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Pancreatitis Overview Inflammation of the pancreas Occurs in acute and chronic forms, with 10% to 15% mortality rate in the acute form Irreversible tissue damage with the chronic form, which tends to progress to significant pancreatic function loss Possibly idiopathic, but sometimes associated with biliary tract disease, alcoholism, trauma, and certain drugs Pathophysiology The exact trigger or mechanism to initiate enzyme activation is unknown. Common bile duct blockage from gallstones leads to reflux of juices back into the pancreas after initial release. Acute Pancreatitis Enzymes normally excreted into the duodenum by the pancreas are activated in the pancreas or its ducts and start to autodigest pancreatic tissue. (See Necrotizing pancreatitis.) Consequent inflammation causes intense pain, third spacing of large fluid volumes, pancreatic fat necrosis with consumption of serum calcium and, occasionally, hemorrhage. Chronic Pancreatitis Progressive inflammatory changes lead to permanent structural damage. Exocrine and endocrine functions of the pancreas are disrupted. Necrotizing pancreatitis The illustration below shows the cell death and tissue damage in necrotizing pancreatitis. Causes Idiopathic Genetic mutations Risk Factors Acute Pancreatitis Alcohol abuse Postendoscopic retrograde cholangiography Abdominal trauma Smoking Obstruction of the ampulla Hypertriglyceridemia Hypercalcemia Drugs, such as sulfonamides, diuretics, didanosine, and pentamidine Infections such as mumps, hepatitis B, cytomegalovirus, Mycoplasma, and Aspergillus Blunt or penetrating trauma Abnormal organ structure Chronic Pancreatitis Alcohol abuse Genetic mutations Ductal obstruction Systemic diseases, such as systemic lupus erythematosus and hypertriglyceridemia Autoimmune response Incidence Acute pancreatitis occurs in more than 200,000 people each year. Chronic pancreatitis occurs in approximately 87,000 individuals each year. Acute or chronic pancreatitis affects men slightly more commonly than women. Acute pancreatitis can occur at any age; chronic pancreatitis commonly affects those older than age 45. Complications Diabetes mellitus Massive hemorrhage Shock and coma Acute respiratory distress syndrome Atelectasis and pleural effusion Pneumonia Paralytic ileus GI bleeding or obstruction Pancreatic abscess and cancer Pseudocysts Renal failure Assessment History Sudden, steady, intense epigastric pain centered close to the umbilicus and radiating to the back, between the 10th thoracic and 6th lumbar vertebrae (acute); intermittent or constant dull, severe pain in mid- to upper left abdomen, possibly radiating to the back and lasting for several hours (chronic); improvement in pain when lying down (acute) Pain aggravated by fatty foods, alcohol consumption (chronic), or walking or lying down and relieved by sitting up or leaning forward (acute) Nausea, vomiting Weight loss (chronic) Predisposing factor History of alcohol or medication use Bloating (acute) Diarrhea (acute) Physical Findings Hypotension Tachycardia Fever Dyspnea, orthopnea Pleural effusion Generalized jaundice Hypoactive bowel sounds Cullen sign (bluish periumbilical discoloration) Turner sign (bluish flank discoloration) Steatorrhea (with chronic pancreatitis) Abdominal tenderness, distention, rigidity, and guarding Diagnostic Test Results Laboratory In Acute Pancreatitis Amylase (serum) level test and lipase test results are elevated. White blood cell count is elevated; hematocrit may be elevated. Bilirubin level test is elevated. Transient hyperglycemia and glycosuria are present. C-reactive protein test is elevated. Amylase (urine) level test is increased. Serum alanine aminotransferase level test, aspartate aminotransferase level test, and alkaline phosphatase level test results are mildly elevated when alcoholic hepatitis or choledocholithiasis is present. In Chronic Pancreatitis Serum alkaline phosphatase level test and bilirubin level test results are elevated. Amylase (serum) level test and lipase test results may be normal or decreased. Serum glucose level is transiently elevated. Lipid and trypsin levels in stools are elevated. Complete blood count is normal. Imaging Abdominal and chest radiography differentiate pancreatitis from other diseases that cause similar symptoms; they also detect pleural effusions. Computed tomography scanning (abdomen and pelvis) and ultrasonography (pancreas) show increased pancreatic diameter, pancreatic calcification, pancreatic cysts, and pseudocysts. Diagnostic Procedures Endoscopic retrograde cholangiopancreatography (ERCP) shows pancreatic anatomy, identifies ductal system abnormalities, and differentiates pancreatitis from other disorders. Treatment General Emergency treatment of shock, as needed; vigorous I.V. replacement of fluid, electrolytes, and proteins (acute) Blood transfusions (for hemorrhage) Nasogastric suctioning Venous thromboembolism (VTE) prophylaxis Diet Nothing by mouth (NPO) Once crisis starts to resolve, oral feedings high in carbohydrate and low in fat and protein, implemented gradually, for the acute form, or low in fat and high in protein and calories for the chronic form Total parenteral nutrition, if oral intake isn't