PANCREATITIS

ACC, RNSG 1247

Acute PancreatitisDefinition

An acute inflammatory process of the pancreas

Degree of inflammation varies from ___ edema to ______ necrosis

Most common in middle-age

African 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 trypsin

In 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 pancreatitisMild 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

Pancreatic pseudocysts

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 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 Care

Surgical therapy – if related to gallstones

ERCP

Endoscopic sphincterotomy

Stent placement

Laparoscopic cholecystectomy

Endoscopic Sphincterotomy

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

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 Pathophysiology

May follow acute pancreatitis

May occur in absence of any history of acute condition

Two major typesChronic obstructive pancreatitis

Chronic 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 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 Pancreatitis: Goals of Treatment and Nursing Care

Prevention of attacks * Follow acute therapy during acute attack

Relief of pain

Control 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 Care

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

Divert 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 diabetes

Taking pancreatic enzymes

Patient and family teaching

Pancreatic Cancer

Highest mortality rate

Other risk factors: smoking, DM, family history

Cause of high mortality: hard to detect when surgical removal is still possible

Signs/Symptoms: weight loss, nausea, changes in stool , diabetes

TX: surgery, chemotherapy

Highest mortality rate

The End