Pancreatitis Flashcards
- Acute and chronic.
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Is an acute inflammation of the pancreas
> ° of inflammation varies from mild edema to severe hemorrhagic necrosis
Most common in middle-aged men & women; affects genders equally
Rate in African Americans is 3x higher than in white persons
Acute pancreatitis (AP)
> Involves a spillage of pancreatic enzymes into surrounding pancreatic tissue causing autodigestion & severe pain
Etiology
- In the US, the most common cause is __ __ (more common in women)
- 2nd most common cause is chronic alcohol intake (more common in men)
- Smoking is an independent risk factor for AP
gallbladder disease (gallstones)
- Biliary sludge or microlithiasis, a mixture of cholesterol crystals & calcium salts, is found in 20-40% of pts w/AP
> Formation of biliary sludge is seen in pts w/bile stasis - AP attacks are also assoc w/___ (serum levels >1000 mg/dL)
hypertriglyceridemia
- Less common causes
> Trauma [postop, post-procedure following ERCP]
> Viral infections [mumps, coxsackievirus B, HIV]
> Penetrating duodenal ulcers
> Cysts
> Abscesses
> Cystic fibrosis
Kaposi sarcoma
Certain drugs [corticosteroids, thiazide diuretics, oral contraceptives, sulfonamides, NSAIDs)
Metabolic disorders [hyperparathyroidism, renal failure]
Vascular diseases
Idiopathic [unknown] causes
Pathophysiology
- Caused by autodigestion of pancreas
> Injury to pancreatic cells
> Activation of pancreatic enzymes
- Activation of trypsinogen to trypsin within pancreas leads to bleeding
- May be d/t reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi
- Reflux may be d/t blockage created by gallstones; obstruction of pancreatic ducts results in pancreatic ischemia
?
This is an inactive proteolytic enzyme produced by the pancreas
> It’s released into the SI via the pancreatic duct
Trypsinogen
> In the SI, it’s activated to trypsin by enterokinase
> Normally, trypsin inhibitors in the pancreas & plasma bind & inactivate any trypsin that’s inadvertently produced
> In pancreatitis, activated trypsin is present in the pancreas
> This enzyme can digest the pancreas & produce bleeding
Pathogenic Process of AP
- Alcohol consumption is another common cause
> Exact mechanism unknown
> Alcohol may increase production of pancreatic enzymes
> 5-10% of alcohol abusers develop pancreatitis
___ pancreatitis
- Necrotizing
- Endocrine & exocrine dysfunction
- Necrosis, organ failure, sepsis
- Rate of mortality: 25%
Severe [pancreatitis] (also called necrotizing pancreatitis)
___ pancreatitis
- Edematous or interstitial
Mild [pancreatitis] (also known as edematous or interstitial pancreatitis)
Clinical Manifestations
! Abdominal pain predominant
> LUQ or mid-epigastrium [d/t distention of the pancreas, peritoneal irritation, & obstruction of the biliary tract]
> Radiates to back [b/c of the retroperitoneal location of the pancreas]
> Sudden onset
> Deep, piercing, continuous or steady
> Aggravated by eating
Starts when recumbent
Not relieved w/vomiting
- Flushing
- Cyanosis
- Dyspnea
- N/V
- Low-grade fever
- Leukocytosis
- Hypotension, tachycardia
- Jaundice
- Abd tenderness w/muscle guarding is common
- Decreased or absent bowel sounds [paralytic ileus can occur & causes marked distention]
- Crackles in lungs
- Abdominal skin discoloration [d/t intravascular damage from circulating trypsin]
> Grey Turner’s spots or sign [a bluish flank discoloration]
> Cullen’s sign [a bluish, periumbilical discoloration]
These result from seepage of blood-stained exudate from the pancreas & may occur in severe cases
Shock
- D/t hemorrhage into the pancreas
- Toxemia from activated pancreatic enzymes
- Hypovolemia as a result of fluid shift into retroperitoneal space (massive fluid shifts)
What are 2 significant local complications of AP?