tolerated Alcohol and caffeine abstention Activity As tolerated Medications Acute Pancreatitis Analgesics, such as meperidine hydrochloride (Demerol) I.V. or I.M (acute), acetaminophen (Tylenol), and tramadol hydrochloride (Ultram); hydromorphone hydrochloride (Dilaudid) or fentanyl citrate (Sublimaze) via patient-controlled analgesia Antibiotics (acute), such as imipenem-cilastatin sodium (Primaxin) or meropenem (Merrem IV) Supplemental oxygen, as appropriate Chronic Pancreatitis Analgesics, such as acetaminophen (Tylenol), acetaminophen oxycodone hydrochloride (Percocet), acetaminophen hydrocodone bitartrate (Vicodin); morphine sulfate continuous release or fentanyl transdermal system (Duragesic) for persistent pain Pancreatic enzyme supplements Octreotide acetate (Sandostatin) to reduce exocrine secretion Medium-chain triglycerides for fat malabsorption Fat-soluble vitamin supplementation Insulin therapy to address glucose intolerance Surgery Not indicated in acute pancreatitis unless complications occur For chronic pancreatitis: Sphincterotomy, duct drainage, or pancreatectomy Pancreaticojejunostomy Endoscopic or percutaneous aspiration of pseudocysts (when symptomatic or larger than 7 cm) Nursing Considerations Nursing Diagnoses Acute pain Anxiety Chronic pain Decreased cardiac output Deficient fluid volume Deficient knowledge: Disease process Deficient knowledge: Treatment Diarrhea Disturbed body image Hopelessness Hyperthermia Imbalanced nutrition: Less than body requirements Impaired comfort Impaired gas exchange Ineffective breathing pattern Ineffective coping Nausea Risk for electrolyte imbalance Risk for impaired skin integrity Risk for injury Risk for unstable blood glucose level Risk-prone health behavior Expected Outcomes The patient will: verbalize feelings of increased comfort and decreased pain express feelings of decreased anxiety and fear maintain normal cardiac function and hemodynamic stability relate an increased understanding of the disease process and treatment maintain normal fluid volume and electrolyte balance regain or maintain normal gastrointestinal motility express positive feelings about self participate in decisions about care achieve adequate caloric and nutritional intake maintain an effective breathing pattern and adequate gas exchange maintain skin integrity avoid complications and injury maintain normal blood glucose levels comply with a healthy life style. Nursing Interventions Administer parenteral morphine or meperidine, as ordered; ensure patent I.V. access if given I.V. Give I.V. fluid therapy, as ordered. Use nonpharmacologic measures to assist with pain relief, such as distraction, imagery, and progressive muscle relaxation. Administer pancreatic enzyme replacements with meals (chronic). Obtain fingerstick blood glucose levels and administer insulin, as ordered (chronic). Encourage the patient to express his feelings and concerns; provide emotional support. Maintain NPO status until pain and tenderness resolve and GI motility returns. Assist with insertion or insert a nasogastric (NG) tube for decompression; provide NG tube care; maintain NG suction, as ordered; observe the characteristics of NG tube drainage. Administer enteral or parenteral nutrition, as ordered. When oral intake is allowed, provide small, frequent meals; advance the diet, as tolerated. Obtain daily weights. Insert an indwelling urinary catheter, if indicated, to evaluate urine output and renal function. Position the patient with the head of the bed elevated to ease the work of breathing; encourage coughing and deep breathing and incentive spirometry; administer supplemental oxygen, as indicated by oxygen saturation levels via pulse oximetry. Reposition the patient every two hours, and provide skin care to prevent pressure ulcer formation. Apply antiembolism stockings or sequential compression stockings to prevent VTE. Obtain specimens for laboratory testing to evaluate pancreatic enzyme levels, glucose levels, and overall fluid and electrolyte status. Prepare the patient with chronic pancreatitis and his family for possible surgery. Monitoring Vital signs NG tube function and drainage Respiratory status Acid-base balance Serum glucose level Amylase and lipase levels Fluid and electrolyte balance Daily weight Pain level and effectiveness of interventions Nutritional status and metabolic requirements Renal function Postoperative status, as appropriate Associated Nursing Procedures Alignment and pressure-reducing device application Antiembolism stocking application, knee-length Antiembolism stocking application, thigh-length Assessment techniques Blood glucose monitoring Blood pressure assessment Cardiac monitoring Health history interview and physical assessment Incentive spirometry Indwelling urinary catheter (Foley) care and management Indwelling urinary catheter (Foley) insertion, female Indwelling urinary catheter (Foley) insertion, male Indwelling urinary catheter (Foley) removal Informed consent IV bag preparation IV bolus injection IV catheter insertion IV catheter removal IV dressing change IV pump use IV secondary line drug infusion IV solution change IV tubing change Intake and output assessment Nasogastric tube insertion Nasogastric tube irrigation Nasogastric