消化系统疾病30胃肠道中英文18校feline pancreatitis triaditis unterer

FelinePancreatitis/TriaditisDiagnosisandManagementDr.StefanUntererDiplomateCase15FemaleCaseHistoryAnorexiasincefewAcutevomiting2WeightReference5–10x5.6–9.30.3–0.44180–550x6–18x-0–0.5x-1–4x-0–0.6x-3–11x-00–0.6xReference0–630–1140–940–4.740–414total57–9426–565–11.30–1693.7–6.9ReferenceP0.97–2.36100–124146–165K3.5–5.62.3–3.07.34–36–4085–9519–24-4–---5.5–+----------------Spec.1.035–CaseProblemlistRule-outlistDiagnosticand LiverandbileAnatomy CorpusLobusdexterLobussinisterDuctalsystemDuctusendbothatPapilladuodeniAusBudras,K.D.:AtlasderAnatomiedesPancreatitisAcutepancreatitisusuallysevereclinicalreversiblehistopathologicChronicpancreatitismoreoftenbenignclinicalirreversiblehistopathologicTriaditisSyndromeincatsitantinflammmationof肝

toryBowel(Cholangitis~Prevalencetrueprevalencerarelydiagnosedincats罕见诊断于猫（组织学retrospective(histo)pathologic0.57%,1.3%and67%ofnecropsiedcatsshowedpancreaticchanges0.571.367MoreandmorediagnosedduetobetterdiagnostictoolsPancreatitisisnotarareChronicpancreatitismorePancreatitiscanbeNon-specificsymptomsClinicalpathologyinsensitiveandnon-(exceptionfelinepancreaticlipaseimmunoreactivityfPLI)PatientswithpancreatitscanlooklikepatientshepatobiliaryTriaditis–Studiessuggest itantinfl tionofliver,pancreasandintestinesHigherprevalenceofpancreatitsandIBDincatswithcholangitisthancatwithoutinfl itantinfl tionofliver,pancreasandintestinesin22/49cats2itanthepatobiliarydiseaseandacute1Weissetal.,1996;2Simpsonetal.,2001;3Akoletal.,2001;4Hilletal.,1993;5Kellyetal.,EtiologyandAcuteautodigestionofpancreatictissuebyfalslyactivateddigestiveenzymeswithinthepancreasEtiologyandAcutepancreatitisIschemiaTraumaAscendingbacterialinfectionViralinfections(Herpes,FIP,virulentCaliciParasitesOrganophosphateintoxicationHypercalcemiaDrugs(Azathioprin,L-药物（硫唑嘌呤，左旋天冬酰胺酶EtiologyandAcutepancreatitisObesityHyperlipidemiaFatcontentoffoodseemtoylittletonoroleinthedevelopmentofacutepancreatitsinthecat–incontrasttohumansanddogs1Expertopinion–noEtiologyandAcutepancreatitishepatobiliarydiseaseAscendingbacterialinfectionthroughsharedductalSecondaryhepaticlipidosiscausedbySecondaryliverinjuryduetoproteases/infl mediatorsandhypoxia(thrombi,hypotension)EtiologyandChronicpancreatitis/triaditis慢性胰腺炎/三联Incitingcauseforlymphocytic/smacyticinfltionunknownHypothesisascendingbacterialinfectionsduetosharedductalsystemleadtoinfltion itisanimmunemediateddiseaseaffectingmultiple Etiologyandvarioussubstancespasstheintestinalbarriereasilyduetointestinalinfltion(felineIBD)andleadtoinfltioninneighbouringorgansEndotoxinsInflammmatorymediatorsBacteriaClinicalsigns临FelinepancreatitisCommonunspecific

>90>90>90Rare,morespecificAbdominalpain

3525Clinicalsigns临SignsinsomeSignsinsomecasesasseenwithacuteliverfailure!Commonunspecific

