PANCREATITIS

OBJECTIVES

Define acute pancreatitis

Etiological factors of pancreatitis
Pathophysiology of acute pancreatitis
Enlist the clinical manifestations
Identify the complication
Diagnostic evaluation
Discuss the treatment modalities of acute pancreatitis
Surgical management of acute pancreatitis
Chronic pancreatitis
Clinical manifestations of chronic pancreatitis
Diagnostic evaluation of chronic pancreatitis
Management of chronic pancreatitis
Preventive and health promotion measures for
pancreatitis
REVIEW OF ANATOMY AND
PHYSIOLOGY
 FUNCTIONS
EXOCRINE : ENDOCRINE:

Pancreatic juice Isets of langerhans

Amylase Alpha cells: Glucagon
Lipase (20%)
Beta cells: Insulin (75%)
Trypsin
Gamma cells :
Chymotripsin
Somatostatin
Carboxypeptidase Polypeptide cells
 MEANING
Acute pancreatitis is an acute inflammation of the
pancreas .
The degree of inflammation varies from mild edema
to severe haemorrhagic necrosis .
Acute pancreatitis is common in middle aged men
and women
 CAUSES

Two main causes for pancreatitis are

Gallstones (38%)
Alcohol (36%)
Other, less common causes of acute
pancreatitis include
Trauma (postsurgical, abdominal)
Viral infections mumps
Coxsackievirus B, HIV
Penetrating duodenal ulcer cysts
 CAUSES

Metabolic disorders
Hyperparathyroidism
Hyperlipidemia
Renal failure
Vascular diseases.
Pancreatitis may occur after surgical procedures on
the pancreas, stomach, duodenum or biliary tract.
 CAUSES
Abscesses
Cystic fibrosis
Kaposi sarcoma
Certain drugs (corticosteroids, thiazide ,
diuretics, oral contraceptives, sulfonamides
NSAIDs)
Pancreatitis can also occur after ERCP.
In some cases the cause is unknown (idiopathic)
 PATHOPHYSIOLOG
Y
Etiological factors
Cause injury to pancreatic cells

Activation of the pancreatic enzymes

Reflux of bile acids into the pancreatic

ducts

Open distended sphincter of Oddi causes reflux

 CLINICAL
MANIFESTATION
FEVER
Rarely exceeds 102 degree F

ABDOMINAL FINDINGS
Rigidity, tenderness, guarding
Distension
Decreased or absent peristalsis
 CLINICAL
MANIFESTATION
ABDOMINAL PAIN
Steady and severe excruciating
Located in the left upper quadrant or in
the mid epigastrium may radiate to the
back

Worsened by lying supine may be

lessened by flexed knee, curved back
positioning
 CLINICAL
MANIFESTATION
VOMITTING
Varies in severity but is
usually protacted.
Worsened by ingestion of
food or fluid.
Does not relieve the pain.
Usually accompanied by
nausea.
 CLINICAL MANIFESTATION
Cullen’s signGrey’s turner sign

Bluish discoloration around Bluish discoloration along

the umbilicus the flanks
 COMPLICATION
S
Hypotension or shock from hypovolemia or
hypoalbuminemia
Leukocytosis, anemia , disseminated intravascular
coagulation from unknown causes
Atelectasis, pneumonia, pleural effusion,
acute respiratory distress syndrome
Gastrointestinal bleeding
 COMPLICATION
S
Pancreatic pseudocysts, pancreatic
necrosis, pancreatic abscesses, pancreatic
ascites
Oliguria and acute tubular necrosis
Hyperglycemia, hypocalcemia,
hyperlipidemia
 DIAGNOSIS

History and physical examination

Liver function tests: elevations commonly seen
Serum trigylycerides
 DIAGNOSIS

• Serum amylase: Levels elevated within a few hours

of disease onset
• Serum lipase: Levels remain elevated up to 7 days
after disease onset
• Serum glucose: Hyperglycaemia of 500 to 900 mg/d
• Serum calcium: Hypocalcaemia from calcium
sequestering in abdomen; hypocalcemia is a poor
prognostic sign
 DIAGNOSIS

