Pacreatitis grand rounds

Devastating pancreatitis and duodenal necrosis in a dog

Case advisors: Dr K Murphy, Dr J BrownProgram advisor: Dr K Mathews

Signalment and history‘Kita’ 6 y.o NF HuskyIdiopathic epilepsy since 1

y.o, on phenobarbGot into garbage 5 days

prior to admissionVomiting 48 hours laterGeneralised seizures X 2Hospitalised on IV fluids

for last 2 days, no improvement

Physical examGeneralised weakness, mentally dullPyrexic at 40.1°CHR=200bpm, normotensiveAbdominal pain, abdominal free fluidInjected m.membs

Assessment: Hypovolemic +/- distributive shock DDx- severe acute pancreatitis vs septic peritonitis

Treatment: IV fluid bolus 20ml/kg PLA Hydromorphone

Lab findingsAbdominal fluid cytology-

degenerate neutrophils +++, no bacteria

Severe mixed metabolic and respiratory acidosis

PvCO2=30mmHg (27.9 )BE=-13.3Hyperchloremic (-9 of

BE)Lactate=2.7

Lab findingsCoagulopathic- PT and

aPTT 2X high normalPlatelet count 154,000Albumin=26g/LCreatinine=297umol/lTBIL=68umol/lLipase=11,620Leukocytosis + left shift

9% bands

Assessment?early DICrenal insultsuspect biliary

obstruction

Imaging

Imaging

Assessment

Severe acute pancreatitis+SIRS+/- DIC

Global perfusion compromise, acute renal insult, at risk for ARF

Suspect common bile duct obstruction

?? SepsisSuspect duodenal FB

Mechanisms of renal insult in acute pancreatitis

Renal injury

Loss of protective autoregulation

Microthrombus, ischemia, tissue damage

Cytokines

Endotoxins

Bilirubinemia

↑Blood viscosity, ↓RBC deformation

↓Glucagon

Hypovolemia

Vomiting, 3rd space losses, vasodilation

Stabilisation planCrystalloids 50ml/kg+ pentastarch 5ml/kg to achieve

adequate volume status- HR↓ 124bpmU-cath- monitor urine output as @ risk for ARFFentanyl analgesiaFFP 10ml/kg vs coagulopathyNG tube passed, aspirated 1500mls gastric fluidAmpicillin 22mg/kg Q6 pending cultures

Surgical plan‘Seek and destroy’ FBView pancreas- biopsy for

histo+ cultureVisualise biliary systemLavage abdomen and

place abdominal drainsPlace e-tubePlace central line

Blood supplyExocrine ducts

• 68% dogs have pancreatic duct and accessory pancreatic duct

• Accessory duct >>pancreatic duct

• 32% have accessory duct alone, or 3 ducts

Biliary ducts

Options?Duodenum necrotic from

pylorus to 20cm distallyEntire right limb of the

pancreas necroticCommon bile duct

occludedLeft limb of the pancreas

inflamed

Literature reviewNo case series or formal case reports xTechnique of canine total

pancreatectomy for generating a human diabetes research model

Anecdotal reports- EPI+DM

Human literature reviewSakorafas GH Experience with duodenal necrosis- A rare

complication of acute necrotizing pancreatitis International J Pancreatology 1999

Kingham TP Management and spectrum of complications in patients undergoing surgical debridement for pancreatic necrosis The American Surgeon 2008

Heidt DG Total and partial pancreatectomy: Indications, Operative technique, Postoperative sequelae J Gastrointest Surg 2007

Kahl S Exocrine and endocrine pancreatic insufficiency after pancreatic surgery Clinical Gastroenterology 2004

Pancreatic surgery in acute pancreatitisIndications in humans...

Bacteria on cytology or culture from aspirates of peripancreatic fluid

- manifests lateCT signs of abscess or wide area

failing to enhance→necrosisPersistent sepsis manifesting as

hemodynamic instability without identifiable source

Failure to improve after> 14 days

Key points...Anticipate staged approach and need for

several proceduresConservative technique

Retain all tissues/ structures until inflammation ↓ Place drains to

Remove local fluid collections Achieve temporary biliary bypass- flank cystostomy tubes Evacuate intraluminal duodenal /gastric secretions

Manage small duodenal perforations with local drainage until later definitive repair

Achieve enteral feeding

InsulinHormone of energy

storageInsulin dependency

likely post pancreatectomy > 50% (pancreatitis) >80% neoplasia

‘Brittle’ diabetesGlargine insulin of

choice

GlucagonHormone of energy releaseDeficit results in

↑insulin sensitivity ↑hypoglycemic crises ↓ketosis ↓catecholamine

response to hypoglycemia

hepatic lipidosisDog has some enteric

sources of glucagon

Pancreatectomy- impact on endocrine function

Pancreatectomy- impact on exocrine functionEPI inevitable in TP or if pancreatic duct and accessory

pancreatic ducts lost↓ HCO3 in GI→ chronic ulcersMalabsorbtion compounded by concurrent gastrectomyLong term therapy with

Pancreatic enzymes Proton pump inhibitors Multivitamins

Surgical re-routing of exocrine secretions possible

Duodenectomy and partial pancreatectomyAdvantages

Lower risk of insulin dependency vs TP (30-50% vs 100%)

Some glucagon secretion maintained →↓hepatic lipidosis

Disadvantages Exocrine duct ligation → EPI+

acute/ chronic pancreatitis in pancreatic remnant

Pancreaticojejunostomy?

Partial pancreatectomy , choleduodenostomy and pancreaticojejunostomy

Total pancreatectomyInsulin dependency, ‘brittle’

diabetes inevitableEPI inevitableBiliary re-routing requiredSplenectomy may be requiredPancreatic pain reducedInflammatory focus removed

High complication rate20-40% mortality with severe

pancreatic necrosis80-100% mortality with infected pancreatic necrosis

managed non-surgicallyMedian ICU stay 20 days15-20% incidence of ARF40-60% incidence ARDS requiring mechanical ventilation20% incidence significant intra-abdominal hemorrhage

Outcome for Kita......euthanasia in surgery

Questions?