Download Acute Pancreatitis

Focus on
Pancreatitis
(Relates to Chapter 44,
“Nursing Management:
Liver, Pancreas, and Biliary Tract Problems”
in the textbook)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Acute Pancreatitis
• An acute inflammatory process of
the pancreas
• Degree of inflammation varies from
mild edema to severe necrosis.
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2
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.
• African American rate 3 times higher
than that of whites
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Acute Pancreatitis
Etiology and Pathophysiology
• Primary etiologic factors are
• Biliary tract disease
• Most common in women
• Alcoholism
• Most common in men
• Hypertriglyceridemia
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Acute Pancreatitis
Etiology and Pathophysiology
• Less common causes
• Trauma (postsurgical, abdominal)
• Viral infection
• Penetrating duodenal ulcer
• Cysts
• Idiopathic causes
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Acute Pancreatitis
Etiology and Pathophysiology
• Less common causes (cont’d)
• Abscesses
• Cystic fibrosis
• Kaposi sarcoma
• Metabolic disorders
• Vascular diseases
• Postop GI surgery
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Acute Pancreatitis
Etiology and Pathophysiology
• Less common causes (cont’d)
• Drugs
• Corticosteroids
• Thiazide diuretics
• Oral contraceptives
• Sulfonamides
• NSAIDs
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Acute Pancreatitis
Etiology and Pathophysiology
• Caused by autodigestion of pancreas
• Etiologic factors
• Injury to pancreatic cells
• Activation of pancreatic enzymes
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Acute Pancreatitis
Fig. 44-13. Pathogenic process of acute pancreatitis. GI, Gastrointestinal.
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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.
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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
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Acute Pancreatitis
Etiology and Pathophysiology
• Phospholipase A
• Plays a major role in autodigestion
• Activated by trypsin and bile acids
• Causes fat necrosis
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Acute Pancreatitis
Etiology and Pathophysiology
Trypsin
Elastase
Edema, necrosis,
hemorrhage
Hemorrhage
Phospholipase A Fat necrosis
Kallikrein
Edema, vascular
permeability, smooth
muscle contraction, shock
Lipase
Fat necrosis
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Acute Pancreatitis
Etiology and Pathophysiology
• Alcohol
• May stimulate production of digestive
enzymes
• Increases sensitivity to hormone
cholecystokinin
• Stimulates production of pancreatic
enzymes
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Acute Pancreatitis
Etiology and Pathophysiology
• Edematous pancreatitis
• Mild and self-limiting
• Necrotizing pancreatitis
• Degree of necrosis correlates with
severity of manifestations.
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Acute Pancreatitis
Fig. 44-14. In acute pancreatitis, the pancreas appears edematous and is commonly
hemorrhagic (H).
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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
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Acute Pancreatitis
Clinical Manifestations
• Abdominal pain (cont’d)
• Sudden onset
• Severe, deep, piercing, steady
• Aggravated by eating
• Onset when recumbent
• Not relieved by vomiting
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Acute Pancreatitis
Clinical Manifestations
•
•
•
•
•
•
Flushing
Cyanosis
Dyspnea
Edema
Nausea/vomiting
Bowel sounds decreased or absent
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Acute Pancreatitis
Clinical Manifestations
•
•
•
•
•
•
Low-grade fever
Leukocytosis
Hypotension
Tachycardia
Jaundice
Abdominal tenderness
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Acute Pancreatitis
Clinical Manifestations
• Abnormal lung sounds
• Crackles
• Discoloration of abdominal wall
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21
Acute Pancreatitis
Complications
• Two significant local complications
• Pseudocyst
• Abscess
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Acute Pancreatitis
Complications
• Pseudocyst
• Cavity surrounding outside of pancreas
filled with necrotic products and liquid
secretions
• Abdominal pain
• Palpable epigastric mass
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Acute Pancreatitis
Complications
• Pseudocyst (cont’d)
• Nausea, vomiting, and anorexia
• Elevated serum amylase
• May resolve spontaneously within a
few weeks, or may perforate, causing
peritonitis
• Treatment: Internal drainage
procedure
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Acute Pancreatitis
Complications
• Pancreatic abscess
• A large fluid-containing cavity within
the pancreas
• Results from extensive necrosis in the
pancreas
• Upper abdominal pain
• Abdominal mass
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Acute Pancreatitis
Complications
• Pancreatic abscess (cont’d)
• High fever
• Leukocytosis
• Requires surgical drainage
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Acute Pancreatitis
Complications
• Main systemic complications
• Pulmonary
• Pleural effusion
• Atelectasis
• Pneumonia
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Acute Pancreatitis
Complications
• Systemic complications (cont’d)
• Cardiovascular
• Hypotension
• Tetany (caused by hypocalcemia)
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Acute Pancreatitis
Diagnostic Studies
• Laboratory tests
• Serum amylase
• Serum lipase
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Acute Pancreatitis
Diagnostic Studies
• Laboratory tests (cont’d)
