If they could only talk

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Some days physicians' jobs seem like cake walk. Notwithstanding the fact that M.D.s only work on one single species (human), while vets are licensed to medicate and surgicate on everything else- starting with a tarantula and extending east of a rhino; and  the fact that M.D.s often specialize in just one organ--gallbladders, for instance--while the majority of us are generalists doing everything from manicures to chemotherapy;  the fact that our patients can't speak to us and describe their symptoms actually makes  the most profound difference. For a vet the skill of  history gathering is a science and an art, sometimes taking circuitous routes into strange lands.

I can tell the precise time  and day when my history taking skills hit their zenith.  At 6:57pm  on a Friday night, as Natalie was  tucking in the patients in the back of the hospital and as I picked up the car keys, my nose and  palate already tasting the  bouquet and rich flavor of a 7 year old Pinot Noir I had at home, the hospital phone rang.
"Bellflower Veterinary Hospital"
Distressed, sobbing female caller on the other side of the line. " Hi. My name is Shelly Smith. I think my dog Herb has a brain tumor.  He has been having seizures for half an hour.  We are on the 91 Freeway--can you please see us?"
"A brain tumor? How old is your dog, Shelly?"
" He is two." A little too young for a tumor, I thought to myself.
" I am so sorry. If your dog is having seizures, you are probably better off taking him to the ER because he will need overnight care and  we close in  three minutes"
The woman  sounding more agitated: "I don't know this area at all....we are from Washington state ....drove down to show Peaches and Herb at the Eukanuba International dog show in Long Beach tomorrow. I don't know where the ER  is  II am  really very worried about Herb.  Please! Is it Ok if we bring Herb in- we are on the off ramp to your clinic?"
" Well, OK. We'll see you in a minute"

Natalie came up to the lobby looking puzzled at the sight of  the intravenous catheter and fluids set up.
"Natalie. I am  very sorry,  we need to see a seizing patient. Can you please get the valium out of the drug safe?".
"Sure, not a problem. Didn't have grand plans for tonight anyways"
Four  minutes later Natalie and I greeted  a worried woman, tears welling up in her eyes, clutching the cutest  Cairn terrier we've ever seen. Herb would put Toto to shame.

I quickly examined Herb in Natalie's arms, while Shelly filled out our admission forms.
His mucous membranes were pink and he was well hydrated. The chest sounded normal on auscultation, though his heart was racing. His pupils were dilated and responsive to light and he was visual. Except for his eyes rapidly exploring the lobby around him as if  surrounded by swarms of invisible fairies, there were no signs of  abnormalities on a brief exam. Herb was not seizing but there was something a little different and odd about him. Cairn terriers are normally very busy little dogs, but this one looked busier than normal.

"Most dogs with brain tumors are geriatric Ms. Smith  Lets not panic, OK?

"Is it possible that Herb got into something", asked Natalie,"a toxin of some sort.... could he have gotten into the garbage, eaten some moldy food, insecticides, pesticides, human drugs?"
"No, it isn't possible. We have Peaches and Herb crated when they aren't being directly observed."
"Nat...  could you please put Herb down on the floor so we can evaluate his gait?"

She set the adorable little terrier on the ceramic tile. The scruffy little thing proceeded to  ricochet from the counter to the chairs to the walls chasing invisible hockey pucks in our lobby."
 Has Herb been eating well, Ms. Smith?
"Yes"
"Vomiting, diarrhea, coughing, sneezing, drinking excessively?"
"No"
"Is he normally this active and busy, Ms. Smith?"
" Well..... yes and no. He seems to have  more energy than normal"
" Have you noticed him circling to one side, head tilt, any signs of gait abnormalities....acting blind before this incident?"
"No. He was completely normal until about  an hour ago".
"So what happened an hour ago, Shelly... where was  Herb?"
"We unpacked our stuff and let him out of his carrier in our hotel room. He went under the bed for a few minutes"
"Where was Peaches while Herb was sniffing around under the bed?
"She was in her crate in the hotel room"
"How is she?"
"Peaches is  fine. She happens to be the number one Cairn terrier in the country... won Westminster last year. The Eukanuba show was going to be Herb's first show... we had high hopes for him until he got the brain tumor"
"So Herb was OK until he went exploring under the bed. Peaches was crated and she is perfectly fine.
How much did you pay for your hotel room, Shelly?"
"Excuse me?"
"Was it over a hundred dollars.... under a hundred dollars, less than fifty dollars?'
" I don't understand why that would make any difference to you,  Doctor. What does the cost of my hotel room have to do with Herb's brain tumor?"
Natalie and I inflated the Doppler cuff and checked his blood pressure... 140mmHg.
"Ms Smith -Herb's blood pressure is OK. We will  perform an EKG  to be sure he isn't having any heart issues and run some blood-work on him. Is that OK?"
"Sure, do whatever you need to do"
After getting a blood sample and recording a lead II EKG strip we put Herb in a cage to do happy little figure eights  racing with the lollipop guild.   Fifteen minutes  later, our blood tests were completed.

