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*Pancreatitis*

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- an inflammatory condition Acute pancreatitis in the U. S. 70 - 80 cases per 100,000 80% admitted with mild disease 20% with severe disease, mortality reaching up to 30%, 40 - 70% if necrosis suspected Estimated cost $3 to $6 billion Chronic pancreatitis in the U. S. 3 - 10 per 100,000

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Acute pancreatitis - etiology

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Biliary tract disease Alchoholism Trauma (post surgical & abdominal) Viral infections (mumps & coxsackievirus B) Penetrating duodenal ulcer Cysts, abscesses Cystic fibrosis Kaposi's sarcoma Certain drugs

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Predisposing factors

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Most common are gallstones (45% of the cases) and alcohol abuse (35%) The term suggests an infection, most patients don't have one Infection may occur as a complication

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Acute pancreatitis - pathophysiology

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Acute inflammatory process of the pancreas Intra-pancreatic activation of enzymes Common pathogenic mechanism is autodigestion of the pancreas that occurs before the enzymes leave the pancreas instead of going into the small intestine

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Autodigestion

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Leads to erosion through the pancreas and into the abdominal cavity Produces -profound inflammation - Fluid shifts - Hypovolemia - Hemorrhage - May cause abdominal compartment syndrome

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abdominal compartment syndrome

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a. Increased intraabdominal pressure leading to hypoperfusion and ischemia of the intestines

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Autodigestive effects of pancreatic enzymes

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Trypsin/elastase - proteases - protein Edema Necrosis Hemorrhage Amylase - carbohydrates Hemorrhage Phospholipase A & Lipase - fat Fat necrosis

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Acute pancreatitis- clinical manifestations

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Epigastric pain N/V Abdominal tenderness Low-grade fever Leukocytosis Hypotension Tachycardia Jaundice ?/absent BS Hypovolemia Grey Turner spots & Cullen's sign Seepage of bloodstained exudate from the pancrea

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More about the pain

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Severe abdominal or epigastric Sudden onset Described as burning, or boring pain that radiates to the back Position changes don't help Consuming EtOH or fatty foods worsens the pain

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Physical Assessment

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Firm, distended, diffusely tender abdomen Possibly rebound tenderness

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Acute pancreatitis - complications

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Pseudocyst

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Pseudocyst

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A cavity continuous or surrounding the outside of the pancreas Filled with necrotic products, plasma, pancreatic enzymes, inflammatory exudates Usually resolve spontaneously Rupture?peritonitis, stomach,

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Pathology

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Pancreas is edematous and is enlarged. Pancreas can show acute inflammation, hemorrhage and or extensive necrosis. There can be extensive peripancreatic inflammation. Fluid can accumulate in lesser sac and pleural space Neutrophils infiltrate the edge of the necrotic areas and extend into the adjacent lobules of fat and produce fat necrosis. Calcification can be seen in chronic pancreatitis. Calcification in pancreas.

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Potential complications

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- Abscess/pseudocyst - As liquefaction of necrotic pancreatic tissue progresses, it will gradually take on the appearance of localized fluid collection - pseudocyst. - This may be in the region of the pancreas or extend beyond the pancreatic region. - Pancreatic rupture/hemorrhage - Obstructive jaundice - Pulmonary complications in severely ill patients - ARDS - GI obstruction - Acute renal failure

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Manifestations of pseudocyst

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Abdominal pain Palpable epigastric mass N/V Anorexia Serum amylase ?

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Treatment of pseudocyst

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Internal drainage procedure with an anastomosis between pancreatic duct and the jejunum

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Acute pancreatitis complications

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Abscess Large fluid-containing cavity within the pancreas Becomes infected or perforate

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Manifestations of abscess

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Upper abdominal pain Abdominal mass High fever Leukocytosis

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Treatment of abscess

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Prompt surgical drainage to prevent sepsis

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Acute pancreatitis - systemic complications

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Pulmonary Pleural effusion Atelectasis Pneumonia ARDS Cardiovascular (hypotension) Tetany (hypocalcemia)

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Nursing Interventions: Pulmonary Complications

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Respiratory assessment ? Breath sounds Wheezes, crackles Pulse oximetry Encourage early ambulation Coughing, deep breathing, IS Change position q 2hr

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Acute pancreatitis - lab values

