The Panic of Pancreatitis

Is there anyone who’s heard ‘pancreatitis’ and not freaked out a little? And if you didn’t freak out, maybe its because you truly just didn’t know much about it. I will review what pancreatitis is, how its diagnosed, how its treated, the prognosis, how to prevent pancreatitis and our personal pancreatitis journey with not 1 but 2 doxies.

First you might be wondering what your dog’s pancreas has to do with diabetes. The pancreas is an organ that has both endocrine (think insulin production) and exocrine (think digestive enzymes for fat and protein breakdown) functions. So since the pancreas has endocrine functions it is most definitely involved in diabetes. Pancreatitis can be acute or chronic. It can be mild or subclinical, it can also be severe. Pancreatitis can cause diabetes. Its also said that diabetes can cause pancreatitis.

Here’s a little breakdown of how pancreatitis happens: Pancreatic ‘juices’ get secreted ➡️ Other enzymes get activated ➡️ Damage to the exocrine pancreas occurs (Ex. Bleeding, swelling, inflammation, breakdown including fat breakdown, etc) ➡️ The body mounts an inflammatory response ➡️ Enzymes and inflammatory substances spread throughout the body ➡️ General inflammation spreads throughout the body affecting multiple organs. So with all this potentially going on, you can see how even just one episode of pancreatitis could cause permanent changes to your dog’s pancreas.

SYMPTOMS of pancreatitis can be vomiting, anorexia/hyporexia (not eating at all versus decreased appetite), dehydration, fatigue, weakness, pain, depression, diarrhea, fever, high heart rate, breathing difficulties, shock, etc. My non-diabetic dachshund was diagnosed with pancreatitis years ago and her only symptom was that she wasn’t sleeping well. She was constantly up and down, because she was unable to get comfortable due to pain.

You may never know the CAUSE of your dog’s pancreatitis. Many cases are idiopathic, or cause unknown. Here are some potential causes:

    Diet and nutrition are important triggers. Generally this is a high fat/low protein diet. There are typically an increase in cases around the holidays when dogs tend to get into table food they shouldn’t. Always ensure your dog can’t get to food or your trash! It can happen with just one ‘meal’ of fatty table scraps. Also certain prescription diets such as those that help dissolve bladder stones.
    Hypertriglyceridemia is when there is excess fats circulating in the dog’s blood (typically >500mg/dL).
    Trauma
    Hyperadrenocorticism
    Obesity
    Surgery – although this is now thought to be caused by decreased perfusion to the pancreas during anesthesia
    Drugs/Toxins
    Infections
    Hypercalcemia
    Associated illnesses

Any dog can be affected by pancreatitis. It is more common in middle aged to elderly dogs. It is more common in females. Research from necropsies are beginning to show far more dogs are affected than anyone originally thought. Certain breeds are known to be more predisposed to pancreatitis. Those include: Schnauzers, Poodles, Cocker Spaniels, Yorkshire Terriers, Dachshunds, etc.

DIAGNOSING pancreatitis whether acute or chronic can be very tricky! I was shocked to discover Beignet had chronic pancreatitis. How could I have not known she had it??? In humans, lipase and amylase elevations typically give you your diagnosis but do not determine severity of disease. Amylase shows elevations within 5-8 hours of symptom onset and returns to normal by day 3-4 and reaches a maximum 12-72 hours after symptom onset. Some research supports only checking lipase in humans due to it being elevated both in the early and late stage. Lipase elevates within 4-8 hours of symptom onset, peaks at 24 hours and returns to normal within 8-14 hours. In humans, both amylase and lipase can also increase with other disorders. I feel its important to understand a little about human diagnosis to help us understand dog diagnosis. Below I will go through each diagnostic option in dogs:

