1. Pancreatitis

2. Acute Pancreatitis An acute inflammatory process of the pancreas
Degree of inflammation varies from mild edema to severe necrosis

3. 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

4. Acute Pancreatitis Etiology and Pathophysiology (Cont’d)
Primary etiologic factors are
Biliary tract disease
Most common: Gallbladder disease
Alcoholism

5. Acute Pancreatitis Etiology and Pathophysiology (Cont’d)
Less common causes
Trauma (postsurgical, abdominal)
Viral infections (mumps, coxsackievirus HIV)
Penetrating duodenal ulcer
Cysts
Idiopathic

6. Acute Pancreatitis Etiology and Pathophysiology
Less common causes (cont’d)
Abscesses
Metabolic disorders
Vascular diseases
Postop GI surgery

7. Acute Pancreatitis Etiology and Pathophysiology
Less common causes (cont’d)
Drugs
Corticosteroids
Thiazide diuretics
Oral contraceptives
NSAIDs

8. Acute Pancreatitis Etiology and Pathophysiology
Caused by autodigestion of pancreas
Etiologic factors
Injury to pancreatic cells
Activate pancreatic enzymes

9. Acute Pancreatitis

10. 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

11. 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

12. Acute Pancreatitis Etiology and Pathophysiology
Phospholipase A
Plays a major role in autodigestion
Activated by trypsin and bile acids
Causes fat necrosis

13. Acute Pancreatitis Etiology and Pathophysiology (Cont’d)
Alcohol
May stimulate production of digestive enzymes
Increases sensitivity to hormone cholecystokinin
Stimulates production of pancreatic enzymes

14. 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

15. Acute Pancreatitis Clinical Manifestations
Abdominal pain (cont’d)
Sudden onset
Severe, deep
Aggravated by eating
Not relieved by vomiting

16. Acute Pancreatitis Clinical Manifestations
Flushing
Cyanosis
Dyspnea
Edema
Nausea/vomiting
Bowel sounds decreased or absent

17. Acute Pancreatitis Clinical Manifestations (Cont’d)
Low-grade fever
Leukocytosis
Hypotension
Tachycardia
Jaundice
Abdominal tenderness

18. Acute Pancreatitis Clinical Manifestations (Cont’d)
Abdominal distention
Abnormal lung sounds
Crackles
Discoloration of abdominal wall

19. Acute Pancreatitis Complications
Pancreatic abscess
A large fluid-containing cavity within pancreas
Results from extensive necrosis in the pancreas
Upper abdominal pain
Abdominal mass

20. Acute Pancreatitis Complications
Pancreatic abscess (cont’d)
High fever
Leukocytosis
Requires surgical drainage

21. Acute Pancreatitis Diagnostic Studies
History and physical examination
Laboratory tests
Serum amylase
Serum lipase
2-hour urinary amylase

22. Acute Pancreatitis Diagnostic Studies
Laboratory tests (cont’d)
Blood glucose
Serum calcium
Triglycerides

23. Acute Pancreatitis Diagnostic Studies
Flat plate of abdomen
Abdominal/endoscopic ultrasound
Endoscopic retrograde cholangiopancreatography (ERCP)
Chest x-ray

25. Acute Pancreatitis Diagnostic Studies (Cont’d)
CT of pancreas
Magnetic resonance cholangiopancreatography (MRCP)

26. 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

27. 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

28. 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

29. Acute Pancreatitis Collaborative Care
Conservative therapy (cont’d)
Suppression of pancreatic enzymes
NPO
NG suction
Prevent infections
Peritoneal lavage or dialysis

30. Acute Pancreatitis Collaborative Care
Surgical therapy indicated if
Presence of gallstones
Uncertain diagnosis
Unresponsive to conservative therapy
Abscess or severe peritonitis

31. Acute Pancreatitis Collaborative Care
Surgical therapy (cont’d)
ERCP
Endoscopic sphincterotomy
Laparoscopic cholecystectomy

32. Acute Pancreatitis Collaborative Care (Cont’d)
Drug therapy
IV morphine
Nitroglycerin
Antispasmodics
Antacids
Histamine (H2) receptor

33. 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

34. Acute Pancreatitis Collaborative Care
Nutritional therapy (cont’d)
Supplemental fat-soluble vitamins
Supplemental commercial liquid preparations
Parenteral nutrition
No caffeine or alcohol

35. Acute Pancreatitis Nursing Assessment
Health history
Biliary tract disease
Alcohol use
Abdominal trauma
Duodenal ulcers
Infection
Metabolic disorders

