feature article Therapy may be absent or intermittent in cats with pancreatitis. Antiemetic Treating Feline Pancreatitis: therapy is recommended to control vomiting when present and to treat Recommendations for managing this disease nausea in the absence of vomiting. and common concurrent conditions There are several available. (Reglan®) remains a popular antiemetic. However, metoclopramide is a dopamine antagonist and inhibits vomiting by blocking the fluids should correct dehydration over central nervous system (CNS) dopamine Jane Robertson the first 12–24 hours, while also meeting receptors in the chemoreceptor trigger DVM, DACVIM maintenance needs and replacing zone (CRTZ). It is often ineffective in Head of Internal Medicine ongoing losses. Acid-base and electrolyte cats because cats are reported to have few IDEXX Laboratories abnormalities should be monitored closely CNS dopamine receptors in the CRTZ. and corrected. If hypocalcemia is present, (Anzemet®) and ® it should be treated with a calcium (Zofran ) act on the serotonin 5-HT3 Background gluconate infusion of 50–150 mg/kg receptors in the CRTZ and are very Pancreatitis is an elusive disease over 12–24 hours while monitoring effective in cats. Maropitant citrate in cats and consequently has been serum calcium concentrations. Colloids, (Cerenia®) acts on the neurokinin (NK) underdiagnosed.1, 6 Cats with pancreatitis such as dextran or hetastarch, can be receptors in the vomiting center. It is only present with vague signs of illness, used to support oncotic pressure, labeled for use in , but has become a including lethargy, decreased , especially in patients that are hypo- popular and effective antiemetic in cats. dehydration and weight loss. Physical albuminemic. Plasma therapy can be examination and routine laboratory used if available when there is evidence Nutritional Support findings are nonspecific, and until recently, of a coagulopathy or disseminated The historical recommendation of there have been limited diagnostic tools intravascular coagulation (DIC). nothing per os (NPO) for animals with for this disease. The Spec fPL™ (feline pancreatitis is no longer accepted. In pancreas-specific lipase) Test is now Pain Management addition, cats can develop hepatic lipidosis available to assist in diagnosing and Abdominal pain is rarely recognized if not provided adequate calories. Enteral monitoring cats with pancreatitis. in cats with pancreatitis. Nonetheless, nutrition stabilizes the gastrointestinal Fluid therapy, pain management many cats will show clinical improvement barrier, improves enterocyte health and nutritional support are the if provided therapy; therefore and immune function, improves mainstay of therapy for treating cats pain management should be provided gastrointestinal motility, prevents with pancreatitis. Many cats with to all cats with acute pancreatitis. catabolism and decreases morbidity pancreatitis have concurrent illnesses therapy is recommended. One and mortality. Cats with pancreatitis (e.g., diabetes mellitus, hepatic lipidosis, recommended protocol is to provide are inappetant; therefore, ingestion of cholangiohepatitis and inflammatory immediate analgesia with an intravenous adequate calories is rare. Force feeding is bowel disease).2–4 Diagnosis and narcotic such as buprenorphine and not recommended; it is difficult to achieve management of both pancreatitis and place a fentanyl patch for longer duration adequate caloric intake and can lead to concurrent conditions are critical to a of pain control. Cats with chronic food aversion.6 Enteral nutrition can be successful outcome.5 pancreatitis may also benefit from pain provided by a variety of feeding tubes, management, and options for outpatient including nasogastric, nasoesophageal, Fluid Therapy treatment include a fentanyl patch, esophagostomy, gastrostomy or Fluid therapy is essential for patient sublingual buprenorphine, and oral jejunostomy tubes. support and to ensure adequate perfusion butorphanol or tramadol. If vomiting cannot be controlled, then of the pancreas. In hospitalized patients, partial parenteral nutrition (PPN) or