  • CBC & Chemistry Profile: These are extremely important to evaluate the dog for systemic complications, but are NOT useful to diagnose pancreatitis. In a dog with pancreatitis, you may commonly find signs suggestive of nonspecific inflammation, a decrease in platelet count, an increase in neutrophils with a left shift, increased BUN and creatinine, increased liver enzymes, increased bilirubin, etc. Although amylase and lipase are on the Chem profile, they are described below.
  • Amylase: Has very poor sensitivity and specificity. Very limited as a measure of pancreatitis diagnosis. Possibly given the human info above, its already potentially normalized by the time the dog presents to their vet.
  • Lipase: This is generally on most in-office metabolic panels. Lipases are something released from multiple organs including the pancreas, liver, stomach, endothelium etc). A serum total lipase is NOT specific for pancreatitis. An article online from Texas A&M Vet School said it could miss up to 86.4% of pancreatitis patients. Lipase can be increased by steroids, cancer as well as diseases of the kidney, GI tract, and liver. Also there is an increase in false negatives in pancreatitis patients due to hemolysis, lipemia and icterus (jaundice). Beignet has never had an elevated amylase or lipase.
  • Serum Pancreatic Lipase Immunoreactivity (PLI): The Spec cPL®️ specifically tests for pancreatic lipase and has rare false positives. In office rapid cPL tests are available, but generally cPL tests are send out tests for most vets. This test is how we got Beignet’s diagnosis of chronic pancreatitis. http://vetmed.tamu.edu/gilab/service/assays/pli. Be aware that many GI conditions can cause mild pancreatic inflammation. This in turn can increase your cPL test. Sometimes a repeat cPL maybe needed to help determine if the dog has a primary or secondary pancreatitis.
  • Trypsin-like Immunoreactivity (TLI): This is the diagnostic test of choice for EPI as it tests exocrine pancreas function. It is not very sensitive for pancreatitis though.
  • Abdominal X-ray: This is more important to help excluse other diagnoses in your vet’s differential diagnosis (the diagnoses your vet is ruling in or out including pancreatitis). Findings in pancreatitis will be nonspecific.
  • Abdominal CT or MRI: Very insensitive in cats and never truly evaluated in dogs. Probably not worth what this would cost you.
  • Abdominal Ultrasound: Highly specific for pancreatitis, but just seeing an enlarged pancreas with fluid accumulation around it is not enough to give you the diagnosis. With newer high resolution ultrasounds, occasionally pancreatic nodular hyperplasia could be misinterpreted as pancreatitis. When it comes to an ultrasound, consider the expertise of the ultrasonographer (who maybe your vet), quality of the machine, and the level of suspicion of your ultrasonographer. When Beignet was sick, my vet told me his ultrasound machine was older and if we wanted to do one locally, he would send us to do one on a better machine. We were going to a vet school, and chose to wait to do one there done by their radiologist. I was able to see chronic changes quite easily on the entire left side of Bennie’s pancreas on her ultrasound😢. Contrast enhanced ultrasounds have improved diagnostic evaluations but aren’t routinely done.
  • Pancreatic Cytology or Histopathology: This can give you a definitive diagnosis. FNA (fine needle aspiration) of the pancreas has been reported to be safe. But sometimes the disease is very localized, so a normal FNA does not exclude pancreatitis. Biopsy on the other hand can increase a dog’s risk of pancreatitis as compared to FNA. If pancreatitis is severe, a dog’s anesthesia risk is much greater. An exploratory lap or FNA may be too risky in severe pancreatitis.

If your dog has joined us in the pancreatitis club, you maybe curious about TREATMENT options:

  • Aggressive fluid treatments with electrolyte replacements if needed.
  • Remove any potential causes.
  • +/- Gut rest. Recommendations on this vary. Definitely will be done if the dog is vomiting despite anti-nausea medications. Beignet required it.
  • Nausea medications: Cerenia and ondansetron are potential options
  • Pain medications
  • +/- Antibiotics: these have questionable value so are not routinely recommended.
  • Reglan (metoclopramide) for improving gastric motility. It can help with nausea but should not be used as the dog’s anti-nausea medication in pancreatitis. I read that it could decrease blood flow to the pancreas potentially. Bennie was put on this for gastric emptying and it was increased from twice to three times a day when she was hospitalized at a vet school.
  • Reflux medications. Many dogs are put on them but I haven’t seen them listed as parts of treatment. Bennie was put on omeprazole but advised to stop after a week due to potential issues with long term PPI use. However she may have been put on this more for her suspected IBD than her pancreatitis.
  • Food: May require a permanent food change. Generally <10% dry matter fat, but Ultra Low Fat diets are what we will see being recommended in the future. Stay tuned for an upcoming post with all my dry matter fat calculations. Do not use the fat percent on your dog food label (unless Hill’s, who often has the actual dry matter fat values on their labels) but instead put the information into a calculator like this one http://fnae.org/dmb.html. Know that these values are minimums and typically the food contains ~3% more fat than what you calculate. You can always contact the company to ask for the actual value. Early nutritional support is a key component of successful treatment in humans with pancreatitis.
  • Plasma transfusions maybe needed in severe cases of pancreatitis.
  • If a dog isn’t responding, prednisone, prednisilone, or cyclosporine maybe given. Cyclosporine for a dog with diabetes is preferred as it has less of an impact on insulin resistance. There is not a lot of data on its use in chronic cases.
  • Entyce – a newer appetite stimulant maybe needed to get your dog to eat. Since I forgot to originally add this, I will post about Entyce in an upcoming blog.

