VETgirl December 2024 BEAT e-Magazine

QUARTERLY BEAT / DECEMBER 2024

while a concentration of ≥ 400 ug/L is suggestive of pancreatitis. Spec cPL concentrations between 200 – 400 ug/L are considered equivocal. The SNAP cPL has higher sensitivity (74 – 100%) compared to its specificity (59 – 78%). A normal SNAP cPL correlates with a Spec cPL concentration of < 200 ug/L indicating AP is unlikely and other disease processes should be considered. On the other hand, an abnormal SNAP cPL correlates with a Spec cPL concentration ≥ 200 ug/L (including both the equivocal and the positive results) and should be followed up with a Spec cPL, which is qualitative. Catalytic assays measure sample (serum/plasma) lipase activity by quantifying formation of catalytic product. Catalytic assays are inexpensive and may be included on routine serum chemistry panels. Various substrates are used in catalytic assays including 1,2-diglyceride, 1-oleo-2,3-diacetylglycerol (e.g., Idexx chemistry), 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6’-methylresorufin) ester [DGGR] (e.g., PrecisionPSL), and triolein (e.g., Fuji Dri-Chem v–lip-p). Catalytic lipase assays may detect extra- pancreatic lipases which limits their analytic specificity. 3,4 Diagnostic Imaging Abdominal ultrasound is useful as a non-invasive diagnostic modality to image the pancreas. In dogs, the right limb of the pancreas is more easily identified when compared to the body or left limb. 5 The pancreas may appear enlarged with hypoechoic parenchyma and hyperechoic surrounding mesentery. Other findings may include pancreatic fluid accumulation, extrahepatic bile duct obstruction (EHBDO), gastric or duodenal wall thickening, and peripancreatic fluid accumulation. 6 There appears to be a lag time between the development of pancreatitis and ultrasonographic findings. Other non-inflammatory conditions (such as portal hypertension and hypoalbuminemia) can result in pancreatic edema. 7 TREATMENT UPDATES Acute pancreatitis in dogs can vary in clinical severity. Patients with self-limiting disease can be managed at home while patients that are affected systemically will require intensive care in hospital. Identify Cause(s) Several risk factors of AP have been identified including dietary (high-fat diet), drugs/toxins (L-asparaginase, phenobarbital, potassium bromide, azathioprine), endocrinopathies (Cushing’s, hypothyroid, diabetes mellitus), hypertriglyceridemia (but not hypercholesterolemia), and various breed predisposition and hereditary factors (miniature schnauzers). Often, a specific underlying cause cannot be identified. 8

Fluid Therapy Poor pancreatic perfusion may lead to the progression of self- limiting pancreatitis to severe necrotizing pancreatitis. Therefore, aggressive fluid therapy has been recommended for many years in both human and veterinary pancreatitis patients. Commonly used fluids include normal saline and lactated Ringer’s. Recent meta-analyses in people have shown that lactated Ringer’s, but not aggressive fluid therapy, prevented the progression of mild to moderate/severe AP. 9,10 In fact, the incidence of fluid overload is higher in patients receiving aggressive fluid therapy. 9 There is no evidence to show that the use of colloids or fresh-frozen plasma for AP is helpful. 11 Recognizing and Managing Complications Local complications of AP include pancreatic necrosis, pancreatic fluid accumulations, pancreatitis-associated EHBDO, gastrointestinal dysmotility, amongst others. Systemic complications include aspiration pneumonia, SIRS, MODS, DIC, AKI, or cardiac injury. Antiemetics/Antinausea Vomiting is thought to occur in dogs with AP due to centrally and peripherally mediated mechanisms. Maropitant (NK-1 antagonist) acts on both central and peripheral emetic pathways and is useful in controlling vomiting, but not nausea, in dogs. 12 Ondansetron (5- HT3 receptor antagonist) is reported to have both antiemetic and antinausea properties in dogs. 13 Metoclopramide only has minimal antiemetic properties and is not recommended to be used as an antiemetic in dogs. Analgesics Abdominal pain should be assumed to be present in any dog with a diagnosis of pancreatitis. Opioids are commonly used as a first- line pain management. 14 The author will typically use methadone (0.1 - 0.5 mg/kg IV SC IM q4-8h) or fentanyl (3 mcg/kg/hour IV bolus followed by CRI at 3 – 5 mcg/kg/hour IV) when the patient is hospitalized. Opioid-sparing analgesics (such as lidocaine or ketamine CRI) can be used to reduce side-effects of opioids. Patients that can be discharged should continue to receive pain management at home. In smaller dogs, transdermal buprenorphine (Zorbium®) can be used off-label at 2 mg/kg transdermal. Fentanyl patches can be prescribed to larger-sized dogs, but care must be taken to prevent inadvertent exposure to family members (especially children). Nutrition Delayed enteral feeding can cause enterocyte damage, gut barrier dysfunction, and dysbiosis. 15 Therefore, early enteral nutrition should be provided, and this can be achieved via placement of a temporary feeding tube (nasogastric or nasoesophageal tube) or a semi- permanent esophageal tube. Begin feeding about 1/3 of RER using a liquid diet (such as Royal Canin Veterinary GI Low Fat Liquid [1 kCal/ mL] or low-fat diet (typically <2 g of fat/100 kCal) given in multiple small meals (trickle feeding or boluses q4-6h).

FEATURED STORY

In this VETgirl featured article sponsored* by CEVA, Dr. Sue Yee Lim, PhD, DACVIM (SAIM) discusses what you need to know about updates in canine pancreatitis. From what’s new in the diagnosis to what’s new with treatment of pancreatitis, you’ll want to keep on reading! *Please note the opinions of this article are the expressed opinion of the author and not directly endorsed by VETgirl.

UPDATES IN ACUTE ONSET PANCREATITIS IN DOGS: EVERYTHING YOU NEED TO KNOW IN 30 MINUTES

BY DR. SUE YEE LIM PhD, DACVIM (SAIM) Gastrointestinal Laboratory, Texas A&M University

DIAGNOSTIC UPDATES The diagnosis of acute onset pancreatitis (AP) in dogs should be made based on global assessment of clinical data including history, clinical signs, physical examination findings, clinicopathologic findings (including measurement of pancreatic lipase), and diagnostic imaging findings. 1 Pancreatic Lipase Testing The measurement of pancreatic lipase can be helpful as a non-invasive marker of pancreatic inflammation. There are numerous methods to measure serum (pancreatic) lipase. 2 Common lipase assays are broadly divided into immunologic and catalytic assays. The immunologic assays use pairs of antibodies for canine pancreatic lipase and measure pancreatic lipase concentration. Examples of immunologic assays include Spec and SNAP cPL (Idexx laboratories), VetScan cPL Rapid Test (Zoetis), and Vcheck cPL 2.0 (Bionote). A Spec cPL concentration of < 200 ug/L makes acute pancreatitis unlikely

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