PATOLOGI KLINIK

VETERINER
Dr. drh. Dwi Kesuma Sari

PROGRAM STUDI KEDOKTERAN HEWAN

FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
KELAINAN FUNGSI
PANKREAS
Dr. drh. Dwi Kesuma Sari

PROGRAM STUDI KEDOKTERAN HEWAN

FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
Mata Kuliah : Patologi Klinik
Kode MK : 441O1103
Jumlah SKS : 3(2-3)

Deskripsi MK:
Mata kuliah ini menjelaskan berbagai penyimpangan fisik, seluler dan biokimiawi
metabolit pada berbagai cairan tubuh meliputi darah, urin, serebrospinal,
sinovial, eksudat, dan transudat, serta tinja, dan sebab-akibat dari
penyimpangan-penyimpangan tersebut.

Sasaran Pembelajaran Materi ke-5:

Kelainan fungsi pankreas: analisis komposisi darah dan tinja akibat gangguan
fungsi pankreas
PATOLOGI KLINIK PENYAKIT PANKREAS (EKSOKRIN)
Pankreas eksokrin  organ kelenjar sistem
pencernaan  sekresi ke duodenum via duktus
pankreas/saluran pankreas

Ekskresi  enzim dan elektrolit (lipolytic enzyme

lipase, proteolytic enzyme tripsin dan chymotrypsin,
amylolytic enzyme amylase

Semua enzim  low level ada di serum

Panyakit Pankreas
Akut, necrosa, kronik  insuffisinsi fungsi

Akut /nekrotising  kekurangan enzim pencernaan di

serum
Kronik  tidak ada perubahan di serum  pemeriksaan
feses dan khusus

Panel Primer Pankreas  diagnosa penyakit pankreas

akut
PANEL PANKREATIK PRIMER

Amylase, lipase dan BUN

Anjing  aktifitas sirkulasi  2 enzim pencernaan: amylaze

dan lipase

Interpretasi  susah
1. Range luas, standar deviasi besar
2. Amylaze  short-half life  hasil bisa terlihat normal
Amylaze  ekskresi atau degradasi oleh ginjal 
peningkatan level amylaze  gangguan fungsi ginjal
Amylaze  bisa juga gangguan di usus halus
Amylase dan lipase
Anjing:
Lipase  diagnostik test yang baik untuk pankratitis akut di
anjing
Penyakit ginjal  ada peningkatan level lipase
Dexamethasone  peningkatan sd 5 kali level lipase tapi tidak
ada peningkatan serum amylase (tidak ada kelainan pankreas)
Pankretitis  2 kali peningkatan serum amylase dan lipase, tidk
ada perubahan di BUN

Kucing:
 lebih umum  pankreatitis
Tidak ada perubahan amylase  Perubahan lipase  dijadikan
referens
PANEL PANKREATIK SEKUNDER

CALSIUM, ALBUMIN

50% Pankreatitis  terjadi hipokalsemia  peripankreatic fat,

deposit focal calsium, glukagon keluar dari pankreas

Glukagon  stimulasi peningkatan produksi calsitonin (penyebab

hypoglicalcemia)

Hipokalsemia  terkait dengan level amylase dan lipase yg naik

 pankreatitis
PANEL PANKREATIK SEKUNDER

CALSIUM, ALBUMIN

Serum kalsium dievaluasi berdasarkan serum albumin

Serum albumin turun, serum kalsium turun

Hipokalsemia with pankreatitis  serum albumin normal

PANEL PANKREATIK SEKUNDER

GLUKOSA

Selain Pankreatitis  Diabetes

Diabetes  level glukosa darah
Glukosa darah meningkat  pankreatitis, diabetes

Setelah penyakit akut disembuhkan  monitor kembali

PANEL PANKREATIK SEKUNDER

ALT, ALP

Pankreatitis  berhubungan dengan peritonitis dan edema

peripankretik
Hati dan duodenum  terjadi perubahan
Udema pankreas dan duodenum  partial obstruction bile duct