To PREVENT pancreatitis, keep your dog at their recommended, ideal weight. Avoid feeding foods high in fat. Work on a weight loss plan for your dog if they are overweight. Discuss any medications your dog is on with your vet to determine if they potentially increase your pet’s risk.

Your dog’s PROGNOSIS depends on the severity of disease. Risk factors for poor outcomes include: hypothermia, acidosis, low calcium and failure of 1 or more organs. Chronic pancreatitis typically has better outcomes, but may eventually cause diabetes (like in Bennie) and/or other diseases that affect the dog’s quality of life. There are many dog’s like Beignet that have an upset tummy here and there, but aren’t very ill. So even with a visit to the vet, no one is aware that the dog is actually having a mild pancreatitis flare. Chronic pancreatitis maybe associated with intestinal or liver inflammation.

This went a little longer than I initially intended. My information is more to give a better understanding of pancreatitis and should not replace the care and advice of your vet team. My information comes from my own personal medical knowledge and reading various articles over the past months. Texas A&M vet school has many great articles on pancreatitis. The Merck Manual online also has some great reading on dog and cat pancreatitis. Hopefully if you experience an acute flare your dog does well! I will tell Bennie’s story in a future post.

-Devoted Doxie Mom

How to Test Your Dog’s Blood Sugar

So the strangest thing as a physician on bringing my newly diabetic dog home, was that I had absolutely no idea what her blood sugar was. In the human world, a diabetic would never be sent home without a glucometer. My anxiety level greatly decreased when with the help of our vet, we got set up for a home testing program. The benefits of home testing are numerous. Your dog will be far better regulated which will decrease the likelihood of acquiring diabetic complications. Your dog will feel better. And get this – your vet bills will decrease. Thats right, your vet bills will decrease. Veterinary blood sugar checks do add up. Not to mention your most accurate blood sugars will always be at home in your pet’s everyday environment. If your dog gets stressed at the vet, they could have a falsely high or low blood sugar. Your vet will help you learn how to adjust your dog’s dose based on home tests and glucose curves. You will be able to make changes faster to regulate your dog by providing this valuable information to your vet. Pretty soon your confidence will soar and you will be pretty much managing your dog’s insulin dosing on your own. In future posts I will go through the different meter options and how to do glucose curves and interpret blood sugars. My preferred meter is the AlphaTrak2 but I will be sure to give pros and cons of all the meters including the AT2.

Click on pic above to purchase our favorite strips.

Click on pic above to purchase our favorite meter.

A few tips not mentioned in the videos: You can fill an old sock with rice that you heat up in the microwave before applying to any test site except the inner lip. This will help bring blood to the area and help you get your sample. Also many pet owners use the Genteel lancing device (www.mygenteel.com) for pain free pokes on everywhere except the inner lip. These occasionally go down to ~$70 in certain colors on Amazon. Since we’ve never needed one, we’d love some feedback from Genteel users!

Click on pic above to purchase.

Hopefully our videos will help get you started. Be sure and comment below with your favorite test sites. We hope everyone has great sugars!

-Devoted Doxie Mom

Click the link above if you need some lancets!

Expect The Unexpected…

Its clear your lives will never be considered boring again once you bring home a diabetic dog. Now coming home each day is a time of uncertainty – what are you going to come home too??? This weeks post was supposed to be some more information to help new doggie diabetic owners. Instead we ended up at the ER vet getting diagnosed with bilateral corneal ulcers (worse on the right)😢😢. Now we are home in our cone of shame trying a pain med we think she tolerates and starting an eye drops instead of the ointment she’s been on for conjunctivitis the last few days.

On this topic, the best thing you can do for you dog is to follow your gut. Just like tonight, when the ER doctor said it was definitely a good thing I did not wait until morning to have her checked. Our instincts about our pets are usually spot on. Trust yourself. Don’t feel stupid for asking too many questions or scheduling too many visits. Do what you need to do to make your dog healthy and happy.

I’m off to try to get my little conehead to bed. Hopefully we sleep well!! It reminds me of our first week as a diabetic when she had to wear a cone so she’d quit trying to pull her IV out and those were some sleepless nights. 🤞🏻😴.

Also feel free to always comment with your own stories, etc on any of our posts.

Night!

-Devoted Doxie Mom

Syringes matter!

