Case Study

Acute on chronic pancreatitis in an 11 year old MN Toy Poodle

An 11-year-old neutered male Toy Poodle dog was presented for evaluation of protracted vomiting with a history of Addison’s disease (managed with daily prednisone and monthly DOCP injections) and recently diagnosed with diabetes mellitus (managed with insulin). On serum biochemistry, hyperglycemia (288), mildly elevated ALP, and mildly elevated amylase were present.

Sonographic Differential Diagnosis

Extensive, acute on chronic pancreatitis with areas of necrosis and duodenal spasming and entrapment. There is a minor potential for neoplasia. There is a strong risk for post hepatic obstruction.

Image Interpretation

The pancreas in this patient presented multiple areas of mixed, hypoechoic parenchymal changes and coarse architecture with hyperechoic surrounding fat. This is consistent with acute on chronic pancreatic necrosis. Minor areas of coalesced free fluid were noted. The left limb of the pancreas presented serpentine contour and hypoechoic, ill defined parenchyma with hyperechoic surrounding fat. This is consistent with saponification of omental fat. The right pancreatic limb revealed a section of 3 x 4 cm of complete avascular, hypoechoic tissue that is consistent with necrosis. The changes were equally dramatic in the left and right with areas of more dramatic necrosis on the right limb. The stomach was unremarkable. The upper duodenum presented spasming with some areas of loss of detail and entrapment by regional omental inflammation. The liver was swollen in contour with mildly increased portal markings. The gallbladder was turgid with suspended debris. The region of the common bile duct was enveloped by inflamed fat. Gastric stasis was noted due to ileus, duodenal spasming and delayed outflow.

DX

Acute on chronic pancreatitis

Outcome

None

Comments

Recommend aggressive treatment for pancreatitis. FNA of the hypoechoic portion of the right pancreatic limb would be recommended. Urine culture and sensitivity would be recommended. Plasma transfusion, plasma expanders, enrofloxacin and metronidazole combination along with gastrointestinal protectants and aggressive pain management would all be warranted. Trickle feeding is warranted after 24 hour NPO protocol. Recheck sonogram in 5 days prior to consideration of discharge.

Clinical Differential Diagnosis

Pancreatic pathology: acute pancreatitis, abscessation, neoplasia; Addison’s disease relapse; GIT pathology: neoplasia, ulceration, foreign body, neoplasia; Gall bladder pathology: cholecystitis, mucocele.