Pancreatitis in a dog

RE: Pancreatitis in a dog

David Mills — Wed, 07 Apr 2021 18:43:34 GMT

[quote userid="2451" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog/229471#229471"]so I don't think its good enough to change a current standard of care (which is not to give steroids)[/quote]

Defined by whom?

[quote userid="2451" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog/229471#229471"]NGLISH cockers might be different as they likely do have an immune-mediated form of the disease (often impacting other organ systems as well) but even then we generally only immunosuppress chronically if they respond badly to standard treatment.[/quote]

Steroids are being given at anti-inflammatory doses in our cases, not immunosuppressive doses so it's a bit of a non-sequitur. Spaniels likely have a different disease to 'garden' pancreatitis.

[quote userid="2451" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog/229471#229471"]This case would likely have minimal adverse effects of a steroid but that is not the same for more severe acute cases - they can easily ulcerate the gut and we have managed some horror cases that have gone very wrong after steroids were given. That is not only a risk when given orally.[/quote]

I'm not doubting you have seen this, but correlation is not causation.

In the converse, we see or suspect acute pancreatitis in about 3 or 4 dogs per week (so around 200+ annually) in our hospital. Some of these may not have pancreatitis, some are confirmed (as much as one can confirm) by ultrasound, others not. We haven't had any ulcerations or disastrous consequences. Dexamethasone also has positive effects of anti-emesis, appetite stimulant and a potent anti-inflammatory. I suppose this neatly demonstrates the difference between seeing the sharp end of unusual cases at referral centres and the vast numbers of mild-moderate cases in first opinion practice.

[quote userid="2451" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog/229471#229471"]The study that supposedly demonstrated a benefit is flawed - ie its based on a practice that changed its treatment over time so the cases were also separated in time [/quote]

Most (all?) studies are flawed in some way, but they can still add value to the knowledge base.

RE: Pancreatitis in a dog

Neil Wheadon — Sat, 27 Mar 2021 10:17:09 GMT

Here are the bloods

It's a list which is never easy
IDEXX SDMA 12 1 - 14 μg/dL
Creatinine 36.0 44.0 - 133.0 μmol/L L
Urea 4.1 3.1 - 10.1 mmol/L 4.1
Phosphorus 1.34 0.80 - 1.60 mmol/L
Calcium 2.07 2.36 - 2.84 mmol/L L
Sodium 149.0 135.0 - 155.0 mmol/L
Potassium 5.21 3.60 - 5.60 mmol/L
Na: K Ratio 28.60 28.80 - 40.00 L
Chloride 110.7 100.0 - 116.0 mmol/L
Total Protein 56.7 54.9 - 75.3 g/L 54.5
Albumin 24.9 26.3 - 38.2 g/L L 25.1
Globulin 31.8 23.4 - 42.2 g/L 29.4
Albumin:
Globulin Ratio
0.78 0.70 - 1.40 0.85
ALT 54.5 19.8 - 124.0 U/L 17.0
ALP 252.0 <= 130.0 U/L 447.0
GGT 7.4 2.0 - 5.7 U/L H 5.7
Bilirubin - Total 2.6 <= 5.1 μmol/L 1.9
Cholesterol 1.97 3.20 - 6.20 mmol/L L 2.39
Triglyceride 0.87 0.30 - 1.20 mmol/L
Amylase 923.3 100.0 - 1,200.0 U/L
Lipase 1,289.0 <= 200.0 U/L
Creatine Kinase 229.7 20.0 - 225.0 U/L H
Bile Acids
Preprandial /
Random
16.0 0.1 - 5.0 μmol/L H 6.0
Spec cPL 1,150 <= 200 μg/L

RBC 5.81 5.39 - 8.70 x10^12/L 5.56
Haematocrit 0.428 0.383 - 0.565 L/L 0.412
Haemoglobin 140 134 - 207 g/L 135
MCV 73.7 59.0 - 76.0 fL 74.1
MCH 24.1 21.9 - 26.1 pg 24.3
MCHC 327 326 - 392 g/L 328
Reticulocytes 24.4 <= 110.0 K/μL 32.8
Reticulocyte
Haemoglobin
28.0 24.5 - 31.8 pg 26.3
WBC 11.6 4.9 - 17.6 x10^9/L 19.3
% Neutrophils 75.0 % 79.0
% Bands 7.0 % 1.0
% Lymphocytes 8.0 % 8.0
% Monocytes 7.0 % 10.0
% Eosinophils 3.0 % 2.0
% Basophils 0.0 % 0.0
Neutrophils 8.70 2.94 - 12.67 x10^9/L 15.25
Bands 0.81 0.00 - 0.17 x10^9/L H 0.19
Lymphocytes 0.93 1.06 - 4.95 x10^9/L L 1.54
Monocytes 0.81 0.13 - 1.15 x10^9/L 1.93
Eosinophils 0.35 0.07 - 1.49 x10^9/L 0.39
Basophils 0.00 0.00 - 0.10 x10^9/L 0.00
Nucleated RBC 0.12 10^9/L
Platelets 474 143 - 448 x10^9/L

RE: Pancreatitis in a dog

Neil Wheadon — Sat, 27 Mar 2021 10:12:16 GMT

[quote userid="2451" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog/229471#229471"]Just my thoughts![/quote]

and very much appreciated thankyou

In this case, no vomitting just intermittent diarrhoea over 6 weeks and 'not quite right'

The whole 'gut' thing is fascinating.

The more I look into this the more I look at B12/folate/cPLi/TLI. The main issue though is cost of the tests in cases, but the information it gives...

In this case i didn't do a B12/Folate. it was on the list as IDEXX have the blood to do more tests.