So my first topic is going to be making sure you are using the right insulin syringe! Vetsulin requires a U-40 syringe. Novalin N & Humalin N (NPH Insulin) require a U-100 syringe. 1 unit in a U-40 does NOT equal 1 unit in a U-100. U-40’s should have a red needle cap and U-100’s should have an orange needle cap (however always verify your syringe says U-40 or U-100 because some brands are misleading). Syringes comes in different sizes with different size needles. Remember that the smaller the gauge needle, the larger it actually is. So small dogs need a higher gauge. When my ~10lb dachshund was on Vetsulin for a short period, we did use a 29 gauge U-40 but on Novolin N she uses a 3/10cc 31 gauge U-100. A 3/10cc syringe would be my recommendation for a small dog who should never come close to needing 30 units of insulin. I prefer a syringe that has half unit markings as small dogs typically increase doses in half unit increments. I pictured my favorite syringes I buy in a 5 box special deal at a great price from http://www.adwdiabetes.com. I accidentally bought 50 unit syringes in bulk once that didn’t have half unit markings. I hated them. I had a ton of fur shots because the needles seemed flimsy (a fur shot is when you miss some or all of your injection and the insulin ends up in the fur and not in the dog) plus it was harder for me to pull up smaller dose without a ton of air bubbles. I ended up donating them all to my vet. Another important point is if you ever switch between Vetsulin and NPH insulin please make sure there is no way your syringes can get accidentally mixed up. If your syringe does not have half unit markings and you want to dose a half unit, on most syringes if you line up the black tip end of your plunger with the hash from the unit below, the tip of your plunger usually ends up at the halfway mark. This isn’t true for all syringes though. Hope this helps!!

-Devoted Doxie Mom

Welcome to our journey!

If you read my bio, you know I’m the proud doxie mom of Andouille Sausage (age 11.5yo) and Beignet (age 7.5yo).  On New Years Day 2018, our world drastically changed.  While watching LSU’s bowl game at my parents, Beignet started having multiple accidents in their house which had never happened before.  She guzzled an entire dog bowl full of water and started trying to drink out of their swimming pool shortly after.  I thought, could she be diabetic???  I immediately rushed her to the Line Avenue Emergency Vet in Shreveport, where the veterinarian confirmed my worst fears for my Bennie.  She had to spend the  night at the ER to get started on insulin and was to be immediately taken to our vet the following morning.  I was in shock…  How could this happen???  How could this happen to the world’s happiest, most loving dog?  Did I do something wrong to cause this??  I went home in a fog.  Going home without her was tough.  So much uncertainty it was hard to know what the coming days and weeks would hold for us.  Plus I was just worried about how she was doing at the ER without me.  Not that I should worry much, because Bennie is notorious at all pet friendly locations.  She was probably getting multiple tummy rubs while I sat home and cried.  I actually ended up taking her favorite blanket back up there.  They so thoughtfully allowed her to come to a room and spend about 15 minutes with Andouille and me before they needed to hook her back up to her fluids.  This was night 1 of 3 months of my  life I would never want to relive….

The first thing so many people said upon finding out about Bennie’s diagnosis was “Well you’re a doctor, this will be nothing to you.”  Let’s clarify, I’m a pediatrician.  The doctors that often high tail it out of the room while their nurses give the shots…  Do I understand diabetes – of course.  Did that make me even more terrified – absolutely!  My point is no matter what your background is, getting this diagnosis for your pet is terrifying.  I spent weeks reading everything I could.  I learned 1 in 100 dogs are diagnosed with diabetes.  Dogs are always Type 1 diabetics (insulin dependent or Juvenile-onset) although cats are often Type 2 diabetics (non-insulin dependent).  Since dogs are Type 1 diabetics, they always require insulin.  The greatest risk of mortality is in the first 6 months following diagnosis (which we just made on 7/1/18!!!).  My dog now has a high risk of developing cataracts and becoming blind.  Both of my dogs that have always free fed throughout the day would now both be required to eat on command twice a day so that Bennie could be given her insulin.  My life would now revolve around being home at specific time intervals to give insulin ~ every 12 hours.  And probably the absolutely hardest concept to grasp was that, I, world’s worst spoiler of wiener dogs, would be giving my baby girl shots.  For each of you who have gotten this diagnosis, you knew the same feeling.  Being completely overwhelmed.  Dr. Brad our vet assured me that Bennie would realize the shots made her feel better and not mind them at all.  Thankfully he was so right.

This blog will be to help me remember where we started and how far we’ve come.  It will be to help others on this journey navigate this dreadful disease.  I am not a veterinarian or an expert, but I’m someone who’s been in your shoes.  I will discuss home testing, feeding woes, new unexpected diagnoses, vet visits, dog diabetes resources and I’m sure multiple other things.  If I am doing something different than what your vet has advised, please discuss these things with your vet and do not base changes off of anything that I do with Beignet.  Good luck on your Sugar Baby Journey!

~Devoted Doxie Mom