Level ALT dan ALP

PANEL PANKREATIK SEKUNDER

Cholesterol dan Trigliserida

Pankreas dan hati  metabolisme lemak

Lipase  terlibat dalam metabolisme lemak di usus
Pankreatitis  fungsi ini terganggu

Diabetes  ketoacidosis  mobilisasi lemak dari tubuh

Cholesterol dan trigliserida  meningkat di pankreas
Terjadi  Lipemia pd kasus pankreatitis
A fecal canine elastase concentration assay has recently
been developed and validated. This assay has been shown to
be inferior to serum cTLI measurement and leads to many
false-positive test results. The assay is also more
cumbersome and more expensive than measurement of
serum cTLI concentration. Fecal elastase concentration
might be useful for the diagnosis of EPI due to obstruction of
the pancreatic duct. However, this condition is extremely
rare in both dogs and cats. If fecal elastase concentration is
to be used as a screening test for EPI, each positive test (ie,
an elastase concentration of <10 μg/g feces) must be
confirmed by measurement of serum cTLI concentration.
Fecal Occult Blood Tests
Fecal occult blood tests are indicated in conditions where GI blood loss is suspected
(e.g., unexplained microcytic anemia), but overt melena or hematochezia are not
seen. The available tests are based on guaiac or orthotolodine reactions. They are
sensitive to amounts of blood that are 20 to 50 times less than the amounts required
to cause melena.62
Immunologic tests for humans should not be used because
their cross-reactivities with canine or feline hemoglobin are
not documented. The sensitivity of fecal occult blood tests is
very high, but false-negative results are possible when only
very small amounts of blood are leaking in the GI tract.
False-positive results can occur when meat and/or raw fish
are a component of the diet.63,64 Therefore, in the face of a
positive test, it is recommended to change the diet to a commercial
fish-based (not raw fish) or soy-protein-based diet
and to repeat the test after 5 days on the new food.
Tests
Another popular test is the Fecal Protease Test, where a stool sample
is tested for protein digesting enzymes. Fasting is not necessary and
any fecal sample will do; however, 3 consecutive samples are needed
to get a consistent result as there is tremendous variability in fecal
enzyme activity over the day. Sometimes soybeans are given to dogs
to help stimulate release of pancreatic protein digestion enzymes
and get a more accurate test.
The Fecal Elastase test (elastase being another digestive enzyme) is
the newest test and it is only available for dogs. A single fecal sample
is needed but the problem is that some times normal dogs will test
negative for elastase. This means that EPI can be ruled out when the
Elastase test is positive but not confirmed when the elastase test is
negative.
Fecal analysis: proteolytic activity - trypsin
Dr Helen Milner
Mr James Simpson
Overview
Sampling
Test(s)
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Overview
Trypsin and chymotrypsin are proteolytic enzymes produced by the exocrine pancreas to digest dietary protein.
Some proteolytic enzymes may be found in fecal samples of normal dogs.
This proteolytic activity can be measured in fecal samples using various methods.
Measurement of fecal trypsin has been used as a method of detecting exocrine pancreatic insufficiency EPI .
Several methods of detecting the presence of trypsin in feces have been described:
X-ray film test an unreliable test and now considered outdated.
Gelatin tube test - an unreliable test and now considered outdated.
Radial enzyme diffusion test more reliable compared with the above two tests.
These tests have now been superceded by the serum Trypsin Like Immunoassay (TLI) test .
Uses
Alone
Measurement of fecal proteolytic enzyme activity.
Failure to detect proteolytic activity suggests EPI [Exocrine pancreatic insufficiency].
Advantages
Simplicity of the tests.
May aid in the diagnosis of EPI where the tyrpsin like immunoassay (TLI) test is unavailable.
Disadvantages
Unreliability of the x-ray film, gelatin tube and radial enzyme diffusion tests.
The x-ray film, gelatin tube and radial enzyme diffusion tests are now rarely performed, having been largely replaced by the TLI test.
Normal dogs may have very variable enzyme activities from day to day.
Difficult to interpret results.
Alternatives
Carry out a serum TLI test [Blood biochemistry: trypsin-like immunoreactivity] for a definitive diagnosis of EPI
[Exocrine pancreatic insufficiency].
STUDI KASUS
Kasus 1
Signalement:
3 tahun female Boston Terrier
History:
Vomit, blood diarrhea
Suhu: 103° F
P: 100
R: panting

