Pancreatitis

Pancreatitis 150 150 Tony Guo

Pancreatitis

Acute Pancreatitis

  • Acute inflammatory process of pancreas
  • Spillage of pancreatic enzymes into surrounding pancreatic tissue causing autodigestion and severe pain 
  • Varies from mild edema to severe necrosis

Etiology and Pathophysiology

  • Gallbladder disease (women)
  • Chronic alcohol intake (men)
  • Smoking
  • Hypertriglyceridemia
  • Less common causes 
    • Trauma
    • Viral infections
    • Penetrating duodenal ulcers
    • Cysts
    • Abscesses
    • Cystic fibrosis
    • Kaposi sarcoma
    • Certain drugs
    • Metabolic disorders
    • Vascular diseases
    • Idiopathic causes
  • Caused by auto-digestion of pancreas
    • Injury to pancreatic cells 
    • Activation of pancreatic enzymes
      • Autodigestive effects of pancreatic enzymes
        • Trypsin
          • Edema
          • Necrosis
          • Hemorrhage
        • Elastase
          • Hemorrhage
        • Phospholipase A and lipase
          • Fat necrosis
        • Kallikrein
          • Edema
          • Vascular permeability
          • Smooth muscle contraction
          • Shock
  • Alcohol consumption is another common cause
    • Exact mechanism unknown
    • Alcohol may increase production of pancreatic enzymes
    • 5% to 10% of alcohol abusers develop pancreatitis
  • Classification
    • Mild pancreatitis
      • Edematous or interstitial
    • Severe pancreatitis
      • Necrotizing 
      • Endocrine and exocrine dysfunction
      • Necrosis, organ failure, sepsis
      • Rate of mortality: 25%

 

  • Clinical Manifestations
  • Abdominal pain predominant 
    • Left upper quadrant or midepigastrium
    • Radiates to back
    • Sudden onset
    • Deep, piercing, continuous or steady
    • Aggravated by eating
    • Starts when recumbent
    • Not relieved with vomiting
  • Flushing
  • Cyanosis
  • Dyspnea
  • Nausea/vomiting
  • Low-grade fever
  • Leukocytosis
  • Hypotension, tachycardia
  • Jaundice
  • Abdominal tenderness with muscle guarding
  • Decreased or absent bowel sounds
  • Crackles in lungs
  • Abdominal skin discoloration
    • Grey Turner’s spots or sign
    • Cullen’s sign
  • Shock

 

  • Complications
    • Pseudocyst
      • Fluid, enzyme, debris, and exudates surrounded by wall 
      • Abdominal pain, palpable mass, nausea/vomiting, anorexia
      • Detected with imaging
      • Resolves spontaneously or may perforate and cause peritonitis
      • Surgical or endoscopic drainage
    • Pancreatic abscess
      • Infected pseudocyst
      • Results from extensive necrosis
      • May rupture or perforate
      • Upper abdominal pain, mass, high fever, leukocytosis
      • Requires prompt surgical drainage
    • Systemic complications
      • The pulmonary complications are likely due to the passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels
        • Pleural effusion
        • Atelectasis
        • Pneumonia 
        • ARDS (acute respiratory distress syndrome)
        • Hypotension
        • Thrombi, pulmonary embolism, DIC
        • Hypocalcemia: tetany
          • Due in part to the combining of calcium and fatty acids during fat necrosis. 
          • The exact mechanisms of how or why hypocalcemia occurs are not well understood
  • Diagnostic studies
    • Laboratory tests
      • Serum amylase level
        • Usually elevated early and remains elevated for 24 to 72 hours.
      • Serum lipase level
        • Also elevated in acute pancreatitis
        • Is an important test because other disorders (e.g., mumps, cerebral trauma, renal transplantation) may increase serum amylase levels
      • Liver enzyme levels
      • Triglyceride levels
      • Glucose level
      • Bilirubin level
      • Serum calcium level
    • Abdominal ultrasonography
    • X-ray
    • Contrast-enhanced CT scan
      • Identify pancreatic problems
    • Endoscopic retrograde cholangiopancreatography (ERCP)
    • Endoscopic ultrasonography (EUS)
    • Magnetic resonance cholangiopancreatography (MRCP)
    • Angiography
    • Chest x-ray
      • May show pulmonary changes, including atelectasis and pleural effusions

