EDUCATIONEducation is learning what you didn’t

even know you didn’t know.-Daniel J. Boorstin

DISEASES OF THE PARATHYROID GLANDS

HYPERPARATHYROIDISM

HYPOPARATHYROIDISM

Thyroid/Parathyroid glands

1=normal thyroid gland2 and 3=parathyroid gland4=enlarged thyroid gland

2 glands for each thyroid lobe2 glands for each thyroid lobe

Parathyroid gland

• Secretion: Parathyroid hormone (PTH, Parathormone)

• Function: ↑ plasma Ca2+ concentration– 1. ↑ osteoclast activity– 2. ↑ Ca++ absorption from GI tract– 3. ↑ Ca++ reabsorption from kidney tubules

• Hyperparathyroidism → ________________• Hypoparathyroidism → __________________

Hyperparathyroidism

• Causes:– 1º hyperparathyroidism— ___________________________

– 2º hyperparathyroidism—poor diet; low Ca intake

• Clinical signs:– Many animals show __________________________

– signs occur as organ dysfunction occurs

• urinary/renal calculi (high plasma Ca++)

• cardiac arrhythmias, tremors (Ca++ necessary for normal muscle contraction)

• Anorexia, vomiting, constipation

• weakness

Signalment: 7-11 yrs; Keeshoondren

Hyperparathyroidism

Dx:• Routine chemistry panel

– ↑ blood Calcium (normal: ~ _____________ mg/dl))

– +/- ↓ blood Phosphorus (normal: ~2-6 mg/dl)

• PTH assay– normal PTH: dogs ~20 pg/ml, cats ~17 pg/ml– In a normal animal: if blood Ca++ is high, PTH is low (neg feedback)

– 1º Hyperparathyroidism: ______________________________

• Ultrasound of neck – enlarged glands, abdomen - uroliths

Dff: neoplasia (LSA), Addison’s, rodenticide toxicosis, ARF

Hyperparathyroidism

Tx:1. _________________________ of diseased parathyroid (generally 4 lobes are imbedded in thyroid gland)

Other options:2. Ultrasound-guided chemical (ethanol)

3. Ultrasound-guided heat (laser) ablation

Post-Op Care:1. Hospitalize for 1 wk; ↓PTH may predispose animal to hypocalcemia2. _____________________ (oral tabs, liquid)3. Vit D supplements (promotes Ca intestinal absorption)

Hyperparathyroidism

Client Info

1. Most hyperparathyroid animals show no signs when first diagnosed

2. Run _____________ chem panels on all normal, older animals

Hypercalcemia: Other causes

• Causes– Neoplasia (lymphoma, perianal gland

tumors)– Renal failure– Hypoadenocorticism– Vitamin D rodenticide– Drugs or artifacts (ex lipemia)

• Clinical signs vary with cause– PU/PD, anorexia, lethargy, vomiting,

weakness, stupor/coma (severe), uroliths

Hypercalcemia

• Tests– Elevated serum calcium levels

– Low to low-normal phosphorus concentrations

Hypercalcemia

• Treatment– Fluids: 0.9% NaCl

• No Ca2+ containing fluids

– Diuretics (furosemide): dilute urine

– Steroids

• Complications– Irreversible renal failure

– Soft tissue calcifications

Hypocalcemia

Causes:1. Parathyroid disease

a. Inadvertent removal of ____________________ during thyroidectomy (most common cause

b. 1º Hypoparathyroidism (uncommon in animals)

2. Chronic renal failure—a. may cause ↑ serum P, which can result in ↓ serum Ca (Ca:P __________________)b. Vit D normally activated in kidneyc. Protein-losing nephropathy results in loss of albumin-bound Ca

