Transcript Pancreatitis

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Acute Pancreatitis
 An acute inflammatory process of the pancreas
 Degree of inflammation varies from mild edema to
severe necrosis
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Acute Pancreatitis
Etiology and Pathophysiology
 Most common in middle-aged men and women
 Severity of the disease varies according to the extent of
pancreatic destruction
 Can be life-threatening
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Acute Pancreatitis
Etiology and Pathophysiology (Cont’d)
 Primary etiologic factors are
 Biliary tract disease

Most common: Gallbladder disease
 Alcoholism
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Acute Pancreatitis
Etiology and Pathophysiology (Cont’d)
 Less common causes
 Trauma (postsurgical, abdominal)
 Viral infections (mumps, coxsackievirus HIV)
 Penetrating duodenal ulcer
 Cysts
 Idiopathic
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Acute Pancreatitis
Etiology and Pathophysiology
 Less common causes (cont’d)
 Abscesses
 Metabolic disorders
 Vascular diseases
 Postop GI surgery
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Acute Pancreatitis
Etiology and Pathophysiology
 Less common causes (cont’d)
 Drugs




Corticosteroids
Thiazide diuretics
Oral contraceptives
NSAIDs
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Acute Pancreatitis
Etiology and Pathophysiology
 Caused by autodigestion of pancreas
 Etiologic factors
 Injury to pancreatic cells
 Activate pancreatic enzymes
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Acute Pancreatitis
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Acute Pancreatitis
Etiology and Pathophysiology
 Trypsinogen
 Activated to trypsin by enterokinase
 Inhibitors usually inactivate trypsin
 Enzyme can digest the pancreas and can activate other
proteolytic enzymes
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Pancreatitis
Etiology and Pathophysiology
 Elastase
 Activated by trypsin


Plays a major role in autodigestion
Causes hemorrhage by producing dissolution of the elastic
fibers of blood vessels
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Acute Pancreatitis
Etiology and Pathophysiology
 Phospholipase A
 Plays a major role in autodigestion
 Activated by trypsin and bile acids
 Causes fat necrosis
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Acute Pancreatitis
Etiology and Pathophysiology (Cont’d)
 Alcohol
 May stimulate production of digestive enzymes
 Increases sensitivity to hormone cholecystokinin

Stimulates production of pancreatic enzymes
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Acute Pancreatitis
Clinical Manifestations
 Abdominal pain is predominant symptom
 Pain located in the left upper quadrant
 Pain may be in the midepigastrium
 Commonly radiates to the back
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Acute Pancreatitis
Clinical Manifestations
 Abdominal pain (cont’d)
 Sudden onset
 Severe, deep
 Aggravated by eating
 Not relieved by vomiting
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Acute Pancreatitis
Clinical Manifestations
 Flushing
 Cyanosis
 Dyspnea
 Edema
 Nausea/vomiting
 Bowel sounds decreased or absent
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Acute Pancreatitis
Clinical Manifestations (Cont’d)
 Low-grade fever
 Leukocytosis
 Hypotension
 Tachycardia
 Jaundice
 Abdominal tenderness
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Acute Pancreatitis
Clinical Manifestations
(Cont’d)
 Abdominal distention
 Abnormal lung sounds
 Crackles
 Discoloration of abdominal wall
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Acute Pancreatitis
Complications
 Pancreatic abscess
 A large fluid-containing cavity within pancreas
 Results from extensive necrosis in the pancreas
 Upper abdominal pain
 Abdominal mass
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Acute Pancreatitis
Complications
 Pancreatic abscess (cont’d)
 High fever
 Leukocytosis
 Requires surgical drainage
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Acute Pancreatitis
Diagnostic Studies
 History and physical examination
 Laboratory tests
 Serum amylase
 Serum lipase
 2-hour urinary amylase
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Acute Pancreatitis
Diagnostic Studies
 Laboratory tests (cont’d)
 Blood glucose
 Serum calcium
 Triglycerides
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Acute Pancreatitis
Diagnostic Studies
 Flat plate of abdomen
 Abdominal/endoscopic ultrasound
 Endoscopic retrograde cholangiopancreatography
(ERCP)
 Chest x-ray
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Acute Pancreatitis
Diagnostic Studies (Cont’d)
 CT of pancreas
 Magnetic resonance cholangiopancreatography
(MRCP)
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Acute Pancreatitis
Collaborative Care
 Objectives include
 Relief of pain
 Prevention or alleviation of shock
 ↓ of pancreatic secretions
 Fluid/electrolyte balance
 Removal of the precipitating cause
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Acute Pancreatitis
Collaborative Care (Cont’d)
 Conservative therapy
 Supportive care




