[quote user="Alan Tevendale"]

Dog seems brighter today[/quote] Another success to chalk up to therapeutic airing of the abdomen?

(Or maybe the H2 blockers/antacids)

Re: GI JRT

Alan Tevendale — Tue, 03 Sep 2013 14:19:54 GMT

Dog seems brighter today and results as follows:

Test Result Alert Units Reference Range

*Canine SpecPL 577 High ug/L <= 200
The canine SpecPL result is consistent with inflammatory
pancreatic disease.

Still waiting on the histology.

Re: GI JRT

John Flynn — Sun, 01 Sep 2013 20:13:25 GMT

[quote user="Alan Tevendale"]The pyloric region was thickened and when biopsied appeared ulcerated.[/quote]

Sounds like inflammatory disease rather than chronic hypertrophic pyloric gastropathy (and would be pretty young for neoplasia to be much of a consideration).

Do let us know what the biopsy shows!

Hopefully wee dog well on the way to the mend now

Re: GI JRT

Alan Tevendale — Sun, 01 Sep 2013 18:58:45 GMT

Okay things here have been busy while I've been away. The dog continued to vomit overnight last night and this morning and was generally looking more depressed. Repeat xrays were unrewarding (I'm away from the surgery right now so can't post them) and ultrasound showed more hyperechogenicity in the cranial abdomen. Given the deterioration we elected to exlap. The pyloric region was thickened and when biopsied appeared ulcerated. I could find no forgein body. The rest of the stomach and intestines were normal in appearance.

To answer the above questions:

The biochemistry in this case was unremarkable. The dog produces mucoid diarrhoea of a fairly low volume. I could find no evidence of peritonitis/free abdominal fluid. The stomach was no longer distended this morning although the proximal duodenum appeared fairly distended. We have started the dog on H2 blockers and Antepsin in addition to it's IVFT and antibiotics.

Re: GI JRT

Richard Carter — Sun, 01 Sep 2013 09:31:07 GMT

Back to the case - any faeces produced or still in git stasis? Abdominocentesis ? as looks like small amount fluid/ peritonitis present. Opiods very good for colic pain. repeat xray - is stomach still distended? Barium - will help soothe pancreatitis as well. Think ex-lap sooner than later if not responding. You can have a definitive answer in 10 minutes.

Most of pancreatitis cases I have seen the ALKP/ALT, renal and cholesterol readings are all cooked as well, the lipaemia, vomiting and dehydration spectacular.

Re: GI JRT

John Flynn — Sat, 31 Aug 2013 19:23:44 GMT

[quote user="Christopher Saul"]

I've just re-read my own post and I guess I'm not that clear.

I'm not saying that every acute pancreatitis patient will go on to develop chronic pancreatitis (and hence needs a low fat diet); rather if you do make the diagnosis of acute pancreatitis you can then

1)have the owners look out for similar clinical signs in future and they then can be more 'on the ball' for the development of CP.

2) If you want to be fancy measure serum TGs once the episode has settled , high serum TGs are a risk factor...

[/quote]

OK. I think i've got it - chronic pancreatitis is treated with low-fat food; acute pancreatitis patients may develop chronic pancreatitis.

Thanks for clarification and further details re TGs

Re: GI JRT

Christopher Saul — Sat, 31 Aug 2013 19:00:52 GMT

[quote user="John Flynn"]I'll bear in mind the low fat diet advice in future.[/quote]

I've just re-read my own post and I guess I'm not that clear.

1)have the owners look out for similar clinical signs in future and they then can be more 'on the ball' for the development of CP.

2) If you want to be fancy measure serum TGs once the episode has settled , high serum TGs are a risk factor...

[quote user="John Flynn"]The most memorable times I've been caught out were dogs with pancreatitis secondary to a FB (eg peach stone) in adjacent duodenum, linear FB, partial pyloric obstruction etc. There was a PM study a number of years back that found pancreatitis in 65% of dogs that had died for a number of reasons - that made me wonder about how common pancreatic inflammation was as a part of other disease conditions as opposed to as a primary condition.[/quote]

Absolutely. cPL should never be considered a replacement for good imaging; rather it is an adjunct to other tests.

Re: GI JRT

John Flynn — Sat, 31 Aug 2013 18:42:01 GMT

Hi Chris,

I think you largely get where I'm coming from re SpecCPL (or at least the bits I've managed to articulate here!) + I understand why SpecCPL might be helpful in Alan's case then.

[quote user="Christopher Saul"]it is becoming generally more accepted that chronic pancreatitis is a real entity and so a dog with an acute episode should really be given a lower fat diet in the future etc.[/quote]

Thanks for that - I guess that does change things. I'd always thought of chronic pancreatitis as a separate entity and hadn't thought to do much aftercare for suspected acute pancreatitis cases (other than advise to avoid scaevnging or extra treats/scraps etc - ie the same as would for any GI disturbance prone dog as you say) - I'll bear in mind the low fat diet advice in future.

