Successful treatment of feline pancreatitis using an endoscopically placed gastrojejunostomy tube

Evaluation of various gastrojejunostomy tube constructs for enteral support of small animal patients

OBJECTIVE To evaluate the feasibility of manufacturing gastrojejunostomy tubes from jejunostomy and gastrostomy tubes that would allow for gastric and enteral feeding of and aspiration of gastric contents from small animal patients. DESIGN In vitro study. SAMPLE 9 gastrojejunostomy constructs. PROCEDURES Commercially available gastrostomy and jejunostomy tubes were combined to create 9 constructs. Three investigators tested each construct with 4 solutions (tap water, a commercial enteral diet, and 2 canned food-water mixtures) and 3 syringe sizes for ease of injection through the gastrostomy and jejunostomy tubes and aspiration through the gastrostomy tube. Flow rates were calculated and analyzed to evaluate effects of tube diameter and syringe size for each solution. RESULTS The 20F/8F, 24F/8F, 28F/8F, and 28F/10F (gastrostomy tube/jejunostomy tube) constructs allowed for injection and aspiration of all solutions. The 5F jejunostomy tubes allowed only water to be injected, whereas the 8F jejunostomy tubes did not allow injection of the canned food-water mixtures. The 20F/10F construct did not allow injection or aspiration through the gastrostomy tube, whereas the 18F/8F construct allowed injection but not aspiration through the gastrostomy tube. Faster flow rates through the gastrostomy tube were associated with larger gastrostomy tube diameter, smaller jejunostomy tube diameter, and smaller syringe size. Faster flow rates through the jejunostomy tube were associated with smaller jejunostomy tube diameter. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that homemade gastrojejunostomy constructs would allow for administration of a variety of enteral diets. Limitations to the administration and aspiration of various enteral diets as well as patient needs should be considered before a gastrojejunostomy tube combination is chosen.

Pancreatitis in cats: is it acute, is it chronic, is it significant?

PRACTICAL RELEVANCE

Pancreatitis is a frequent finding in cats, the chronic form being more common than the acute form. Despite the large number of diseases or conditions that may be associated with feline pancreatitis, in most cases no cause is diagnosed and the pancreatitis is said to be idiopathic. The chronic form can be mild and asymptomatic, and has a high prevalence in apparently healthy cats. This has generated debate concerning the clinical significance of chronic feline pancreatitis. However, several reports have demonstrated the severity of clinical signs in certain forms of acute feline pancreatitis, while other studies have reported a strong association between chronic pancreatitis and the development of comorbidities such as hepatic lipidosis, diabetes mellitus, inflammatory bowel disease or exocrine pancreatic insufficiency. This suggests that feline pancreatitis should not be overlooked.

CLINICAL CHALLENGES

Diagnosis of feline pancreatitis is complicated by the non-specific clinical signs and poor diagnostic value of basic biochemistry and haematology or imaging techniques. Development of a feline-specific pancreatic lipase immunoassay has improved our diagnostic ability in the past decade, but may have more limited application for mild and chronic forms of pancreatitis. Moreover, histopathology (the 'gold standard' diagnostic test) can be associated with false-negative results due to multifocal distribution of lesions or mild forms of the disease. With respect to treatment, it is important to take into account the idiosyncrasies of the feline species when considering medical therapies.

EVIDENCE BASE

This article reviews the literature on feline pancreatitis, focusing on the different forms and their relative clinical significance, while explaining difficulties inherent in the diagnosis of this disease. An overview of current recommendations for the management of cats with pancreatitis is also provided.

Endoscopically Assisted Nasojejunal Feeding Tube Placement: Technique and Results in Five Dogs

Interest in noninvasive feeding tube placement in companion animals led to the adaption of a human technique utilizing endoscopy to place nasojejunal feeding tubes. Data from medical records in which nasojejunal feeding tubes were attempted were reviewed. Feeding tubes were attempted and successfully placed in five dogs within a median of 35 min. Feeding tubes remained in place for approximately 7 days. Complications included facial irritation (5/5), sneezing (5/5), fractured facial sutures (4/5), vomiting (3/5), diarrhea (3/5), crimping of feeding tube (3/5), regurgitation (1/5), epistaxis (1/5), clogging of the feeding tube (2/5), and oral migration with premature removal of the feeding tube (1/5). The deployment technique used in this study was found to be cumbersome. Despite minor complications, endoscopy can be used to rapidly and accurately place nasoenteric feeding devices.

Critical care nutrition for feline patients

Nutritional treatment in critical care patients is an important component of the complete treatment plan. Assessment of nutritional status and careful consideration of the disease course will help guide the selection of the most appropriate assisted-feeding method. Enteral nutrition is favored over parenteral nutrition when the gastrointestinal tract is functional. Common routes of enteral feeding include nasoesophageal, esophagostomy, gastrostomy, and jejunostomy feeding tubes. Parenteral nutrition is indicated for patients who cannot tolerate enteral feedings, or are poor anesthetic candidates for proper feeding tube placement. Appropriate diet selection and implementation of proper feeding guidelines and monitoring will aide in limiting complications associated with enteral and/or parenteral feeding.

