Week 11 Endocrine Pancreatic Diseases w/ Addisons/Cushings woDM PDF

Metabolic & Endocrine Diseases / Disorders (w/ Pancreatic) Hypothyroidism Hyperthyroidism Diabetes Mellitus Hypoadrenocorticism (Addisons) Hyperadrenocorticism (Cushings) Pancreatitis Exocrine Pancreatic Insufficiency (EPI) Endocrine system… a Refresher Oversees & integrates...

Metabolic & Endocrine Diseases / Disorders (w/ Pancreatic) Hypothyroidism Hyperthyroidism Diabetes Mellitus Hypoadrenocorticism (Addisons) Hyperadrenocorticism (Cushings) Pancreatitis Exocrine Pancreatic Insufficiency (EPI) Endocrine system… a Refresher Oversees & integrates functions all over the body using hormones Glands to maintain homeostasis! Pituitary, thyroid, parathyroid, adrenals, pancreas, & gonads (*kidneys & uterus can sometimes function as an endocrine gland) Brain controls secretions of endocrine glands, and hypothalamus also assists with water balance, metabolism, & body temperature Diseases of these glands often stem from autoimmune attacks, or the organ malfunctioning (over or under production of  Thyroid Gland Ventral cervical region, lateral margins of trachea Not palpable in healthy animals Produce hormones: T3 – hormone primarily found in circulation T4 - hormone primarily found intracellularly Function together to control metabolism Produces calcitonin Deposits calcium in bone, reduces free calcium in blood Underactive vs overactive Hypothyr Thyroid hormone deficiency oid Leads to decreased Disease metabolic rate Hypothyroidism common disease of dogs 6-10 years of age, females more prone Genetic disposition Golden Retrievers, Labs Dobermans Irish Setters Miniature Schnauzers Spaniels Dachshunds Hypothyroidism in Animals - Endocri ne System - Merck Veterinary Manu Cocker Spaniel al Airedale Terriers  Hypothyroid Disease Etiology  Dysfunction anywhere in the hypothalamic- pituitary-thyroid axis may result in thyroid hormone deficiency > 95% of cases are dogs and is from destruction of gland itself termed “primary hypothyroidism” or thyroid atrophy  Causes: lymphocytic thyroiditis (autoimmune disease) and idiopathic atrophy of the thyroid gland  Secondary is uncommon but may be from a tumor, or congenital. Hypothyroid Disease Clinical Signs Metabolic & Dermatological Signs Lethargy Weight gain Altered skin/coat: alopecia, excessive shedding, dry skin coat Loss of hair on tail common, “rat tail” Sun seeking Recurrent skin infections, UTI’s Reproductive problems (anestrus)  Hypothyroidism is probably one of the most Hypothyroid Disease overdiagnosed diseases in dogs *can easily mimic Diagnosis other diseases Clinical Signs *careful attention to +/- Hypercholesterolemia Low T3, free T4 Serum thyroid hormone testing: “Thyroid Stimulating Hormone” (TSH) = high  tra ex When hypothyroidism is suspected based on a low T4, low fT4, or high TSH concentration, response to a therapeutic trial with levothyroxine helps confirm the diagnosis. Hypothyroid Disease Treatment Lifelong supplement with thyroid hormone replacement Human options make treatment fairly inexpensive Orally BID, good success Monitor dosage frequently Too high a dosage = hyperthyroid Once stabilized recheck 1-2 times Thyrotoxicosis is rare in dogs and can result in polyuria and per year polydipsia, weight loss, Indication of tx success = clinical panting, nervousness, or improvement tachycardia. Hyperthyroid Diseases Hyperthyroidism in Animals - Endocrine System - M erck Veterinary Manual Hyperthyroidism common disease of cats Middle aged – older cats most common Excess of T3 & T4 due to thyroid adenoma, thyroid carcinoma possibly Screening & early detection: T4 Blood tests, esp in senior cats Can sometimes palpate enlarged gland without other clinical signs and T4 concentration normal, recheck T4 in 6 months or if clinical signs develop Non clinical signs of Hyperthyroidis m  Hyperthyroid Diseases Clinical Signs Weight loss Polyphagia Occasional vomiting Increased appetite Tachycardia +/- murmur Hypertension Blindness + retinal detachment Increased vocalization, especially at night Hyperthyroid Diseases Diagnosis Increased T4 in serum chemistry is diagnostic if clinical signs present If high and no CS, recheck in 2 weeks Palpate enlarged thyroid glands DI  Hyperthyroid Diseases Treatment 1. Radioactive Iodine-131 Curative treatment of choice Simple & effective Diseased tissue absorb radioactive 131 = destruction of cells Hospitalization until radioactive material becomes absent from body Specialized procedure Hyperthyroid Diseases …Treatment 2.Antithyroid drug therapy Palliative approach Daily, life-long Block thyroid hormone synthesis Oral, transdermal, caution when touching Routine blood, BP, physical exam monitoring E.g. methimazole, carbimazole Hyperthyroid Diseases …Treatment 3. Diet o Lifelong o Iodine-deficient diet o Without iodine the thyroid can’t produce hormones o