1. PANCREATITIS ACC, RNSG 1247

2. Acute Pancreatitis Definition 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

3. Acute Pancreatitis: Risk Factors Primary risk factors are ________ ____ ______ (women) Gallbladder disease _____________ (men) * May stimulate production of digestive enzymes

4. Pancreatitis from gallstones

5. (AP) Acute Pancreatitis: Pathophysiology 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?

6. Acute Pancreatitis: pathophysiologic results of autodigestion Fig. 44-14

7. Acute Pancreatitis: “Degree of involvement” Edematous pancreatitis Mild and self-limiting Necrotizing pancreatitis Degree of necrosis correlates with severity of manifestations

8. Acute Pancreatitis Clinical 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

9. Acute Pancreatitis Clinical 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 Turner’s or Cullen’s sign

10. Acute Pancreatitis Complications Two significant local complications Pseudocyst Abscess

11. Acute Pancreatitis Complications (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

12. Pancreatic pseudocysts

13. 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

14. Acute Pancreatitis Complications : Systemic Main systemic complications Pulmonary Pleural effusion Atelectasis Pneumonia Cardiovascular Hypotension Tetany (caused by hypocalcemia)

15. Acute Pancreatitis Diagnostic Studies History and physical examination Laboratory tests Serum amylase Serum lipase 2-hour urinary amylase and renal amylase clearance Blood glucose Serum calcium Triglycerides

16. Acute Pancreatitis Diagnostic Studies Flat plate of abdomen Abdominal/endoscopic ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) Chest x-ray CECT of pancreas Magnetic resonance cholangiopancreatography (MRCP)

17. 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 ________

18. Acute Pancreatitis Treatment and Nursing Care Surgical therapy – if related to gallstones ERCP Endoscopic sphincterotomy Stent placement Laparoscopic cholecystectomy

19. Endoscopic Sphincterotomy

20. Acute Pancreatitis Treatment 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

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

22. Acute Pancreatitis: Home 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

23. 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

24. 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

25. 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.

26. Chronic Pancreatitis Clinical 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

27. Chronic Pancreatitis Clinical Manifestations Complications include Pseudocyst formation Bile duct or duodenal obstruction Pancreatic ascites Pleural effusion Splenic vein thrombosis Pseudoaneurysms Pancreatic cancer

28. Chronic Pancreatitis Diagnostic Studies Laboratory tests Serum amylase/lipase May be ↑ slightly or not at all ↑ Serum bilirubin ↑ Alkaline phosphatase Mild leukocytosis Elevated sedimentation rate

29. Chronic Pancreatitis Diagnostic Studies CT MRI MRCP Transabdominal ultrasound Endoscopic ultrasound Secretin stimulation test ERCP

30. 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

31. Chronic Pancreatitis Treatment 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)

32. Chronic Pancreatitis Home/Ambulatory Care Focus is on chronic care and health promotion Dietary control No alcohol Control of diabetes Taking pancreatic enzymes Patient and family teaching

33. 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

34. The End