Abdomen  sakit
Vomit, bloody diarrhea
 Akut gastroenteritis or akut
pankreatitis, akut hepatic
disease, akut renal disease 
abdominal pain
STUDI KASUS
Kasus 1
Interpretasi:
RBC: relative polycythemia
RBC parameter  borderline high to elevated
Total Protein  normal
WBC  active inflammatory leukogram
 leukositosis with neutrophilia dan monositosis
 Limfosit normal  tidak ada stress
 classic active inflammatory leukogram in dog
PLT  normal
STUDI KASUS
Kasus 1
Kimia dan Urinalisis:
Primary exocrine pancreatic panel (BUN, amylase, lipase)
Acute pancreatic disease
Amylase dan lipase meningkat
Inflamatory leukogram, abdomen pain, vomit
BUN  normal  no impaired glomerular filtration
 ACUTE PANCREATITIS

Hepatic panel (TP, albumin, ALT, ALP, GGT)

Normal

Urinary panel (BUN, creatinine, specific grativity)

Normal
STUDI KASUS
Kasus 1
Intestinal panel (BUN, TP, albumin, sodium, potassium, chloride)
Hiperchloremia  chloride tinggi
Secretory acidosis

Additional Findings:
Mild metabolic acidosis
Bocarbonat rendah, anion gap naik  metabolic acidosis
STUDI KASUS
Kasus 2

Signalement:
6 tahun, female, Miniature Poodle
History:
vomit selama 3 hari
Menelan tulang kalkun
T: 103,2°F, P: 106, R: panting

Initial assesment:
Vomit, abdominal pain, fever
Abdominal disease
 Evaluasi pankreas, usus, hati dan
ginjal
STUDI KASUS
Kasus 2

Interpretasi:
Hematology:
Relative polycythemia  HCT naik
Penyebab polycythemia di hewan  dehidrasi
TP  naik, histori: vomit  dehidrasi
 hyperproteinemia  dehidrasi
WBC: active inflammatory diagram  with neutrophilia dan monicytosis
 inflamasi
Stress leukogram: Lymphopenia  stress  pengaruh steroid
PLT  normal
STUDI KASUS
Kasus 2

Chemistry dan Urinalysis

Pancreatic panel (BUN, amylase, lipase)
Kemungkinan pankreatitis akut
Amilase  normal, lipase naik
BUN  naik
Hipokalsemia dan Albumin normal  akut pankreatitis
Hiperglikemia, hypertriglyceridemia (abnormalitas lipid)
Pankreatitis

Intestinal panel (TP, albumin, sodium, potassium, chloride)

Tidak ada kelainan untuk primary enteric disease
Hyperproteinemia  dehidrasi
Note: untuk intestinal disease  hipoproteinemia
STUDI KASUS
Kasus 2

Chemistry dan Urinalysis

Hepatic panel (TP, albumin, ALT, ALP, GGT)
Mild hepatocellular injury.
Level 2 kali lipat ALT  primer dan sekunder  perubahan hepatology
Mild elevated alkaline phosphate  non spesific

Urinary panel (BUN, creatinine, specific gravity)

Prerenal azotemia  BUN dan kreatinin
 dehidrasi
STUDI KASUS
Kasus 2

Chemistry dan Urinalysis

Hepatic panel (TP, albumin, ALT, ALP, GGT)
Mild hepatocellular injury.
Level 2 kali lipat ALT  primer dan sekunder  perubahan hepatology
Mild elevated alkaline phosphate  non spesific

Urinary panel (BUN, creatinine, specific gravity)

Prerenal azotemia  BUN dan kreatinin
 dehidrasi
TUGAS:

Signalement:
2 tahun, male, German
Shepperd-Collie mix
History:
Habis berkeliaran, vomit,
depresi
Depresi, anoreksia 
memburuk dalam 48 jam
T: 39.67°C, P: 90, R: panting
Initial assesment:
Acut pain abdomen, vomit,
depresi