 

  • Interprofessional Care
    • Objectives include
      • Relief of pain
      • Prevention or alleviation of shock
      • Decreased pancreatic secretions
      • Correction of fluid/electrolyte imbalance
      • Prevention/treatment of infections
      • Removal of precipitating cause
    • Conservative Therapy 
      • Supportive care
        • Aggressive hydration
        • Pain management
          • IV morphine, antispasmodic agent
        • Management of metabolic complications
          • Oxygen, glucose levels
        • Minimizing pancreatic stimulation
          • NPO status, NG suction, decreased acid secretion, enteral nutrition if needed
      • Conservative Therapy
        • Shock 
          • Plasma or plasma volume expanders (dextran or albumin)
        • Fluid/electrolyte imbalance
          • Lactated Ringer’s solution
        • Ongoing hypotension
          • Vasoactive drugs: dopamine 
        • Prevent infection
          • Enteral nutrition
          • Antibiotics
          • Endoscopically or CT-guided percutaneous aspiration
      • Surgical Therapy 
        • For gallstones 
          • ERCP
          • Cholecystectomy
        • Uncertain diagnosis 
        • Not responding to conservative therapy
        • Drainage of necrotic fluid collections
      • Drug Therapy
        • IV morphine
        • Antispasmodics 
        • Carbonic anhydrase inhibitors
        • Antacids
        • Proton pump inhibitors
Drug Mechanism of Action
Acute Pancreatitis
Morphine Relief of pain
Antispasmodics (e.g., dicyclomine [Bentyl])
  • Decreased vagal stimulation, motility, pancreatic outflow (decreased volume and concentration of bicarbonate and enzyme secretion)
  • Contraindicated in paralytic ileus
Carbonic anhydrase inhibitor (acetazolamide)
  • Decreased volume and bicarbonate concentration of pancreatic secretion
Antacids 
  • Neutralization of gastric hydrochloric (HCl) acid secretion
  • Decreased production and secretion of pancreatic enzymes and bicarbonate
Proton pump inhibitors (e.g., omeprazole [Prilosec])
  • Decreased HCl acid secretion (HCl acid stimulates pancreatic activity)
Chronic Pancreatitis
Pancreatic enzyme products (pancrelipase [Pancrease, Zenpep, Creon, Viokace])
  • Replacement therapy for pancreatic enzymes
Insulin 
  • Treatment for diabetes mellitus or hyperglycemia, if needed

 

  • Nutritional Therapy
    • NPO status initially 
    • Enteral versus parenteral nutrition
    • Monitor triglycerides if IV lipids given
    • Small, frequent feedings when able
      • High-carbohydrate
    • No alcohol
    • Supplemental fat-soluble vitamins

 