• Liver enzymes
• Blood glucose
• Triglycerides
• Bilirubin
• Serum calcium
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Acute Pancreatitis
Diagnostic Studies
•
•
•
•
Abdominal/endoscopic ultrasound
X-ray
Contrast-enhanced CT scan
Endoscopic retrograde
cholangiopancreatography (ERCP)
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Acute Pancreatitis
Diagnostic Studies
• Endoscopic ultrasound
• Magnetic resonance
cholangiopancreatography (MRCP)
• Chest x-ray
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Acute Pancreatitis
Collaborative Care
• Objectives include
• Relief of pain
• Prevention or alleviation of shock
• ↓ of pancreatic secretions
• Fluid/electrolyte balance
• Prevention/treatment of infection
• Removal of the precipitating cause
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Acute Pancreatitis
Collaborative Care
• Conservative therapy
• Supportive care
• Aggressive hydration
• Pain management
• IV morphine
• Combined with antispasmodic agent
• Management of metabolic complications
• Minimizing stimulation
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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)
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Acute Pancreatitis
Collaborative Care
• Conservative therapy (cont’d)
• Suppression of pancreatic enzymes
• NPO
• NG suction
• Prevent infections
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Acute Pancreatitis
Collaborative Care
• Surgical therapy indicated if
• Presence of gallstones
• Uncertain diagnosis
• Unresponsive to conservative therapy
• Abscess, pseudocyst, or severe
peritonitis
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Acute Pancreatitis
Collaborative Care
• Surgical therapy
• ERCP
• Endoscopic sphincterotomy
• Laparoscopic cholecystectomy
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Acute Pancreatitis
Collaborative Care
• Drug therapy
• IV morphine
• Nitroglycerin or papaverine
• Antispasmodics
• Carbonic anhydrase inhibitors
• Antacids
• Histamine (H2) receptor blockers
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Acute Pancreatitis
Collaborative Care
• Nutritional therapy
• NPO status initially to reduce
pancreatic secretion
• IV lipids
• Monitor triglycerides.
• Small, frequent feedings
• High-carbohydrate, low-fat,
high-protein diet
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Acute Pancreatitis
Collaborative Care
• Nutritional therapy (cont’d)
• Supplemental fat-soluble vitamins
• No alcohol
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Acute Pancreatitis
Nursing Assessment
• Health history
• Biliary tract disease
• Alcohol use
• Abdominal trauma
• Duodenal ulcers
• Infection
• Metabolic disorders
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Acute Pancreatitis
Nursing Assessment
• Medication usage
• Thiazides, estrogens, corticosteroids,
NSAIDs
•
•
•
•
Surgical procedures
Nausea/vomiting
Dyspnea
Severe pain
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Acute Pancreatitis
Nursing Assessment
• Physical examination findings
• Fever
• Jaundice
• Discoloration of abdomen/flank
• Tachycardia
• Hypotension
• Abdominal distention/tenderness
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Acute Pancreatitis
Nursing Assessment
• Abnormal laboratory findings
• ↑ serum amylase/lipase
• Leukocytosis
• Hyperglycemia
• Hyperlipidemia
• Hypocalcemia
• Abnormal ultrasound/CT/ERCP
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Acute Pancreatitis
Nursing Diagnoses
• Acute pain
• Deficient fluid volume
• Imbalanced nutrition: Less than
body requirements
• Ineffective self-health management
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Acute Pancreatitis
Planning
• Overall goals
• Relief of pain
• Normal fluid and electrolyte balance
• Minimal to no complications
• No recurrent attacks
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48
Acute Pancreatitis
Nursing Implementation
• Health promotion
• Assessment of predisposing factors
• Early diagnosis/treatment of
cholelithiasis
• Elimination of alcohol intake
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Acute Pancreatitis
Nursing Implementation
• Acute intervention
•
•
•
•
•
Monitoring vital signs
IV fluids
Observation of side effects of medications
Assessment of respiratory function
Pain assessment and management
• Frequent position changes
• Side-lying with HOB elevated 45 degrees
• Knees up to abdomen
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Acute Pancreatitis
Nursing Implementation
• Acute intervention (cont’d)
• Fluid/electrolyte balance
• Blood glucose monitoring
• Monitoring for signs of hypocalcemia
• Tetany (jerking, irritability, twitching)
• Numbness around lips/fingers
• Positive Chvostek’s or Trousseau’s sign
• Monitoring for hypomagnesemia
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Acute Pancreatitis
Nursing Implementation
• Acute intervention (cont’d)
• NG tube care
• Frequent oral/nasal care
• Observation for signs of infection
• Wound care
• Observation for paralytic ileus, renal
failure, mental changes
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Acute Pancreatitis
Nursing Implementation
• Ambulatory and home care
• Physical therapy
• Counseling regarding abstinence from
alcohol, caffeine, and smoking
• Assessment of narcotic addiction
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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
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Acute Pancreatitis
Nursing Implementation
• Expected outcomes
• Have adequate pain control
• Maintain adequate fluid volume
• Be knowledgeable about treatment
regimen
• Get help for alcohol dependence, if
appropriate
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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.
