Pancreatitis Level 2

Gallbladder and Pancreatitis

Inflammation of the Pancreas

The pancreas is susceptible to inflammation, a condition known as pancreatitis.

Pancreatitis Causes

In the U.S., the most common cause of pancreatitis is gallstones. The second most common cause is alcohol abuse.

Pancreatic Function

The exocrine function of the pancreas involves producing digestive enzymes that aid in breaking down food for nutrient absorption. Key questions to consider include: What specific enzymes does the pancreas produce? What is the endocrine function of the pancreas?

Acute Pancreatitis: Etiology

Acute pancreatitis can arise from the following sequence of events:

  1. Pancreatic Duct Obstruction: Blockage of pancreatic ducts.

  2. Hypersecretion of Enzymes: Excessive production of pancreatic enzymes.

  3. Enzyme Activation in Bile Duct: Digestive enzymes enter the bile duct, become activated, and back up into the pancreatic duct along with bile.

  4. Pancreatic Autodigestion: The pancreatic enzymes start digesting the pancreas itself.

Progression of Acute Pancreatitis

The progression of acute pancreatitis involves:

  1. Enzyme Backup: Digestive enzymes back up into the pancreas.

  2. Acute Inflammation: The pancreas becomes acutely inflamed.

  3. Necrosis: Pancreatic tissue undergoes necrosis.

  4. Vascular Damage: Digestion of vascular walls leads to thrombus formation and hemorrhage.

  5. Shock and Death: Ultimately leading to shock and potentially death.

Clinical Manifestations of Acute Pancreatitis

Key symptoms and signs:

  • Extreme Abdominal Pain: This is the main symptom with sudden onset in the LUQ/epigastric region, possibly radiating to the back and intensifying with eating.

  • Gastrointestinal Issues: Nausea and vomiting, decreased or absent bowel sounds leading to abdominal distention.

  • Systemic Symptoms: Low-grade fever and leukocytosis.

  • Jaundice: Yellowing of the skin and eyes.

  • Abdominal Wall Discoloration

  • Signs of Shock: Hypotension (low blood pressure), tachycardia (rapid heart rate), and dyspnea (difficulty breathing).

  • Cullen’s Sign

Hot Spots: Pain Location

The most likely site of intense pain with pancreatitis is a key diagnostic consideration.

Acute Pancreatitis - Diagnostic Studies

Diagnostic tests for acute pancreatitis include:

  • Serum Amylase and Lipase: Blood tests to measure amylase and lipase levels.

  • X-ray of Abdomen (KUB)

  • Abdominal Ultrasound

  • CT of Pancreas: The best imaging technique for pancreatitis.

  • ERCP: Endoscopic Retrograde Cholangiopancreatography, though it can potentially cause acute pancreatitis. Alternatives include EUS, MRCP (magnetic resonance cholangiopancreatography), and angiography.

Treatment and Nursing Care

Key interventions:

  1. Pain Management:

    • IV opioid analgesics.

    • Antispasmodic agents like Bentyl (dicyclomine).

    • Positioning: sitting up and leaning forward, or side-lying with knees flexed. Rationale: Pain relief is paramount.

  2. Suppress Pancreatic Enzymes:

    • NPO (nothing per oral).

    • NG (nasogastric) suction.

    • Antacids, PPIs (proton pump inhibitors).

  3. Nutrition:

    • Enteral nutrition or TPN (total parenteral nutrition) if enteral is not tolerated.

  4. Correction of Electrolyte Imbalance:

    • Assess for hypocalcemia, chloride, K^+, Na^+ levels.

    • IV fluids.

  5. Prevention of Shock (Hypovolemic or Septic):

    • Monitor vital signs (V/S).

    • Assess lung sounds and dyspnea.

    • Monitor for bleeding.

    • Type and cross match done.

    • Monitor for infection.

ERCP with Sphincterotomy

  • ERCP (endoscopic retrograde cholangiopancreatography) with sphincterotomy

  • Laparoscopic cholecystectomy

Acute Pancreatitis: Complications

Two significant local complications:

  • Pseudocyst

  • Abscess

Complications: Pseudocyst

A fluid-filled sac next to the pancreas. While typically benign and painful, it can cause abdominal pain, a palpable epigastric mass, nausea, vomiting, anorexia, and elevated serum amylase. It usually resolves spontaneously but can become infected, leading to an abscess.

Complications: Pancreatic Abscess

Infection of a pseudocyst leads to necrosis and abscess formation, indicated by upper abdominal pain, an abdominal mass, high fever, and leukocytosis. Pancreatic abscess requires prompt surgical drainage.

Systemic Complications

Main systemic complications include:

  • Cardiovascular and Pulmonary: Pleural effusion, atelectasis, pneumonia, ARDS (acute respiratory distress syndrome).

  • Hypovolemic Shock: Due to fluid loss.

  • Septic Shock: Due to infection.

  • Electrolyte Imbalance: Hypocalcemia and hypokalemia.

Pancreatic Cancer

The cause is unknown but highly linked to smoking. It has a very poor prognosis. Symptoms include abdominal pain, jaundice, and weight loss. Diagnosis involves CT, ERCP, and MRI. Surgical treatment includes the Whipple procedure.