Pancreas Flashcards
Pancreas
acinar cells
secrete inactive digestive enzymes into pancreatic duct
- Also produces bicarb & fluid to help neutralize secretions
islets of Langerhans
secretes hormones into blood
Pancreas
- functions as both an endocrine and exocrine gland
- Exocrine function- to produce enzymes to help with digestion -by acinar cells: *INACTIVE digestive enzymes get secreted into the pancreatic duct
(amylase, trypsin, lipase) - Endocrine function- to send out hormones to regulate blood glucose - by islets of Langerhans: Release hormones into the blood stream
— (insulin, glucagon)
Age considerations:
- Little change in size of the pancreas with age.
- However, there is an increase in fibrous material and some fatty deposition on the normal pancreas in people older than 70.
- Decreased rate of pancreatic enzyme secretion (Can lead to):
— Problems with digestion
— Malabsorption
— Blood sugar regulation problems - Increased risk of gallstones (a main cause of acute pancreatitis)
Acute Pancreatitis
- Sudden Inflammation of the pancreas (associated with a high risk of life-threatening complications & mortality)
- When inflammation occurs inside the pancreas , cells that secrete hormones & enzymes get very irritated.
- Cells start malfunctioning causing enzymes to active inside the pancreas
- Pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas
— Self digestion of the pancreas by its own enzymes (mainly trypsin) causes acute pancreatitis
Acute pancreatitis Incidence
- Older adults and post-op pancreatitis pts have high rate of incidence
- Pancreatic “attacks” are common during holidays & vacations
— When *large amounts of alcohol are consumed, especially in men
— Women are affected most often after cholelithiasis and biliary tract problems. They are also most at risk with-in several months after childbirth. - CHOLELITHIASIS & HIGH AMOUNT OF ALCOHOL
- Prognosis- *typically reversible if treated quickly and properly
— Poor prognosis if alcoholism is present
Acute Pancreatitis Causes:
Main Causes:
- Gallstones
- ETOH
-
Caused by premature activation of excessive pancreatic enzymes
- These enzymes destroy ductal tissue and pancreatic cells
— results in autodigestion and fibrosis of the pancreas
— Inflammation will cause enzymes to start working inside pancreas
— Pancreas swells and leaks digestive enzymes into surrounding tissues & organs (extreme pain) causing:
— - abnormal blood glucose levels
— - Abdominal swelling (ascites)
— - Malabsorption from digestive enzymes not digesting fats (oily stools/diarrhea)
— - Extreme GI pain
— - - NO morphine (causes spasms)
— - Free digestive enzymes can flow to surrounding tissues & organs causing damage to lungs (pul edema-ARDS) & vessels (bleeding, hemorrhage)
Pancreatitis can range from:
- Mild pancreatitis (edema & inflammation confined to pancreas)
- Severe necrotizing hemorrhagic pancreatitis (NHP)
— Diffuse bleeding of pancreatic tissue with fibrosis and tissue death.
Process of autodigestion in acute pancreatitis.
Acute pancreatitis s/s
- Acute pain (DX) in mid-epigastric or upper left abdomen
— agonizing, burning, continuous, refractory, excruciating
— Radiates towards the back, left flank or left shoulder
— feels like a “ boring” sensation pain going through the body
— Aggravating factor: supine position
— Relieving factor: sitting up and leaning forward - Ineffective breathing pattern (DX)
- Imbalanced nutrition (DX)
- Impaired skin integrity (DX)
- Pt may report wt loss from N/V
- Generalized jaundice
- *Grey Turner’s Sign : (bruising on flanks)
— Grey/blue discoloration of abd or flanks from pancreatic enzyme leakage into tissue from peritoneal cavity. - Cullen’s Sign: w/ severe pancreatitis (blueish around the umbilicus)
- Absent or decreased bowel sounds indicative of paralytic ileus.
- Abd tenderness, rigidity, guarding, and ascites present
Complications of Acute Pancreatitis- can be medical emergency associated with high risk life-threatening conditions
- Intermittent hyperglycemia
- Pancreatic infection (causes septic shock)
- Hypovolemia, Hypovolemic or septic shock
- Acute kidney failure
- Hemorrhage (necrotizing hemorrhagic pancreatitis)
— Diffusely bleeding pancreatic tissue with scarring and tissue death - Disseminated intravascular coagulation (DIC)
- Atelectasis, pneumonia
- Acute Resp distress syndrome (ARDs)
*Nsg Care of acute pancreatitis
- NPO (for 24-48hrs if severe pancreatitis) & rest
- IV isotonic solution, IV replacement of calcium
- NGT to suction for continuous vomiting –prevents gastric juices from flowing into duodenum
- Paralytic ileus is common
— Assess if pt passed flatus or had a stool - Daily wts
- Avoid caffeine containing foods and alcohol
— (tea, coffee cola, chocolate) - no caffiene - Allow pancreas to rest and control pain! This is very painful
- DIET
— Keep pt NPO initially
— Don’t want any stimulation that produces enzymes
— NPO initially then slowly introduce liquids
— Avoid alcohol or greasy fatty foods
— Low fat, bland, small meals
— Limit sugars
— Consume more complex carbs (veggies) which use less insulin
*Acute pancreatitis Meds
- Opioids
- Antiemetics
- diuretics
- H2 blockers & PPI
- antibiotics
- insulin
Nursing Safety Priority! ~Acute pancreatitis
- Monitor for significant changes in vital signs that may indicate life- threatening complications of shock.