"Shelly.... Fortunately  Herb's lab-work, chemistry, electrolytes and  heart are fine. His red  blood cell count was a bit high, and the EKG showed a sinus tachycardia which is understandable. He has a bit of a respiratory alkalosis probably due to hyperventilation.  Things  look better than we have a right to expect.  I  totally understand that this makes no sense to you, but did you pay less than $60 for your hotel room?"
"Well, yes... we don't know this area, but we found a  little motel a few miles from here for $49 a night"
"I don't know much about Washington, Shelly, but do you know who tends to use $49 motel rooms in Southern California?"

"No...who?"
"Hookers and drug users"
Shelly stared at me as if a  unicorn horn just sprouted from my skull. " Have you heard of meth- the most common of all street drugs? It would take a few particles licked  off the carpet under the bed  for a little creature to do just what you are seeing. I am afraid Herb is tweaking"
"He is doing what?"  It felt like the horn on my head just grew a few inches.
"Tweaking. Tweaking is slang for being  high on methamphetamines.  Your doggie, Herb,  has gone way over the rainbow".

"Is he going to be OK?"

"I think he needs to be monitored for hypertension and for arrhythmias until the drug wears off.  We are going to give him some IV fluids for supportive care.
 I sure hope he will be OK--he is a cutie and I really want him to do well tomorrow".

We heard from Shelly a few days after the show- Peaches earned first place.
Herb was better than OK--he earned second place in a national dog competition on his first time out--we will never know if illicit drugs had anything to do with it.

If you believe your pet got into toxins or drugs, please do let your veterinarian know. Our job is to help your pet.  You could help us greatly in this effort by being observant.  Although often there are no specific antidotes available  to ingestion of illicit drugs and toxins, please be honest with us even if it makes you a bit uncomfortable. We are not the police and we will not report you-- being informed enables us to optimize patient care increasing chances of a good outcome for you and your pet.

"If your dog ate your pot, it is really important that you tell the doctor that your dog ate your pot. THC is toxic to dogs. If your dog ate any prescription medication (legally obtained or otherwise), tell your vet. If your dog ate a condom that SOMEHOW has peanut butter inside it, tell your vet. Vets are also bound by doctor-patient confidentiality, so they’re not going to narc on you. They will report abuse however, such as people drugging their pets to “see what would happen.” Don’t do that." 
http://www.xojane.com/relationships/how-not-to-be-a-dick-at-the-vet-hospital


http://www.huffingtonpost.com/2012/03/23/poison-prevention-week-pet-poisons_n_1375075.html#s807071&title=Also_On_The

http://veterinaryteam.dvm360.com/firstline/article/articleDetail.jsp?id=807099&pageID=1

http://petdoctormom.wordpress.com/2011/01/21/moldy-walnuts/

http://www.2ndchance.info/antifreeze-ASPCAsop.pdf

Pancreatitis... medical challenge & enigma.

Pancreatitis.   Much more common  in cats then we realize. 

The pancreas performs two important and different jobs

1. The exocrine pancreas produces digestive enzymes to break down and aid digestion of  fat, protein, and carbohydrates. These chemicals are very caustic to normal tissues and cause tremendous damage if they leak out into the belly in the course of pancreatitis,  literally causing digestion of organs.  They are secreted inside the small intestine ( duodenum) through a tube known as the pancreatic duct, which in cats joins the common bile duct from the liver. 
2. The endocrine part of the pancreas makes hormones such as insulin ( the absence of which causes diabetes ),  as well as glucagon and somatostatin. 

Pancreatitis means inflammation or infection of the pancreas.

Cats unlike people and dogs can have very subtle and vague signs. 

 In dogs and people the disease produces extreme abdominal pain and nausea but these signs are absent in cats. Often cats with pancreatitis are presented with symptoms we like to call ADR ( ain't doing right).