12 | DX Consult : Winter 2009 decrease dependency on the feeding tube Veterinary products, Marin™ (vitamin over time and may support the removal E and silybin), Denosyl® (SAMe) and of feeding tubes in cats with pancreatitis. Denamarin® (SAMe and silybin), (Remeron®), used off-label, manufactured by Nutramax Laboratories, and are two effective Inc., are available for cats. appetite stimulants in cats. Cobalamin (Vitamin B12) See page 14 for a case study on Feline Pancreatitis. Glucocorticoid Therapy Supplementation total parenteral nutrition (TPN) can be It is common for cats with Cobalamin (vitamin B12) is a water- provided. However, parenteral nutrition pancreatitis to have other concurrent soluble vitamin that is absorbed in the doesn’t nourish the enterocytes. Therefore conditions. The term “triaditis” has ileum. Reduction in serum cobalamin microenteral nutrition, by trickle feeding been used to describe the complex of concentrations can be seen in cats through a feeding tube, should be cholangiohepatitis, inflammatory bowel with gastrointestinal disease. Cats with provided concurrently to prevent the disease and pancreatitis. Treatment with pancreatitis commonly have concurrent complications of NPO. anti-inflammatory doses of prednisone, inflammatory bowel disease; therefore prednisolone or is not measuring serum cobalamin concentrations Diet Selection contraindicated in these cats. Cats with in cats with pancreatitis is recommended. There are no studies to support chronic pancreatitis alone may actually Cobalamin can be supplemented by dietary choices for cats with pancreatitis. benefit from the anti-inflammatory effects parenteral injection at a dosage of High-fat foods are not implicated in of corticosteroids. 250 μg/injection weekly for six weeks, causing pancreatitis in cats; however, followed by one dose every two weeks for some internists avoid feeding high-fat Antibiotic Therapy six weeks, then monthly injections.7 diets when treating these cats. Liquid Pancreatitis is usually a sterile process diets are required for use in nasogastric, in cats and antibiotics are rarely indicated. Insulin Therapy nasoesophageal and jejunostomy tubes. Antibiotics can cause nausea and vomiting Cats with acute pancreatitis can Commercially available CliniCare® in cats, so they should only be used become insulin resistant and develop Canine/Feline Liquid Diet (Abbott Animal when indicated. Indications for their use transient diabetes mellitus.3 Diabetes Health) is high in fat but commonly used. include sepsis (may result from bacterial may resolve or become permanent, Human-formulated liquid diets are too low translocation from the gastrointestinal especially if chronic pancreatitis persists. in protein to be used in cats. Low-residue, tract), bacterial peritonitis, other Insulin therapy should be tailored to the low-fat, easy-to-digest blended canned infections (e.g., urinary tract infection) individual cat. Insulin requirements may diets can be used in esophagostomy or and possibly in cases with a suppurative vary as a result of waxing and waning of gastrostomy tubes. cholangiohepatitis where a suppurative the severity of the pancreatitis. Recommendations for feeding cats pancreatitis is suspected. with pancreatitis are based upon opinion. Monitoring Trial and error is often required to find a Antacid Therapy Hospitalized cats require close diet that works for a particular cat. Cats H2-receptor antagonists (ranitidine or monitoring. Body weight and respiratory with pancreatitis often have concurrent famotidine) or proton-pump inhibitors rate can be monitored to ensure fluids are disease. A low-residue diet might be (pantoprazole) are not routinely recom- being tolerated. Blood pressure and urine the diet of choice in a cat that only has mended but should be considered if there output should be assessed daily. Repeat pancreatitis, but if concurrent intestinal is concern for gastrointestinal ulceration. laboratory testing should be performed disease is present, a novel protein diet regularly to monitor the patient’s might be a better choice. Antioxidant Therapy progress. The Spec fPL concentration can There is some rationale to consider be repeated every 2–3 days in hospitalized Appetite Stimulants antioxidant therapy in cats with cats to assess pancreatic inflammation. Appetite stimulants can help to pancreatitis. Vitamins C and E, silybin, The frequency with which cats at home support caloric intake, may reduce the S-Adenosylmethionine (SAMe) and should be reassessed will depend upon need for feeding tube placement, may omega-3 fatty acids could be prescribed. (continued on page 16)

