Case Study

Interstitial pancreatitis in a 9 year old MN Bichon Frise dog

This 9-year-old MN Bichon Frise dog with a 7-year history of epilepsy and phenobarbital therapy presented for 1 week of progressive vomiting and anorexia. The physical exam revealed mild scleral and mucosal jaundice and tender cranial abdominal palpation. The preliminary CBC and blood chemistry analysis revealed normal CBC with mildly elevated amylase, mildly elevated lipase and mildly elevated AST levels, moderately elevated bilirubin, moderately elevated ALT, and moderately elevated cholesterol, and a severely elevated SAP with mild hypomagnesemia.

This 9-year-old MN Bichon Frise dog with a 7-year history of epilepsy and phenobarbital therapy presented for 1 week of progressive vomiting and anorexia. The physical exam revealed mild scleral and mucosal jaundice and tender cranial abdominal palpation. The preliminary CBC and blood chemistry analysis revealed normal CBC with mildly elevated amylase, mildly elevated lipase and mildly elevated AST levels, moderately elevated bilirubin, moderately elevated ALT, and moderately elevated cholesterol, and a severely elevated SAP with mild hypomagnesemia. Leptospirosis titers were initially negative but converted seropositivity at 1:200 for L. icterohemmorrhagica and 1:100 for L. canicola at a 5 week follow-up titer. These values may not be clinically significant given that they did not demonstrate a four-fold increase. (ref: CVT XI p 261)

DX

Moderate chronic active, fibrosing, interstitial pancreatitis.

Sonographic Differential Diagnosis

Pancreas: suggestive for possible pancreatic adenocarcinoma with associated lymphadenopathy, possibility of pancreatic necrosis, pancreatitis. Gall bladder: cholangiohepatitis.

Image Interpretation

The cranial abdomen presented large mixed echogenic and hypoechoic lesions throughout the pancreas. The patient was not visibly painful upon imaging of this area. Focal hyperechoic areas amidst hypoechoic pancreatic base were noted suggestive of possible carcinoma or pancreatic sequestrum. Video 1 reveals a mixed hypoechoic region of the right pancreatic base with anechoic center is suggestive for severe necrosis or abscessation. FNA first is recommended in this scenario to ensure that this is not a fluid filled lesion. If the lesion is solid then US-guided core biopsy may be performed. Video 2: Ultrasound guided biopsy of the pancreas was performed after coagulation panel was largely normal with a PT of 13 seconds and aPTT of 97 seconds which was 15 seconds elevated. The biopsy needle travels through the largely non diagnostic hyperechoic portion and enters the hypoechoic tissue in the far field. It is important to sample a transition of variety of echogenic presentations. No evidence of bleeding occurred during the biopsy procedure.

Outcome

The patient responded to 1 week of hospitalization and was thriving at follow-up examinations at 1 and 2 months post diagnosis. The blood parameters all normalized except for a stable persistently mildly elevated SAP.

Clinical Differential Diagnosis

Cholangiohepatitis, gallbladder mucocele or rupture, other biliary obstruction, pancreatitis with post hepatic obstruction, leptospirosis.

Sampling

After the patient was stabilized and coagulation parameters were normal, multiple 18-gauge US-guided biopsies were performed of the variable echogenic presentations of the pancreas. Diagnosis: moderate chronic active, fibrosing, interstitial pancreatitis. Predominant cell type was lymphocytic, plasmacytic with a minor neutrophilic population.