PANCREATITIS

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PANCREATITIS

• ACC, RNSG 1247

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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

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Acute Pancreatitis Risk Factors

• Primary risk factors are
• ________ ____ ______ (women)
• Gallbladder disease
• _____________ (men)
• May stimulate production of digestive
• enzymes

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Pancreatitis from gallstones
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(AP) Acute PancreatitisPathophysiology

• Trypsinogen
• 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?

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Acute Pancreatitis pathophysiologic results of
autodigestion
Fig. 44-14
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Acute Pancreatitis Degree of involvement

• Edematous pancreatitis
• Mild and self-limiting
• Necrotizing pancreatitis
• Degree of necrosis correlates with severity of
  manifestations

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Acute PancreatitisClinical Manifestations

• Abdominal pain is predominant symptom
• Pain 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

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Acute PancreatitisClinical Manifestations

• Cyanosis, Dyspnea
• Edema
• N/V, Bowel sounds decreased or absent
• Low-grade fever, Leukocytosis
• Hypotension, Tachycardia
• Jaundice
• Flushing
• Abdominal tenderness, distention
• Abnormal lung sounds - Crackles
• Grey Turners or Cullens sign

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Acute PancreatitisComplications

• Two significant local complications
• Pseudocyst
• Abscess

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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

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Pancreatic pseudocysts
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Acute Pancreatitis Complications (local)

• Pancreatic abscess
• A large fluid-containing cavity within pancreas
• Results from extensive necrosis in the pancreas
• Upper abdominal pain
• Abdominal mass
• High fever
• Leukocytosis

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Acute PancreatitisComplications Systemic

• Main systemic complications
• Pulmonary
• Pleural effusion
• Atelectasis
• Pneumonia
• Cardiovascular
• Hypotension
• Tetany (caused by hypocalcemia)

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Acute PancreatitisDiagnostic Studies

• History and physical examination
• Laboratory tests
• Serum amylase
• Serum lipase
• 2-hour urinary amylase and renal amylase
  clearance
• Blood glucose
• Serum calcium
• Triglycerides

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Acute PancreatitisDiagnostic Studies

• Flat plate of abdomen
• Abdominal/endoscopic ultrasound
• Endoscopic retrograde cholangiopancreatography
  (ERCP)
• Chest x-ray
• CECT of pancreas
• Magnetic resonance cholangiopancreatography
  (MRCP)

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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 solution
• 3. Suppress __________ _______
• - NPO, NG suction, antacids, H2
  receptor
• antagonist
• 4. Prevent ________

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Acute PancreatitisTreatment and Nursing Care

• Surgical therapy if related to gallstones
• ERCP
• Endoscopic sphincterotomy
• Stent placement
• Laparoscopic cholecystectomy

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Endoscopic Sphincterotomy
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Acute PancreatitisTreatment and Nursing Care

• Nutritional therapy
• NPO status initially
• IV lipids - monitor triglycerides
• Enteral or parenteral feeding
• Small, frequent feedings if allowed
• High-carbohydrate, low-fat, high-protein

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Acute PancreatitisNursing Diagnoses

• Acute pain
• Deficient fluid volume
• Imbalanced nutrition Less than body requirements
• Ineffective therapeutic regimen management

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Acute PancreatitisHome Care

• Pain control/prevention
• Dietary teaching
• High-carbohydrate, low-fat diet
• Abstinence from alcohol, also caffeine, smoking
• Patient/family teaching
• Signs of infection, high blood
  glucose,
• steatorrhea

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Chronic Pancreatitis Definition

• 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 PancreatitisEtiology and Pathophysiology

• May follow acute pancreatitis
• 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 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.

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Chronic PancreatitisClinical Manifestations

• Abdominal pain
• Located in the same areas as in AP
• Heavy, gnawing feeling burning and cramp-like
• Malabsorption with weight loss
• Constipation
• Mild jaundice with dark urine
• Steatorrhea
• Frothy urine/stool
• Diabetes mellitus

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Chronic PancreatitisClinical Manifestations

• Complications include
• Pseudocyst formation
• Bile duct or duodenal obstruction
• Pancreatic ascites
• Pleural effusion
• Splenic vein thrombosis
• Pseudoaneurysms
• Pancreatic cancer

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Chronic PancreatitisDiagnostic Studies

• Laboratory tests
• Serum amylase/lipase
• May be ? slightly or not at all
• ? Serum bilirubin
• ? Alkaline phosphatase
• Mild leukocytosis
• Elevated sedimentation rate

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Chronic PancreatitisDiagnostic Studies

• CT
• MRI
• MRCP
• Transabdominal ultrasound
• Endoscopic ultrasound
• Secretin stimulation test
• ERCP

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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

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Chronic PancreatitisTreatment and Nursing Care

• Surgery
• Indicated when biliary disease is present or if
  obstruction or pseudocyst develops
• Divert bile flow ( Ex choledochojejunostmy)
• Or relieve ductal obstruction ( Ex
  sphincterectomy)

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Chronic PancreatitisHome/Ambulatory Care

• 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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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

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The End