Nursing Management: Acute Pancreatitis

  • Nursing Assessment
    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Biliary tract disease, alcohol use, abdominal trauma, duodenal ulcers, infection, metabolic disorders
        • Medications: 
          • Thiazides
          • Nonsteroidal anti-inflammatory drugs
        • Surgery or other treatments: 
          • Surgical procedures on the pancreas, stomach, duodenum, or biliary tract. 
          • Endoscopic retrograde cholangiopancreatography (ERCP)
      • Functional Health Patterns
        • Health perception–health management: 
          • Chronic alcohol use, fatigue
        • Nutritional-metabolic: 
          • Nausea and vomiting, anorexia
        • Activity-exercise: 
          • Dyspnea
        • Cognitive-perceptual: 
          • Severe midepigastric or left upper quadrant pain that may radiate to the back, aggravated by food and alcohol intake and unrelieved by vomiting
    • Objective Data
      • General
        • Restlessness, anxiety, low-grade fever
      • Integumentary
        • Flushing, diaphoresis, discoloration of abdomen and flanks, cyanosis, jaundice. Decreased skin turgor, dry mucous membranes
      • Respiratory
        • Tachypnea, basilar crackles
      • Cardiovascular
        • Tachycardia, hypotension
      • Gastrointestinal
        • Abdominal distention, tenderness, and muscle guarding. Diminished bowel sounds
      • Possible Diagnostic Findings
        • Increased serum amylase and lipase
        • Leukocytosis
        • Hyperglycemia
        • Hypocalcemia
        • Abnormal ultrasound and CT scans of pancreas
        • Abnormal ERCP or MRCP
  • Nursing Diagnoses
    • Acute pain related to distention of pancreas, peritoneal irritation, obstruction of biliary tract, and ineffective pain and comfort measures
    • Deficient fluid volume related to nausea, vomiting, restricted oral intake, and fluid shift into the retroperitoneal space
    • Imbalanced nutrition: less than body requirements related to anorexia, dietary restrictions, nausea, loss of nutrients from vomiting, and impaired digestion
    • Ineffective health management related to lack of knowledge of preventive measures, diet restrictions, alcohol intake restriction, and follow-up care
  • Nursing Planning
    • The overall goals are that the patient with acute pancreatitis will have 
      • Relief of pain
      • Normal fluid and electrolyte balance
      • Minimal to no complications
      • No recurrent attacks
  • Nursing Implementation
    • Health Promotion
      • Assessment of patient for predisposing and etiologic factors
      • Encouragement of early treatment of these factors
      • Early diagnosis/treatment of biliary tract disease
      • Elimination of alcohol intake
    • Acute Care
      • Monitoring vital signs
      • Monitor response to IV fluids
      • Closely monitor fluid and electrolyte balance
      • Assess respiratory function
      • Monitor fluid and electrolyte balance
        • Chloride, sodium, and potassium
        • Hypocalcemia 
          • Tetany
          • Calcium gluconate to treat
            • Chvostek’s sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. 
            • Trousseau’s sign is a carpal spasm induced by 
            • Inflating a blood pressure cuff above the systolic pressure for a few minutes.
        • Hypomagnesemia
      • Pain assessment and management
        • Morphine
        • Position of comfort with frequent position changes
          • Flex trunk and draw knees to abdomen
          • Side-lying with head of bed elevated 45 degrees
        • Frequent oral/nasal care
        • Proper administration of antacids
        • Observation for signs of infection
        • TCDB, semi-Fowler’s position
        • Wound care
        • Observation for paralytic ileus, renal failure, mental changes 
        • Monitor serum glucose
        • Post-op wound care
    • Ambulatory Care
      • Physical therapy
      • Assessment of opioid addiction
      • Counseling regarding abstinence from alcohol and smoking
      • Dietary teaching
        • Low-fat, high-carbohydrate
        • No crash diets
      • Patient/family teaching
        • Signs of infection, diabetes mellitus, steatorrhea
        • Medications/diet
      • Expected Outcomes
        • Have adequate pain control
        • Maintain adequate fluid volume
        • Be knowledgeable about treatment regimen
        • Get help for alcohol dependence and smoking cessation (if appropriate)

Chronic Pancreatitis

  • Continuous, prolonged inflammatory, and fibrosing process of the pancreas
  • Etiology
    • Alcohol, gallstones, tumor, pseudocysts, trauma, systemic disease
    • Acute pancreatitis
    • Idiopathic
  • Classifications
    • Two major types
      • Chronic obstructive pancreatitis
        • Inflammation of sphincter of Oddi
        • Cancer of ampulla of Vater, duodenum, or pancreas
      • Chronic non-obstructive pancreatitis
        • Inflammation and sclerosis in head of pancreas and around duct
        • Most common cause is alcohol abuse
  • Clinical Manifestations
    • Abdominal pain
      • Located in same areas as in acute pancreatitis 
      • Heavy, gnawing feeling; burning and cramp-like
    • Malabsorption with weight loss
    • Constipation
    • Mild jaundice with dark urine
    • Steatorrhea
    • Diabetes mellitus
  • Interprofessional Care
    • Pancreatic enzyme replacement
    • Bile salts
    • Insulin or oral hypoglycemic agents
    • Acid-neutralizing and acid-inhibiting drugs 
    • Antidepressants
  • Nursing Management
    • Focus is on chronic care and health promotion
    • Patient and family teaching 
      • Dietary control
      • Pancreatic enzyme with meals/snack
      • Observe for steatorrhea
      • Monitor glucose levels
      • Antacids after meals and at bedtime
      • No alcohol

 

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