Page 2: Acute Pancreatitis Definition and Etiology

• Acute pancreatitis is an acute inflammatory process of the pancreas.

• The degree of inflammation varies from mild edema to severe necrosis.

• It is most common in middle-aged men and women.

• The severity of the disease varies according to the extent of pancreatic destruction.

• African Americans have a three times higher rate of acute pancreatitis compared to whites.

• The primary etiologic factors are biliary tract disease, with gallbladder disease being the most common, and alcoholism.

Page 3: Less Common Causes of Acute Pancreatitis

• Less common causes of acute pancreatitis include trauma (postsurgical, abdominal), viral infections (mumps, coxsackievirus, HIV), penetrating duodenal ulcer, cysts, and idiopathic cases.

• Other less common causes include abscesses, cystic fibrosis, Kaposi's sarcoma, metabolic disorders, vascular diseases, and postoperative gastrointestinal surgery.

Page 4: Drugs and Autodigestion as Causes of Acute Pancreatitis

• Drugs such as corticosteroids, thiazide diuretics, oral contraceptives, sulfonamides, and NSAIDs can also cause acute pancreatitis.

• Acute pancreatitis is caused by the autodigestion of the pancreas due to injury to pancreatic cells and the activation of pancreatic enzymes.

Page 5: Alcohol and Pancreatic Enzyme Production

• Alcohol may stimulate the production of digestive enzymes in the pancreas.

• It increases sensitivity to the hormone cholecystokinin, which stimulates the production of pancreatic enzymes.

Page 6: Clinical Manifestations of Acute Pancreatitis

• Abdominal pain is the predominant symptom of acute pancreatitis.

• The pain is located in the left upper quadrant and may also be in the midepigastrium.

• The pain is sudden onset, severe, deep, piercing, and steady.

• It is aggravated by eating and not relieved by vomiting.

• Other clinical manifestations include flushing, cyanosis, dyspnea, edema, nausea/vomiting, decreased or absent bowel sounds, low-grade fever, leukocytosis, hypotension, tachycardia, jaundice, and abdominal tenderness.

Page 7: Additional Clinical Manifestations and Complications of Acute Pancreatitis

• Additional clinical manifestations include abdominal distention, abnormal lung sounds (crackles), and discoloration of the abdominal wall (Cullen's sign and Grey-Turner's sign).

• Two significant local complications of acute pancreatitis are pseudocyst and abscess.

• A pseudocyst is a cavity surrounding the outside of the pancreas filled with necrotic products and liquid secretions.

• It can cause abdominal pain and a palpable epigastric mass.

• A pancreatic abscess is a large fluid-containing cavity within the pancreas that results from extensive necrosis.

• It presents with upper abdominal pain and an abdominal mass.

Page 8: Treatment and Systemic Complications of Acute Pancreatitis

• Pseudocysts may resolve spontaneously within a few weeks or may require treatment such as internal drainage procedures.

• Pancreatic abscesses require surgical drainage.

• Systemic complications of acute pancreatitis include pulmonary complications such as pleural effusion, atelectasis, and pneumonia.

• Cardiovascular complications may include hypotension and tetany caused by hypocalcemia.

Page 9: Systemic Complications of Acute Pancreatitis

• Other systemic complications of acute pancreatitis include gastrointestinal bleeding, renal failure, and metabolic complications.

• Pulmonary complications may also include acute respiratory distress syndrome (ARDS) and respiratory failure.

Page 10: Acute Pancreatitis Lab Studies

• History and physical examination

• Laboratory tests

  • Serum amylase

  • Serum lipase

  • Blood glucose

  • Serum calcium

  • Triglycerides

  • CBC

  • Chemistry

• Diagnostic Studies

  • Flat plate of abdomen

  • Abdominal/endoscopic ultrasound

  • Endoscopic retrograde cholangiopancreatography (ERCP)

  • Chest x-ray

  • CT of pancreas

  • Magnetic resonance cholangiopancreatography (MRCP)

Page 11: Acute Pancreatitis Collaborative Care

• Objectives include:

  • Relief of pain

  • Prevention or alleviation of shock

  • Decrease of pancreatic secretions

  • Fluid/electrolyte balance

  • Removal of the precipitating cause

• Conservative therapy

  • Supportive care

  • Aggressive hydration

  • Pain management

  • IV morphine

  • Combined with antispasmodic agent

  • Management of metabolic complications

  • Minimizing stimulation

• 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)

  • Increased systemic vascular resistance

• Conservative therapy (cont'd)

  • Suppression of pancreatic enzymes

  • NPO

  • NG suction

  • Prevent infections

  • Peritoneal lavage or dialysis

  • Remove kinin and phospholipase A exudate

Page 12: Acute Pancreatitis Collaborative Care

• Surgical therapy indicated if:

  • Presence of gallstones

  • Uncertain diagnosis

  • Unresponsive to conservative therapy

  • Abscess, pseudocyst, or severe peritonitis

• ERCP

Page 13: Acute Pancreatitis Collaborative Care

• Drug therapy

  • IV morphine

  • Nitroglycerin or papaverine

  • Antispasmodics

  • Carbonic anhydrase inhibitor

  • Antacids

  • Histamine (H2) receptor

• 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

  • Supplemental fat-soluble vitamins

  • Supplemental commercial liquid preparations

  • Parenteral nutrition

  • No caffeine or alcohol

Page 14: Acute Pancreatitis

• Abnormal laboratory findings

  • Increased serum amylase/lipase

  • Leukocytosis

  • Hyperglycemia

  • Hyperlipidemia

  • Hypocalcemia

  • Abnormal ultrasound/CT/ERCP

• Nursing Diagnoses

  • Acute pain

  • Deficient fluid volume

  • Imbalanced nutrition: Less than body requirements

  • Ineffective therapeutic regimen management

• Planning

  • Overall goals

    • Relief of pain

    • Normal fluid and electrolyte balance

    • Minimal to no complications

    • No recurrent attacks

Page 15: Acute Pancreatitis Nursing Implementation

• Health promotion

  • Assessment of predisposing factors

  • Early diagnosis/treatment of cholelithiasis

  • Eliminate alcohol intake

• 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

• Acute intervention (cont'd)

  • Fluid/electrolyte balance

  • Blood glucose monitoring

  • Monitor for signs of hypocalcemia

  • Tetany (jerking, irritability, twitching)

  • Numbness around lips/fingers

  • Positive Chvostek or Trousseau sign

  • Monitor for hypomagnesemia

Page 16: Acute Pancreatitis Nursing Implementation

• Positive Trousseau and Chvostek signs

• 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

• Ambulatory and home care

  • Physical therapy

  • Counseling regarding abstinence from alcohol, caffeine, and smoking

  • Assessment of narcotic addiction

Page 17

Acute Pancreatitis Nursing Implementation - Ambulatory and home care

• Dietary teaching

  • High-carbohydrate, low-fat diet

• Patient/family teaching

  • Signs of infection

  • Signs of high blood glucose

  • Signs of steatorrhea

  • Medications/diet

Acute Pancreatitis Nursing Implementation - Expected outcomes

• Maintains adequate fluid volume

• Maintains weight appropriate for height

• Food and fluid intake adequate to meet nutritional needs

Page 18

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

Chronic Pancreatitis - Etiology 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

Pathology

• Chronic pancreatitis: The pancreas is shrunken and fibrotic. The main duct is dilated and filled with calcified secretions.

Page 19

Chronic Pancreatitis - Etiology and Pathophysiology

• Chronic obstructive pancreatitis

  • Associated with biliary disease

  • Most common cause

  • Inflammation of the sphincter of Oddi associated with cholelithiasis

  • Other causes include cancer of ampulla of Vater, duodenum, or pancreas

Chronic Pancreatitis - Etiology and Pathophysiology

• Chronic calcifying pancreatitis

  • Inflammation

  • Sclerosis

  • Mainly in the head of the pancreas and around the pancreatic duct

  • Most common form of chronic pancreatitis

  • May be referred to as alcohol-induced pancreatitis

Page 20

Chronic Pancreatitis - Clinical Manifestations

• Abdominal pain

• Abdominal tenderness

• Malabsorption with weight loss

Chronic Pancreatitis - Clinical Manifestations

• Constipation

• Mild jaundice with dark urine

• Steatorrhea

• Frothy urine/stool

• Diabetes mellitus

Chronic Pancreatitis - Clinical Manifestations

• Complications include

  • Pseudocyst formation

  • Bile duct or duodenal obstruction

  • Pancreatic ascites

  • Pleural effusion

Page 21

Chronic Pancreatitis - Clinical Manifestations

• Complications (cont’d)

  • Splenic vein thrombosis

  • Pseudoaneurysms

  • Pancreatic cancer

Chronic Pancreatitis - Diagnostic Studies

• Confirming diagnosis can be challenging

• Based on signs/symptoms, laboratory studies, and imaging

• Laboratory tests

  • Serum amylase/lipase

  • Serum bilirubin

  • Alkaline phosphatase

  • Mild leukocytosis

  • Elevated sedimentation rate

Chronic Pancreatitis - Diagnostic Studies

• ERCP

• CT

• MRI

• MRCP

• Transabdominal ultrasound

• Endoscopic ultrasound

• Secretin stimulation test

Page 22

Chronic Pancreatitis - Collaborative Care

• Prevention of attacks

• Relief of pain

• Control of pancreatic exocrine and endocrine insufficiency

Chronic Pancreatitis - Collaborative Care

• Bland low-fat, high-carbohydrate diet

• Bile salts

• Control of diabetes

• No alcohol

Chronic Pancreatitis - Collaborative Care

• Pancreatic enzyme replacement

• Acid-neutralizing and acid-inhibiting drugs

Page 23

Chronic Pancreatitis - Collaborative Care

• Surgery

  • Indicated when biliary disease is present or if obstruction or pseudocyst develops

  • Divert bile flow or relieve ductal obstruction

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

Page 24

• The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of NPO