Goliath Jedziniak, 8 year old, MN, Miniature Poodle

Presented to UF ECC Service on 4/25 for:

Icterus Acute abdominal pain

On Monday, Goliath went to the yard to urinate, 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 presented in lateral recumbency and defecated blood. MM: pale white, moist and cold.

Epinephrine IM Solu Delta Cortef Famotidine LRS @ 450ml/hr for 30mins, reduced to 220ml/hr for 30mins then decreased to 30ml/hr. Diphenhydramine Metoclopramide PO, but continued to vomit, then given Maropitant SQ.

Diagnosed with anaphylactic shock. Diphenhydramine 12.5mg q6hrs Famotidine 5mg q12hrs Metoclopramide syrup 1ml q8hrs Probiotic 1 capsule q24hrs #30 Epi pen jr 0.15/0.3ml

On PE his sclera and skin were icteric, with harsh lung sounds. IV fluids Buprenorphine Metronidazole IV

Bloodwork:
Moderate

thrombocytosis: 1436 Ku/L (174-500) ALP: 1268 U/L (23-212) GGT: 55 U/L (0-7) Bilirubin 23.3mg/dl (00.9) Amylase >2500 U/L (500-1500) Lipase >6000 U/L (2001800

Was transferred to an Emergency Clinic for supportive care:

5fr urinary catheter

was placed (140 mls of dark amber urine)

PE:

Abdomen was

Chemistry:

distended, tense and profoundly painful on light palpation. Melena

CBC:

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

Mild leukopenia: 5.36

K/UL (5.5-16.9) Moderate thrombocytosis: 1117 K/uL (174-500)

PE: Jaundice, tachypneic, normothermic, CRT >3secs

Hyperbilirubenimia (icterus) Painful abdomen Elevated liver enzymes Elevated lipase and amylase Diarrhea Dehydration

Blood Gas:
TBilirubin 26.1 mg/dL

CBC:
Mild normochromic,

Prolonged coagulation test Urinalysis:

USG: 1.014 Blood: 3+ Ictotest: 3+

normocytic anemia HCT: 35.2% 1+ polychromasia, 1+spherocytes Thrombocytopenia 59 K/uL Normal neutrophil count with a left shift

Abdominal ultrasound:
Sludge in the gall

bladder Scant amount of effusion in the abdomen

Peritoneal effusion:
Non septic

exudate

Fresh frozen plasma Vitamin K 2mg Methadone 0.8 Unasyn 90mg

Dietary indiscretion Blunt abdominal trauma Hypercalcemia Pancreatic hypoperfusion Pharmaceuticals: potassium bromide, phenobarbital, L-asparaginase, azathioprine, trimethoprim-sulfa, and others Severe hypertriglyceridemia and disorders of lipid metabolism

Any number of insults can lead to premature activation of trypsinogen to trypsin. Trypsin, in turn, activates more trypsinogen and other pancreatic zymogens. Prematurely activated pancreatic digestive enzymes lead to local and systemic damage. This process also leads to recruitment of inflammatory cells and cytokine release, causing further systemic changes. In general, premature activation of pancreatic digestive enzymes leads to initiation of pancreatitis, while the inflammatory response leads to progression of the disease and systemic complications.

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

Azotemia, severely increased liver enzymes, Tbilirubin of 16 mg/dL, leukocytosis with a marked left shift, anemia. Continued to be extremely painful and lethargic, vomiting and diarrhea On 4/28 started to have respiratory distress at which point owners decided to euthanize.

Survival rate for dogs with extrahepatic biliary obstruction due to pancreatitis was 41%. Animals diagnosed with extrahepatic biliary tract obstruction had a relatively good long-term prognosis, provided they were not compromised substantially due to severe necrotizing pancreatitis or neoplasia.

Fahie, Ma, Martin, RA, Extrahepatic biliary tract obstruction: a

retrospective study of 45 cases (1983-1993). J Am An Hosp Ass. November 1, 1995 vol. 31 no. 6 478-482

Some cases may be poor candidates for surgical correction of the extrahepatic biliary obstruction because surgery may exacerbate the pancreatitis and pose additional risks. Although, in most dogs, extrahepatic biliary tract obstruction secondary to acute pancreatitis resolves spontaneously as the pancreatitis improves, decompression of the gallbladder may be beneficial in dogs in which the obstruction does not resolve or causes complications.

Percutaneous ultrasound-guided cholecystocentesis can be used for gallbladder decompression in dogs with extrahepatic biliary tract obstruction secondary to acute pancreatitis. Bile leakage and subsequent peritonitis are potential complications of percutaneous cholecystocentesis.

Herman, BA, Brawer, RS, Murtaugh, RJ, Hackner, SG (2005) Therapeutic percutaneous ultrasound-guided cholecystocentesis in three dogs with extrahepatic biliary obstruction and pancreatitis. JAVMA, Vol 227, No. 11, December 1, 2005