Case Study

Acute necrotizing pancreatitis in a 14 year old FS Wire Fox Terrier

A 14-year-old FS Wire Fox Terrier dog with history of hypothyroidism was presented for acute vomiting and anorexia. Pulmonary crackles in the left lung field were noted on auscultation. Other physical examination abnormalities included 10% dehydration, a lumpy feeling on abdominal palpation, and bilateral cataracts. Marked hyperamylasemia and hyperlipasemia were present on serum biochemistry. 4DX test was negative. The patient was treated with I.V. fluids, antibiotics, gastroprotectants, and pain medication. After 24 hours she was much brighter, but still mildly dehydrated.

DX

Acute necrotizing pancreatitis

Sonographic Differential Diagnosis

Acute primary pancreatitis, or pancreatitis associated with neoplasia.

Image Interpretation

Image 1: The proximal descending duodenum is present in the near field and demonstrates a loss of mural detail with an adherent right limb of the pancreas. The pancreas (mid field) is composed of mixed hypoechoic tissue with loss of parenchymal detail consistent with necrosis or neoplasia. Hyperechoic ill defined inflamed fat is also present from the 3 to 6 o`clock position around the necrotic or neoplastic hypoechoic region. Image 2: Power Doppler reveals some areas of blood flow but a significant hypoechoic region void of vascularity is suggestive for necrosis. The thickened descending duodenum is present in the near field with some luminal fluid dilation. Image 3: High resolution image of the same affected duodenum with adhered right limb pancreatic pathology. Loss of detail is evident in the far field wall of the duodenum, and a hyperechoic focus on the border between duodenum and pancreas is suggestive for gas penetration or mineralization potentially due to carcinoma. Video 1: The right limb of the pancreas is markedly hypoechoic with irregular margins and increased echogenicity associated with peripancreatic tissues. There are small traces of effusion, and there is loss of duodenal serosal detail. Video 4 & 5: Clips of the affected area show traces of effusion, irregular pancreatic margins, variable pancreatic echogenicity, increased peripancreatic echo with decreased pancreatic echo, loss of serosal and muscularis detail in the duodenum.

Outcome

Follow up liver profile showed mild hypoalbuminemia, hyperphosphatemia, low total bilirubin, hypercholesterolemia, improving hyperamylasemia, and marked improvement in the hyperlipasemia (5967). The antibiotics, Hetastarch, pain medication, and gastroprotectants therapy was continued. Follow-up blood chemistry a few days later showed slight hypoalbuminemia, hyperamylasemia, and hyperlipasemia. Antibiotics, gastroprotectant medication, and bland diet were continued. At the last communication, the owner was advised to have lipase, amylase, and albumin rechecked and to increase the amounts of bland diet being fed.

Comments

This patient was scanned twice during a two week period. Samples were taken during the second examination as the condition did not appear to be resolving. Pancreatic Doppler was evaluated to determine if avascular necrosis was a concern.

Clinical Differential Diagnosis

Acute pancreatitis, pancreatic neoplasia, duodenal neoplasia, duodenal foreign body

Sampling

US-guided FNA cytology from the pancreas revealed subacute neutrophilic inflammation and suggested necrosis, compatible with acute necrotizing pancreatitis.