pseudocyst & abscess
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This is an accumulation of fluid, pancreatic enzymes, tissue debris, & inflammatory exudates surrounded by a wall adjacent to the pancreas
> Manifestations include abd pain, palpable epigastric mass, N/V, anorexia
Pseudocyst
- Serum amylase lvl freq remains elevated
- CT, MRI, & EUS may be used to detect a pseudocyst
- Cysts usually resolve spontaneously within a few wks but may perforate, causing peritonitis, or rupture into the stomach or duodenum
- Treatment = surgical drainage procedure; percutaneous catheter placement & drainage; endoscopic drainage
When a pseudocyst gets infected, a __ __ results from necrosis in the pancreas
It may rupture or perforate into adjacent organs
Manifestations include upper abdominal pain, abd mass, high fever, & leukocytosis
Pancreatic abscess
! These necessitate prompt surgical drainage to prevent sepsis
Systemic complications
- Pleural effusion
- Atelectasis
- Pneumonia
- ARDS
- Hypotension
- Thrombi, pulmonary embolism, DIC
- Hypocalcemia = tetany [sign of severe dz]
> D/t combining of calcium & fatty acids during fat necrosis
- Pulmonary complications are probably d/t the passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels
- Enzyme-induced inflammation of the diaphragm occurs w/the result being atelectasis caused by reduced diaphragm movement
- Trypsin can activate prothrombin & plasminogen, inc the risk for intravascular thrombi, pulmonary emboli, & DIC
Laboratory tests
- Serum amylase level
- Serum lipase level
- Liver enzyme levels
- Triglyceride levels
- Glucose level
- Bilirubin level
- Serum calcium level [decrease]
?
This lab result is usually elevated early & remains elevated for 24-72 hrs
serum amylase
?
This lab result is also elevated in AP & is an important test b/c other disorders like mumps, cerebral trauma, & renal transplantation can also inc these lvls
serum lipase
Diagnostic Studies
- Abdominal US
- X-ray
- Contrast-enhanced CT scan
! Is the best imaging test for pancreatitis & related comp’s like pseudocysts & abscesses - Endoscopic retrograde cholangiopancreatography (ERCP)
> Can cause AP in some cases
- Endoscopic ultrasonography (EUS)
- Magnetic resonance cholangiopancreatography (MRCP)
- Angiography
- Chest x-ray [to show pulm changes like atelectasis & pleural effusions]
Interprofessional Care Objectives
- Relief of pain
- Prevention or alleviation of shock
- ↓ pancreatic secretions
- Correction of fluid/electrolyte imbalances
- Prevention/treatment of infections
- Removal of precipitating cause(s), if possible
Conservative Therapy
- Supportive care
> Aggressive hydration
> Pain management - IV morphine, antispasmodic agent
> Management of metabolic complications
- Oxygen, glucose lvls
* Supplemental oxygen is used to maintain O2 sat >95%
* In pts w/severe pancreatitis, serum glucose lvls are closely monitored
> Minimizing pancreatic stimulation
- NPO status, NG suction, decreased acid secretion, enteral nutrition if needed [for severe AP d/t lack of oral intake]
- Atropine & other anticholinergic drugs should be avoided when paralytic ileus is present b/c they can decrease GI mobility, thus exacerbating the problem
- Other rx’s that relax smooth muscles (spasmolytics) like nitroglycerin or papaverine, may be used
- Shock
> Plasma or plasma volume expanders (dextran or albumin)
- Fluid/electrolyte imbalance
> Lactated Ringer’s solution - Central venous pressure readings may be used to assist in determining fluid replacement req’s
- Ongoing hypotension
> Vasoactive drugs: ___ (?)
dopamine
Increases systemic vascular resistance in pts w/ongoing hypotension
- Prevent infection
> Enteral nutrition
> Antibiotics
> Endoscopically or CT-guided percutaneous aspiration (w/Gram stain & culture)
Surgical Therapy
- For gallstones
> ERCP
> Cholecystectomy - Uncertain diagnosis
- Not responding to conservative therapy
- [Percutaneous] Drainage of necrotic fluid collections (w/a drainage tube left in place)
- When AP is r/t the presence of gallstones, an urgent ERCP plus endoscopic sphincterotomy (severing of the muscle layers of the sphincter of Oddi) may be done
> May be followed by laparoscopic cholecystectomy to reduce potential for recurrence
Drug Therapy
- IV morphine
- Antispasmodics
- Carbonic anhydrase inhibitors
- Antacids
- Proton pump inhibitors
- Morphine - for pain relief
?
acetazolamide [Diamox]
↓ volume & bicarbonate conc of pancreatic secretion
Carbonic anhydrase inhibitor(s)
?