36. Acute Pancreatitis Nursing Assessment (Cont’d)
Medication usage
Thiazides, estrogens, corticosteroids, NSAIDs
Surgical procedures
Nausea/vomiting
Dyspnea
Severe pain

37. Acute Pancreatitis Nursing Assessment (Cont’d)
Physical examination findings
Fever
Jaundice
Discoloration of abdomen/flank
Tachycardia
Hypotension
Abdominal distention/tenderness

38. Acute Pancreatitis Nursing Assessment (Cont’d)
Abnormal laboratory findings
↑ Serum amylase/lipase
Leukocytosis
Hyperglycemia
Hyperlipidemia
Hypocalcemia
Abnormal ultrasound/ CT/ ERCP

39. Acute Pancreatitis Nursing Diagnoses
Acute pain
Deficient fluid volume
Imbalanced nutrition: Less than body requirements
Ineffective therapeutic regimen management

40. Acute Pancreatitis Planning
Overall goals
Relief of pain
Normal fluid and electrolyte balance
Minimal to no complications
No recurrent attacks

41. Acute Pancreatitis Nursing Implementation
Health Promotion
Assessment of predisposing factors
Early diagnosis/treatment
Eliminate alcohol intake

42. 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

43. 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

44. 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

45. Acute Pancreatitis Nursing Implementation
Ambulatory and Home Care
Physical therapy
Counseling regarding abstinence from alcohol, caffeine, and smoking
Assessment of narcotic addiction

46. 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

47. 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

48. 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

49. Chronic Pancreatitis Etiology and Pathophysiology
May occur in absence of any history of acute condition
Two major types
Chronic obstructive pancreatitis
Chronic calcifying pancreatitis

50. 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

51. Chronic Pancreatitis Etiology and Pathophysiology (Cont’d)
Chronic calcifying pancreatitis
Inflammation
Sclerosis
Mainly in the head of the pancreas and around the pancreatic duct

52. Chronic Pancreatitis Etiology and Pathophysiology
Chronic calcifying pancreatitis (cont’d)
Most common form of chronic pancreatitis
May be referred to as alcohol-induced pancreatitis

53. Chronic Pancreatitis Etiology and Pathophysiology
Chronic calcifying pancreatitis (cont’d)
Ducts are obstructed with protein precipitates
Precipitates block the pancreatic duct and eventually calcify

54. Chronic Pancreatitis Etiology and Pathophysiology
Chronic calcifying pancreatitis (cont’d)
Calcification is followed by fibrosis and glandular atrophy
abscesses commonly develop

55. Chronic Pancreatitis Clinical Manifestations
Abdominal pain
Located in the same areas as in acute pancreatitis
Abdominal tenderness
Malabsorption with weight loss

56. Chronic Pancreatitis Clinical Manifestations (Cont’d)
Constipation
Mild jaundice with dark urine
Steatorrhea
Diabetes mellitus

57. Chronic Pancreatitis Clinical Manifestations (Cont’d)
Complications
Bile duct or duodenal obstruction
Pancreatic ascites
Pleural effusion
Pancreatic cancer

58. Chronic Pancreatitis Diagnostic Studies
Confirming diagnosis can be challenging
Based on signs/symptoms, laboratory studies, and imaging

59. Chronic Pancreatitis Diagnostic Studies (Cont’d)
Laboratory tests
Serum amylase/lipase
May be ↑ slightly or not at all
↑ Serum bilirubin
↑ Alkaline phosphatase

60. Chronic Pancreatitis Diagnostic Studies
Laboratory tests (cont’d)
Mild leukocytosis
Elevated sedimentation rate
ERCP
Visualize pancreatic/common bile duct

61. Chronic Pancreatitis Diagnostic StudiesCT
MRI
MRCP
Transabdominal ultrasound
Endoscopic ultrasound

62. Chronic Pancreatitis Collaborative Care
Prevention of attacks
During acute attack, follow acute therapy
Relief of pain

63. 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

64. Chronic Pancreatitis Collaborative Care (Cont’d)
Pancreatic enzyme replacement
Acid-neutralizing and acid-inhibiting drugs

65. Chronic Pancreatitis Collaborative Care (Cont’d)
Surgery
Indicated when biliary disease is present or if obstruction
Divert bile flow or relieve ductal obstruction

66. 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

67. Case Study

68. 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

69. Case Study (Cont’d) Pain began 24 hours ago
She is divorced, retired, and smokes a half-pack of cigarettes a day

70. 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

71. Discussion Questions What are the possible causes of pancreatitis?
What is her priority of care?

72. Discussion Questions (Cont’d)
What labs are the most important to monitor in acute pancreatitis?
What patient teaching should you do with her?