Indicated if not a candidate for radioiodine/thyroidectomy o Most effective if only moderate increases in T4 o Can’t eat any other food than this! (no treats, prey, scraps…)  Hyperthyroid Diseases Treatment 4. Surgery - Thyroidectomy Potentially curative but with anesthetic risks Removal of thyroid glands = removal of thyroid hormone = cure One (unilateral) or both (bilateral) tyroid gland removal Requires competent surgeon who will spare parathyroid glands Supplement with thyroid hormone orally  Hyperthyroidism Complications Secondary disorder that can arise: Thyrotoxic hypertrophic cardiomyopathy Systemic hypertension Chronic kidney disease (CKD) EXTRA: Parathyroid Gland Overview of the Parathyroid Glands and Disorders of Calcium Regulation in Dog s and Cats - Endocrine System - Merck Veterinary Manual (merckvetmanual.co m) Disorders of the parathyroid glands result in abnormal calcium level (and or phosphorus) Merck Video – case post op parathyroid ectomy https://www.merckvetmanual.com/mult imedia/video/v81477419 Most dogs have four parathyroid glands, which are located on or in the capsule of the thyroid glands2. If the parathyroid glands produce too much parathyroid hormone (PTH), it can cause hyperparathyroidism, which can lead to excessive Adrenal Glands Paired endocrine organs located in the retroperitoneal space left adrenal gland is the larger of the pair & is positioned near the craniomedial border of the left kidney; the right adrenal gland is adjacent to the hilus of the right kidney. Overview of the Adrenal Glands in Animals - Endocrine System - Merck Veterinary Man ual  Adrenal Glands The adrenal cortex is composed of three zones: The outermost zone (zona glomerulosa) synthesizes and secretes mineralocorticoids. Aldosterone The middle zone (zona fasciculata) produces glucocorticoids. cortisol and corticosterone The inner zone (zona reticularis) secretes sex steroids. Overview of the Adrenal Glands in Animals - Endocrine System - Merck Veterinary Man ual  Hypoadrenocorticis m  Lack of Addison glucocorticoids, Disease mineralocorticoids, or both  THINK: Addisons & Absents of steroids - small, skinny, weak..  “the great imitator” b/c clinical signs so vague Addison Disease (Hypoadrenocorticism) in Ani mals - Endocrine System - Merck Veterinary M anual EXTRA: Canine Hypoadre nocorticism - Add ison's Disease | AtDove  Predispositions Addison  Young to middle ages Disease  Canines: Nova Scotia Duck Tolling Retriever, Great Dane, Standard Poodle, West Highland White Terrier, Bearded Collie, Portuguese Water Dog Cause: Hypoadrenocort primary adrenocortical failure (immune- icism mediated?) Other - adrenocortical failure = from cytotoxic drugs, neoplasia or granulomatous disease, and adrenal gland hemorrhage EXTRA: Some animals develop isolated glucocorticoid deficiency—termed "atypical Addison disease"—that can progress to mineralocorticoid deficiency. Diagnosis: ACTH stimulation [blood] test..Addison (hypoadrenocorticism) Diagnosis Dx requires an ACTH stimulation [blood] test in which cortisol concentration is measured before and after the administration of exogenous ACTH Draw blood, administer ACTH (ouch IM), set timer, draw blood again ~1 hour post, prep & send to lab *label correctly! Levels in the samples are compared and then interpreted extra Addison Disease Hypoadrenocorticism Clinical Signs o Can be vague, nonspecific, & wax and wine o Anorexia o Weight loss o Poor appetite o Vomiting and diarrhea o PU o PD o Dehydration o Brachycardia o Intolerance for heat o Hypoalbuminemia, hypocholesterolemia, & mild to moderate ionized hypercalcemia. Addison Disease Hypoadrenocorticism Treatment IV fluid therapy Tx highly successful is often Correction of hypoglycemia throughout the life of the Antiemetic, antinausea, and nutritional patient supportive care Glucocorticoid and mineralocorticoid replacement Dogs in an addisonian crisis should be treated on an emergent basis – present in shock Nursing care and monitoring: Hypovolemia and shock are the most life- threatening concerns  careful monitoring of heart rate and ECG *addisonian crisis requires advanced nursing skills, very rewarding to treat these patients - often hospitalized in critical care unit and managed by both internal medicine specialists and critical care specialists  Hyperadrenocorticism  elevated cortisol concentrations  adrenocortical hormones of Cushings any cause.  