Further Resources ONLINE COURSE, “Advances in Diagnosing and Treating Feline Pancreatitis” DX Consult : Winter 2009 | 13 www.idexxlearningcenter.com/felinepancreatitis CASE STUDY were determined to evaluate gastrointestinal function, and a Additional testing: Problems identified by the initial Cobalamin is a B-group, water-soluble vitamin that is Spec fPL™ Test was performed to identify pancreatic inflammation. laboratory work included nonregenerative anemia, hyperglycemia absorbed from the distal small intestinal along with cofactor with glycosuria and microscopic hematuria, hypocobalaminemia produced in the pancreas. Frisky’s cobalamin deficiency in face Feline Pancreatitis Laboratory findings and pancreatic inflammation. After reviewing these results, the of her normal pancreatic function was indicative of chronic small following additional tests were performed: intestinal disease. Inflammatory bowel disease and intestinal Audrey K. Cook, HEMATOLOGY VALUE UNITS REF INTERVAL lymphoma are the most common causes of hypocobalaminemia BVM&S, MRCVS, DACVIM-SAIM, DECVIM-CA Plasma Protein 8 TS-g/dL ( 6 – 8 ) RBC 4.57 M/µL Low ( 5.00 – 10.00 ) additional tests VALUE UNITS REF INTERVAL in cats, but small intestinal biopsies would be required for HCT 18.7 % Low ( 24.0 – 45.0 ) Urine Culture Negative HGB 6.70 g/dL Low ( 8.0 – 15.0 ) definitive diagnosis. Trypsin-like MCV 40.9 fL ( 39.0 – 55.0 ) immunoreactivity 10.6 µg/L ( 9.7 – 21.6 ) 3. Nonregenerative anemia: Likely due to chronic disease. MCHC 35.8 g/dL High ( 31.0 – 35.0 ) Fructosamine 250 µmol/L ( <375 ) Retic (%) <0.2 % Low ( 0.2 – 1.6 ) Frisky had a moderate to severe anemia with no WBC 13.4 K/µL ( 5.5 – 19.5 ) Neutrophil 11792 ( 2500 – 12500 ) reticulocytosis. Pancreatitis is an inflammatory condition and Lymphocyte 938 Low ( 1500 – 7000 ) Frisky Monocyte 402 ( 0 – 850 ) Abdominal ultrasonography revealed a prominent pancreas, a nonregenerative anemia is the most frequent hematologic Eosinophil 268 ( 0 – 1500 ) abnormality that occurs with this disease. PLT (Automated) Clumped /µL ( 300 – 800 ) with diffuse mottling and an irregular margin. The tissue Patient: Frisky, 16-year-old, spayed PLT (Estimate) Normal appeared hypoechoic, whilst the surrounding mesentery was female domestic long-haired cat hyperechoic. Renal parenchyma was slightly hyperechoic; these Therapeutic plan changes appeared consistent with age. The remainder of the scan Day 1: Frisky was admitted to the hospital and started on Serum biochemical profile VALUE UNITS REF INTERVAL Presenting complaint: Glucose 242 mg/dL High ( 65 – 131 ) was unremarkable. intravenous fluid therapy. Her estimated deficit and on-going Blood Urea Nitrogen 22 mg/dL ( 19 – 33 ) needs were provided with lactated Ringer’s solution (13 mL/hour Creatinine 1.3 mg/dL ( 0.8 – 1.8 ) History: Progressive loss of Phosphorus 5.0 mg/dL ( 3.8 – 7.5 ) initially), supplemented with 16 mEq/L of KCl. A continuous-rate Calcium 8.9 mg/dL ( 8.4 – 11.8 ) appetite over the last six weeks. No response to Magnesium 2.4 mg/dL High ( 1.7 – 2.3 ) infusion (CRI) of fentanyl (2 µg/kg/hour) was started to manage appetite stimulants (cyproheptadine, mirtazapine) or Sodium 153 mmol/L ( 144 – 155 ) her pain. Her respiration rate and pain score (see table 1 on Potassium 4.5 mmol/L ( 3.5 – 5.1 ) pancreas antiemetic therapy (metoclopramide). Diagnosed with Chloride 122 mmol/L ( 113 – 123 ) page 16) were monitored closely so that adjustments could TCO2 20 mmol/L ( 19 – 26 ) hyperthyroidism three years earlier; effectively managed Anion Gap 16 mmol/L ( 12 – 19 ) be made if necessary. Cyanocobalamin was administered Lactic Acid 16.6 mg/dL High ( 5.4 – 15.3 ) with oral methimazole. Total Protein 7.0 g/dL ( 6.1 – 7.7 ) subcutaneously (250 µg) to address the hypocobalaminemia. Albumin 2.5 g/dL ( 2.5 – 3.3 ) Day 2: Frisky was briefly anesthetized for placement of an Globulin 4.5 g/dL High ( 2.3 – 3.8 ) ALT <3 U/L Low ( 26 – 84 ) esophagostomy feeding tube (e-tube). The procedure took ALKP 27 U/L ( 20 – 109 ) Physical examination GGT 6 U/L ( 0 – 12 ) less than 10 minutes and she recovered with no complications. Frisky was quiet but responsive. Her heart rate was 192 beats Total Bilirubin 0.4 mg/dL ( 0 – 0.6 ) Tube feedings started that same day, using an energy-dense