Neil

RE: Pancreatitis in a dog

Andrew Kent — Sat, 27 Mar 2021 09:08:25 GMT

For me the first question here is whether or not the dog actually has pancreatitis - we see raised cPLI in dogs with other diseases as well, such as inflammatory gut disease. This is a fairly high level but still it may or may not be pancreatitis - ideally we would get some imaging of the abdomen to exclude other causes and see how the pancreas appears. A high cPLI is not enough to diagnose that disease in my view - especially when the signs here are not classical for acute pancreatitis (they could be more in keeping with chronic).

What you use as a symptomatic treatment would depend a lot on your exam - any pain? any vomiting? I agree I would personally not use antacids in this context.

I might consider running B12/folate to give myself more or less evidence to support a gut cause. Also worth watching TLI in case this is a dog developing EPI.

But I would likely reach for diet first - either ultra low fat (I agree with the comment above that just avoiding high fat may actually be enough) or even novel protein/hydrolysed depending whether I lean more towards gut or pancreas. But diet is always trial and error.....

I don't buy at all the steroids thing in most pancreatitis. The study that supposedly demonstrated a benefit is flawed - ie its based on a practice that changed its treatment over time so the cases were also separated in time (and managed by different people) so I don't think its good enough to change a current standard of care (which is not to give steroids). ENGLISH cockers might be different as they likely do have an immune-mediated form of the disease (often impacting other organ systems as well) but even then we generally only immunosuppress chronically if they respond badly to standard treatment.

This case would likely have minimal adverse effects of a steroid but that is not the same for more severe acute cases - they can easily ulcerate the gut and we have managed some horror cases that have gone very wrong after steroids were given. That is not only a risk when given orally.

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog"]Initial bloods showed a mild low albumin and a high WBC (19) Treated with metrobactin[/quote]

This is a slightly separate discussion but I also try to avoid antibiotics with acute gut disease now - metronidazole can have a significant impact on the gut bacteria which take a long time to recover and is likely the opposite of what we need. High WBC doesn't equate to bacterial infection, maybe just inflammation.

Just my thoughts!

Andy

RE: Pancreatitis in a dog

David Mills — Fri, 26 Mar 2021 22:03:17 GMT

Spaniels + pancreatitis = use steroids

In fact scratch that, dogs and cats with pancreatitis = use steroids.

It has been documented to quicken recovery from episodes and it is certainly our experience. Any oral drug can cause GI signs, including pancreatitis, steroids are no different or even riskier. If you're concerned about preds in particular, give them something parenteral with an extended duration e.g. dexafort.

+ paracetamol, buscopan, maropitant (all have some analgesic effects).

Antibiotics - pointless.

Gastroprotectants don't make sense to me at all. They might increase pH but this is neutralised by bile anyway so I can't see their indication. One of the most overused drugs in veterinary medicine, have a read of this:

https://onlinelibrary.wiley.com/doi/10.1111/jvim.15337

"There is no evidence that acid suppression treatment is beneficial or indicated in the management of dogs or cats with pancreatitis, unless the animal has concurrent evidence of GUE (gastroduosenal ulceration and erosion)"

RE: Pancreatitis in a dog

Lucy Fleming — Fri, 26 Mar 2021 19:26:31 GMT

I tend to use quite a bit of maropitant in "low key" pancreatitis cases to alleviate nausea and keep them eating ok. But not necessarily a good "long term" option (is it needed? And fairly costly. I have used daily long term in IBD cats though...)

Plus ca change, last time I spoke to one of Langford's internal medics on the topic they mentioned they don't worry too much about dietary fat content unless the patient has elevated triglycerides (this was in the context of a very fussy chronic pancreatitis dog who wouldn't eat any suitable options). Interestingly, this one was also an American Cocker and apparently spaniels (can't recall if just AKCs or all spanners) are thought to have a type of immune-mediated pancreatitis that is steroid responsive...so the pred may be helping?

Could he maybe have an underlying more generalised enteropathy? Worth a hydrolysed diet trial, or maybe a period on B12 (or a B12/probiotic combo?)

I must admit I tend to just treat any clinical flares, but seems counter-intuituve to to treat the underlying disease better. Perhaps they should all go on a biologically appropriate raw diet

RE: Pancreatitis in a dog

Julian Earl — Fri, 26 Mar 2021 15:10:52 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog"]Thoughts?[/quote]

Neil,

I believe the immediate priority is the pain relief plus fluids. A low fat diet is very important. I am not sure that antibiotics are routinely helpful in most cases.

Supplementary pancreatic enzymes are indeed usually recommended as well as you have already noted. I used to give steroids to relieve the inflammation and ergo the pain until I read that steroids can predispose towards pancreatitis in the first case! I have then tried NSAIDs without apparent adverse effects instead of the steroids. NB, warn the owners that it can be recurrent!

I hope that this helps the poor dog?

RE: Pancreatitis in a dog

Anthony Dennison — Fri, 26 Mar 2021 14:10:11 GMT

There's a bit of to-ing and fro-ing with gastrenterologists about sung pancreatic enzyme supplements in these cases to 'rest' the pancreas. No hard and fast rule, sometimes it works, sometimes it doesn't.

Agree on the low fat diet, but also needs to be easily digestible.

RE: Pancreatitis in a dog

Neil Wheadon — Fri, 26 Mar 2021 12:29:17 GMT

[quote userid="8424" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/29745/pancreatitis-in-a-dog/229458#229458"]gastro protectants[/quote]

Thanks

What's the logic in doing that?

Neil

RE: Pancreatitis in a dog

Dagmar Steele — Fri, 26 Mar 2021 11:51:45 GMT

Low fat diet, gastro protectants, if painful I use metamizole (I think you can't get that, right?)