tube monitoring Nasogastric tube removal Oral care Oxygen administration Pain assessment Pain management Pressure ulcer prevention Pulse assessment Pulse oximetry Relaxation and stress management techniques Respiration assessment Safe medication administration practices, general Sequential compression therapy Standard precautions Stool specimen collection, random Surgical wound dressing application Temperature assessment Urine specimen collection, random Venipuncture Weight measurement Wound assessment Patient Teaching General Be sure to cover: disorder, possible underlying causes, diagnostic tests, and treatment, including the need for I.V. fluids, NPO status, and pain control, as appropriate identification and avoidance of acute pancreatitis triggers dietary needs, including small, frequent meals that are high in carbohydrates and low in fat and protein (acute pancreatitis) or small, low-protein, high-calorie meals (chronic pancreatitis), and appropriate food choices signs and symptoms of recurrence of pancreatitis and the need to notify the practitioner immediately prescribed medication therapy, such as pancreatic enzyme supplements as treatment for chronic pancreatitis; the need to take pancreatic enzymes before or with meals and snacks technique for insulin administration, if appropriate, for the patient with chronic pancreatitis importance of abstaining from alcohol ingestion need for smoking cessation need for continued follow-up, including laboratory testing to evaluate the effectiveness of therapy. Discharge Planning Refer the patient to appropriate community resource and support services, as needed. Refer the patient to an alcohol rehabilitation program or smoking cessation program, as appropriate. INSERT_HANDOUTS Resources Alcoholics Anonymous: www.aa.org American Pancreatic Association: www.american-pancreatic-association.org Digestive Disease National Coalition: www.ddnc.org National Digestive Diseases Information Clearinghouse: http://digestive.niddk.nih.gov National Pancreas Foundation:http://pancreasfoundation.org American Gastroenterological Association: http://www.gastro.org/patientcenter/digestive-conditions/pancreatitis Selected References 1. Ahmed Ali, U., et al. (2015). Endoscopic or surgical intervention for painful obstructive chronic pancreatitis. Cochrane Database of Systematic Reviews, 2015(3), CD007884. (Level I) 2. Dorlon, M., et al. (2013). Increase in postoperative insulin requirements does not lead to decreased quality of life after total pancreatectomy with islet cell autotransplantation for chronic pancreatitis. The American Surgeon, 79(7), 676–680. Abstract | Complete Reference 3. Freedman, S. D. Clinical manifestations and diagnosis of chronic pancreatitis in adults. (2014). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 4. Freedman, S. D. Complications of chronic pancreatitis. (2013). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 5. Freedman, S. D., & Lewis, M. D. Etiology and pathogenesis of chronic pancreatitis in adults. (2013). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 6. Freedman, S. D. Treatment of chronic pancreatitis. (2013). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 7. Gardner, T. B. (2015). “Acute pancreatitis” [Online]. Accessed April 12, 2015 via the Web at http://emedicine.medscape.com/article/181364-overview 8. Gelrud, A., & Whitcomb, D. C. Hypertriglyceridemia-induced acute pancreatitis. (2015). In: UpToDate, Friedman, L. S. (Ed.). Retrieved from: www.uptodate.com 9. Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses: Definitions & Classification 2015–2017. Oxford: Wiley Blackwell. 10. Huffman, J. L. (2015). “Chronic pancreatitis” [Online]. Accessed April 12, 2015 via the Web at http://emedicine.medscape.com/article/181554-overview 11. Khoury, G. (2013). “Emergent management of pancreatitis” [Online]. Accessed April 20, 2014 via the Web at http://emedicine.medscape.com/article/775867-overview 12. Lim, C. L., et al. (2015). Role of antibiotic prophylaxis in necrotizing pancreatitis: A meta-analysis. Journal of Gastrointestinal Surgery, 19(3), 480–491. (Level I) Abstract | Complete Reference 13. Nettina, S. (2014). Lippincott manual of nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer. 14. Njgaard, C., et al. (2013). Update of exocrine functional diagnostics in chronic pancreatitis. Clinical Physiology and Functional Imaging, 33(3), 167–172. Abstract | Complete Reference 15. Ona, X. B., et al. (2013). Opioids for acute pancreatitis pain. Cochrane Database of Systematic Reviews, 2013(7), CD009179. (Level I) 16. Phillip, V., et al. (2013). Time period from onset of pain to hospital admission and patients' awareness in acute pancreatitis. Pancreas, 42(4), 647–654. Abstract | Complete Reference 17. Swaroop Vege, S. Clinical manifestations and diagnosis of acute pancreatitis. (2014). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 18. Swaroop Vege, S. Etiology of acute pancreatitis. (2013). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 19. Swaroop Vege, S. Management of acute pancreatitis. (2014). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com 20. Swaroop Vege, S. Predicting the severity of acute pancreatitis. (2013). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com