Dogs: 

 

Causes

• toxins and drugs: potassium bromide, L-aspraginase, sulfa drugs, azathioprine
• obesity
• hyperlipidemia -familial in miniature Schnauzer
• high fat or spicy meals--- getting in the garbage
• high calcium levels
• hypothyroidism
• Cushing's disease
• blunt force trauma

Symptoms:

• abdominal pain
• loss of appetite
• nausea, diarrhea
• weakness
• dehydration
• shock

 

Cats:

 

Causes

• blunt force trauma- rare
• high calcium-rare
• viral infections : FIP, calici, herpes
• parasitic: Toxoplasma, flukes
• high fat meals not implicated

concurrent diseases:

• inflammatory bowel disease
• hepatic lipidosis-  can be seen since pancreatitis can lead to loss of appetite and mobilization of fat
• cholangitis/ cholangiohepatitis
• diabetes

Symptoms

• lethargy
• depressed appetite
• weight loss

Less commonly seen,  unlike dogs are: abdominal pain in less than a quarter of cats and vomiting in  less than half of cases. 

•  diarrhea, jaundice, abdominal mass felt on examination, fever

Diagnosis:

Blood Count changes are non specific.

anemia ( low red blood cell counts), elevation and decrease of white blood  cells in less than 1/4 of cases

depressed platelet counts especially in the more severe cases leaning to D.I.C. ( disseminated intra-vascular coagulation)

Biochemistry

• elevated bilirubin
• elevated liver enzymes
• electrolyte abnormalities
• azotemia: elevated BUN due to dehydration
• low calcium due to saponification of fat in severe cases
• glucose can be elevated due to stress/ concurrent diabetes- or- depressed
• amylase is of no utility in cats
• Lipase of 2-3 times normal range is specific for pancreatitis in dogs, but not in cats
• Pancreas Specific Lipases:

spec cPL is a  sensitive test (93%) of pancreatitis in dogs , while spec fPL is slightly less sensitive  test of pancreatitis for cats. While when elevated these tests help diagnose pancreatitis, absence  of elevation  doesn't rule it out completely.

Radiographs (X-rays) are helpful in diagnosing pancreatitis about 25% of the time, but they are often performed to rule out  other causes of vomiting such as obstructions and foreign bodies. 

Abdominal ultrasound is a very useful tool in diagnosing pancreatitis if performed by a skilled, experienced ultrasonographer using newer and more sensitive equipment.


As the symptoms  of pancreatitis can be  vague and nonspecific in cats: lethargy, loss of appetite and dehydration- the disorder is easy to miss and is believed to be under-diagnosed in cats.


Treatment

There is no specific treatment for pancreatitis, and the patients are typically hospitalized for supportive symptomatic care, and it consists of: 

1. Intravenous fluids to correct dehydration, improve blood flow to the pancreas and correct acid-base and  electrolyte abnormalities
2. Anti-emetics to control nausea
3. Analgesics  to control pain, which can be extremely severe requiring opioid pain relievers.
4. Plasma transfusions in some cases to provide anti-proteases, clotting factors and macroglobulins and/ or synthetic colloids to improve pancreatic perfusion ( blood supply).
5. Antacids if there is evidence of gastrointestinal bleeding
6. Dogs are fed small amounts of  bland fat-restricted diets, while in cats fat- restriction is not needed and is not effective. Cats sometimes required feeding tubes to prevent or treat coexisting hepatic lipidosis ( fatty liver disease).
7. B12 vitamin deficiency is common in cats with intestinal disease, so it is often supplemented
8. Corticosteroids which used to be thought of as a cause of pancreatitis are now being used to treat chronic pancreatitis in cats due to high frequency of coexisting inflammatory bowel disease and inflammatory liver diseases.  
9. Insulin is administered if  pancreatitis has progressed to diabetes mellitus. 

References:
Treatment Recommendations for Feline Pancreatitis

Take-away: 

In most dogs and cats where dietary indiscretion, such as ingestion of garbage or a fatty/spicy meal has been ruled out, the cause is unknown.

A recent study found evidence of pancreatitis  in 67% of the cats  admitted to a teaching hospital for various unrelated causes on autopsy, though remarkably in the 90's the disorder was diagnosed in  less than 1% of cats.   So either we are much better at diagnosing this illness,  or there has been a profound environmental change since the 1990s predisposing cats to pancreatitis.

I tend to believe it is the latter, and so feel  it is important to evaluate the  changes occurring  in the cats' diets in the last several decades. This brings us back  to genetic modification of soy, which is commonly included in pet foods and was demonstrated to induce alteration in  pancreatic zymogen granules in rodents. http://www.ncbi.nlm.nih.gov/pubmed/12448776.  Therefore, until thorough studies are performed, the precautionary principle dictates not feeding cats soy.