Case Study

Islet tumor in a 10 year old Bernese Mountain dog of unknown gender.

A 10-year-old Bernese mountain dog was presented for vomiting, anorexia, and diarrhea for 4 days. Physical examination was unremarkable. Abnormalities on CBC and blood chemistry were leukocytosis, monocytosis, neutrophilia, lymphopenia, mild thrombocytopenia, hypoalbuminemia, and hypoproteinemia. Radiographs showed a prominent pylorus and some gas accumulation in the small intestines.

A 10-year-old Bernese mountain dog was presented for vomiting, anorexia, and diarrhea for 4 days. Physical examination was unremarkable. Abnormalities on CBC and blood chemistry were leukocytosis, monocytosis, neutrophilia, lymphopenia, mild thrombocytopenia, hypoalbuminemia, and hypoproteinemia. Radiographs showed a prominent pylorus and some gas accumulation in the small intestines.

Sonographic Differential Diagnosis

Minor gastrointestinal obstructive pattern possibly due to adhesion or dysfunctional bowel. Possible infiltrative disease such as early lymphoma. Pancreatitis.

Image Interpretation

The stomach in this patient was dilated with edematous wall that continued into the duodenum. Anechoic luminal fluid was present. The descending duodenum was dilated yet peristaltic with multiple areas of adhesions continuing out of the area of the pancreas. Some mixed hypoechoic changes consistent with pancreatitis were also present, however this is considered part of the process and not the primary cause. Some omental inflammation continued into the area of the right kidney which was also swollen and painful. The small intestinal dilation continued into the mid jejunum which was empty at that point and aperistaltic. This is an obstructive pattern, however no overt foreign body could be seen other than some artifact. Intestinal foreign body or obstruction due to dysfunctional bowel or adhesion would also be a possibility. Transmural pathology is suspected given that some omental adhesions were present along the affected small intestines with gas penetration into the wall. Complicated inflammatory disease or potential underlying intestinal lymphoma or other round cell neoplasia are entirely possible. Full thickness biopsies as well as liberation of any dysfunctional bowel or potential bowel infarction is highly recommended.

DX

Pancreas- Islet tumor. Duodenum- lympho-plasmacytic-eosinophilic enteritis, suggestive of IBD.

Outcome

The patient was treated postoperatively with I.V. fluids, famotadine, Baytril, and Buprenex and discharged several days later with Baytril, metronidazole, Pepcid, Rimadyl, and eventual Prednisone. At the sutures out appointment the patient was doing well on the current medications.

Comments

Islet cell pancreatic tumors (insulinoma) can be very difficult to find sonographically and often are diagnosed by sampling the metastatic lesions in regional lymph nodes and hepatic nodules that are metastatic in nature. This particular case necessitated exploratory surgery and sampling of a bland heterogeneous region of the pancreas in order to obtain the diagnosis.

Clinical Differential Diagnosis

GI tract – neoplasia, foreign body, IBD, motility disorder, ulceration. Pancreas – pancreatitis, neoplasia. Peritonitis. Liver – chronic liver disease, neoplasia.

Sampling

Full-thickness surgical biopsies of the ascending duodenum and the distal tip of the right side of the pancreas were performed. Biopsy of the pancreas revealed an islet tumor whereas the duodenum revealed moderate lymphoplasmacytic, eosinophilic enteritis, suggestive of IBD.