Neutralization of gastric HCI acid secretion
↓ production & secretion of pancreatic enzymes & bicarbonate
Antacids
?
dicyclomine [Bentyl]
↓ vagal stimulation, motility, pancreatic outflow
↓ volume & conc of bicarbonate & enzyme secretion
! contraindicated in paralytic ileus
antispasmodics
?
omeprazole [Prilosec]
↓ HCI acid secretion (HCI acid stimulates pancreatic activity)
Proton pump inhibitors
Nutritional Therapy
- NPO status initially
- Enteral (via nasojejunal tube) vs parenteral nutrition
- Monitor blood triglycerides if IV lipids given
- Small, freq feedings when able
> High-carbohydrates (b/c that is least stimulating to exocrine portion of pancreas) - No alcohol
- Supplemental fat-soluble vitamins
Nursing Assessment - Subjective Data
- Past health history
> Biliary tract dz
> Alcohol use
> Abdominal trauma
> Duodenal ulcers
> Infection
> Metabolic disorders
- Medications
> Thiazides, NSAIDs - Surgery or other treatments
> Pancreas, stomach, duodenum, biliary tract
> ERCP
Subjective Data: Functional Health
- Alcohol abuse; fatigue [health perception - health management]
- N/V, anorexia [nutritional-metabolic]
- Dyspnea [activity-exercise]
- Pain [cognitive-perceptual]
> severe mid-epigastric or LUQ pain that may radiate to the back, aggravated by food & alcohol intake & unrelieved by vomiting
Objective Data
- Restlessness, anxiety, low-grade fever [general]
- Flushing, diaphoresis [integumentary]
- Discoloration of abdomen/flank
- Cyanosis
- Jaundice
- Decreased skin turgor
- Dry mucous membranes
- Tachypnea, basilar crackles [respiratory]
- Tachycardia, hypotension [cardiovascular]
- Abd distention/tenderness [gastrointestinal]
- Muscle guarding
- Diminished bowel sounds
Possible diagnostic findings
↓ or ↑ serum amylase/serum lipase lvls (?)
- Leukocytosis
- Hyperglycemia
Hypo or hypercalcemia (?)
- Abn findings on US/CT scans, ERCP
↑
Hypocalcemia
Nursing Diagnoses
- Acute pain
- Deficient fluid volume
- Imbalanced nutrition: less than body requirements
- Ineffective health management
Patient will have
- Relief of pain
- Normal fluid & electrolyte imbalance
- Minimal to no complications
- No recurrent attacks
> These aren’t SMART goals
Health Promotion
- 1. Assessment of pt for predisposing & etiologic factors
- 2. Encouragement of early treatment of these factors (to prevent occurrence of AP)
- Early diagnosis & treatment of biliary tract dz, such as cholelithiasis
- Elimination of alcohol intake
Acute Care
- Monitoring VS (what’s going on in the acute phase?)
> Hemodynamic stability may be compromised by hypotension, fever, & tachypnea - Monitor response to IV fluids
- Closely monitor F&E balance
> Freq vomiting along w/gastric suction, may result in dec Cl, Na, & K lvls
- Assess resp function (lung sounds, O2 sat)
> Resp failure can develop in pt w/severe AP
> If ARDS develops, pt may req intubation & mechanical ventilation support
Acute Care: Monitor F&E balance
> Cl, Na, & K
Hypocalcemia
- Tetany [jerking, irritability, & muscular twitching]
! Numbness or tingling around the lips & in the fingers is an early indicator of hypocalcemia
- Calcium gluconate to treat
> Hypomagnesemia
?
Is a carpal spasm induced by inflating a BP cuff above the systolic pressure for a few min
Trousseau’s sign
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Is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear
Chvostek’s sign
- Pain assessment & management
> Morphine
Position of comfort w/freq position changes
- Flex trunk & draw knees to abdomen
- Side-lying w/HOB elevated 45°
- Freq oral/nasal care
> Oral care essential to prevent parotitis
> If pt is taking anticholinergics to dec GI secretions, there will be addl dryness of the mouth - Proper admin of antacids [to neutralize gastric acid secretion]
> Sip slowly or insert in NG tube
- Observation for signs of infection (fever; resp infections [shallow, guarded breaths])
- TCDB, semi-Fowler’s position
- Wound care (for an anastomotic leak or a fistula)
- Observation for paralytic ileus, renal failure, mental changes
- Monitor serum glucose (to assess damage to β-cells of islets of Langerhans)
- Post-op wound care
> Prevent skin irritation
> Pouching, drains; sterile pouching systems; WOCN consult
Ambulatory Care
> Physical therapy
Assessment of opioid addiction (more common in chronic than acute)
Counseling regarding abstinence from alcohol & smoking
- Dietary teaching
> Low-fat, high carbohydrate
> No crash diets or bingeing as they can precipitate attacks - Pt/family teaching
> Signs of infection, DM, steatorrhea (foul-smelling, fatty stools)
> Rx’s/diet
Restrict fats b/c they stimulate the secretion of ___, which then simulates the pancreas
cholecystokinin
Nursing Implementation - AP Expected Outcomes
- Have adequate pain control
- Maintain adequate fluid volume
- Be knowledgeable about treatment regimen
- Get help for alcohol dependence & smoking cessation (if appropriate)
?
