Case Study

Pancreatitis in a 10 year old FS Burmese cat

A 10-year-old FS Burmese was presented for anorexia, vomiting, and soft stool. The physical exam revealed mild dehydration, tacky mucous membranes, fever of 104 degrees F, and mild cranial abdominal pain on palpation. CBC and blood chemistry analysis revealed only mildly elevated triglycerides.

DX

Pancreatitis

Sonographic Differential Diagnosis

Pancreatic necrosis/pancreatitis with possibility of pancreatic carcinoma, lymphoma, or nodular hyperplasia. Ileo-cecal region demonstrates cecal stasis, a common finding in systemically sick patients with diminished GI motility. This is not to be confused with an “obstructive pattern” given the distal ileum to the right and cecum to the left. Video of the ileo-cecal valve demonstrating the ileum being “driven” into the cecum to differentiate this from an obstructive pattern.

Image Interpretation

On radiographs, minor retention of barium is noted in the transverse colon. Otherwise, no significant abnormalities are present. The left limb of the pancreas is coarse and excessively hypoechoic compared to surrounding omentum. Limb enlargement is present with a width greater than 1 cm, and hypoechoic extension of the tissue through at least 3 cm of the left pancreatic limb. Dilation of the pancreatic duct is noted in its normal central location. Deviation from curvilinear capsular and duct contour is noted. The patient demonstrated focal pain upon imaging of this region but tolerated the probe pressure readily in other regions of the abdomen. Power Doppler assessment of the pancreatic parenchyma demonstrates subnormal blood flow consistent with some level of avascular necrosis. Video of another region of the left pancreatic limb demonstrates better power Doppler signal in portions of the pancreatic tissue. Utilizing harmonics helps to improve resolution of the pathology and eliminate unnecessary artifact. Minor uniform splenic enlargement was noted.

Outcome

10-days follow-up of the same patient after 1 week of IV fluid therapy, Zithromax, GI protectants and nutritional support. Significantly diminished pathological volume is evident in the left pancreatic limb. The patient was only minimally painful upon imaging during this session. A 1 cm width x 2 cm length of residual pathology is evident Same lesion with high resolution linear probe demonstrates duct (central) and capsular deviation consistent with chronic retraction due to fibrosis. The patient was mildly painful upon imaging indicating persistent active inflammation and edema. However, the width of the pancreatic limb has diminished corresponding to the clinical improvement. The lesion is now more localized and sectorial compared to the diffuse left limb pathology noted at the initial presentation. Power Doppler assessment of the follow-up presentation demonstrates subnormal blood flow to the residual hypoechoic region of the left pancreatic limb. A 3-week follow-up of the same left pancreatic limb demonstrates residual excessive thickness and parenchymal remodeling. The patient was no longer painful in this region however. Clinical signs were essentially resolved at this point. Undulating capsule was now noted consistent with fibrous retraction which is a common sequela to an inflammatory event. The patient was stable as an outpatient after 1 month of Zithromax and hypoallergenic diet.

Comments

Note that a 22-gauge needle was used for aspiration and was precisely placed into the hypoechoic pancreatic pathology to maximize sampling accuracy. The hypoechoic non-vascular regions are most accurate representations of the pathology in my experience. Sampling multiple regions of varying sonographic echogenicities helps improve the representation of the pathology for the cytologist when performing FNA or histopathology when performing tru-cut biopsies. Video of FNA of the pancreas. Given that there is little room for sampling (1-1.5 cm width of pathology), short jabs are taken followed by a slight twist of the syringe (“corkscrew technique”) during the jab.

Clinical Differential Diagnosis

GI pathology (IBD, neoplasia, foreign body), pancreatic pathology (pancreatitis, neoplasia, cyst, abscess), hepatic pathology (cholangiohepatitis, hepatitis, neoplasia), peritonitis.

Sampling

US-guided fine needle aspiration of multiple areas of the pancreas revealed well differentiated pancreatic cells with increased neutrophils admixed with blood consistent with suppurative inflammation. US-guided fine needle aspiration of the spleen also revealed suppurative inflammation. See comments section.