A collection of disorders (“umbrella term”)  Most cats with Cushing syndrome have concurrent diabetes mellitus, which is often poorly regulated Types:  1. pituitary-dependent hyperadrenocorticism  THINK: Cushing & cushions of (PDH or “Cushing steroids! Big, Round… disease”)  Predispositions  Middle to older-aged canines Poodle, especially the Miniature Poodle Cushing Dachshund Disease Boxer Boston Terrier Yorkshire Terrier Hyperadrenocor Staffordshire terriers ticism Cause 85% have pituitary-dependent hyperadrenocorticism Hyperadrenocorticism (PDH), and 15% have a cortisol-producing adrenal : Diagnosis and Treat tumor ment | AtDove Diagnosis History, physical examination, clinicopathological testing, endocrine testing, and diagnostic imaging are all part of diagnosis..Cushings (hyperadrenocorticism) Diagnosis Canine Adrenal and Pituitary Function Tests The low-dose dexamethasone suppression test (LDDST) is the screening test of choice for Cushing syndrome because of its high sensitivity and its ability not only to confirm the presence of hyperadrenocorticism but also to differentiate between PDH and ADH in many cases. ACTH - shorter, simpler dynamic test for the diagnosis of various disorders, including iatrogenic hyperadrenocorticism and spontaneous hyperadrenocorticism of adrenal or pituitary origin High-Dose Dexamethasone Suppression Test DI Cushings Hyperadrenocorticism Clinical Signs Pot-Belly!!!!!! a pendulous abdomen distended belly, abdominal enlargement Sway back polyuria/polydipsia, polyphagia Panting *dogs muscle wasting dermatological changes – hair loss, skin/coat changes, pyoderma Heat intolerance Weakness, lethargy Recurrent UTIs Bruising, hyperpigmentation Cushing Disease Hyperadrenocorticism Treatment Medical treatment mitotane or trilostane Surgery EXTRA: Radiotherapy  hyperadrenocorticism treated with the Treatment options available for adrenal enzyme inhibitor trilostane Cushing disease in dogs include  Radiotherapy medical treatment, surgery, and When a dog is showing neurological signs radiotherapy. All three have (eg, anorexia, stupor, or seizures) and a been used with varying amounts large pituitary tumor (macroadenoma) is of success. identified  Cushing Disease Hyperadrenocorticism Prognosis Good for dogs! Mean survival 2 years with or without medical treatment dogs with early hyperadrenocorticism that have no comorbidities (eg, dermatological signs only) can live much longer when treated Pancreatitis  Inflammation of the pancreas Pancreati Most common exocrine tis disorder in dogs and cats OUCH, my Acute or Chronic pancreas hurts! Can be very severe - necrotizing Pancreatitis Pancreatic secretions decrease, which causes pancreatic enzymes to increase Enzymes begin “auto digesting” pancreas Widespread damage to pancreas Inflammation Pain +/- necrosis  Causes: Sometimes unknown High fat diet, inappropriate foods, obesity High cholesterol High triglycerides Trauma, tumors Meds – furosemide, azathioprine, sulfonamides, tetracyclines Hypoadrenocorticism Genetic – Mini Schnauzers, yorkies, Pancreatitis Cocker spaniels, poodles, dachshunds, more  Pancreatitis Clinical Signs Nausea Anorexia Vomiting & Diarrhea Weakness Abdominal pain (photo) Can be severe Dehydration +/- pyrexia Sometimes the pancreatitis is less severe and only causes anorexia,  Pancreatitis Diagnosis cPLI Snap test in clinic Canine pancreatic lipase immunoreactivity Radiographs Chem panel Increased liver enzymes (ALT, ALP) Hypocalcemia Hyperlipidemia +/- increased amylase, lipase CBC Leukocytosis Increased PCV d/t dehydration Pancreatitis Treatment Fluid therapy + KCl if needed NPO for 3-4 days, depending on severity Antibiotic therapy (Enrofloxacin, Trimethoprim-sulfadiazine) Analgesics! +/- Plasma or albumin therapy Low fat diet long term Px: Fairly good prognosis with prompt & proper treatment, and owner compliance Can result in death  Exocrine Pancreatic Insufficiency (EPI) Exocrine Pancreatic Insufficiency in Dogs a nd Cats - Digestive System - Merck Veterin ary Manual  EPI - decreased production of digestive enzymes by the pancreas Recall normal functions = secretions from the pancreas are carried to the SI by the pancreatic duct EPI = Failure to produce enough pancreatic enzymes to digest fats, carbohydrates, and proteins Leads to poor absorption of nutrients EPI - insufficient synthesis and secretion of digestive enzymes by the exocrine portion of the pancreas. Dogs Genetic Predispositions German Shepherd Collie Chow chow Cavalier King Charles Spaniel Congenital – present from birth, although sometimes undiagnosed until later Secondary to chronic pancreatitis –progressive loss of cells EPI Clinical Signs Evidence of maldigestion & malabsorption Weight loss, normal appetite nutrients remaining in the intestinal lumen lead to: loose, voluminous feces, pale, & steatorrhea. Chronic diarrhea +/- vomiting EPI Treatment digestive enzymes, cobalamin, & improve gut microbiome Pancreatic Enzyme Replacement Powders more effective than tabs Viokase Pancreazyme Fresh pancreas may be a viable alternative (raw) Vitamins - esp B12 (cobalamin) Pre & Probiotics +/- antibiotics with diagnosis d/t +++bacteria (metronidazole, Tylosin) EPI Diagnosis Serum trypsin-like immunoreactivity concentrations Hx & Clinical signs Assay that measures fecal elastase in dogs has been validated The end