The most memorable times I've been caught out were dogs with pancreatitis secondary to a FB (eg peach stone) in adjacent duodenum, linear FB, partial pyloric obstruction etc. There was a PM study a number of years back that found pancreatitis in 65% of dogs that had died for a number of reasons - that made me wonder about how common pancreatic inflammation was as a part of other disease conditions as opposed to as a primary condition.

As you say - a discussion for another day...!

Re: GI JRT

John Flynn — Sat, 31 Aug 2013 18:41:11 GMT

Hi Chris,

I think you largely get where I'm coming from re SpecCPL (or at least the bits I've managed to articulate here!) + I understand why SpecCPL might be helpful in Alan's case then.

As you say - a discussion for another day...!

Re: GI JRT

Christopher Saul — Sat, 31 Aug 2013 18:14:05 GMT

From what I can see John, your main reasoning is something along the lines of:

Does it really matter whether a dog has pancreatitis vs, say, an acute gastroenterits when the treatments for both are largely the same (ie symptomatic)? And your answer it would seem is no because of the cost of the test.

I guess I can seed that logic but if a dog really does have pancreatitis then it does have implications for ongoing management; it is becoming generally more accepted that chronic pancreatitis is a real entity and so a dog with an acute episode should really be given a lower fat diet in the future etc.

[quote user="John Flynn"]If a "standard" lipase is very high (>2-3X upper refernce limit, say) then that adds confidence to a diagnosis of pancreatic inflammation[/quote]

In Alan's case he seems to suggest there was nothing on biochemistry (am I right Alan?); I am suggesting running a PLI in this case because of its superior sensitivity

[quote user="John Flynn"]even if there is 100% certainty of this, one still needs to exclude other causes of clinical signs - i.e. primary pancreatitis remains a diagnosis of exclusion?[/quote]

Yes John you are correct there. Pancreatitis can certainly be secondary to, say, a septic peritonitis. But that is much easier to eliminate on ultrasound than is pancreatitis; imaging of the pancreas is difficult whereas free abdominal fluid is generally much easer to image, even for a relatively inexperienced ultrasonographer. Also pancreatic neoplasia is a rare primary cause of pancreatitis - you could argue we should be FNAing pancreata, but that is a debate for another day.....

Re: GI JRT

John Flynn — Sat, 31 Aug 2013 17:31:02 GMT

[quote user="Christopher Saul"]The cut off for the standard lipase was the top of the standard-accepted reference range I believe, whereas 2 different ranges were quoted on the PLi because such a cut off has not been elucidated.[/quote]

I guess I just don't find such a comparison likely to convince me that SpecCPL results are worth the extra cost/effort.

[quote user="Christopher Saul"]

[quote user="John Flynn"]if I suspect pancreatitis, and have tried my very best to rule out a surgical lesion with imaging, then I would say that there is a >90% chance that the dog has pancreatitis [/quote]

I take it then that you're pretty hot ultrasonographer, and if so then yes I would agree that PLI may not add as much as it might to someone who may not be so confident with ultrasound.

[/quote]

I'm sadly a pretty poor ultrasonographer with pretty basic first opinion ultrasound machine. I was trying to estimate the pre-test prevalence based on my own guestimates and may be horribly far out, but I believe pancreatitis to be fairly common and while I remember cases that I've thought had pancreatitis and I thought I'd excluded a surgical lesion but did eventually ex lap and turned out did have surgical lesion, I think these are less that 1 in 10 dogs that have been treating medically for pancreatitis? I think my line of reasoning involves too many estimates that I can't make reliabble to be worth pursuing.

[quote user="Christopher Saul"]For someone with little confidence in ultrasound, a very high cPLI would add confidence to his/her diagnosis[/quote]

I guess I used to think this when test came out and used it enthusiastically 5 years ago or so. I just didn't find that it was really the big extra help i expected it to be (perhaps i'm just disillusioned because my expectations were unreasonably high). If a "standard" lipase is very high (>2-3X upper refernce limit, say) then that adds confidence to a diagnosis of pancreatic inflammation. What i don't know is how much more useful (or not) a SpecCPL really is as a proper comparison doesn't seem to have been done? There is still the issue though that no matter how much pancreatic inflammation is present, even if there is 100% certainty of this, one still needs to exclude other causes of clinical signs - i.e. primary pancreatitis remains a diagnosis of exclusion?

[quote user="Christopher Saul"]As I say I can think of a number of occasions where lipase has been within reference and the dog has turned out to have pancreatitis. From real world experience we can say that it has a superior sensitivity. [/quote]

I'm not claiming that lipase levels less than that found in 95% of healthy dogs would be a sensible cut-off for excluding (or doubting a previous suspicion of) pancreatitis.

I'll try to read and understand the paper in full (it's quite detailed!) - who knows, I could become a convert yet

[If it was part of a routine blood panel i did I wouldn't think twice - it's just the extra cost/effort that makes me less inclined unless i can see a clear benefit and i haven;'t managed to get my head round one properly yet]

PS - I'll start a new thread on the speccpl if i have anything further to add so can focus this one on alans case

Re: GI JRT

Christopher Saul — Sat, 31 Aug 2013 16:32:59 GMT

The cut off for the standard lipase was the top of the standard-accepted reference range I believe, whereas 2 different ranges were quoted on the PLi because such a cut off has not been elucidated.