Cholesterol 152 mg/dL ( 56 – 161 ) per minute, with normal rate and rhythm. No murmurs were prescription diet (Royal Canin Veterinary Diet™ Recovery ausculted. She was substantially underweight at 2.5 kg with a RS™). Her calorie needs were calculated based on an estimated 0.75 body condition score of 2/9. Moderate dental tartar and calculus Urinalysis VALUE UNITS optimal body weight of 4 kg (4 kg × 70 = 198 calories). To Color/Transparency Yellow/clear were noted, but there was no apparent oral pain. Abdominal Specific Gravity 1.028 The pancreas and liver are labelled in the image above. The pancreas is avoid complications from refeeding syndrome, she received palpation was within normal limits, although she seemed pH 6.5 enlarged and hypoechoic with an irregular margin. The surrounding mesentery one third of her target calorie needs on the first day, divided Protein 30 mg/dL High is hyperechoic. uncomfortable in the cranial abdomen. A small thyroid nodule Glucose 2000 mg/dL High into 4 equal meals. Her fluids were changed to a maintenance Ketones Negative ® was noted in the left cervical region. Frisky appeared moderately Bilirubin Negative Final diagnosis type (Normosol -M with dextrose, supplemented with 7 mEq dehydrated (7%) based on skin turgor. Blood Moderate High 1. Pancreatitis: Likely an acute exacerbation of a KCl/L at 6 mL/hour). Blood glucose and serum electrolytes were Urobilinogen 0.2 mg/dL WBC 0–2 /hpf chronic condition. rechecked; all parameters were within the normal range. Her RBC 6–10 /hpf High Initial assessment Bacteria None seen /hpf Frisky’s progressive inappetance and poor body condition packed cell volume (PCV) had decreased to 17%. The most likely differentials for the persistent anorexia were consistent with the diagnosis of pancreatitis. The findings on Day 3: The fentanyl CRI was discontinued and buprenorphine in this patient included metabolic dysfunction (e.g., renal or the abdominal ultrasound combined with an elevated Spec fPL (0.02 mg/kg) was administered sublingually instead. The volume other tests VALUE UNITS REF INTERVAL hepatic disease), gastrointestinal disease (e.g., inflammatory Cobalamin 224 ng/L Low ( 290 – 1499 ) concentration confirmed the diagnosis of pancreatitis. of each e-tube feeding was doubled. Methimazole was restarted or infiltrative disease, pancreatitis), occult infection (e.g., Folate 10.6 µg/L ( 9.7 – 21.6 ) Minimal biochemical abnormalities and a normal trypsin- at the previous dose (2.5 mg twice daily, through the e-tube). Total T4 2.12 µg/dL ( 0.78 – 3.82 ) pyelonephritis) or occult neoplasia (e.g., intestinal, pulmonary). Spec fPL 8.6 µg/L High ( 0.1 – 3.5 ) like immunoreactivity (TLI) are not uncommon in cats with Day 4: Intravenous fluids were discontinued and the e-tube ≤3.5 µg/L—Serum Spec fPL concentration is in the normal range. It is unlikely that the cat has pancreatitis. Investigate for other diseases that could cause observed clinical signs. pancreatitis. Frisky’s normal fructosamine in face of her feedings were increased to the target volume. Frisky showed 3.6– 5.3 µg/L—Serum Spec fPL concentration is increased. The cat may have pancreatitis and Spec fPL Diagnostic plan concentration should be reevaluated in two weeks if clinical signs persist. Investigate for other diseases hyperglycemia and glucosuria suggested she had transient stress- some interest in food, but still would not eat. She was given that could cause observed clinical signs. The initial plan included a complete blood count (CBC), ≥5.4 µg/L—Serum Spec fPL concentration is consistent with pancreatitis. The cat most likely has induced hyperglycemia. another injection of cyanocobalamin (250 µg subcutaneously) and pancreatitis. Consider investigating for risk factors and concurrent diseases (e.g., IBD, cholangitis, serum biochemical profile, urine analysis and measurement of hepatitic lipidosis, diabetes mellitus). Periodic monitoring of Spec fPL concentration may help assess 2. Hypocobalaminemia: Likely due to chronic small discharged from the hospital with instructions to continue the e-tube response to therapy. serum total thyroxine. Serum cobalamin and folate concentrations intestinal disease. feedings, buprenorphine and methimazole. (continued on next page)