3. Puerperal Tetany (Eclampsia)—late gestation thru post-partum perioda. Improper prenatal ______________________________________b. Heavy lactationc. Inappropriate Ca++ supplementationd. Post-partum and late gestaion

http://www.thepetcenter.com/gen/eclampsia.html#The_video

Hypocalcemia

Clinical Signs:1. Restlessness, muscle tremors, tonic-clonic contractions,

seizures

2. ______________________ with excitement; __________________ in severe cases (Ca++ is necessary for proper muscle contractions)

3. Hyperthermia

4. Stiffness, ataxic

Hypocalcemia

Dx:Total serum < ______________ mg/dl

Tx:1. IV infusion of _______________________

solution (monitor HR and rhythm during infusion)2. ___________________ (IV) to control seizures3. Oral supplements of Ca (tabs, caps, syrup)4. Improve nutrition

Hypocalcemia

Client info:

1. Well-balanced diet; increase volume as pregnancy progresses

2. Signs in pregnant animal is _____________; call vet immediately

3. May recur with subsequent pregnancies

4. Early weaning is recommended

LIFE“Nobody can go back and start a new beginning, but anyone can start today

and make a new ending.”

-Maria Robinson

DISEASES OF THE PANCREAS

DIABETES MELLITUS (DM)INSULINOMA

EXOCRINE PANCREATIC INSUFFICIENCY (EPI)

Review of pancreas functions

• Long flat organ near _________________ and stomach

• Exocrine function (the majority of the pancreas):– ________________ enzymes

• Endocrine function – islets of Langerhans– Alpha cells => _______________– Beta cells => ___________________– Delta cells => ___________________

Pancreas

Pancreas: beta cells

Review

• Insulin – Moves glucose into ___________ to be used for energy

(glycolysis)

– _______________ blood glucose

• Glucagon– _________________ blood glucose

• Stimulates liver to release glucose

• Stimulates gluconeogenesis– Other hormones from other glands perform similar functions

(hyperglycemic effect)

• Growth hormone

• Glucocorticoids

Insulin/Glucagon Balance

Endocrine Pancreas

• Hyperglycemia– Definition: Excessively high blood glucose

levels• Normal in dogs: _________________ mg/dl

• Normal in cats: __________________ mg/dl

Diabetes Mellitus

• Definition: Disorder of carbohydrate, fat and protein metabolism caused by an absolute or relative ___________ deficiency

• Type I – Insulin Dependent DM – very low or absent insulin secretory ability

• Type II – Non insulin dependent DM (insulin insensitivity) – inadequate or delayed insulin secretion relative to the needs of the patient

Diabetes mellitusIncidence:

Dogs: ~100% Type I (Insulin dependent)Cats: ~ 50% Type I and 50% Type II

-non-insulin dependent catscan sometimes be managed withdiet and drug therapy

Causes: Chronic pancreatitis_______________________________ -beta cell destruction

Predisposing/risk factors:Cushing’s DiseaseAcromegalyObesityGenetic predispositionDrugs (steroids)

Diabetes mellitus

• Age/sex: – Dogs: 4-14 yrs, females 2x more likely to

be affected

– Cats: all ages, but 75% are 8-13yrs, neutered males most affected

• Breeds: Poodles, Schnauzers, Keeshonds, Cairn Terriers, Dachshunds, Cockers, Beagles

DM

• Pathophysiology– Insulin deficiency => impaired ability to use glucose from

______________, __________________ and _______________

– Impaired glucose utilization + gluconeogenesis => hyperglycemia

– Clinical signs develop when:• Exceeds capacity of renal tubular cells to reabsorb

• Dogs – BG > ________________ mg/dl

• Cats - BG > __________________mg/dl

– Glycosuria develops• Osmotic diuresis

• Polyuria/polydipsia

DM• SYSTEMS AFFECTED:

– Endocrine/metabolic: electrolyte depletion and metabolic _________________

– Hepatic: liver failure 2° to hepatic lipidosis (mobilization of free fatty acids to liver leads to hepatic lipidosis and ketogenesis)

