PANCREATITIS

ACC, RNSG 1247

Acute PancreatitisDefinition & Etiology

An acute inflammatory process of the pancreas

Degree of inflammation varies from mild to edema to severe necrosis

Most common in middle-age

African American rate three times higher than for whites

Acute PancreatitisEtiology and Pathophysiology Primary etiologic factors are

Biliary tract disease Most common: Gallbladder disease

Alcoholism

* May stimulate production of digestive

enzymes

Pancreatitis from gallstones

Acute PancreatitisEtiology and Pathophysiology Caused by auto digestion of pancreas

Etiologic factorsInjury to pancreatic cells

Activate pancreatic enzymes

Acute Pancreatitis

Fig. 44-14Fig. 44-14

(AP) Acute PancreatitisEtiology and PathophysiologyTrypsinogen

Normally released into the small intestine, where it is activated to trypsin

In AP, activated trypsin is present or released in pancreas thus auto digestion of pancreas

Acute PancreatitisEtiology and Pathophysiology 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 LUQ

Pain may be in the midepigastrium

Commonly radiates to the back

Sudden onset

Severe, deep, piercing, steady

Aggravated by eating

Not 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 complicationsPseudocyst

Abscess

Acute PancreatitisComplications (local)

Pseudocyst Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions

Abdominal pain

Palpable epigastric mass

Nausea, vomiting, and anorexia

Elevated serum amylase

Acute Pancreatitis Complications (local)

Pancreatic abscessA large fluid-containing cavity within pancreas

Results from extensive necrosis in the pancreas

Upper abdominal pain

Abdominal mass

High fever

Leukocytosis

Acute PancreatitisComplications : Systemic

Main systemic complicationsPulmonary

Pleural effusion

Atelectasis

Pneumonia

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 Pancreatis:Goals of Care

Relieve pain

Prevent or alleviate shock

Reduce pancreatic secretions

Maintain fluid and electrolyte balance

Remove precipitating cause

Acute Pancreatitis: Treatment and Nursing Care

1. Pain management– IV morphine– Combined with antispasmodic agent

2. Prevention of Shock - Plasma or volume expanders• - LR solution

3. Suppress pancreatic enzymes - NPO, NG suction, antacids, H2 receptor antagonist

4. Antibiotics

Acute PancreatitisTreatment and Nursing Care

Surgical therapy – if related to gallstones

ERCP

Endoscopic sphincterotomy

Stent placement

Laparoscopic cholecystectomy

Acute PancreatitisTreatment and Nursing Care

Nutritional therapyNPO status initially

IV lipids - monitor triglycerides

Enteral or parenteral feeding

Small, frequent feedings if allowed

High-carbohydrate, low-fat, high-protein

Acute PancreatitisNursing Diagnoses

Acute pain

Deficient fluid volume

Imbalanced nutrition: Less than body requirements

Ineffective therapeutic regimen management

Acute Pancreatitis:Home Care

Follow up care Dietary teaching

High-carbohydrate, low-fat dietAbstinence from alcohol,

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

steatorrhea

Chronic PancreatitisDefinition

Continuous, 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 condition

Two major typesChronic obstructive pancreatitis

Chronic calcifying pancreatitis

Chronic PancreatitisEtiology and Pathophysiology

Chronic obstructive pancreatitisAssociated with biliary disease

Most common cause– Inflammation of the sphincter of Oddi associated with

cholelithiasis

Other causes includeCancer of ampulla of Vater, duodenum, or pancreas

Chronic PancreatitisEtiology and PathophysiologyChronic calcifying pancreatitis

Also called alcoholic inducedInflammation and sclerosis

Mainly in the head of the pancreas and around the pancreatic duct

*** Ducts are obstructed with protein precipitates which block 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 formation

Bile duct or duodenal obstruction

Pancreatic ascites

Pleural effusion

Splenic vein thrombosis

Pseudoaneurysms

Pancreatic cancer

Chronic PancreatitisDiagnostic Studies

Laboratory testsSerum amylase/lipase

May be ↑ slightly or not at all

↑ Serum bilirubin

↑ Alkaline phosphatase

Mild leukocytosis

Elevated sedimentation rate

Chronic PancreatitisDiagnostic Studies

CT

MRI

MRCP

Transabdominal ultrasound

Endoscopic ultrasound

Secretin stimulation test

ERCP

Chronic PancreatitisGoals of Care

Prevention of attacksDuring acute attack follow acute therapy

Relief of pain

Control of pancreatic exocrine and endocrine insufficiency

Bland, low-fat, high-carbohydrate diet

Chronic PancreatitisTreatment and Nursing Care Cont.

Bile salts

Control of diabetes

No alcohol

Pancreatic enzyme replacement

Acid-neutralizing and acid-inhibiting drugs

Chronic PancreatitisTreatment and Nursing Care

SurgeryIndicated when biliary disease is present or if obstruction or pseudocyst develops

Divert bile flow or relieve ductal obstruction

Chronic PancreatitisHome/Ambulatory Care

Focus is on chronic care and health promotion

Dietary controlNo alcohol

Control of diabetes

Taking pancreatic enzymes

Patient and family teaching

The End