Today's Veterinary Practice

SEP-OCT 2016

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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 57 Serum lipase activity has traditionally been used to estimate pancreatic lipase in serum. None of the substrates available (including newer substrates, such as triolein or DGGR [1,2-o-dilauryl-rac- glycero3-glutaric acid 6-methyl resorufin ester]), however, are specific for the measurement of pancreatic lipase, and results of clinical studies using these assays are inconsistent. 6,8 Cytology & Histopathology Pancreatitis can be confirmed by cytologic evaluation of a fine-needle aspirate of the pancreas. 7 Histopathology of the pancreas has traditionally been considered the gold standard for diagnosis and classification of pancreatitis. However, a recent study 9 suggests that a negative finding (ie, no inflammatory lesions in the biopsy) does not rule out pancreatitis because pancreatic inflammation can be highly localized. Advanced Imaging Advanced imaging modalities, including contrast- enhanced computed tomography (CECT) and contrast-enhanced multidetector helical computed tomography (CE-MDCT), have been evaluated and shown different utility for diagnosing pancreatitis in dogs. A study using CE-MDCT 10 showed low sensitivity for diagnosing pancreatitis in dogs presented with acute abdominal signs even though CE-MDCT was suggested as a good screening test to differentiate between surgical and nonsurgical conditions. A more recent study 11 using CECT concluded that CECT under sedation can confirm a clinical suspicion of pancreatitis. However, these modalities have limited availability for general use. ACUTE PANCREATITIS: TREATMENT Because most cases of acute pancreatitis in dogs are idiopathic, the mainstay of treatment is supportive care that includes risk factor control, fluid therapy, nutritional support, and pain control. Fluid Therapy Fluids are important to correct hypovolemia, dehydration, and electrolyte and acid–base imbalances as early as possible to prevent any systemic complications, which can be associated with a negative outcome. A study in human medicine 12 suggested a possible benefit of using lactated Ringer's solution because the alkalinizing property of that solution prevented further trypsin activation within the acinar cells, but no data are available for dogs. Nutritional Support Several studies in both humans and dogs suggest that early enteral nutritional support is superior to parenteral feeding in patients with acute pancreatitis as long as it is tolerated. 13-16 • Enteral feeding can be achieved by voluntary intake in mild cases or by using different types of feeding tubes (nasoesophageal, nasogastric, esophagostomy, gastrostomy, or jejunostomy tubes) in more severe cases. 17 • Gradually increasing the volume fed until the full energy requirement is reached is recommended regardless of the method of enteral alimentation. • Generally, an easily digestible food is recommended. The benefit of using a low fat diet is anecdotal, but we feel strongly that an ultra low fat diet should be chosen for feeding. These diets should be fed both during hospitalization and also after discharge. • If patients demonstrate severe nausea, vomiting, or abdominal pain before, during, or after feeding, enteral feeding should be discontinued and attempted later when these signs have been successfully controlled. Pain Management Every dog with acute pancreatitis should be considered as having abdominal pain even if it is not clinically apparent. A multimodal approach for pain management is advised for better pain control, lower dosages, and fewer adverse effects. • Most commonly used analgesics include opioids, ketamine, or lidocaine for hospitalized patients. • The use of a CRI of ketamine (5–20 mcg/kg/min) or lidocaine (25–50 mcg/kg/min) can decrease the amount of opioids required. Lidocaine may have some anti-inflammatory properties, based on evidence in human medicine. 18 • Outpatients can receive tramadol (5 mg/kg PO Q 6–8 H), an opioid, gabapentin (5–15 mg/kg PO Q 12 H), and/or a fentanyl patch. Antiemetic Agents Antiemetic treatment should be started as early as possible even in dogs without overt nausea or vomiting to encourage patients to eat voluntarily. • Maropitant (1 mg/kg SC Q 24 H for a maximum 5 days), a neurokinin1 receptor inhibitor, is recommended as a first choice antiemetic due to its high efficacy and visceral analgesic properties. • Dolasetron (0.6 mg/kg IV or SC Q 12–24 H) or ondansetron (0.1–0.2 mg/kg slow IV Q 6–12 H), both 5-HT 3 antagonists, can also be used.

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