I take it then that you're pretty hot ultrasonographer, and if so then yes I would agree that PLI may not add as much as it might to someone who may not be so confident with ultrasound. Alan specified in his original post that he was not as confident in his ultrasound findings as perhaps you are. For someone with little confidence in ultrasound, a very high cPLI would add confidence to his/her diagnosis

As I say I can think of a number of occasions where lipase has been within reference and the dog has turned out to have pancreatitis. From real world experience we can say that it has a superior sensitivity.

I know a number of fellow medicine clinicians who also use the cPLI test frequently.

Returning to the original question, I take it there was no evidence of free abdo fluid on your original scan??

Chris

Re: GI JRT

John Flynn — Sat, 31 Aug 2013 16:06:36 GMT

[quote user="Christopher Saul"]well, the same paper suggests that standard lipase has a sensitivity of around 43.4-53.6%, which is pretty poor compared with that of 91.5-94.1% for cPL.[/quote]

I don't htink the numbers you quote here are comparable.

You can't choose a single arbitrary cut-off point for lipase and then compare the sensitivity & spec at that single cut-off point with the 2 separate cut-off points for SpecCPL and conclude that the latter is "better".

I think part of the issue for me might be a general practice thing.

As you say, if SpecCPL < 200, then you should look really hard for another cause. Unfortunately, I also need to look hard for another cause if SpecCPL >200, and as a GP, there's only so hard I can look (xrays/ultrasound +/- rule out addisons, failing all else ex lap).

Also if I suspect pancreatitis, and have tried my very best to rule out a surgical lesion with imaging, then I would say that there is a >90% chance that the dog has pancreatitis (i.e. I think less than 1 in 10 dogs presenting like this that turn out to have a surgical lesion). With a pre-test prevalence of 90%, then figure 1 of the paper indicates an approx 60% negative predictive value to SpecCPL at 200 cut-off - would such a result really make me look any harder than I already had?

Re: GI JRT

Christopher Saul — Sat, 31 Aug 2013 15:44:45 GMT

[quote user="John Flynn"] I'm far from convinced that the extra cost compared to a bed-side "standard" lipase really adds that much to this aim?[/quote]

well, the same paper suggests that standard lipase has a sensitivity of around 43.4-53.6%, which is pretty poor compared with that of 91.5-94.1% for cPL.

Anecdotally, I can think of several cases of total lipase being normal, only for an ultrasound scan and PLI both indicating pancreatitis.

cPL is not perfect but it is useful as just one part of a jigsaw puzzle

Re: GI JRT

John Flynn — Sat, 31 Aug 2013 15:30:22 GMT

[quote user="Christopher Saul"]McCord et al, JVIM Aug 2012 gives a nice little summary. [/quote]

Haven't read that paper before and it looks like it deserves more than a skim read! Thanks for drawing my attention

I understnad that the reported aim of the Spec CPL is to rule out "clinically-significant pancreatitis" with a result of <200 and it probably does this with a success of about 85% in vomiting dogs?

I'm just not totally sure that this is really very practically helpful when I'm working up cases, and I'm far from convinced that the extra cost compared to a bed-side "standard" lipase really adds that much to this aim?

I need to read the paper in more detail at some point to do it justice as looks generally like a well put together study with respect to the SpecCPL results and their predictive value, but a quick look didn't convince me that I'm going to start to find SpecCPL more useful than I currently do with "standard" lipase. They used a single cut-off point for standard lipase and then seem to compare this directly to using 2 separate cut-off points for SpecCPL (I may have missed somethin in skim-reading)?? I don't think this really demonstrates that SpecCPL is a more reliable rule-out test than standard lipase?! (but I'll try to read the study properly... that is if i can understand it!)

Re: GI JRT

Christopher Saul — Sat, 31 Aug 2013 14:15:36 GMT

[quote user="John Flynn"]When presented with vomiting, I tend to be interested in the question "Does this GI disturbance need surgical intervention or not?"[/quote]

Couldn't agree more, and this question can actually be more challenging than some people think. I myself can think of many cases where I have struggled to answer this hot potato, and have had to ask a diplomate imager for help. PL is just a part of this assessment. Ultrasound is great for this too.

[quote user="John Flynn"]I can't quite figure what SpecCPL adds to such cases[/quote]

cPLI is comfortably the most sensitive and specific ante-mortem test for pancreatitis, so IT IS indicated in this case. It is highly sensitive when taking 200 ug/L as a cut off value, meaning that if you have a value of < 200 then you should really look hard for other causes.( McCord et al, JVIM Aug 2012 gives a nice little summary. It's NOT a perfect test - no test is, but it is useful)

Where PLI is not appropriate is as a standalone blind /screening test where you either have no clinical information about the patient and no other diagnostic tests available. It is conversely very useful in the context of clinical signs and other diagnostic tests such as ultrasound.

that said, the area you indicate in green arrows could well be pylorus as you suggest, though could be hepatomegaly. Ultrasound, PLI and Orthagonal views of the abdomen, as well as ruling out addson's are be the way I would be going.

Hope this helps

Chris