– Ophthalmic: __________ (dogs) from glaucoma

– Renal/urologic: UTI, osmotic diuresis– Nervous: peripheral neuropathy in cats– Musculoskeletal: Compensatory weight

loss

Diabetes Mellitus

• Clinical Signs:– ____________________

– ____________________

– Weight loss (esp. cats)

– Dehydration

– Cataract formation-dogs

– Plantigrade stance-cats

Plantigrade postureDiabetic neuropathy

Diabetes in Cats:Plantigrade posture

Diabetes: Cataracts

Increase in sugar (sorbitol) in lens causes an influxof water, which breaks down the lens fibers

Diabetic Ketoacidosis

2 metabolic crises: ↑ lipolysis in adipose tissue → fatty acids →ketone bodies →ketoacidosis →coma (insulin normally _________________ lipolysis)↑ hepatic gluconeogenesis (in spite of high plasma glucose levels)

(insulin normally ____________________ gluconeogenesis)

Diabetic Ketoacidosis

• Definition: True medical _______________ secondary to absolute or relative insulin deficiency causing hyperglycemia, ketonemia, metabolic acidosis, dehydration and electrolyte depletion

• DM causes increased lipolysis => _________ production and _______________

Diabetic Ketoacidosis

• Diagnosed with ketones in urine or ketones in blood – Can use urine dip stick with serum.

• Clinical Signs– All of the DM signs

– Depression

– Weakness

– Tachypnea

– Vomiting

– Odor of acetone on breath

Diabetic Ketoacidosis

• IV fluids to rehydrate 0.9% NaCl – K (potassium) supplement

• Regular insulin to slowly decrease BG

• Monitor BG q 2-3 hrs

• When BG close to normal and patient stable switch to longer acting insulin

DM

• DIAGNOSIS:– CBC: normal– Biochemistry panel:

• Glucose > ________mg/dl (dogs), > _____________ (cats)

– UA• ____________________!!!!• ______________________• USG – low

– Electrolytes may be low due to osmotic diuresis– Blood gases (if ketoacidotic)– Fructosamine levels – mean glucose level for last 2-3 weeks

(dogs)• Ideal to test for regulation checks

DM Rx: INSULIN AND DIET!!!Table 1. Traditional insulin outline.

Duration/onset category

Insulin types Concentration

Rapid acting (emergency)

Regular (Humulin R) U-100 (100 units/ml)

Intermediate acting NPH (Humulin N) U-100

Lente (Vetsulin® by Intervet) NO LONGERAVAILABLE*

U-40 (40 units/ml)

Long acting PZI (Idexx) U-40

Ultralente NO LONGERAVAILABLE*

U-100

Glargine insulin analog U-100

Diabetes: Insulin therapy

DM: Insulin therapy

• INSULIN

– Beef-origin insulin is biologically similar to cat insulin

– Porcine-origin insulin is biologically similar to dog insulin

– Dogs and cats have responded well to human insulin products

• INSULIN ADMINISTRATION:

– ALWAYS USE THE ______________________ INSULIN SYRINGE! (U-40 vs. U-100)

• Insulin is given in units (insulin syringes are labeled in units, not mL)

DM: dietary management

• DIET– DOGS: high _____________-, complex carbohydrate diets

• Slows digestion, reduces the post-prandial glucose spike, promotes weight loss, reduces risk of pancreatitis

• Hill’s R/D or W/D– CATS: high _______________, low carbohydrate diets

• Cats use protein as their primary source of energy – blood glucose is maintained primarily through liver metabolism of fats and proteins

• Purina DM, Hill’s M/D• Often a diet change in cats can dramatically reduce or

eliminate the need for insulin– This is particularly true for type II

DM

• Oral hypoglycemics (cats NIDDM)o Sulfonylureas – Glipizide

oDirect stimulation of insulin secretion from the pancreas

oAlpha-Glucosidase Inhibitors – Acarbose (dogs)oDelays digestion of complex carbohydrates and delays

absorption of glucose from the intestinal tract.