>90>90>90Rare,morespecificAbdominalpain

3525Non-specificchangesAnemiaIncreasedliverenzymeactivitiesIncreasedbilirubinHyperglycemiaHypercholesterolemiaHypocalcemiaionizedCa<1mmol/l=negativeprognosticfactorNon-specificchangesAnemiaIncreasedliverenzymeactivitiesNodefinitivethroughNodefinitivethroughlabHyperglycemiaHypercholesterolemiaHypocalcemiaionizedCa<1mmol/l=negativeprognosticfactorPancreatitis=toryPancreatitis=toryPancreatitis=toryBUT–allcombinationsVeryhighWBCcount(>50NormalWBCPancreatitis=toryBUT–allcombinationsVeryhighWBCcount(>50NormalWBCLowWBCPancreatitis=toryBUT–allcombinationsVeryhighWBCcount(>50NormalWBCLowWBCYoucannotexcludepancreatitsbecauseofanormalHypocalcemiaMostspecificlaboratory DuetosaponificationofabdominalDecreasedtotalcalciumwithlowIonizedcalcium<1mmol/l=negativeprognosticAmylaseandlipaseInsensitiveandnon-NodifferenceCatswithacutepancreatits(n=急性胰腺炎的猫Catswithotherillnesses(n=其他疾病的猫Healthycats(n=健康猫Trypsinelikeimmunoreactivity类胰蛋白酶免疫反应Specific(ruleoutazotemia30–60%sensitivityinGoldstandardfordiagnosisofexocrinepancreaticTrypsinelikeimmunoreactivity类胰蛋白酶免疫反应TLIisspeciesTLIisspeciesspecificfelineTLI(fTLI)canineTLI(cTLI)(ruleoutazotemia30–60%sensitivityinGoldstandardfordiagnosisofexocrinepancreaticExperimentallyinducedpancreatitisin12catsWilliamsDAetal:,JVetIntMed17:445,2003 FelinePancreaticLipaseImmunoreactivity猫胰腺脂肪酶免疫反应InacutepancreatitisSensitivity100敏感度Sensitivityinchronic/mildFewstudiesSensitivity~50敏感度HardtopickupcaseswithmildSpecialTests特殊FelinePancreaticLipaseImmunoreactivity猫胰腺脂肪酶免疫反应SpecificPLIispancreasspecificIncreaseinfPLIpancreatitisAlmostnostudiesinpatientswithextra-pancreaticSpecialTestsSpecialTestsNewtest:SNAP®fPLTestSpecialTestsNewtest:SNAP®fPLTestPositivetestresultSpeccPL>200特异性cPL>200SensitivePancreatitiswithSpeccPL>400胰腺炎的特异性cPL400LessspecificSpecialTestsNewtest:SNAP®fPLTestPositivetestresultSpeccPL>200特异性cPL>200SensitivePancreatitiswithSpeccPL>400胰腺炎的特异性cPL400Lessspecific→HelpfulforexclusionofacuteSpecialTestsNewtest:SNAP®fPLTestPositivetestresultSpeccPL>200特异性cPL>200SensitivePancreatitiswithSpeccPL>400胰腺炎的特异性cPL400Lessspecific→Helpfulforexclusionofacute→FurthertestsfordefinitiveSNAP®fPL™pancreatitisveryunlikelypancreatitisveryunlikely