Clinical and Laboratory Investigation of Experimental Acute Pancreatitis in the Cat

The main objective of this study is the serial evaluation of clinical and laboratory changes in cats with experimentally-induced acute pancreatitis (AP). A total of 16 clinically healthy young adult DSH cats were included in the study. Acute pancreatitis was induced in 10 (AP group) by infusing oleic acid into the pancreatic duct, while the other 6 cats served as sham-operated controls (C group). Depression or lethargy, anorexia, abdominal pain, and a palpable mass in the anterior abdomen were the main clinical findings in cats of the AP group. Laboratory data revealed non-regenerative anaemia, mild hypoalbuminaemia, transient hyperglycaemia, and hypertriglyceridaemia. Serum lipase activity, feline trypsin-like immunoreactivity (fTLI) concentration, and feline pancreatic lipase immunoreactivity (fPLI) concentration increased significantly within the first 24 hours after the infusion of oleic acid, with time-dependent positive correlation. In both group of cats urine amylase-creatinine ratio and amylase-creatinine clearance ratio were increased. In cats of the AP group, abdominal ultrasonography revealed a hypoechogenic and enlarged pancreas, along with peripancreatic fluid accumulation. Peritoneal effusion was consistent with a sterile exudate, with higher lipase but lower amylase activities when compared to their serum counterparts in all AP group cats. The induction of AP was confirmed by pancreatic histopathology. AP is characterized by vague symptomatology. Increases in serum fTLI and fPLI concentrations occur early in cats with pancreatitis. In general the two analytes run a parallel course, but fPLI may be increased longer than fTLI. The measurement of lipase activity in the peritoneal fluid could be considered diagnostic.

Isolated abdominal fat tissue inflammation and necrosis in a cat

This report describes a rare clinical case of a 4.5-month-old, female domestic shorthair, cat with isolated abdominal fat tissue inflammation and necrosis, resembling human omental panniculitis. Its possible relationship with pancreatitis or bile induced chemical peritonitis is also discussed. The overall clinical course was considered benign. Initial clinical signs were vomiting and anorexia, presumably due to inflammation, followed by mass development. It was speculated that, eventually, the kitten was vomiting because of mechanical pressure from the mass, and that this pressure subsided as the kitten grew. The mass was surgically resected and no relapse was evident during the next 4 years.

Nutrition in critical illness

Malnutrition associated with critical illness has been unequivocally associated with increased morbidity and mortality in humans. Because malnutrition may similarly affect veterinary patients, the nutritional requirements of hospitalized critically ill animals must be properly addressed. Proper nutritional support is increasingly being recognized as an important therapeutic intervention in the care of critically ill patients. The current focus of veterinary critical care nutrition, and the major focus of this article, is on carefully selecting the patients most likely to benefit from nutritional support, deciding when to intervene, and optimizing nutritional support to individual patients.

A case of feline pancreatitis

A 14-year-old, spayed female, domestic shorthair cat was referred to us with anorexia, pyrexia, and jaundice. Total bilirubin (TBIL) and feline trypsin-like immunoreactivity (fTLI) levels were remarkably high. Based on laparoscopic biopsy of the pancreas, the cat was diagnosed as having pancreatitis. As a result of treatment with a synthetic protease inhibitor and corticosteroid, the TBIL and fTLI values returned to normal and the clinical course was good.

Placement of jejunal feeding tubes for post-gastric feeding

In veterinary patients, postgastric feeding is indicated for uncontrollable gastric vomiting, gastroparesis, biliary tract disease, pancreatitis, and for patients at increased risk for aspirating secondary to decreased mentation, prolonged recumbency, or an unprotected airway. Postgastric feeding may be implemented via the placement of a jejunal feeding tube. These tubes can be placed surgically (jejunostomy tubes) or with fluoroscopic or endoscopic guidance. This article will focus on methods of jejunal feeding-tube placement, advantages and disadvantages of the methods described, and complications associated with jejunal feeding.

The acute abdomen: a surgeon's approach to diagnosis and treatment

Clinical approach to a patient with acute abdominal distress involves decision making: whether to take a patient to surgery, or manage the patient medically. A thorough and systematic approach requires the use of diagnostic imaging modalities, including radiology and ultrasonography, performing diagnostic peritoneal lavage or abdominal paracentesis techniques, and bloodwork evaluation, including complete blood count and serum biochemistry profiles. In some cases, the results of diagnostic tests may lead to surgical versus medical management, particularly when a patient fails to respond to medical management alone. In other cases, such as GDV syndrome, penetrating abdominal wounds, pyometra, or uncontrolled abdominal hemorrhage, rapid surgical management is necessary for patient survival. This article describes a systematic approach to a small animal patient with acute abdomen.