14 | DX Consult : Vol. 2 No. 1 2009 DX Consult : Vol. 2 No. 1 2009 | 15 CASE STUDY were determined to evaluate gastrointestinal function, and a Additional testing: Problems identified by the initial Cobalamin is a B-group, water-soluble vitamin that is Spec fPL™ Test was performed to identify pancreatic inflammation. laboratory work included nonregenerative anemia, hyperglycemia absorbed from the distal small intestinal along with cofactor with glycosuria and microscopic hematuria, hypocobalaminemia produced in the pancreas. Frisky’s cobalamin deficiency in face Feline Pancreatitis Laboratory findings and pancreatic inflammation. After reviewing these results, the of her normal pancreatic function was indicative of chronic small following additional tests were performed: intestinal disease. Inflammatory bowel disease and intestinal Audrey K. Cook, HEMATOLOGY VALUE UNITS REF INTERVAL lymphoma are the most common causes of hypocobalaminemia BVM&S, MRCVS, DACVIM-SAIM, DECVIM-CA Plasma Protein 8 TS-g/dL ( 6 – 8 ) RBC 4.57 M/µL Low ( 5.00 – 10.00 ) additional tests VALUE UNITS REF INTERVAL in cats, but small intestinal biopsies would be required for HCT 18.7 % Low ( 24.0 – 45.0 ) Urine Culture Negative HGB 6.70 g/dL Low ( 8.0 – 15.0 ) definitive diagnosis. Trypsin-like MCV 40.9 fL ( 39.0 – 55.0 ) immunoreactivity 10.6 µg/L ( 9.7 – 21.6 ) 3. Nonregenerative anemia: Likely due to chronic disease. MCHC 35.8 g/dL High ( 31.0 – 35.0 ) Fructosamine 250 µmol/L ( <375 ) Retic (%) <0.2 % Low ( 0.2 – 1.6 ) Frisky had a moderate to severe anemia with no WBC 13.4 K/µL ( 5.5 – 19.5 ) Neutrophil 11792 ( 2500 – 12500 ) reticulocytosis. Pancreatitis is an inflammatory condition and Lymphocyte 938 Low ( 1500 – 7000 ) Frisky Monocyte 402 ( 0 – 850 ) Abdominal ultrasonography revealed a prominent pancreas, a nonregenerative anemia is the most frequent hematologic Eosinophil 268 ( 0 – 1500 ) abnormality that occurs with this disease. PLT (Automated) Clumped /µL ( 300 – 800 ) with diffuse mottling and an irregular margin. The tissue Patient: Frisky, 16-year-old, spayed PLT (Estimate) Normal appeared hypoechoic, whilst the surrounding mesentery was female domestic long-haired cat hyperechoic. Renal parenchyma was slightly hyperechoic; these Therapeutic plan changes appeared consistent with age. The remainder of the scan Day 1: Frisky was admitted to the hospital and started on Serum biochemical profile VALUE UNITS REF INTERVAL Presenting complaint: Anorexia Glucose 242 mg/dL High ( 65 – 131 ) was unremarkable. intravenous fluid therapy. Her estimated deficit and on-going Blood Urea Nitrogen 22 mg/dL ( 19 – 33 ) needs were provided with lactated Ringer’s solution (13 mL/hour Creatinine 1.3 mg/dL ( 0.8 – 1.8 ) History: Progressive loss of Phosphorus 5.0 mg/dL ( 3.8 – 7.5 ) initially), supplemented with 16 mEq/L of KCl. A continuous-rate Calcium 8.9 mg/dL ( 8.4 – 11.8 ) appetite over the last six weeks. No response to Magnesium 2.4 mg/dL High ( 1.7 – 2.3 ) infusion (CRI) of fentanyl (2 µg/kg/hour) was started to manage appetite stimulants (cyproheptadine, mirtazapine) or Sodium 153 mmol/L ( 144 – 155 ) her pain. Her respiration rate and pain score (see table 1 on Potassium 4.5 mmol/L ( 3.5 – 5.1 ) pancreas antiemetic therapy (metoclopramide). Diagnosed with Chloride 122 mmol/L ( 113 – 123 ) liver page 16) were monitored closely so that adjustments could TCO2 20 mmol/L ( 19 – 26 ) hyperthyroidism three years earlier; effectively managed Anion Gap 16 mmol/L ( 12 – 19 ) be made if necessary. Cyanocobalamin was administered Lactic Acid 16.6 mg/dL High ( 5.4 – 15.3 ) with oral methimazole. Total Protein 7.0 g/dL ( 6.1 – 7.7 ) subcutaneously (250 µg) to address the hypocobalaminemia. Albumin 2.5 g/dL ( 2.5 – 3.3 ) Day 2: Frisky was briefly anesthetized for placement of an Globulin 4.5 g/dL High ( 2.3 – 3.8 ) ALT <3 U/L Low ( 26 – 84 ) esophagostomy feeding tube (e-tube). The procedure took ALKP 27 U/L ( 20 – 109 ) Physical examination GGT 6 U/L ( 0 – 12 ) less than 10 minutes and she recovered with no complications. Frisky was quiet but responsive. Her heart rate was 192 beats Total Bilirubin 0.4 mg/dL ( 0 – 0.6 ) Tube feedings started that same day, using an energy-dense Cholesterol 152 mg/dL ( 56 – 161 ) per minute, with normal rate and rhythm. No murmurs were prescription diet (Royal Canin Veterinary Diet™ Recovery ausculted. She was substantially underweight at 2.5 kg with a RS™). Her calorie needs were calculated based