PANCREATITIS

ACC, RNSG 1247

Acute PancreatitisDefinition

An acute inflammatory process of the pancreasDegree of inflammation varies from ___ edema to ______ necrosisMost common in middle-ageAfrican American rate three times higher than for whites

Acute Pancreatitis: Risk Factors

Primary risk factors are ________ ____ ______ (women)

Gallbladder disease

_____________ (men) * May stimulate production of digestive enzymes

Pancreatitis from gallstones

(AP) Acute Pancreatitis:PathophysiologyTrypsinogen

Normally released into the small intestine, where it is activated to trypsinIn AP, activated trypsin is present or released in pancreas thus auto digestion of pancreas

What happens in autodigestion?

Acute Pancreatitis: pathophysiologic results of autodigestion

Fig. 44-14Fig. 44-14

Acute Pancreatitis: “Degree of involvement” Edematous pancreatitis

Mild and self-limiting

Necrotizing pancreatitisDegree of necrosis correlates with severity of manifestations

Acute PancreatitisClinical Manifestations

Abdominal pain is predominant symptomPain located in LUQPain may be in the midepigastriumCommonly radiates to the backSudden onsetSevere, deep, piercing, steadyAggravated by eatingNot relieved by vomiting

Acute PancreatitisClinical Manifestations

Cyanosis, DyspneaEdemaN/V, Bowel sounds decreased or absentLow-grade fever, LeukocytosisHypotension, TachycardiaJaundice FlushingAbdominal tenderness, distentionAbnormal lung sounds - CracklesGrey Turner’s or Cullen’s sign

Acute PancreatitisComplications

Two significant local complicationsPseudocystAbscess

Acute PancreatitisComplications (local)Pseudocyst

Cavity surrounding outside of pancreas filled with necrotic products and liquid secretionsAbdominal painPalpable epigastric mass Nausea, vomiting, and anorexiaElevated serum amylase

Pancreatic pseudocysts

Acute Pancreatitis Complications (local)Pancreatic abscess

A large fluid-containing cavity within pancreasResults from extensive necrosis in the pancreasUpper abdominal painAbdominal massHigh feverLeukocytosis

Acute PancreatitisComplications : Systemic

Main systemic complicationsPulmonary

Pleural effusionAtelectasisPneumonia

CardiovascularHypotension

Tetany (caused by hypocalcemia)

Acute PancreatitisDiagnostic Studies

History and physical examinationLaboratory tests

Serum amylaseSerum lipase2-hour urinary amylase and renal amylase clearanceBlood glucoseSerum calciumTriglycerides

Acute PancreatitisDiagnostic Studies

Flat plate of abdomenAbdominal/endoscopic ultrasoundEndoscopic retrograde cholangiopancreatography (ERCP)Chest x-rayCECT of pancreasMagnetic resonance cholangiopancreatography (MRCP)

Acute Pancreatitis: Goals of Treatment and Nursing Care

1. Manage _____– IV morphine, Hydromorphone– Combined with antispasmodic agent

2. Prevent or alleviate _____ - Plasma or volume expanders• - LR solution3. Suppress __________ _______ - NPO, NG suction, antacids, H2 receptor antagonist4. Prevent ________

Acute PancreatitisTreatment and Nursing CareSurgical therapy – if related to gallstones

ERCPEndoscopic sphincterotomyStent placementLaparoscopic cholecystectomy

Endoscopic Sphincterotomy

Acute PancreatitisTreatment and Nursing Care

Nutritional therapyNPO status initially IV lipids - monitor triglyceridesEnteral or parenteral feedingSmall, frequent feedings if allowedHigh-carbohydrate, low-fat, high-protein

Acute PancreatitisNursing DiagnosesAcute painDeficient fluid volumeImbalanced nutrition: Less than body requirementsIneffective therapeutic regimen management

Acute Pancreatitis:Home Care

Pain control/prevention Dietary teaching

High-carbohydrate, low-fat dietAbstinence from alcohol, also caffeine, smoking

Patient/family teaching * Signs of infection, high blood glucose, steatorrhea

Chronic Pancreatitis: DefinitionContinuous, prolonged inflammatory, and fibrosing process of the pancreas

Pancreas becomes destroyed as it is replaced by fibrotic tissue Strictures and calcifications can also occur

Chronic PancreatitisEtiology and PathophysiologyMay follow acute pancreatitis May occur in absence of any history of acute conditionTwo major types

Chronic obstructive pancreatitisChronic calcifying pancreatitis

Chronic Pancreatitis: Types and risk factors

Chronic obstructive pancreatitis

Associated with biliary disease; commonly associated with cholelithiasis Other causes include:

Cancer of ampulla of Vater, duodenum, or pancreas

Chronic calcifying pancreatitis

– AKA alcohol induced– Inflammation and sclerosis in the head of the pancreas and around the pancreatic duct

*** Ducts are obstructed with protein precipitates blocking

the pancreatic duct causing it to calcify then fibrosed and atrophied.

Chronic PancreatitisClinical Manifestations

Abdominal painLocated in the same areas as in AP Heavy, gnawing feeling; burning and cramp-like

Malabsorption with weight lossConstipationMild jaundice with dark urineSteatorrheaFrothy urine/stoolDiabetes mellitus

Chronic PancreatitisClinical Manifestations

Complications includePseudocyst formationBile duct or duodenal obstructionPancreatic ascitesPleural effusionSplenic vein thrombosisPseudoaneurysmsPancreatic cancer

Chronic PancreatitisDiagnostic Studies

Laboratory testsSerum amylase/lipase

May be ↑ slightly or not at all

↑ Serum bilirubin↑ Alkaline phosphataseMild leukocytosisElevated sedimentation rate

Chronic PancreatitisDiagnostic StudiesCTMRIMRCPTransabdominal ultrasoundEndoscopic ultrasoundSecretin stimulation testERCP

Chronic Pancreatitis: Goals of Treatment and Nursing CarePrevention of attacks

* Follow acute therapy during acute attack

Relief of painControl of pancreatic exocrine and endocrine insufficiency

* Pancreatic enzyme replacement; bile salts * Acid-neutralizing and acid-inhibiting drugs

Bland, low-fat, high-carbohydrate diet

Chronic PancreatitisTreatment and Nursing CareSurgery

Indicated when biliary disease is present or if obstruction or pseudocyst developsDivert bile flow ( Ex: choledochojejunostmy) Or relieve ductal obstruction ( Ex: sphincterectomy)

Chronic PancreatitisHome/Ambulatory Care Focus is on chronic care and health promotion

Dietary controlNo alcohol

Control of diabetesTaking pancreatic enzymesPatient and family teaching

Pancreatic Cancer

Highest mortality rateOther risk factors: smoking, DM, family historyCause of high mortality: hard to detect when surgical removal is still possibleSigns/Symptoms: weight loss, nausea, changes in stool , diabetesTX: surgery, chemotherapy

Highest mortality rate

The End