Acute Necrotizing Pancreatitis Goliath

7/31/2019 Acute Necrotizing Pancreatitis Goliath

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2/25

Goliath Jedziniak, 8 year old, MN,Miniature Poodle


3/25

Presented to UF ECC Service on 4/25 for:

Icterus

Acute abdominal pain


4/25

On Monday, Goliath went to the yard tourinate, came running back with his left

hind limb tucked underneath him. Started to act strange, defecating

around the house and vomiting.

Was taken to rDVM where he presentedin lateral recumbency and defecatedblood.

MM: pale white, moist and cold.


5/25

Epinephrine IM Solu Delta Cortef Famotidine LRS @ 450ml/hr for

30mins, reduced to220ml/hr for 30minsthen decreased to30ml/hr.

Diphenhydramine

Metoclopramide PO,but continued tovomit, then givenMaropitant SQ.

Diagnosed withanaphylactic shock.

Diphenhydramine12.5mg q6hrs

Famotidine 5mgq12hrs

Metoclopramide syrup1ml q8hrs

Probiotic 1 capsule

q24hrs #30 Epi pen jr 0.15/0.3ml


6/25

On PE his sclera andskin were icteric, withharsh lung sounds.

IV fluids

Buprenorphine

Metronidazole IV

Bloodwork:

Moderatethrombocytosis: 1436Ku/L (174-500)

ALP: 1268 U/L (23-212) GGT: 55 U/L (0-7)

Bilirubin 23.3mg/dl (0-0.9)

Amylase >2500 U/L(500-1500)

Lipase >6000 U/L (200-1800


7/25

Was transferred toan Emergency Clinicfor supportive care:

5fr urinary catheterwas placed (140 mlsof dark amberurine)


8/25

PE: Abdomen was

distended, tense andprofoundly painful onlight palpation.

Melena

Chemistry: BUN: 28mg/dL ALT: 652 U/L (10-100) ALP: 582 U/L (23-212)

GGT: 19 U/L (0-7) Tbilirubin: 21.8 mg/dL Elevated Amylase

and Lipase

CBC: Mild leukopenia: 5.36

K/UL (5.5-16.9) Moderate

thrombocytosis: 1117K/uL (174-500)


9/25

PE: Jaundice,tachypneic,normothermic, CRT

>3secs


10/25

Hyperbilirubenimia(icterus)

Painful abdomen

Elevated liverenzymes

Elevated lipase andamylase

Diarrhea

Dehydration


11/25

Blood Gas:

TBilirubin 26.1 mg/dL

CBC:

Mild normochromic,normocytic anemia

HCT: 35.2%

1+ polychromasia,1+spherocytes

Thrombocytopenia 59K/uL

Normal neutrophilcount with a left shift

Prolongedcoagulation test

Urinalysis:

USG: 1.014

Blood: 3+

Ictotest: 3+


12/25

Abdominalultrasound:

Sludge in the gallbladder

Scant amount ofeffusion in theabdomen

Peritoneal

effusion: Non septic

exudate


13/25

Fresh frozen plasma

Vitamin K 2mg

Methadone 0.8

Unasyn 90mg


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19/25

Dietary indiscretion

Blunt abdominal trauma

Hypercalcemia Pancreatic hypoperfusion

Pharmaceuticals: potassium bromide,phenobarbital, L-asparaginase,azathioprine, trimethoprim-sulfa, and others

Severe hypertriglyceridemia and disordersof lipid metabolism


20/25

Any number of insults can lead to prematureactivation of trypsinogen to trypsin.

Trypsin, in turn, activates more trypsinogen and otherpancreatic zymogens.

Prematurely activated pancreatic digestive enzymeslead to local and systemic damage.

This process also leads to recruitment of inflammatorycells and cytokine release, causing further systemicchanges.

In general, premature activation of pancreaticdigestive enzymes leads to initiation of pancreatitis,while the inflammatory response leads to progressionof the disease and systemic complications.


21/25

Pantoprazole 1mg/kg IV SID

Maropitant 1mg/kg SQ SID

Ursodiol 0.8mg PO SID Acetylcysteine 7mg/kg q6hrs

Vitamin K SQ 2mg SID Methadone 0.8mg IV q4hrs

Unasyn 90mg IV q8hrs

Fentanyl CRI 3-5mcg/kg/min IV

Lidocaine CRI 20-40mcg/kg/min

Ketamine CRI 3-5mcg/kg/min IV LRS @30ml/hr + 30mEq KCl

Fenoldopam CRI 0.5mcg/kg/min Clinicare/vivonex 2ml/hr via J-tube


22/25

Azotemia, severely increased liverenzymes, Tbilirubin of 16 mg/dL,

leukocytosis with a marked left shift,anemia.

Continued to be extremely painful andlethargic, vomiting and diarrhea

On 4/28 started to have respiratorydistress at which point owners decidedto euthanize.


23/25

Survival rate for dogs with extrahepaticbiliary obstruction due to pancreatitis was41%.

Animals diagnosed with extrahepatic biliarytract obstruction had a relatively goodlong-term prognosis, provided they werenot compromised substantially due to

severe necrotizing pancreatitis or neoplasia.

Fahie, Ma, Martin, RA, Extrahepatic biliary tract obstruction: aretrospective study of 45 cases (1983-1993). J Am An Hosp Ass.November 1, 1995 vol. 31 no. 6 478-482


24/25

Some cases may be poor candidates forsurgical correction of the extrahepaticbiliary obstruction because surgery may

exacerbate the pancreatitis and poseadditional risks. Although, in most dogs, extrahepatic biliary

tract obstruction secondary to acutepancreatitis resolves spontaneously as the

pancreatitis improves, decompression ofthe gallbladder may be beneficial in dogsin which the obstruction does not resolve orcauses complications.


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Percutaneous ultrasound-guidedcholecystocentesis can be used forgallbladder decompression in dogs with

extrahepatic biliary tract obstructionsecondary to acute pancreatitis. Bileleakage and subsequent peritonitis arepotential complications of percutaneouscholecystocentesis. Herman, BA, Brawer, RS, Murtaugh, RJ, Hackner, SG (2005) Therapeutic

percutaneous ultrasound-guided cholecystocentesis in three dogs withextrahepatic biliary obstruction and pancreatitis. JAVMA, Vol 227, No. 11,December 1, 2005

Acute Necrotizing Pancreatitis Goliath

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