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? Amylase - serum 3x the normal level ----- Elevated for 24 to 72 hours ----- Normal serum amylase *35 to 115* units/L ? Lipase - serum (more sensitive test of pancreatic function) ------- Levels rise in 3 to 4 hours, peak in 24 and stay high for up to 2 weeks ------- EtOH induced ------- Normal serum lipase* 32 to 80* units/L ? Amylase - urine may persist several days beyond the serum level

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Other lab values

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Blood glucose - hyperglycemia ---------- ß-cell damage? ?insulin Serum calcium - hypocalcemia ---------- Ca++ binds with fatty acids Serum triglycerides - hyperlipidemia C-reactive protein - >150 mg/L 48 hrs after symptom onset reflects acute pancreatitis

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Acute pancreatitis - nursing management

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Goals Relief/ ? pain Prevention or alleviation of shock Reduction of pancreatic secretions Maintain fluid/electrolyte balance Prevention/tx of infections Remove precipitating cause

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Acute pancreatitis - pain control

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Demerol ----- Should be reserved for short course of therapy ----- Normeperidine - toxic metabolite - CNS irritant Morphine - longer ½ life May be combined with an antispasmodic Avoid atropine-like drugs when paralytic ileus is present

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Nursing Interventions

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Assess pain frequently Use an objective pain scale Reassess effectiveness of pain regimen Nonpharmacological interventions Guided imagery Relaxation exercises May fear they will become addicted to opiods - support & teach

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Acute pancreatitis - fluid resuscitation

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Generally require vigorous fluid replacement -------- Prevent hypovolemia r/t third-space losses and vomiting Shock Blood volume replacement - dextran or albumin Fluid replaced with LR or NS

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Nursing Interventions

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Monitor I&O Weight and lab values Watch for signs of hypovolemia and/or third space loss ---------- ? skin turgor, cap refill ---------- Dry mucous membranes ---------- Thirst ---------- Hypotension, tachycardia

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Acute pancreatitis - pancreatic suppression

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Bowel rest ---------- NPO ---------- NGT to LWS TPN Jejunal tube feeding

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Chronic pancreatitis

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Progressive destruction of pancreas with fibrotic replacement of the tissue Strictures and calcifications may be present

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Chronic pancreatitis - pathophysiology

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Chronic obstructive pancreatitis --------- Inflammation of sphincter of Oddi associated with cholelithiasis --------- Cancer may also contribute Chronic calcifying pancreatitis ---------- Ducts obstructed with protein precipitates

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Chronic pancreatitis - clinical manifestations

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Abdominal pain ------- Recurrent months/years ------- Described as heavy, gnawing, burning, cramplike ------- Not relieved with food or antacids Symptoms of pancreatic insufficiency ------- Weight loss ------- Mild jaundice/dark urine ------- steatorrhea

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Chronic pancreatitis - nursing management

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Diet ------ Bland, low fat, high carb ------ Total elimination of EtOH Replacement of pancreatic enzymes ---- Pancreatin (Viokase) ---- Pancrelipase (Cotazym) ---- Given with meals ---- Observe stool

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Common disorders of biliary system

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Cholelithiasis ---------- Gall stones ---------- Lodged in neck or cystic duct Cholecystitis ---------- Inflammation of gall bladder

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Cholecystectomy

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Gallbladder removal

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Choledocholithiasis

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Stone in the common bile duct

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Cholangitis

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Inflammation of biliary ducts

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Steatorrhea

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No bile salts in duodenum, preventing fat emulsion and digestion

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Cholecystitis clinical manifestations

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Indigestion Pain - moderate to severe Fever Jaundice RUQ tenderness Restlessness Diaphoresis N/V

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Cholelithiasis treatment

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Cholesterol solvents Drugs to dissolve stones Endoscopic sphincterotomy Extracorporeal shock-wave lithotripsy Surgery -------- Open chole ------- Lap chole

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Laparoscopic cholecystectomy - post op care

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Bleeding Comfort Prepare for D/C Referred *pain to the shoulder* --------- CO2 irritation to phrenic nerve and diaphragm --------- Intervention - place in Sims' (left side with r. knee flexed)

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Lap chole - post op care

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Deep breathing Movement ; ambulation Clear liquids Ambulation

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Discharge teaching

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Dressings ---------- Dry ---------- Remove next day Minimal analgesics required Notify MD if fever, redness, increased pain, abd distention, vomit, oozing bile Resume normal activity 48-72 hours

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