❖ Abdominal ultrasound
❖ Endoscopic ultrasound
 DIAGNOSIS

Magnetic Resonance
Cholangiopancreatography
(MRCP)
 DIAGNOSIS

Endoscopic Retrograde
Cholangiopancreatography
(ERCP)
 COLLABORATIVE
CARE
GOALS
1) Relief of pain
2) Prevention or alleviation of shock
3) Reduction of pancreatic secretions
4) Correction of fluid and electrolyte imbalances
5) Prevention and treatment of infections
6) Removal of the precipitating cause
 CONSERVATIVE
THERAPY
Focused on primary care:
1) Aggressive hydration
2) Management of metabolic complications
3) Minimization of pancreatic stimulation
 CONSERVATIVE
THERAPY
1) Management of pain
IV morphine ( pain medication may be
combine with antispasmodic agents)
Spasmolytics : Nitroglycerine or papaverine
2)Supplemental oxygen: To maintain oxygen
saturation > 95%
3) Serum glucose : Monitored for Hyperglycemia
 CONSERVATIVE
THERAPY
If shock present
1) Blood volume replacement
2) Plasma or plasma volume expanders : Dextran
or albumin may be given
3) Fluid and electrolyte: Ringer’s lactate solution
4) Increase vascular resistance with hypotension
: Vasoactive drug such as dopamine
 CONSERVATIVE THERAPY
To Suppress the pancreatic
enzymes 1)The patient to be kept in
NPO
2) NG suction :
To reduce vomiting and gastric distension
To prevent gastric acid contents from entering
into the duodenum
3) Drugs such as Antacids, PPI, Acetazolamide
 CONSERVATIVE
THERAPY
4) Enteral nutrition : For patients who does not resume
oral intake
5) Antibiotic therapy: In patients with acute
necrotizing pancreatitis
6) Endoscopic or CT guided percutaneous aspiration
with gram stain and culture may be performed
 SURGICAL THERAPY
1) Acute pancreatitis related to Gallstone:
ERCP together with endoscopic spinchterotomy
followed by laproscopic cholecystectomy to reduce
potential for recurrence

2) Severe acute pancreatitis:

Drainage of necrotic fluid collections
 DRUG THERAPY
DRUG MECHANISM OF ACTION
Morphine Relief of pain
Antispasmodic (e.g diclyclomine) Decrease vagal stimulation ,
motility, pancreatic outflow
Carbonic anhydraseinhibitor Decrease volume and bicarbonate
(acetazolamide) concentration of pancreatic secretion
Proton pump inhibitors
Decrease acid secretion (HCL
Antacids acid stimulate pancreatic activity )
Neutralization of gastric hydrochloride
acid secretion
 NUTRITIONAL MANAGEMENT

Initially the patient to kept on NPO to decrease the

gastric acid secretions
Enteral feeding: Nasojejunal feeding tube
IV lipids : Blood triglyceride levels are monitored
When food is allowed, small, frequent feedings are given.
Carbohydrate rich diet should be given
Needs to abstain from alcohol
Supplemental fat-soluble vitamins may be given
 CHRONIC
PANCREATITIS
DEFINITION
Chronic pancreatitis (CP) is characterised by
prolonged pancreatic inflammation and fibrosis
leading eventually to destruction of pancreatic
parenchyma and loss of exocrine and endocrine
function
 ETIOLOGY

1) Alcohol abuse
2) Obstruction caused by cholelitiasis
3) Tumour
4) Pseudocyst
 ETIOLOGY

5) Trauma
6)Systemic disease (Systemic lupus
erythematosus)
7)Auto immune pancreatitis
8)Cystic fibrosis
 ETIOLOGY
OBSTRUCTIVE NON OBSTRUCTIVE
PANCREATITI PANCREATITIS
S Inflammation and
Inflammation of sclerosis mainly in the
Sphincter of oddi head of pancreas and
associated cholelitiasis
around the pancreatic
Cancer of ampulla of
vater duodenum,
duct
pancreas
 CLINICAL
MANIFESTATION
Abdominal pain :
oEpisode of acute pain and it remains almost
constant
oPain may be locate in the same area as acute
pancreatitis
oDescribe as heavy, gnawing feeling
or sometimes burning and cramplike
 CLINICAL MANIFESTATION

Others include:
Malabsorption with weight loss constipation, mild
jaundice with dark urine, steatorrhea and diabetes
mellitus
Staetorrhea may be voluminous, foul smelling fatty
stools
Urine and stool may be frothy
Some abdominal tenderness may be present
 COMPLICATION
S
Pseudocyst formation
Bile duct or duodenal obstruction
Pancreatic ascitis
Pleural effusion
Splenic vein thrombosis
Pseudoaneurysm
Pancreatic cancer
 DIAGNOSIS

