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7/31/2019 Acute Necrotizing Pancreatitis Goliath
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Goliath Jedziniak, 8 year old, MN,Miniature Poodle
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Presented to UF ECC Service on 4/25 for:
Icterus
Acute abdominal pain
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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.
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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
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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
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Was transferred toan Emergency Clinicfor supportive care:
5fr urinary catheterwas placed (140 mlsof dark amberurine)
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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)
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PE: Jaundice,tachypneic,normothermic, CRT
>3secs
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Hyperbilirubenimia(icterus)
Painful abdomen
Elevated liverenzymes
Elevated lipase andamylase
Diarrhea
Dehydration
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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+
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Abdominalultrasound:
Sludge in the gallbladder
Scant amount ofeffusion in theabdomen
Peritoneal
effusion: Non septic
exudate
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Fresh frozen plasma
Vitamin K 2mg
Methadone 0.8
Unasyn 90mg
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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
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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.
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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
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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.
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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
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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