Aggressive hydration
Pain management
 IV morphine
 Combined with antispasmodic agent
Management of metabolic complications
Minimizing stimulation
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Acute Pancreatitis
Collaborative Care
 Conservative therapy (cont’d)
 Shock

Plasma or plasma volume expanders
(dextran or albumin)
 Fluid/electrolyte imbalance

Lactated Ringer’s solution
 Ongoing hypotension

Vasoactive drugs: Dopamine (Intropin)
 ↑ Systemic vascular resistance
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Acute Pancreatitis
Collaborative Care
 Conservative therapy (cont’d)
 Suppression of pancreatic enzymes


NPO
NG suction
 Prevent infections
 Peritoneal lavage or dialysis
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Acute Pancreatitis
Collaborative Care
 Surgical therapy indicated if
 Presence of gallstones
 Uncertain diagnosis
 Unresponsive to conservative therapy
 Abscess or severe peritonitis
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Acute Pancreatitis
Collaborative Care
 Surgical therapy (cont’d)
 ERCP
 Endoscopic sphincterotomy
 Laparoscopic cholecystectomy
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Acute Pancreatitis
Collaborative Care (Cont’d)
 Drug therapy
 IV morphine
 Nitroglycerin
 Antispasmodics
 Antacids
 Histamine (H2) receptor
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Acute Pancreatitis
Collaborative Care (Cont’d)
 Nutritional therapy
 NPO status initially to reduce pancreatic secretion
 IV lipids

Monitor triglycerides
 Small, frequent feedings
 High-carbohydrate, low-fat,
high-protein diet
 Bland diet
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Acute Pancreatitis
Collaborative Care
 Nutritional therapy (cont’d)
 Supplemental fat-soluble vitamins
 Supplemental commercial liquid preparations
 Parenteral nutrition
 No caffeine or alcohol
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Acute Pancreatitis
Nursing Assessment
 Health history
 Biliary tract disease
 Alcohol use
 Abdominal trauma
 Duodenal ulcers
 Infection
 Metabolic disorders
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Acute Pancreatitis
Nursing Assessment (Cont’d)
 Medication usage
 Thiazides, estrogens, corticosteroids, NSAIDs
 Surgical procedures
 Nausea/vomiting
 Dyspnea
 Severe pain
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Acute Pancreatitis
Nursing Assessment (Cont’d)
 Physical examination findings
 Fever
 Jaundice
 Discoloration of abdomen/flank
 Tachycardia
 Hypotension
 Abdominal distention/tenderness
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Acute Pancreatitis
Nursing Assessment (Cont’d)
 Abnormal laboratory findings
 ↑ Serum amylase/lipase
 Leukocytosis
 Hyperglycemia
 Hyperlipidemia
 Hypocalcemia
 Abnormal ultrasound/ CT/ ERCP
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Acute Pancreatitis
Nursing Diagnoses
 Acute pain
 Deficient fluid volume
 Imbalanced nutrition: Less than body requirements
 Ineffective therapeutic regimen management
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Acute Pancreatitis
Planning
 Overall goals
 Relief of pain
 Normal fluid and electrolyte balance
 Minimal to no complications
 No recurrent attacks
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Acute Pancreatitis
Nursing Implementation
 Health Promotion
 Assessment of predisposing factors
 Early diagnosis/treatment
 Eliminate alcohol intake
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Acute Pancreatitis
Nursing Implementation (Cont’d)
 Acute Intervention
 Monitor vital signs
 IV fluids
 Observe for side effects of medications
 Assess respiratory function
 Pain assessment and management

Frequent position changes
 Side-lying with HOB elevated 45 degrees
 Knees up to abdomen
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Acute Pancreatitis
Nursing Implementation
 Acute Intervention (cont’d)
 Fluid/electrolyte balance


Blood glucose monitoring
Monitor for signs of hypocalcemia
 Tetany (jerking, irritability, twitching)
 Numbness around lips/fingers
 Monitor for hypomagnesemia
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Acute Pancreatitis
Nursing Implementation
 Acute Intervention (cont’d)
 NG tube care
 Frequent oral/nasal care
 Observe for signs of infection
 Wound care
 Observe for paralytic ileus, renal failure, mental changes
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Acute Pancreatitis
Nursing Implementation
 Ambulatory and Home Care
 Physical therapy
 Counseling regarding abstinence from alcohol, caffeine,
and smoking
 Assessment of narcotic addiction
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Acute Pancreatitis
Nursing Implementation
 Ambulatory and Home Care (cont’d)
 Dietary teaching