炎very 炎1Saundersetal.,2001;2Formanetal.,2004;3Steineretal.,UltrasoundAltionscanchangeveryModerate20–67%beiderKatze1,2,1Saundersetal.,2001;2Formanetal.,2004;3Steineretal.,UltrasoundAltionscanchangeveryModerate20–67%beiderKatze1,2,(dependsonexperiencelevelofGoodAltioninpancreatictissue≈胰腺组织变化胰腺炎（罕见肿瘤1Saundersetal.,2001;2Formanetal.,2004;3Steineretal.,HypoechogenicitypancreaticThickenedMassDilatedbileLocalizedabdominalRarelyneccessaryinacute RarelyneccessaryinacuteGoldstandardinchronicRarelyneccessaryinacuteGoldstandardinchronicAcutepancreatitismedicaldiseaseindicationforsurgeryRarelyneccessaryinacuteGoldstandardinchronicAcutepancreatitismedicaldiseaseindicationforsurgeryalfindingonAlwaystakedeepbiopsiesMaintaingoodperfusionMacroscopicallynormalpancreascanstillbeinfiltratedbypancreaticmass≠pancreatictorySpecialDiagnosticGoldstandardinhumanacutepancreatitis‘NotagoodtestinContrastultrasoundUnderevaluation2ImportantInformationforclinicalwork-Diabetes itantmeasurementoffPLIandanultrasoundareindicatedinpatients ImportantInformationforclinicalwork-Cholangitis itantMeasurementoffPLIandanultrasoundincludigFNAofbileareindicatedpatientswithsignsofcholangitis/hepatitis(jaundice,increasedliverenzymeactivities)1Forcadaetal.,2008;2Weissetal.,SuspicionClinicalsigns:vomiting,abdominalpain,MarkedincreaseinPLUSSuspicionClinicalsigns:vomiting,abdominalpain,MarkedincreaseinPLUSDiagnosisUltrasonographicaltionofpancreaticIncreasedcPLIclinicalsignsTherapyAcuteTherapyAcuteInitialtreatmentTherapyAcuteInitialtreatmentTherapyAcuteInitialtreatmentOptimizeperfusionofandoxygendeliverytothepancreasTherapyAcuteInitialtreatmentOptimizeperfusionofandoxygendeliverytothepancreasTherapyAcuteInitialtreatmentOptimizeperfusionofandoxygendeliverytothepancreasSpecialnutritionandsupportiveTherapyAcuteTherapyAcuteTherapyAcuteAgressivefluidtherapyTherapyAcuteAgressivefluidtherapyImprovemicrocirculationandPriorexclusionofCongestiveheartfailureTherapyAcuteAgressivefluidtherapyImprovemicrocirculationandPriorexclusionofCongestiveheartfailureOliguricrenalfailureTherapyAcuteAgressivefluidtherapyImprovemicrocirculationandPriorexclusionofCongestiveheartfailureOliguricrenalfailuredehydration,2xmaintenance,further TherapyAcuteAgressivefluidtherapyImprovemicrocirculationandPriorexclusionofCongestiveheartfailureOliguricrenalfailuredehydration,2xmaintenance,further (example:4kgcat7%TherapyAcuteAgressivefluidtherapyImprovemicrocirculationandPriorexclusionofCongestiveheartfailureOliguricrenalfailuredehydration,2xmaintenance,further (example:4kgcat7%280ml+400ml+100ml=780例：4kg的猫，7%脱水—280ml400ml100ml780ml/TherapyAcuteTherapyAcuteAgressivefluidtherapyMonitoralbuminIftoolow–oncoticpressuretooPancreaticedemaandAlbumin<15–20g/l: TherapyAcuteAgressivefluidtherapyMonitorSomehemodilutiondesired(PCV会有一些血液稀释（PCVPCV<25%:giveRBCPCV<25%:补充红细胞MonitorbloodLowbloodpressure:giveTherapyAcutePainmanagementMayincreaseSphincter/papillaryNoproofofnegativeimpact ExampleFentanyl-CRI5g/kg/h芬太尼-DosecanbedoubledInitialbolus5g/kgslowly初始剂量为5g/kgTherapyAcuteTherapyAcuteFelineTherapyAcuteFelineDon‘tfastcats!TherapyAcuteFelineDon‘tfastcats!CAVEhepaticlipidosis注意TherapyAcuteFelineDon‘tfastcats!CAVEhepaticlipidosis注意ExceptionvomitingTherapyAcuteFelineDon‘tfastcats!CAVEhepaticlipidosis注意ExceptionvomitingAnorecticcats