Diabetes Mellitus: Monitoring

Find an ear vein Prick the ear to get Place drop of blood blood sample on green tip; readout in

a few seconds

Diabetes Rx: Urine glucose

Diabetes monitoring: Urine glucose

DM: monitoring

DM

• Client Education– ______________________ insulin replacement therapy– Insulin administered by _______________________________– _____________________ insulin, mix _____________ (no

bubbles), single use syringes– Cataracts common, permanent– Consistent diet and exercise– Recheck BG or curve regularly or fructosamine levels– Progressive– If animal _________________- NO INSULIN

Endocrine Pancreas

• Hypoglycemia– Definition: Low blood glucose levels– Causes

• Neonatal and juvenile• Septicemia• Neoplasia• Starvation• Iatrogenic – insulin overdose• Portosystemic shunt• Many others

Insulin Shock

Causes:

1. Insulin overdose (____________ syringe)

2. Too much exercise

3. Anorexia

Signs:

Weakness, incoordination,_______________, coma

Insulin Shock

Prevention

1. ________________ diet (type and amount)/consistent exercise (less insulin with exercise)

2. Monitor urine/blood glucose at same time each day

3. Feed 1/3 with insulin; the rest 8-10 h later (at insulin peak)

4. Have sugar supply handy

Insulinoma

• CAUSE: ______________ of beta cells, secreting an excess of insulin

• SIGNS: prolonged ______________________ →weakness, ataxia, muscle fasciculations, posterior paresis, brain damage, seizures, coma, death,

Insulinoma: Dx

• Chem Panel– ↓blood glucose

– Simultaneous glucose and insulin tests

____________ glucose, __________________ insulin => insulinoma

• Observations– Symptoms occur after _______________ or _________________

– when symptomatic, blood glucose< ______________ mg/dl

– symptoms corrected with sugar administration

Insulinoma: RxSurgical Rx: removal of tumorMedical Rx: Acute, at home: administer glucose (Karo); keep animal quiet, seek vet careAcute, in Hosp adm. glucose (50% Dextrose)Chronic care feed 3-6 small meals/day (high protein, low fat)

limited exerciseglucocorticooid therapy (antagonizes insulin effect at cellular level)Diazoxide (↓insulin secretion, tissue use of glucose, ↑blood glucose)Octreotide (Sandostatin) injections—inhibits synthesis and release of insulin by both normal and neoplastic beta cells

Insulinoma: Client info• 1. Usually, by the time insulinoma is diagnosed, metastasis has occurred

so prognosis is ______________________

• 2. With proper medical therapy, survival may be 12-24 mo

• 3. Always limit _____________ and _________________

• 4. Feed __________ , ________________meals throughout day; keep sugar source close during exercise

• 5. _________________________ on mm provides for rapid absorption of glucose into blood stream

• 6. Avoid placing hand into dog’s mouth during seizure to avoid being bitten

Exocrine Pancreas Insufficiency (EPI)

• Inability to process nutrients efficiently due to ____________ of production of enzymes from pancreas.– Pancreatic acinar atrophy

• Found most commonly in German Shepherds and Rough Collies through a recessive gene.– In cats, EPI is primarily the result of chronic

pancreatitis

Diagnosis of EPI

• Not usually evident until ____________ % of pancreas is unable to secrete enzymes.– _________________ although no change in diet or

appetite (appetite often increases)

– Persistent tarry diarrhea.

– Flatulence

– Poor haircoat

Testing and treatment for EPI

• TLI (trypsin-like immunoreactivity)– Detects trypsin and trypsinogen

– Usually want ____________________ in dogs to be diagnostic • Canine 5.7-45.2

• Feline 12-82

• Treatment includes enzymatic supplement– ___________________ powder (Amylase, protase, lipase)

– Raw ox or pig pancreas

Client considerations

• Usually life long treatment.

• Can be very expensive.

• Can be well controlled.

• Should not breed animal that has EPI.