Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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 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 It affects women and men equally. Some patients recover completely, others have recurring attacks, and chronic pancreatitis develops in others. Acute pancreatitis can be life threatening. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary etiologic factors are Biliary tract disease Most common in women Alcoholism Most common in men Hypertriglyceridemia In the United States, the most common cause is gallbladder disease (gallstones), followed by chronic alcohol intake. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Less common causes Trauma (postsurgical, abdominal) Viral infection Penetrating duodenal ulcer Cysts Idiopathic causes Examples of viral infection include mumps, coxsackievirus B, and HIV. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Less common causes (cont’d) Abscesses Cystic fibrosis Kaposi sarcoma Metabolic disorders Vascular diseases Postop GI surgery Examples of metabolic disorders include hyperparathyroidism and renal failure. Pancreatitis may occur after surgical procedures on the pancreas, stomach, duodenum, or biliary tract are performed. Pancreatitis can also occur after ERCP. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Caused by autodigestion of pancreas Etiologic factors Injury to pancreatic cells Activation of pancreatic enzymes {See next slide for figure.} It is not clear how the activation of pancreatic enzymes occurs. One possible cause is the reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi. This reflux may be due to blockage created by gallstones. Obstruction of pancreatic ducts results in pancreatic ischemia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Trypsinogen Activated to trypsin by enterokinase Inhibitors usually inactivate trypsin. Enzyme can digest the pancreas and can activate other proteolytic enzymes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Trypsin Edema, necrosis, hemorrhage Elastase Hemorrhage Phospholipase A Fat necrosis Kallikrein Edema, vascular permeability, smooth muscle contraction, shock Lipase Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Alcohol May stimulate production of digestive enzymes Increases sensitivity to hormone cholecystokinin Stimulates production of pancreatic enzymes Approximately 5% to 10% of alcohol abusers develop pancreatitis. This suggests that environmental (high-fat diet, smoking) and genetic factors may contribute. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Edematous pancreatitis Mild and self-limiting Necrotizing pancreatitis Degree of necrosis correlates with severity of manifestations. Those patients with severe pancreatitis are at high risk of developing pancreatic necrosis, organ failure, and septic complications, resulting in a 25% mortality rate. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis In acute pancreatitis, the pancreas appears edematous and is commonly hemorrhagic (H). Fig In acute pancreatitis, the pancreas appears edematous and is commonly hemorrhagic (H). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Abdominal pain (cont’d) Sudden onset Severe, deep, piercing, steady Aggravated by eating Onset when recumbent Not relieved by vomiting The patient may assume various positions involving flexion of the spine in an attempt to relieve the severe pain. The pain is due to distention of the pancreas, peritoneal irritation, and obstruction of the biliary tract. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Abnormal lung sounds Crackles Discoloration of abdominal wall Intravascular damage from circulating trypsin may cause areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall. Other areas of ecchymoses are the flanks (Grey Turner’s spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen’s sign, a bluish periumbilical discoloration). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis Complications
Two significant local complications Pseudocyst Abscess Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pseudocyst Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions Abdominal pain Palpable epigastric mass As pancreatic enzymes escape from the pseudocyst, the serosal surfaces next to the pancreas become inflamed, with subsequent formation of granulation tissue leading to encapsulation of the exudate. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pancreatic abscess A large fluid-containing cavity within the pancreas Results from extensive necrosis in the pancreas Upper abdominal pain Abdominal mass Abscess may become infected or may perforate into adjacent organs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Main systemic complications Pulmonary Pleural effusion Atelectasis Pneumonia Pulmonary complications are likely due to the passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Systemic complications (cont’d) Cardiovascular Hypotension Tetany (caused by hypocalcemia) When hypocalcemia occurs, it is a sign of severe disease. It is due in part to the combining of calcium and fatty acids during fat necrosis. The exact mechanisms of how or why hypocalcemia occurs are not well understood. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis Diagnostic Studies