This is a continuous, prolonged, inflammatory, & fibrosing process of the pancreas
> Pancreas becomes progressively destroyed as it’s replaced w/fibrotic tissue
Strictures & calcifications may occur in pancreas
Chronic pancreatitis (CP)
Etiology - CP
- Alcohol abuse
- Gallstones
- Tumor; pseudocysts
- Trauma
- Systemic diseases (SLE)
- Autoimmune pancreatitis, CF
- Idiopathic
Chronic pancreatitis may follow acute pancreatitis, but may also occur in the absence of an acute condition
2 major types
> Chronic obstructive
> Chronic nonobstructive
__ __ pancreatitis (?)
Inflammation & sclerosis in head of pancreas & around duct
> A genetic factor may predispose a person who drinks to the direct toxic effect of the alcohol on the pancreas
Most common cause is alcohol abuse
Chronic nonobstructive (pancreatitis)
Is the most common type of CP
__ __ pancreatitis (?)
Inflammation of the sphincter of Oddi in assoc w/cholelithiasis
Cancer of the ampulla of Vater, duodenum, or pancreas
Chronic obstructive (pancreatitis)
- Abdominal pain
> Located in same areas as in AP
Heavy, gnawing feeling; burning & cramp-like
- Pain is not relieved w/food or antacids
- Attacks can become more & more frequent until they’re almost constant; or may diminish as pancreatic fibrosis develops
- Some abd tenderness may be present
- Malabsorption w/wt loss
- Constipation
- Mild jaundice w/dark urine
- Steatorrhea
- DM
- Complications include
> Pseudocyst formation
Bile duct or duodenal obstruction
Pancreatic ascites or pleural effusion
Splenic vein thrombosis
Pseudoaneurysm
Pancreatic cancer
- Confirming the dx of CP can be challenging
- Based on
> S/S
> Lab studies
> Imaging
Laboratory Tests
- Serum amylase/lipase lvls may be slightly ↑ or not at all
- ↑ serum bilirubin, alkaline phosphatase, & ESR
- Mild leukocytosis
- ERCP [to visualize pancreatic & CBDs)
- CT, MRI, MRCP, abd and/or endoscopic US
- Stool samples for fecal fat content
- ↓ fat-soluble vitamin & cobalamin lvls
- Glucose intolerance/diabetes
- Secretin stimulation test [to assess the ° of pancreatic dysfunction]
- Analgesics for pain relief (morphine or fentanyl transdermal patch [Duragesic])
- Diet
> Bland, low-fat
> Small, frequent meals
- No smoking
- No alcohol or caffeine beverages
- Pancreatic enzyme replacement
pancrelipase (Creon, Zenpep, Pancrease)
> Contain amylase, lipase, & trypsin & are used to replace the deficient pancreatic enzymes
Are usually enteric-coated to prevent their breakdown or inactivation by gastric acid
- Bile salts
> Facilitate the absorption of the fat-soluble vitamins (A, D, E, K) & prevent further fat loss
- If diabetes develops, it’s controlled w/insulin (more commonly) or oral hypoglycemic agents
- Acid-neutralizing [antacids] & acid-inhibiting rx’s [H2-receptor blockers, PPI’s] given to decrease HCI acid secretion but have little overall effect on pt outcomes
- Antidepressants like nortriptyline (Aventyl) have been shown to reduce the neuropathic pain assoc w/CP
- Surgery
> Indicated when biliary dz is present or if obstruction or pseudocyst develops
> Diverts bile flow or relieves ductal obstruction
> Choledochojejunostomy
> Roux-en-Y pancreatojejunostomy
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Is a surgical diverting procedure in which the pancreatic duct is opened & an anastomosis is made w/the jejunum
Roux-en-Y pancreatojejunostomy
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Is a surgical procedure that diverts bile around the ampulla of Vater, where there may be a spasm or hypertrophy of the sphincter
> The CBD is anastomosed into the jejunum
Choledochojejunostomy
- Endoscopic procedures
> Pancreatic drainage
ERCP w/sphincterotomy and/or stent placement
Nursing Management
- Focus is on chronic care & health promotion
- Pt & family teaching
> Dietary control
> Pancreatic enzymes taken w/ meals/snack
> Observe for steatorrhea
> Monitor glucose lvls
> Antacids >meals & @ bedtime (to control gastric acidity)
> No alcohol