on an estimated 0.75 body condition score of 2/9. Moderate dental tartar and calculus Urinalysis VALUE UNITS optimal body weight of 4 kg (4 kg × 70 = 198 calories). To Color/Transparency Yellow/clear were noted, but there was no apparent oral pain. Abdominal Specific Gravity 1.028 The pancreas and liver are labelled in the image above. The pancreas is avoid complications from refeeding syndrome, she received palpation was within normal limits, although she seemed pH 6.5 enlarged and hypoechoic with an irregular margin. The surrounding mesentery one third of her target calorie needs on the first day, divided Protein 30 mg/dL High is hyperechoic. uncomfortable in the cranial abdomen. A small thyroid nodule Glucose 2000 mg/dL High into 4 equal meals. Her fluids were changed to a maintenance Ketones Negative ® was noted in the left cervical region. Frisky appeared moderately Bilirubin Negative Final diagnosis type (Normosol -M with dextrose, supplemented with 7 mEq dehydrated (7%) based on skin turgor. Blood Moderate High 1. Pancreatitis: Likely an acute exacerbation of a KCl/L at 6 mL/hour). Blood glucose and serum electrolytes were Urobilinogen 0.2 mg/dL WBC 0–2 /hpf chronic condition. rechecked; all parameters were within the normal range. Her RBC 6–10 /hpf High Initial assessment Bacteria None seen /hpf Frisky’s progressive inappetance and poor body condition packed cell volume (PCV) had decreased to 17%. The most likely differentials for the persistent anorexia were consistent with the diagnosis of pancreatitis. The findings on Day 3: The fentanyl CRI was discontinued and buprenorphine in this patient included metabolic dysfunction (e.g., renal or the abdominal ultrasound combined with an elevated Spec fPL (0.02 mg/kg) was administered sublingually instead. The volume other tests VALUE UNITS REF INTERVAL hepatic disease), gastrointestinal disease (e.g., inflammatory Cobalamin 224 ng/L Low ( 290 – 1499 ) concentration confirmed the diagnosis of pancreatitis. of each e-tube feeding was doubled. Methimazole was restarted or infiltrative disease, pancreatitis), occult infection (e.g., Folate 10.6 µg/L ( 9.7 – 21.6 ) Minimal biochemical abnormalities and a normal trypsin- at the previous dose (2.5 mg twice daily, through the e-tube). Total T4 2.12 µg/dL ( 0.78 – 3.82 ) pyelonephritis) or occult neoplasia (e.g., intestinal, pulmonary). Spec fPL 8.6 µg/L High ( 0.1 – 3.5 ) like immunoreactivity (TLI) are not uncommon in cats with Day 4: Intravenous fluids were discontinued and the e-tube ≤3.5 µg/L—Serum Spec fPL concentration is in the normal range. It is unlikely that the cat has pancreatitis. Investigate for other diseases that could cause observed clinical signs. pancreatitis. Frisky’s normal fructosamine in face of her feedings were increased to the target volume. Frisky showed 3.6– 5.3 µg/L—Serum Spec fPL concentration is increased. The cat may have pancreatitis and Spec fPL Diagnostic plan concentration should be reevaluated in two weeks if clinical signs persist. Investigate for other diseases hyperglycemia and glucosuria suggested she had transient stress- some interest in food, but still would not eat. She was given that could cause observed clinical signs. The initial plan included a complete blood count (CBC), ≥5.4 µg/L—Serum Spec fPL concentration is consistent with pancreatitis. The cat most likely has induced hyperglycemia. another injection of cyanocobalamin (250 µg subcutaneously) and pancreatitis. Consider investigating for risk factors and concurrent diseases (e.g., IBD, cholangitis, serum biochemical profile, urine analysis and measurement of hepatitic lipidosis, diabetes mellitus). Periodic monitoring of Spec fPL concentration may help assess 2. Hypocobalaminemia: Likely due to chronic small discharged from the hospital with instructions to continue the e-tube response to therapy. serum total thyroxine. Serum cobalamin and folate concentrations intestinal disease. feedings, buprenorphine and methimazole. (continued on next page)

14 | DX Consult : Vol. 2 No. 1 2009 DX Consult : Vol. 2 No. 1 2009 | 15 CASE STUDY feature article