- Hypotension and tachycardia may result from:
— pancreatic hemorrhage
— Excessive fluid volume shifting or
— Toxic effects of abdominal sepsis - Observe for changes in behavior or LOC
— May be related to alcohol withdrawal, hypoxia or impending sepsis with shock
Case study
- Mr. A: 47 yo male admitted into the hospital with severe abdominal
- mid-epigastric pain that radiates to the back.
- He said after work (about 6pm) he stopped at Chipotle and ate a large burrito with rice & beans.
- When asked about what he had to drink, he said he only had some beer to wash it all down.
- Shortly after his meal, he said he had indigestion that was
unrelieved with antacids
- He came to the ER because he started to have severe ab pain and began throwing up around midnight that same night.
Diagnostic & lab test results
- Abd U/S- showed presence of gallstones
- CT with contrast- confirmed acute pancreatitis
- Elevated serum amylase levels
- Elevated WBCs
- Decreased serum albumin
- Hypocalcemia
— correlates with severity
Assessment of client, “Mr. A”
- Vitals: BP=104/68, HR 93, RR 20, temp 100.9
- Pain 10/10, relieved when in fetal positon
- A&Ox4 agitated
- Severe ab pain (guarding)
- N/V
- Rigid abdomen
- Cool clammy skin
What nursing care do you expect to render?
- hx of gallstones/ gallbladder disease
- pain management
- NG tube
-
Pancreatic Cancer
- Pancreatic CA is often discovered late in the progression
— Organ is hidden and surrounded by other organs
— - Making it difficult to diagnose - Treatment has limited results
- 5 yr survival rates are low
- Exact cause of pancreatic cancer is unknown
- High risk populations are elderly 60-80s, smokers
Other Risk factors for Pancreatic Cancer
- Small number have inherited risk
- Mutations in certain genes have been identified
- Cirrhosis
- Pancreatitis
- High intake of red meat
- Long-term exposure to gasoline and pesticides
- Obesity
- Older age
- Male gender
- Cigarette smokers
Pancreatic Cancer sites
- Head of pancreas is the most common site of origin or mets
— Sm lesions with poorly defined margins
— Jaundice occurs from tumor compression and obstruction of common bile duct and from gallbladder dilation causing the organ to enlarge - Cancers of body or tail usually large and invade entire tail and body
— May be palpable masses
— Spread more extensively than pancreatic head carcinomas
— Spreads rapidly through the lymphatic and venous systems to other organs
— - Mets to liver may cause hepatomegaly
Key Features of pancreatic cancer
- Jaundice
- Clay-colored stool
- Dark urine
- Abd pain
- Weight loss
- Anorexia,
- N/V
- Glucose intolerance
- Enlarged spleen
- Flatulence
- GI bleeding
- Ascites
- Leg/calf pain
- Weakness, fatigue
- Venous thromboembolism is a common complication of pancreatic ca
- Necrotic products of tumor are thought to have thromboplastic properties resulting in hypercoagulable state of blood
pancreatic cancer Diagnostic tests
- No specific blood test dx pancreatic cancer
- Elevated serum amylase & lipase
- Elevated carcinoembryonic antigen (CEA) occur in most pancreatic ca pts
- u/s and CT w/ contrast- done to differentiate the tumor from a cyst
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Abd paracentesis- may reveal cancer cells and elevated amylase levels
pancreatic cancer Interventions prevent tumor spread & decrease pain
- Palliative care. Cancers will recur even with treatment
- Chemo & radiation- relieve pain by shrinking tumor
— Combining agents has been more successful than single agent chemo - Kinase inhibitors (tyrosine kinase inhibitors): newer group of drugs
— Focus on cancer cells with little to no effect on healthy cells - External beam radiation or radioactive iodine seeds
— Pain relief by shrinking tumor, alleviating obstruction and improving food absorption
— It does not improve survival rate
pancreatic cancer Surgical management
- For high surgical risks pts, biliary stents are used
— To ensure patency (keep biliary ducts open) & relieve pain - Surgical management- Complete surgical resection of pancreatic tumor
— Only done with small tumors - For larger tumors: Whipple procedure
— The Whipple procedure (pancreaticoduodenectomy) is an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct. The remaining organs are reattached to allow you to digest food normally after surgery.
Whipple Procedure Pre-op care
- Enteral feedings- to prevent reflux and to facilitate absorption
— Monitor for diarrhea to determine tolerance - TPN may be necessary to provide nutrition
— Central line required - NPO 6-8 hrs before surgery
Whipple Procedure Post-op care
- Potential complications of Whipple procedure
- NPO
- NGT to decompress stomach & reduces stimulation of remaining pancreatic tissue
- Monitor GI drainage & tube patency
— In open surgical approach, tubes are placed to remove drainage & secretions and prevent stress on anastomosis sites - Semi fowler to reduce tension on suture line and anastomosis and to optimize lung expansion
- Highest priority for care= fluid volume imbalance… Why?
Patient education s\p whipple procedure
- Will most likely advance to clear liquid diet once intestines begin functioning again (approximately day #3)
- Meds: some pts will need pancreatic enzyme supplements to help with fat digestion
- Expect several watery BMs/day for several weeks.
- This will decrease as GI readjusts
- May have occasional bloating, indigestion, n/v
- In time pt will return to normal bowel function
- Do not lift heavy objects for about 6 wks following procedure
- Call for fever, unusal amount of pain, increased N/V or diarrhea, can’t eat properly or incision not healing properly