jejunalfeedingnasopharyngeal,esophagusor替代方案：TherapyAcuteTherapyAcuteNutritionTherapyAcuteNutritionGITintact/noTherapyAcuteNutritionGITintact/noenlPeros(smallamounts,low口服（少量，低脂JejunalfeedingTherapyAcuteNutritionGITintact/noenlPeros(smallamounts,low口服（少量，低脂JejunalfeedingGastrointestinalTherapyAcuteNutritionGITintact/noenlPeros(smallamounts,low口服（少量，低脂JejunalfeedingGastrointestinalAlbumin15g/l白蛋白TherapyAcuteTherapyAcuteAdditionalmeasuresTherapyAcuteAdditionalmeasuresTherapyAcuteAdditionalmeasuresAntiemeticsTherapyAcuteAdditionalmeasuresAntiemetics(e.g.maropitant1mg/kgSIDsc./p.TherapyAcuteAdditionalmeasuresAntiemetics(e.g.maropitant1mg/kgSIDsc./p.TherapyAcuteAdditionalmeasuresAntiemetics(e.g.maropitant1mg/kgSIDsc./p.Heparine(DICprophylaxis肝素（预防TherapyAcuteAdditionalmeasuresAntiemetics(e.g.maropitant1mg/kgSIDsc./p.Heparine(DICprophylaxis肝素（预防(e.g.Fragmin®75IE/kgTIDTherapyAcuteAdditionalmeasuresAntiemetics(e.g.maropitant1mg/kgSIDsc./p.Heparine(DICprophylaxis肝素（预防(e.g.Fragmin®75IE/kgTIDTherapyAcuteTherapyAcuteAdditionalmeasuresTherapyAcuteAdditionalmeasuresTherapyAcuteAdditionalmeasuresAntibiotics(susp.bacterialinfection–morelikelyin抗生素（怀疑存在细菌—更可能发生于猫TherapyAcuteAdditionalmeasuresAntibiotics(susp.bacterialinfection–morelikelyin抗生素（怀疑存在细菌—更可能发生于猫(e.genrofloxacin5mg/kgSID)（如恩诺沙星5mg/kgTherapyAcuteAdditionalmeasuresAntibiotics(susp.bacterialinfection–morelikelyin抗生素（怀疑存在细菌—更可能发生于猫(e.genrofloxacin5mg/kgSID)（如恩诺沙星5mg/kgAppetitestimulantscatTherapyAcuteAdditionalmeasuresAntibiotics(susp.bacterialinfection–morelikelyin抗生素（怀疑存在细菌—更可能发生于猫(e.genrofloxacin5mg/kgSID)（如恩诺沙星5mg/kgAppetitestimulantscat(mirtazepine3.75mg/kgevery3rddayp.TherapyAcuteAdditionalmeasuresAntibiotics(susp.bacterialinfection–morelikelyin抗生素（怀疑存在细菌—更可能发生于猫(e.genrofloxacin5mg/kgSID)（如恩诺沙星5mg/kgAppetitestimulantscat(mirtazepine3.75mg/kgevery3rddayp.TherapyAcutePancreatitsprimarilynotabacterialSecondarybacterialinfection–rare,but itantacutecholangitis:antibioticsagainstintestinalflora(e.gEnrofloxacinMetronidazol)(恩诺沙星+甲硝哒唑Bestcasescenario:culture(bile/pancreatictissue)incl.TherapyAcuteConsidersurgicalintervention,Noimprovementdespiteoptimaltherapyafter5-7edpancreaticBileductedpancreatic LocalcomplicationsCholangitisCommonincatsinconjunctionwithMonitor:bilirubin/SBA,ultrasoundbileducts,FNAgallbladderTherapy:antibiotics,dependingon2Weissetal.,LocalcomplicationsExtrahepaticbileductRareinsmallanimals/morelikelyincatsthandogs(DuctuscholedocusandD.pancreaticusfusewithinfelinepancreas)PrimarilymedicalLocalcomplicationsExtrahepaticbildeductMedicaltreatmentStentimntationHighercomplicationriskincatsthan1MayhewPD,TherapyAcuteConsidersurgicalintervention,Noimprovementwithmedicaltherapyafter5–7daysSusp.pancreaticBileductSusp.pancreatic TherapychronicChronicpancreatitis+histopathologicdiagnosisLymphocytic/smacyticLymphocytic/smacyticèPrednisoloneCAVE:nosteroidsinDiabetes TherapychronicChronicintestinaldiseaseaspossibleunderlyingcausefor itantinflamationin 肝

(lymphocytic/smacytic(chronicèEliminationdiet/hypoallergenicèMetronidazol(10mg/kgBIDp.osfor4è(Prednisolonetherapy???)（疗法TherapychronicPancreaticenzymeNegativefeedbackdecreasesenzymesecretion(humanmedicine)Decreasedabdominalpaininchronicpancreatitis(humanmedicine）在慢性胰腺炎病例减少腹部疼痛（人医AppetitestimulationVitaminBcomplex复合Cyproheptadine(2mg/catpos) TherapychronicCobalamineVitaminB12钴胺素Measure/monitor测量 Cobalaminesupplementation(250µg/cats.c.FolicacidMeasurefolicacidCheckforintestinaldiseaseFolicacid (200µg/catposdailywithfood)（200ug/SummarySummaryFelinepancreatitisisnotSummaryFelinepancreatitisisnotVariableclinicalsymptomsinSummaryFelinepancreatitisisnotVariableclinicalsymptomsin itantlymphocytic/smacyticinfltioninintestinesandliverpossible(withchronicSummaryFelinepancreatitisisnotVariableclinicalsymptomsin itantlymphocytic/smacyticinfltioninintestinesandliv