Serum amylase
Serum Lipase
Serum bilirubin
Alkaline phosphatase
ESR, mild leucocytosis
ERCP
MRCP
 DIAGNOSIS

CT, MRI
Abdominal ultrasound
Stool sample : Fecal fat content
Deficiencies of fat soluble vitamin and cobalamin,
glucose intolerance
Secretin stimulation test
 SURGICAL MANGEMENT
❖ Pancreaticojejunostomy
Side-to-side anastomosis
of the pancreatic duct to the
jejunum, allows drainage of
the pancreatic secretions
into the jejunum.
 SURGICAL MANGEMENT

❖ Whipple resection
(pancreaticoduodenectomy )
Removal of the head of the pancreas, the
first part of the small intestine (duodenum),
the gallbladder and the bile duct.
 SURGICAL MANGEMENT

Other surgical procedures:

Revision of the sphincter of the ampulla of
Vater
Internal drainage of a pancreatic cyst into the
stomach
Insertion of a stent and wide resection or
removal of the pancreas.
 SURGICAL MANGEMENT

Autotransplantation :
Implantation of the pancreatic islet cells

Moving the pancreas to another location

within the abdomen with revised vascular and
enteric anastomosis
 SURGICAL MANGEMENT

▪ Gall bladder disease : The obstruction is treated by

surgery to explore the common duct and remove the
stones; the gallbladder is removed at the same time.

▪ Drainage : common bile duct and the pancreatic duct

▪ A T-tube usually is placed in the common bile

duct, requiring drainage system to collect the bile
 NURSING MANAGEMENT
Health History.
Assess for
History of gallbladder disease
History of other GI diseases (e.g., peptic ulcer
disease, IBD)
History of alcohol use: amount and duration
Medications in use: prescription, over the counter,
and herbal preparation
 NURSING MANAGEMENT

Onset and progression of symptoms such as:

Pain, which is often steady and severe; is located in
the epigastric or umbilical region or may radiate to the
back; worsens when patient is supine; is unrelieved
by vomiting
Nausea and vomiting
 NURSING MANAGEMENT

Physical Examination.
Assess for:
Vital sign indications of hypovolemia:
tachycardia, tachypnea, normal to low blood
pressure, restlessness, and anxiety
Abdominal rigidity, distention, guarding,
and tenderness to palpation
 NURSING MANAGEMENT

Diminished or absent bowel sounds

on auscultation
Fever : > 102° F
Signs of third spacing: falling urinary
output, decreased skin turgor, dry or sticky
mucous membranes, increased abdominal
girth
 PRIORITIZED NURSING DIAGNOSIS

Acute pain related to inflammation, edema,

distension of pancreatic capsule and activation
of pancreatic enzyme

Ineffective breathing pattern related to

severe pain, pulmonary infiltrates , pleural
effusion, atelectasis and elevated diaphragm
 PRIORITIZED NURSING DIAGNOSIS

Risk for deficient fluid volume related to vomiting,

hyperglycemia, and increased capillary permeability
secondary to acute pancretitis
Imbalanced nutrition less than body requirement related to
vomiting, NPO status and malabsorption secondary to
pancreatitis

Impaired skin integrity related to poor nutritional status,

bed rest, multiple drains, and surgical wound
Does mortality occur early or late in acute
pancreatitis?
Abstract:
Several prior studies have suggested that 80% of deaths in acute
pancreatitis occur late as a result of pancreatic infection. Others have
suggested that approximately half of deaths occur early as a result of
multisystem organ failure. The aim of the present study was to
determine the timing of mortality of acute pancreatitis at a large tertiary-
care hospital in the United States.
 CONCLUSION
Conclusion:
Approximately half of deaths in acute pancreatitis occur
within the first 14 days owing to organ failure and the
remainder of deaths occur later because of complications
associated with necrotizing pancreatitis. Improvement in
mortality in the future will require innovative approaches
to counteract early organ failure and late complications of
necrotizing pancreatitis.
Authors
Muthoka Mutinga,Adam Rosenbluth,Scott M. Tenner,Robert R.
Odze Gregory T. Sica, Peter A. Bank
 REFERENCES
BOOKS
Lewis, Driksen, Heikemper, Bucher. Lewis Textbook
of medical surgical nursing- 2nd edition
Urden D.L StacyM.K Laugh E.M Textbook For
Critical Care Nursing
Myers/Gulanick, Nursing Care Plans. Nursing Diagnosis
And Interventions 6th edition
Linda s. Williams, Paula D. Hopper. Textbook of
medical surgical nursing-4th edition