High-carbohydrate, low-fat diet
 Patient/family teaching


Signs of infection, high blood glucose, steatorrhea
Medications/diet
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Acute Pancreatitis
Nursing Implementation
 Expected outcomes
 Maintains adequate fluid volume
 Maintains weight appropriate for height
 Food and fluid intake adequate to meet nutritional
needsDescribes therapeutic regimen
 Expresses commitment to lifestyle changes
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Chronic Pancreatitis
 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
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Chronic Pancreatitis
Etiology and Pathophysiology
 May occur in absence of any history of acute condition
 Two major types
 Chronic obstructive pancreatitis
 Chronic calcifying pancreatitis
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Chronic Pancreatitis
Etiology and Pathophysiology (Cont’d)
 Chronic obstructive pancreatitis
 Associated with biliary disease

Most common cause
 Inflammation of the sphincter of Oddi associated with
cholelithiasis
 Other causes include

Cancer of duodenum, or pancreas
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Chronic Pancreatitis
Etiology and Pathophysiology (Cont’d)
 Chronic calcifying pancreatitis
 Inflammation
 Sclerosis

Mainly in the head of the pancreas and around the pancreatic
duct
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Chronic Pancreatitis
Etiology and Pathophysiology
 Chronic calcifying pancreatitis (cont’d)
 Most common form of chronic pancreatitis
 May be referred to as alcohol-induced pancreatitis
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Chronic Pancreatitis
Etiology and Pathophysiology
 Chronic calcifying pancreatitis (cont’d)
 Ducts are obstructed with protein precipitates
 Precipitates block the pancreatic duct and eventually
calcify
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Chronic Pancreatitis
Etiology and Pathophysiology
 Chronic calcifying pancreatitis (cont’d)
 Calcification is followed by fibrosis and glandular
atrophy
 abscesses commonly develop
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Chronic Pancreatitis
Clinical Manifestations
 Abdominal pain
 Located in the same areas as in acute pancreatitis
 Abdominal tenderness
 Malabsorption with weight loss
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Chronic Pancreatitis
Clinical Manifestations
(Cont’d)
 Constipation
 Mild jaundice with dark urine
 Steatorrhea
 Diabetes mellitus
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Chronic Pancreatitis
Clinical Manifestations
(Cont’d)
 Complications
 Bile duct or duodenal obstruction
 Pancreatic ascites
 Pleural effusion
 Pancreatic cancer
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Chronic Pancreatitis
Diagnostic Studies
 Confirming diagnosis can be challenging
 Based on signs/symptoms, laboratory studies, and
imaging
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Chronic Pancreatitis
Diagnostic Studies (Cont’d)
 Laboratory tests
 Serum amylase/lipase

May be ↑ slightly or not at all
 ↑ Serum bilirubin
 ↑ Alkaline phosphatase
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Chronic Pancreatitis
Diagnostic Studies
 Laboratory tests (cont’d)
 Mild leukocytosis
 Elevated sedimentation rate
 ERCP
 Visualize pancreatic/common bile duct
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Chronic Pancreatitis
Diagnostic Studies
 CT
 MRI
 MRCP
 Transabdominal ultrasound
 Endoscopic ultrasound
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Chronic Pancreatitis
Collaborative Care
 Prevention of attacks
 During acute attack, follow acute therapy
 Relief of pain
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Chronic Pancreatitis
Collaborative Care (Cont’d)
 Bland low-fat, high-carbohydrate diet
 Bile salts
 Help absorption of fat-soluble vitamins
 Prevent further fat loss
 Control of diabetes
 No alcohol
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Chronic Pancreatitis
Collaborative Care (Cont’d)
 Pancreatic enzyme replacement
 Acid-neutralizing and acid-inhibiting drugs
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Chronic Pancreatitis
Collaborative Care (Cont’d)
 Surgery
 Indicated when biliary disease is present or if
obstruction
 Divert bile flow or relieve ductal obstruction
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Chronic Pancreatitis
Nursing Management
 Focus is on chronic care and health promotion
 Dietary control

No alcohol
 Control of diabetes
 Taking pancreatic enzymes
 Patient and family teaching
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Case
Study
 63-year-old female enters the emergency department
with nausea, vomiting, epigastric pain, left upper
quadrant pain
 She claims the pain is severe, sharp, and boring and
radiates through to her mid-back
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Case
Study
(Cont’d)
 Pain began 24 hours ago
 She is divorced, retired, and smokes a half-pack of
cigarettes a day
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Case
Study
(Cont’d)
 Vital signs
 Blood pressure 100/70 mm Hg
 Heart rate 97 beats/min
 Respiratory rate 30 breaths/min
 Temperature 100.2°F
 She is diagnosed with acute pancreatitis and admitted to
the medical-surgical unit
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Discussion
Questions
1. What are the possible causes of pancreatitis?
2. What is her priority of care?
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Discussion
Questions
(Cont’d)
3. What labs are the most important to monitor in acute
pancreatitis?
4. What patient teaching should you do with her?
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