Clinical case outcome Table 1. 2. Consider the most common diseases first. One week later, Frisky was alert and responsive. She was There is a good reason why we see certain diseases more hydrated and did not appear to have any abdominal discomfort. Pain scoring system for dogs and cats commonly—they have a higher prevalence and therefore should Body weight was improved at 2.7 kg. The owner reported that Analgesia score Patient observations The Top Five Most Commonly be the first diseases we consider. For instance, in our clinic we Frisky was now eating about 50% of her target intake, and she always add a T4 test to the minimum database in cats over the 1: No pain Patient moves freely. Responds appropriately to Misdiagnosed Diseases in was now receiving only two meals a day through the e-tube. environment and interacts readily. Normal heart rate and age of 7. Results of a serum biochemical profile were within normal limits, respiratory rate. Veterinary Medicine and the Spec fPL concentration was substantially improved at 2: Slightly painful Responsive but avoids interaction. Patient looks at 3. Develop a systematic approach to patient diagnosis 3.2 µg/L. Frisky’s clinical improvement and reduction in her affected site if this area is palpated but does not for your hospital. Spec fPL concentration were evidence that her pancreatitis was demonstrate distress. A thorough and consistent approach is the best way to resolving. She was still anemic at 23%, but some regeneration 3: Mildly painful Movements are limited. Patient is somewhat restless. prevent excluding necessary testing and misdiagnosing your was now evident. Another injection of cyanocobalamin (250 µg Objects if affected area is palpated. patients. It will also keep you from performing unnecessary tests Fred L. Metzger subcutaneously) was administered and four more doses were 4: Moderately painful Limited interest in surroundings. Patient is restless and that can be costly and help minimize hospital trips, which the DVM, DABVP dispensed for the owner to give at home at weekly intervals. vocalizing but may be comforted by contact. Guards owner and your patient will certainly appreciate. affected site and tries to escape if palpation is performed. Further evaluation of the via endoscopy was discussed, but the owner declined further diagnostics. A recheck 5: Very painful Pain could not be worse. Patient is tense and shivering. 4. Get a baseline in health! visit was scheduled in two weeks to reevaluate her appetite, Avoids touch if possible. Unsolicited vocalization We use our preanesthetic and wellness testing results to is noted. May have shallow, labored breathing and anemia, Spec fPL concentration and to determine if her e-tube increased heart rate. May not move at all. start trending values on every patient. Doing so creates an could be removed. It is challenging enough to make an accurate diagnosis in individualized reference interval for that patient. Certain Adapted from: Buback JL, Boothe HW, Carroll GL, Green RW. Comparison of three veterinary medicine, but without the proper diagnostics it can parameters like creatinine change very little in health over the methods for relief of pain after ear canal ablation in dogs. Vet Surg. 1996;25:380–385. be impossible. Our patients cannot communicate their pain or life of the patient. If a patient’s creatinine is increasing— even discomfort and we rely on owners for patient histories that are if it is within the reference interval for that parameter, we often inadequate. Our best tool is the physical examination, but become concerned about renal disease. Treating Feline Pancreatitis (continued from page 13) management and commitment by the owner is required. In even in the most experienced hands, this is often insufficient addition, pancreatitis may complicate management of concurrent to make a diagnosis. The need for blood work is paramount in 5. Don’t be afraid to get a second opinion. their progress, the presence or absence of concurrent conditions diseases such as diabetes mellitus, inflammatory bowel disease and making an accurate diagnosis in the sick patient. A complimentary consultation by a board-certified internist and their therapeutic regime. Biweekly visits are warranted initially cholangiohepatitis. The well-being of these cats will depend upon Given these diagnostic challenges, it is no wonder that or clinical pathologist is available for all IDEXX blood work, to evaluate activity level, appetite and body weight. Laboratory the successful management of all concurrent conditions. |DX| many diseases are misdiagnosed in