Pancreatitis and Jaundice

Re: Pancreatitis and Jaundice

Rob Loxley — Fri, 23 Jul 2010 19:23:18 GMT

If you've done a snap cPL, don't IDEXX give you a large discount off the laboratory quantitative cPLI test, may be useful if finances limited?

Re: Pancreatitis and Jaundice

Catherine Coen — Thu, 22 Jul 2010 20:23:54 GMT

Thanks for all your replies everyone,

I saw her back today and she actually seems to have improved over yesterday and this morning - more of an appetite, asking for food for the first time in a while. Didn't do xrays today, will continue conservative treatment for the moment and possibly refer her for an ultrasound early next week. Will be repeating bloods then and may send CPL to the lab. Biochem today showed liver enzymes similar to yesterday, bilirubin has gone down from 170 to 70. How long should I expect liver enzymes to remain elevated even if the pancreatitis appears to be improving?? I think I tend to panic a bit with cases like these, alot of what I thought I knew very well at the end of university seem to have disappeared over the past year!

Catherine

Re: Pancreatitis and Jaundice

Martin Atkinson — Thu, 22 Jul 2010 19:32:36 GMT

[quote user="Ian Battersby"]

Mainitaining food intake is key in pancreatitis . As soon as you can control the vomiting offer food and i place feeding tubes if necessary. I appreciate this is different to the old thinking but good studies in humans show that earlier instigation of feeding reduces morbidity and mortality by maintaining gut function.

[/quote]

I now tell all cases of vomiting and diarrhoea to continue suitable feeding as it is important to maintain gut function and even if most of its seems to come back enough will be mainatined to be of some nutritional benefit. I feel provided that fluid and electrolyte balance is maintained the D&V is the owner's problem not the patients! Are there any situations apart from obviously digestive tract obstruction that you advocate starving these days Ian? I still think its worth getting the lab to do a specCPL because the SNAP test doesn't give an absolute level and if its sky high may influence to prognosis.

Re: Pancreatitis and Jaundice

Richard Carter — Thu, 22 Jul 2010 18:22:42 GMT

and antepsin (sucrulfate) if she can swallow without v+ - does wonders for bile reflux, ulcers, pH neutralising etc

Re: Pancreatitis and Jaundice

Ian Battersby — Thu, 22 Jul 2010 15:05:03 GMT

HI Catherine

I do see pancreatitis cases with marked jaundice that can persist for wekks in a few cases.

Differentials for marked lipeamia - hypothyriodism , pancreatitis, DM, HAC, PLN and then unusual lipoprotein lipase deficiencies

Evelations in ALKP - suppartive cholangitis, steriods, Cushings and cholestasis are the main ones.

So my inclination would be that the jaundice is post hepatic with reactive increases in ALT and given the hyperlipideamia - pancreatitis would be the most probably diagnosis.

If funds are limited i think i would use the money to support her for the most probable diagnosis being treatment pancreatitis whilst you wait to get your ultrasound. I think bile acids and a Spec PLI unlikely to help more in this case and an ultrasound will give you most information regarding pancreatitic architecture and weather there is any masses or physical obstruction.

An abdominal x ray may be not that usedful assess hepatic and [pancreatic architecture so you could save money and miss out that step.

For me personally i dont send these dogs for ex lap if at all possible as the hypotension whilst UGA during the surgery could make the pancreatitis worse ( i guess in those cases though i have already had an ultrasound scan). Canulation of the pancreatic duct is often done in the USA but i have rarely persued this and treated supportively.

Pancreatitis is a painful condition so an opiod trail may help with here appetite etc. I tend to use methadone. i avoid NSAID in pancreatitis cases due to the increased GI ulceration risks. Also drugs like ranitidine which are prokinectic can help with the secondary ileus that can develop. which again can affect appetite. Fluids if she is not eating etc.

Sorry it is breif - it is a big topic to cover but hope that is of some help

Re: Pancreatitis and Jaundice

Ian Ross — Thu, 22 Jul 2010 10:19:41 GMT

[quote user="Martin Atkinson"]

[/quote]

I thought that bile acids would always be high if bilirubin is high? So in this case would be a waste of money? Otherwise yes, SAMe and maybe silymarin (milk thistle) could help, as could any anti-oxidants?

Re: Pancreatitis and Jaundice

Martin Jones — Thu, 22 Jul 2010 10:16:15 GMT

I'd agree with Martin on this one - there are few things better in a case like this than actually laying eyes on the whole area - and costs of ex lap may well be lower than GA and rads, followed by ultrasound and trial treatments. Beware, though, that by this point a chronically inflamed pancreas is easily mistaken for neoplasia.

As an aid to diagnosis, I do also find that ex lap is often preferred by owners with limited funds, as they feel that it's cutting through a swathe of tests. Discuss the possible outcomes - including a peaceful end under anaesthesia if appropriate - and have a really good look

Martin

Re: Pancreatitis and Jaundice

Martin Atkinson — Thu, 22 Jul 2010 09:53:00 GMT

There is a high probability that this is choleostasis due to the pancreatitis rather than primary liver disease, but if you're going to manage it conservatively there's not a lot more you can do although SAMe may be better than Destolit. Bile acids may be useful and I would send away for an absolute specCPL rather than just the SNAP but I have to say that under the given circumstances I would probably ex. lap., at least you can see at first hand what is happening and biopsy if necessary, and potentially save the client money in the long term.

Re: Pancreatitis and Jaundice

Ian Ross — Wed, 21 Jul 2010 22:28:46 GMT

Dear Catherine,

I think that if you could arrange for the ultrasound a little earlier it would be great, but I don't htink that it needs to change your treatment too much at this point.

First off, it depends just how poorly and ill the dog is at the moment - obvious initial treatment would be IV fluids, and analgesics. I think that the xray tomorrow may show you how reactive the area is around the pancreas, and you may be able to see a "groundglass" appearance, but I do not think that this is always present.

I do think that the liver could be this reactive just from the insult of a pancreatitis, and therefore supportive treatment will be helpful. You can get very rapidly raised results. I would start destolit treatmeent, but I am not sure if it is safe to give if there is the possibility of a blockage, either intra or extra-hepatic. Continue antibiotics, and poss have on iv fluids until you can get the scan done on monday. If the albumin levels are normal then a chronic hepatitis less likely, but did any of the liver parameters come out on the previous lipaemic sample??

Hope this helps, I tend to waffle a little!!

Good luck tomorrrow,

Ian