Мои шпаргалки / Болезни / Панкреатит
.docПанкреатит
Эпидемиология и этиология:
- у собак чаще острый
- у кошек чаще хронический
- 90% идиопатический
- питание (много белка и триглицеридов в крови)
- с/а, фуросемид, стероиды (?)
- инфекции
- обструкция протоков
- рефлюкс
- травма
- избыточный вес
Диагностика:
Собаки
- анорексия
- рвота
- слабость
- экзикоз
- болезненность
- температура
- желтуха, анемия
- ПУ/ПД
- диарея
- мелена
- нервные симптомы
Кошки
- депрессия, летаргия
- снижение веса
- анорексия
- желтуха
- экзикоз
- боль
- диарея, рвота
- ПУ/ПД
Кровь:
- TAP крови
- повыш липаза, амилаза, ЩФ
- повыш белок, холистерин, билирубин, креатинин
- нерегенеративная анемия
- тромбоцитопения
- гипогликемия
УЗИ
Лечение
- Инфузия, а/б
- Ингибиторы ферментов
- Рингер-лактат 2 мл/кг/час до 40 мл/сутки
- при рвоте голод, иначе: снижение разовой дозы, зондовое и парентеральное питание, много углеводов
- аналгезия!!!
-
Осложнения:
- системное воспаление
- коллапс
- ОПН
- ОДН
- ДВС
- энцефалопатия
- липодеоистрофия
- полиорганная недостаточность
Treatment
A. Overview
The major goals of treatment include removing any possible inciting causes (drugs, etc.), "resting" the pancreas to minimize pancreatic secretions, and providing supportive fluid and electrolyte therapy.
B. Nothing per os (NPO): rest the pancreas
1. Keep patient NPO as feeding is a potent stimulator of pancreatic secretions. Remember, food anticipation (sight or smell of food) can also trigger pancreatic secretions.
2. When vomiting has ceased for a minimum of 1 - 3 days, small amounts of water can be re-introduced. If well tolerated, small amounts of food can then be introduced.
3. Initially, the patient should receive a diet high in carbohydrate (rice, potato, pasta) as fat and protein are potent stimulators of pancreatic secretions.
4. Long-term, the patient should be placed on a low-fat type of maintenance diet to minimize recurrence.
5. In severe cases necessitating prolonged fasting, nutritional support can be maintained via trickle nasogastric feeds, total parenteral nutrition, or jejunostomy tube.
C. Fluid and electrolyte therapy: cornerstone of treatment
1. Increasing perfusion to the pancreas aids in removal of pancreatic secretions and inflammatory metabolites, and promotes healing.
2. Consider dehydration deficit, maintenance needs, ongoing losses (due to vomiting, diarrhea) and additional electrolyte requirements (potassium or bicarbonate supplementation).
3. A common mistake is to underestimate fluid needs - assume 5% subclinical dehydration if not overtly evident.
4. Shock doses of crystalloids (60 - 90 mls/kg/IV) or colloid solutions should be administered to animals that present in shock.
D. Drug therapy
1. Antibiotics
a. Septic pancreatitis is rare, however parenteral antibiotic therapy may be indicated if fever present, toxic changes on CBC, or to prevent against secondary infection.
b. Trimethoprim-sulphadiazine and enrofloxacin provide for good penetration into pancreas and are effective against likely bacterial pathogens.
2. Analgesics
a. Pancreatitis is a painful condition in most animals - although not all will manifest overt signs of such.
b. Butorphanol, oxymorphone, or fentanyl patches are indicated for pain relief.
3. Anti-emetics
a. *Q: Why do animals with pancreatitis vomit? Animals with pancreatitis vomit secondary to central effects (blood-borne metabolites), as well as peripheral effects (inflammation of pancreas, liver, etc.).
b. Centrally acting anti-emetic's (such as metoclopramide) may be beneficial in cases of refractory vomiting that do not respond to NPO status.
4. Gluco corticoids: controversial
a. Proposed beneficial effects include reduction of inflammation, stabilization of lysosomal enzymes and treatment of shock.
b. Adverse effects - many, including decreased clearance of macroglobulin-bound proteases by the reticuloendothelial system.
c. *Q: When to give? Probably only in very severe cases (life-threatening shock) and just 1 - 2 doses.
E. Additional therapeutics
1. Plasma transfusion
a. Helpful in patients with low albumin (will restore oncotic pressure and hence promote pancreatic perfusion).
b. Provides source of protease inhibitors and alpha-macroglobulin (used up in more severe cases of pancreatitis). Give fresh frozen plasma at 10 - 20 mls/kg.
c. Beneficial in management of DIC (provides antithrombin III and coagulation factors).
2. Heparin therapy
Indicated in management of DIC associated with pancreatitis. Dose: 75 IU/kg SQ TID, must taper prior to discontinuation.
3. Antioxidant therapy (selenium)
As injury in pancreatitis is mediated in part by free-radical damage, antioxidant therapy (selenium added to IV infusions) may be beneficial (appears so in preliminary studies). Investigative work is ongoing.
4. Oral pancreatic enzyme supplements
a. In people, used for management of chronic pancreatitis (decrease pain via negative feedback inhibition of pancreatic secretions).
b. May act via similar mechanism in dogs and cats. Considered experimental.
5. Peritoneal lavage to remove toxic metabolites in effusion
Peritoneal lavage is helpful in humans with pancreatitis and ascites, but not always practical in the small animal patient (invasive, expensive).
F. Unique features in management of the cat pancreatitis
1. Cornerstone of therapy is fluids (as for dog).
2. NPO recommendation is less consistent
a. Many cats do not have vomiting - and many have concurrent hepatic lipidosis.
b. The recommendation to withhold food is clear cut only if vomiting is present.
c. For cats with concurrent lipidosis must feed (via jejunostomy tube or TPN). If vomiting is not present, can use gastrostomy tube to feed.
3. If concurrent inflammatory bowel disease is present, may need to administer anti-inflammatory doses of gluco corticoids.
4. Dopamine constant rate intravenous infusion (consult reference source for infusion protocol)
Beneficial in experimental studies of cats with pancreatitis (if given within 12 hours of onset). Clinical cases rarely detected this early - unknown if still likely to be beneficial later.