1. PANCREATITIS ACC, RNSG 1247

2. Acute Pancreatitis Definition & Etiology An acute inflammatory process of the pancreas Degree of inflammation varies from mild to edema to severe necrosis Most common in middle-age African American rate three times higher than for whites

3. Acute Pancreatitis Etiology and Pathophysiology Primary etiologic factors are Biliary tract disease Most common: Gallbladder disease Alcoholism * May stimulate production of digestive enzymes

4. Pancreatitis from gallstones

5. Acute Pancreatitis Etiology and Pathophysiology Caused by auto digestion of pancreas Etiologic factors Injury to pancreatic cells Activate pancreatic enzymes

6. Acute Pancreatitis Fig. 44-14

7. (AP) Acute Pancreatitis Etiology and 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

8. Acute Pancreatitis Etiology and Pathophysiology Edematous pancreatitis Mild and self-limiting Necrotizing pancreatitis Degree of necrosis correlates with severity of manifestations

9. 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

10. 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

11. Acute Pancreatitis Complications Two significant local complications Pseudocyst Abscess

12. 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

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 Pancreatis: Goals of Care Relieve pain Prevent or alleviate shock Reduce pancreatic secretions Maintain fluid and electrolyte balance Remove precipitating cause

18. Acute Pancreatitis: Treatment and Nursing Care 1. Pain management –IV morphine –Combined with antispasmodic agent 2. Prevention of Shock - Plasma or volume expanders - LR solution 3. Suppress pancreatic enzymes - NPO, NG suction, antacids, H2 receptor antagonist 4. Antibiotics

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

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 Follow up care Dietary teaching High-carbohydrate, low-fat diet Abstinence from alcohol, 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 Etiology and Pathophysiology Chronic obstructive pancreatitis Associated with biliary disease Most common cause –Inflammation of the sphincter of Oddi associated with cholelithiasis Other causes include Cancer of ampulla of Vater, duodenum, or pancreas

26. Chronic Pancreatitis Etiology and Pathophysiology Chronic calcifying pancreatitis Also called alcoholic induced Inflammation and sclerosis Mainly in the head of the pancreas and around the pancreatic duct *** Ducts are obstructed with protein precipitates which block the pancreatic duct causing it to calcify then fibrosed and atrophied.

27. 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

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

29. 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

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

31. Chronic Pancreatitis Goals of Care Prevention of attacks During acute attack follow acute therapy Relief of pain Control of pancreatic exocrine and endocrine insufficiency Bland, low-fat, high-carbohydrate diet

32. Chronic Pancreatitis Treatment and Nursing Care Cont. Bile salts Control of diabetes No alcohol Pancreatic enzyme replacement Acid-neutralizing and acid-inhibiting drugs

33. Chronic Pancreatitis Treatment and Nursing Care Surgery Indicated when biliary disease is present or if obstruction or pseudocyst develops Divert bile flow or relieve ductal obstruction

34. 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

35. The End