Today's Veterinary Practice provides comprehensive information to keep every small animal practitioner up to date on companion animal medicine and surgery as well as practice building and management.
Issue link: http://todaysveterinarypractice.epubxp.com/i/715668
tvpjournal.com | September/October 2016 | T O day' S Ve T erinary Prac T ice a c a S e O f c anine a cu T e Pancrea T i T i S Peer r eviewed 55 Abdominal Radiographs Loss of serosal detail in the right cranial abdomen was consistent with peritoneal effusion, while a mildly enlarged and rounded liver was consistent with hepatic venous congestion, hyperadrenocorticism, diabetes mellitus, neoplasia, or an acute inflammatory hepatopathy. Considering the patient's clinical signs and radiographic findings, the top differential diagnosis was pancreatitis with extrahepatic biliary obstruction. However, inflammatory hepatopathy, such as a gallbladder mucocele with possible bile peritonitis or hepatic neoplasia with hemorrhagic or neoplastic effusion, were also considered differential diagnoses. Abdominal Ultrasonography Ultrasonographic findings (Figure 2 ) included: • Moderate volume of anechoic free abdominal fluid, with a few echoes throughout, consistent with modified transudate or possibly exudate • Enlarged hypoechoic pancreas • Hyperechoic mesenteric fat, consistent with saponification of fat secondary to inflammation • Enlarged liver with multiple hyperechoic nodules likely suggesting a regenerative process, but neoplasia could not be excluded • Undulating, but not plicated, duodenum • Periportal, pancreatic, and gastric lymph node enlargement. These findings were most likely suggestive of pancreatitis, with no evidence of gallbladder mucocele or obvious pancreatic neoplasia. However, hepatic neoplasia could not be completely ruled out. Further diagnostic workup for possible neoplasia and other causes of enlargement of several abdominal lymph nodes was refused by the client. Analysis & Cytology of Abdominal Fluid Findings from abdominocentesis indicated a modified transudate (total protein, 2.7 g/dL; total nucleated cell counts, 10,195/mcL). Cytology showed marked nondegenerative neutrophilic inflammation and mild histiocytic inflammation. DIAGNOSIS Acute pancreatitis was diagnosed based on history, physical examination findings, nonspecific findings on general blood analysis, abnormal pancreatic lipase immunoreactivity (cPLI) based on abnormal SNAP cPL and/or increased Spec cPL results, abdominal radiographs, and ultrasonographic findings. THERAPEUTIC APPROACH Therapy for Acute Pancreatitis • IV fluid therapy: Lactated Ringer's solution was initiated and adjusted on the basis of regular monitoring of hydration status. • Analgesia: Lidocaine (25 mcg/kg/H) was initially given IV as a constant rate infusion (CRI), with buprenorphine added (0.4 mg IV Q 8 H). On day 3 of hospitalization, fentanyl (3 mcg/ kg/H IV CRI) was started, with lidocaine and buprenorphine discontinued. • Nausea control: Maropitant was initially adminis - tered alone at 10.4 mg SC Q 24 H; ondansetron was added on day 2 at 3.12 mg IV Q 12 H. • Nutritional support: Attempts were made to feed several types of commercially available low fat diets for the first 2 days of hospitalization, but Sidney was not interested in eating and seemed to be nauseated despite anti-emetic treatment. On day 3 of hospitalization, a nasoesophageal tube was placed, but the patient pulled it out. On day 4, syringe feeding with canine CliniCare (abbott.com) was tolerated. On day 5, the patient began to eat boiled chicken; CliniCare was adjunctively administered to meet daily energy requirements. Therapy for Early Stage DIC Fresh frozen plasma (20 mL/kg IV) was administered over 4 hours to supplement FIGURE 2. Abdominal ultrasonographic image of the pancreas. The pancreas appears hypoechoic (arrows) next to a cross section of duodenum (arrowheads). Note the hyperechoic mesenteric fat surrounding the pancreas and duodenum. These ultrasonographic findings are typical features of acute pancreatitis. Courtesy Dr. Kathy Spaulding, Texas A&M; University