Care of Persons with Biliary and pancreatic disorders

pancreas function

• exocrine function

• endocrine function

endocrine function of the pancreas

produces hormones that regulate sugar levels

exocrine function of the pancreas

produces digestive enzymes that help break down food in the small intestine

what is pancreatitis?

active inflammation of the pancreas. presented in both acute and chronic forms

2 common causes of pancreatitis in the US?

1. gallstones

2. alcohol use

How can alcohol use lead to pancreatitis?

heavy or prolonged use can injure pancreatic acinar cells, causing premature activation of digestive enzymes

Conditions associated with acute pancreatitis

• choledocholithiasis (primary)

• alchohol

• other

  • medication - DPP-4i or GLP-1

  • hypertriglyceridemia

  • pancreatic cancer

acute pancreatitis classifications

• interstitial (90%)

• necrotizing (10%)

interstitial pancreatitis

acute inflammation of pancreatic parenchyma

Necrotizing pancreatitis

inflammation and necrosis of pancreatic tissue

severe acute pancreatitis

characterized by persistant organ failure (>48 h) that may involve one or multiple organs

PQRST assessment of pancreatitis: Quality

severe, deep, constant, boring, sharp

PQRST assessment of pancreatitis: radiation

• epigastric, LUQ

• common radiation to back

PQRST assessment of pancreatitis: severity

frequently severe

PQRST assessment of pancreatitis: timing

sudden onset, persistent pain lasting hours to days rather than brief intermittent episodes

PQRST assessment of pancreatitis: provocative

• after eating, especially fatty meals

• when supine

PQRST assessment of pancreatitis: palliative

when upright or leaning forward

clinical manifestations of pancreatitis: GI and abdominal

• Nausea and vomiting

• Abdominal distension & rigidity

• Hypoactive or absent bowel sounds (paralytic ileus)

• Epigastric tenderness

clinical manifestations of pancreatitis: systemic and vital signs

• Fever and chills

• Tachycardia & hypotension

• Jaundice (biliary obstruction)

• Dyspnea / crackles in lung bases

• Hyperglycemia

• Dark urine

• Decreased UOP

• Confusion, lethargy

• Diaphoresis

clinical manifestations of pancreatitis: signs

• Cullen's sign: Periumbilical ecchymosis

• Grey Turner's sign: Flank ecchymosis

• Tetany / Chvostek's sign (hypocalcemia)

Which lab values support a diagnosis of pancreatitis?

• Amylase & Lipase (3xULN)

• Leukocytosis, hyperglycemia, hypocalcemia, BUN/creatinine elevation, transaminitis

• Triglycerides > 1000 *

Acute pancreatitis Lab

• Elevated Serum and Urine Amylase

• Elevated Serum Lipase

• Elevated AST, ALT, Alkaline Phosphatase - Suggests gallstone pancreatitis

• Elevated C-Reactive Protein (CRP)

• Hyperglycemia

• Hypocalcemia (Later stage)

Acute pancreatitis diagnostic test and imaging

• abdominal CT scan

• endoscopic ultrasound

• MRCP

• ERCP

Nursing priorities for person with acute pancreatitis first 24-72 h

1. hemodynamic stability and adequate perfusion

2. pain control

3. monitor and prevent complication

4. nutritional support

Care for Persons with Acute Pancreatitis: monitor vital signs

assess early signs of decomposition:

• fever

• tachycardia

• hypotension

Care for Persons with Acute Pancreatitis: O2 status

• continuous O2 monitoring

• assess breath sounds and work of breathing

• watch for pleural effusion or ARDs symptoms

Care for Persons with Acute Pancreatitis: hydration and fluid replacemtn

large amount of IV fluids to replace intravascular losses due to severe third-spacing and fluid shifts

Care for Persons with Acute Pancreatitis: pain management

• opioids

• positioning: fetal position or sitting up leaning forward to relieve pancreatic tension

Care for Persons with Acute Pancreatitis: rest first 24 h

• NPO

• NG tube to intermittent suction if patient is experiencing significant vomiting