Laboratory tests Serum amylase Serum lipase The primary diagnostic tests for acute pancreatitis are serum amylase and lipase. The serum amylase level is usually elevated early and remains elevated for 24 to 72 hours. Serum lipase level is also elevated in acute pancreatitis and is an important test because other disorders (e.g., mumps, cerebral trauma, renal transplantation) may increase serum amylase levels. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Abdominal/endoscopic ultrasound X-ray Contrast-enhanced CT scan Endoscopic retrograde cholangiopancreatography (ERCP) CT scan is the best imaging test for pancreatitis and related complications such as pseudocysts and abscesses. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Endoscopic ultrasound Magnetic resonance cholangiopancreatography (MRCP) Chest x-ray Chest x-rays may show pulmonary changes, including atelectasis and pleural effusion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Conservative therapy Supportive care Aggressive hydration Pain management IV morphine Combined with antispasmodic agent Management of metabolic complications Minimizing stimulation Atropine-like drugs should be avoided when paralytic ileus is present because they may contribute to the problem. Other medications that relax smooth muscles (spasmolytics), such as nitroglycerin or papaverine, may be used. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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) Central venous pressure readings may be used to assist in determination of fluid replacement requirements. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Conservative therapy (cont’d) Suppression of pancreatic enzymes NPO NG suction Prevent infections Pancreatic infection is the leading cause of morbidity and mortality in patients with acute pancreatitis. Therefore it is important to prevent infections. Some controversy remains about the prophylactic use of antibiotics. It is important to monitor the patient closely, so that antibiotic therapy can be instituted early if infection occurs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgical therapy indicated if Presence of gallstones Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst, or severe peritonitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgical therapy ERCP Endoscopic sphincterotomy Laparoscopic cholecystectomy When the acute pancreatitis is related to the presence of gallstones, an urgent ERCP plus endoscopic sphincterotomy may be performed. This may be followed by laparoscopic cholecystectomy to reduce the potential for recurrence. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug therapy IV morphine Nitroglycerin or papaverine Antispasmodics Carbonic anhydrase inhibitors Antacids Histamine (H2) receptor blockers See Table for information on medications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nutritional therapy NPO status initially to reduce pancreatic secretion IV lipids Monitor triglycerides. Small, frequent feedings High-carbohydrate, low-fat, high-protein diet Depending on the severity of the pancreatitis, enteral feedings via nasojejunal tube are initiated. Because of infection risk, parenteral nutrition is reserved for patients who cannot tolerate enteral nutrition. Once food is allowed, suspect intolerance to oral foods when the patient reports pain, exhibits increasing abdominal girth, or has elevations in serum amylase and lipase levels. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis Nursing Assessment
Health history Biliary tract disease Alcohol use Abdominal trauma Duodenal ulcers Infection Metabolic disorders Subjective and objective data that should be obtained from a person with acute pancreatitis are presented in Table Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Abnormal laboratory findings ↑ serum amylase/lipase Leukocytosis Hyperglycemia Hyperlipidemia Hypocalcemia Abnormal ultrasound/CT/ERCP Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis Nursing Diagnoses
Acute pain Deficient fluid volume Imbalanced nutrition: Less than body requirements Ineffective self-health management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis Planning
Overall goals Relief of pain Normal fluid and electrolyte balance Minimal to no complications No recurrent attacks Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Acute Pancreatitis Nursing Implementation
Health promotion Assessment of predisposing factors Early diagnosis/treatment of cholelithiasis Elimination of alcohol intake Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Frequent vomiting, along with gastric suction, may result in decreased chloride, sodium, and potassium levels. Pain and restlessness can increase the metabolic rate and subsequent stimulation of pancreatic enzymes. Measures such as comfortable positioning, frequent changes in position, and relief of nausea and vomiting assist in reducing the restlessness that usually accompanies the pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Calcium gluconate (as ordered) should be given to treat symptomatic hypocalcemia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 If the patient is taking anticholinergics to decrease GI secretions, additional dryness of the mouth will be noted. If the patient is taking antacids to neutralize gastric acid secretion, they should be sipped slowly or inserted into the NG tube. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths. Measures to prevent respiratory infection include turning, coughing, deep breathing, and assuming a semi-Fowler’s position. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory and home care Physical therapy Counseling regarding abstinence from alcohol, caffeine, and smoking Assessment of narcotic addiction Because frequent doses of opioids may be required for this patient during the acute stage, follow-up for assessment of possible opioid addiction may be indicated. This is a more likely problem with chronic pancreatitis than in the patient with acute pancreatitis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 The nurse should instruct the patient to avoid crash dieting and bingeing because they can precipitate attacks. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Expected outcomes Have adequate pain control Maintain adequate fluid volume Be knowledgeable about treatment regimen Get help for alcohol dependence, if appropriate Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Chronic pancreatitis can be due to alcohol abuse; obstruction due to cholelithiasis (gallstones), tumor, pseudocysts, or trauma; and systemic diseases (e.g., systemic lupus erythematosus, cystic fibrosis). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Chronic nonobstructive pancreatitis Inflammation Sclerosis Mainly in the head of the pancreas and around the pancreatic duct Most common form of chronic pancreatitis In the United States, chronic pancreatitis is found almost exclusively in individuals who abuse alcohol. A genetic factor may predispose a person who drinks to the direct toxic effects of alcohol on the pancreas. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 The patient may have episodes of acute pain, but pain usually is chronic (recurrent attacks at intervals of months or years). The attacks may become more and more frequent until they are almost constant, or they may diminish as pancreatic fibrosis develops. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Chronic Pancreatitis Diagnostic Studies
Confirming diagnosis can be challenging. Based on signs/symptoms, laboratory studies, and imaging Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Laboratory tests (cont’d) Mild leukocytosis Elevated sedimentation rate ERCP Visualization of pancreatic/common bile duct Stool samples Changes in the pancreatic ductal system, such as gross dilation and microcysts, can be visualized with ERCP. Stool samples are examined for fecal fat content. Deficiencies of fat-soluble vitamins and cobalamin, glucose intolerance, and possible diabetes may be found in those with chronic pancreatitis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

CT MRI MRCP Transabdominal ultrasound EUS These procedures show a variety of changes, including calcifications, ductal dilation, pseudocysts, and pancreatic enlargement. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secretin stimulation test Assessment of degree of pancreatic function Not useful in diagnosis This test is not widely available, however, and some patients with chronic pancreatitis may have a normal test result. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Chronic Pancreatitis Collaborative Care
Prevention of attacks During acute attack, follow acute therapy. Relief of pain Control of pancreatic exocrine and endocrine insufficiency When the patient with chronic pancreatitis is experiencing an acute attack, therapy is identical to that for acute pancreatitis. It sometimes takes large, frequent doses of analgesics to relieve the pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bland low-fat, high-carbohydrate diet Bile salts Help absorption of fat-soluble vitamins Prevent further fat loss Control of diabetes No alcohol The patient does not tolerate fatty, rich, and stimulating foods, and these should be avoided to decrease pancreatic secretions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pancreatic enzyme replacement Acid-neutralizing and acid-inhibiting drugs Pancreatic enzymes such as pancrelipase (Viokase) and pancrelipase (Cotazym) contain amylase, lipase, and trypsin and are used to replace deficient pancreatic enzymes. They usually are enteric coated to prevent their breakdown or inactivation by gastric hydrochloric acid (HCl). Acid-neutralizing drugs (e.g., antacids) and acid-inhibiting drugs (e.g., H2-receptor blockers, proton pump inhibitors) may be given to decrease HCl acid secretion, but have little overall effect on patient outcomes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgery Indicated when biliary disease is present, or if obstruction or pseudocyst develops Diverts bile flow or relieves ductal obstruction A choledochojejunostomy diverts bile around the ampulla of Vater, where spasm or hypertrophy of the sphincter may occur. Another type of surgical diverting procedure is the Roux-en-Y pancreatojejunostomy, in which the pancreatic duct is opened, and an anastomosis is made with the jejunum. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 The nurse should instruct the patient and the caregiver to observe the stools to help determine the effectiveness of the enzymes. The nurse should ensure that the patient who is taking antisecretory agents or antacids takes them as ordered to control gastric acidity. Antacids should be taken after meals and at bedtime. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Answer: 2 Rationale: Pain from acute pancreatitis is aggravated by eating; NPO status will help to alleviate the pain by decreasing pancreatic secretions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 mid-back. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What are the possible causes of pancreatitis? What is her priority of care? The most likely causes are gallstones and alcohol use. Maintain F&E balance, manage pain, and implement nutritional changes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What laboratory tests are the most important to monitor in acute pancreatitis? What patient teaching should you do with her? 3. Serum amylase, serum lipase Teach her the causes of pancreatitis and the nutritional changes she will need to make temporarily. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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