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Chronic Pancreatitis
Etiology and Pathophysiology
• May follow acute pancreatitis
• May occur in the absence of any
history of an acute condition
• Two major types
• Chronic obstructive pancreatitis
• Chronic nonobstructive pancreatitis
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Chronic Pancreatitis
Etiology and Pathophysiology
• Chronic obstructive pancreatitis
• Associated with biliary disease
• Most common cause of this type
• Inflammation of the sphincter of Oddi
associated with cholelithiasis
• Other causes include
• Cancer of ampulla of Vater, duodenum, or
pancreas
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Chronic Pancreatitis
Etiology and Pathophysiology
• Chronic nonobstructive pancreatitis
• Inflammation
• Sclerosis
• Mainly in the head of the pancreas and
around the pancreatic duct
• Most common form of chronic
pancreatitis
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59
Chronic Pancreatitis
Clinical Manifestations
• Abdominal pain
• Located in the same areas as in acute
pancreatitis
• Heavy, gnawing feeling; burning and
cramplike
• Abdominal tenderness
• Malabsorption with weight loss
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60
Chronic Pancreatitis
Clinical Manifestations
•
•
•
•
•
Constipation
Mild jaundice with dark urine
Steatorrhea
Frothy urine/stool
Diabetes mellitus
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61
Chronic Pancreatitis
Clinical Manifestations
• Complications include
• Pseudocyst formation
• Bile duct or duodenal obstruction
• Pancreatic ascites
• Pleural effusion
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62
Chronic Pancreatitis
Clinical Manifestations
• Complications (cont’d)
• Splenic vein thrombosis
• Pseudoaneurysm
• Pancreatic cancer
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63
Chronic Pancreatitis
Diagnostic Studies
• Confirming diagnosis can be
challenging.
• Based on signs/symptoms,
laboratory studies, and imaging
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64
Chronic Pancreatitis
Diagnostic Studies
• Laboratory tests
• Serum amylase/lipase
• May be ↑ slightly or not at all
• ↑ serum bilirubin
• ↑ alkaline phosphatase
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65
Chronic Pancreatitis
Diagnostic Studies
• Laboratory tests (cont’d)
• Mild leukocytosis
• Elevated sedimentation rate
• ERCP
• Visualization of pancreatic/common
bile duct
• Stool samples
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66
Chronic Pancreatitis
Diagnostic Studies
•
•
•
•
•
CT
MRI
MRCP
Transabdominal ultrasound
EUS
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67
Chronic Pancreatitis
Diagnostic Studies
• Secretin stimulation test
• Assessment of degree of pancreatic
function
• Not useful in diagnosis
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68
Chronic Pancreatitis
Collaborative Care
• Prevention of attacks
• During acute attack, follow acute
therapy.
• Relief of pain
• Control of pancreatic exocrine and
endocrine insufficiency
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69
Chronic Pancreatitis
Collaborative Care
• Bland low-fat, high-carbohydrate
diet
• Bile salts
• Help absorption of fat-soluble vitamins
• Prevent further fat loss
• Control of diabetes
• No alcohol
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Chronic Pancreatitis
Collaborative Care
• Pancreatic enzyme replacement
• Acid-neutralizing and acid-inhibiting
drugs
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Chronic Pancreatitis
Collaborative Care
• Surgery
• Indicated when biliary disease is
present, or if obstruction or
pseudocyst develops
• Diverts bile flow or relieves ductal
obstruction
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72
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
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73
Audience Response Question
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:
1. Antibiotics.
2. NPO status.
3. Antispasmodics.
4. H2R blockers or proton pump inhibitors.
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Case Study
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75
Case Study
• 63-year-old woman 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 midback.
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Case Study
• Pain began 24 hours ago.
• She is divorced and retired, and smokes
a half-pack of cigarettes a day.
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Case Study
• Vital signs
• Blood pressure 100/70
• Heart rate 97
• Respiratory rate 30
• Temperature 100.2°F
• She is diagnosed with acute pancreatitis
and is admitted to the medical-surgical
unit.
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Discussion Questions
1. What are the possible causes of
pancreatitis?
2. What is her priority of care?
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Discussion Questions
3. What laboratory tests are the most
important to monitor in acute
pancreatitis?
4. What patient teaching should you do
with her?
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