Care for Persons with Acute Pancreatitis: nutrition

• oral clear liquids → low fat diet

• moderate/severe: enteral feedings in jejunum

• parenteral nutrition

Care for Persons with Acute Pancreatitis: antibiotics

antibiotics administered

acute pancreatitis: pseudocyst

An encapsulated collection of pancreatic secretions and possibly granulation tissue that forms in or around the pancreas. No true endothelial living; inflammatory and fibrous tissue.

pseudocyst s/s

Persistent abdominal pain, N&V, elevated serum amylase, and low-grade fever.

pseudocyst timeline

occurs more than 4 weeks after onset pancreatitis

pseudocyst management

can resile spontaneously but might need to be drained either percutaneously or via surgery

chronic pancreatitis

a long-standing inflammation of the pancreas that alters the normal structure and functions of the pancreas

chronic pancreatitis etiology

most often associted with chronic alcohol abuse

Clinical manifestation of chronic pancreatitis

• Jaundice

• Icteus - yellow coloration of the eye sclera

• Clay colored stools

• Tea colored urine

• diabetes mellitus

Care for chronic pancreatitis

• pain relief

• no alcohol

• no smoking or caffeine

• diet modifications

• pancreatic enzyme replacement

• acid-neutralizing and acid-inhibiting drugs

• control blood sugar

chronic pancreatitis diet

• bland, low-fat

• small, frequent meals

pancrelipase (creon) mechanism of action

Pancreatic enzyme needed for the breakdown of substances released from the pancreas

pancrelipase (creon) indication

Exocrine pancreatic secretion insufficiency, due to cystic fibrosis (digestive aid), pancreatic enzyme deficiency

pancrelipase (creon) side effects

• hypo/hyperglycemia

• anorexia

• nausea

• vomiting

• diarrhea

• hyperuricuria

pancrelipase (creon) nursing consideration

• administer with every meal and snack

• monitor for steatorrhea

• control blood sugar with insulin

ursodeoxycholic acid (ursodiol) indication

gallstone dissolution

ursodeoxycholic acid (ursodiol) side effects

• yellow in the eyes

• fevers

• loose stools

• muscle or joint aches

• diarrhea

• RUQ abdominal pain

ursodeoxycholic acid (ursodiol) nursing condsideration

• take with food

• emphasize strict adherence complete dissolution take months to 2 years

total pancreatectomy with islet autotransplantation (TPAIT)

a surgical procedure that removes the entire pancreas and infuses the patient’s own insulin-producing islet cells into the liver to preserve endocrine function

TPAIT surgery considrations

• does not cure diabetes - will still require insulin

• lifelong exocrine requiring pancreatic enzyme replacement therapy

TPAIT surgery indication

• recurrent or chronic pancreatitis with severe refractory pain

• pancreatic disease not responsive to other treatment

gallbladder disease labs

• WBC: elevated

• ALT/AST: elevated

• amylase and lipase: elevated

ultrasonography indication

initial test for cholecystitis. identifies gallstones

Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) indication

when cause of cholecystis or cholelithiasis is not known or the patient has symptoms of biliary obstruction 

Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) nursing consideration

1. Pt given oral or IV contrast material (gadolinium) before MRI

2. Ask hx of urticaria (hives) or other allergies 

3. MRI contraindicated in pts with a pacemaker or other incompatible devices

nonsurgical management for patients with cholelithiasis, cholecystitis, and cholecystectomy.

• preventing obesity

• nutrition: withhold foods and fluids if nausea and vomiting occur

• pain management

treatment for cholelithiasis

urodiol and chenodial

surgical management of cholelithiasis, cholecystitis, and cholecystectomy.

laparoscopic cholecystectomy

laparoscopic cholecystectomy nursing consideration

• assess O2 status

• monitor N/V

• elevate HOB

• ambulate early

laparoscopic cholecystectomy

minimally invasive surgery and is the gold standard 

laparoscopic cholecystectomy post op pain pain management

1. Incisional pain - ice and oral opioids 

2. Abdominal or thoracic discomfort - apply hot pack

laparoscopic cholecystectomy post op incision care

typically allowed to bathe or shower after the day after surgery