veterinary medicine. In a both in-house and at the reference laboratory. These specialists testing will depend upon their concurrent conditions and the turbulent economy, you should have a strategic plan to your are available by contacting the Internal Medicine Consulting Spec fPL concentration can be used to evaluate the pancreatitis. diagnostic workup, being smart about when and how you Team at 1-888-433-9987, option 4, option 2. They will help you When treating with glucocorticoids, the cat should be References perform your patient’s diagnostic tests. Here are a few tips we determine not only the best diagnostic plan but also consult on rechecked 10–14 days after initiating therapy. Decisions to 1. Simpson KW. Editorial: The Emergence of Feline Pancreatitis. J Vet Intern Med. use at the Metzger Animal Hospital in our diagnostic approach treatment options and monitoring for your patients. continue or discontinue therapy should be based upon clinical 2001;15:327–328. to the sick animal. I have spoken many times about the most commonly response and trending of laboratory results including the Spec fPL. 2. Akol KG, Washabau RJ, Saunders HM, Hendrick MJ. Acute pancreatitis in cats with misdiagnosed diseases in veterinary medicine at conferences, In cats with concurrent pancreatitis and intestinal disease in hepatic lipidosis. J Vet Intern Med. 1993;7:205–209. 1. Assess every sick patient. meetings and seminars. The talk is always crowded since this which cobalamin supplementation is initiated, repeat cobalamin 3. Goosens MC, Nelson RW, Feldman EC, Griffey SF. Response to insulin treatment and A full history, a thorough physical examination and a is a topic of concern for every practitioner. As you can see on survival in 104 cats with diabetes mellitus (1985–1995). J Vet Intern Med. 1998;12:1–6. and Spec fPL concentrations should be reassessed one month minimum database are a necessary first diagnostic step. the following pages, the list of the top five most commonly after initiation of cobalamin therapy. 4. Weiss DJ, Gagne JM, Armstrong PJ. Relationship between inflammatory hepatic Occasionally we need to sedate uncooperative or distressed misdiagnosed diseases is varied, but one thing is common disease and inflammatory bowel disease, pancreatitis, and nephritis. JAVMA. 1996;209:1114–1116. patients to obtain a physical examination and to complete to them all: if you don’t test for these diseases, you will not

Prognosis 5. Whittemore JC, Campbell VL. Canine and feline pancreatitis. Compend Contin Ed diagnostic procedures. The minimum database should include make an accurate diagnosis. The following table provides brief The prognosis for cats with pancreatitis is directly related Pract Vet. 2005;27:766–775. a CBC, a general chemistry profile with electrolytes and a descriptions of these diseases and what you can do in your to the severity of the disease. Cats with acute, severe disease, 6. Zoran DL. Pancreatitis in cats: diagnosis and management of a challenging disease. complete urinalysis. While this may not be sufficient for a clinic to prevent their misdiagnosis. (continued on next page) especially if systemic complications are present, have a poor J Am Anim Hosp Assoc. 2006;42:1–9. diagnosis, it will help indicate necessary further tests or rule out prognosis. Hypocalcemia is a complication of feline acute 7. Ruaux CG. Cobalamin and gastrointestinal disease. Proceedings from: American diseases, thus narrowing the list of differential diagnoses. The 8 College of Veterinary Internal Medicine 20th Annual Forum, May 29–June 1, 2002; necrotizing pancreatitis that is associated with a worse prognosis. Dallas, Texas. minimum database should be performed on every sick patient. Cats with concurrent acute pancreatitis and hepatic lipidosis Not doing so may lead to a misdiagnosis. 8. Kimmel SE, Washabau RJ, Drobatz, KJ. Incidence and prognostic value of low have a poorer prognosis than cats with hepatic lipidosis plasma ionized calcium concentration in cats with acute pancreatitis: 46 cases alone.1 Chronic pancreatitis is common in cats and long-term (1996–1998). JAVMA. 2001;219:1105–1109.

16 | DX Consult : Vol. 2 No. 1 2009 Further Resources ARCHIVED WEBINAR, “The Most Commonly Misdiagnosed Diseases in Veterinary Medicine—2008”DX Consult : Vol. 2 No. 1 2009 | 17 www.idexxlearningcenter.com/misdiagnosed