Post on 28-Dec-2015
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Acute PancreatitisDefinition & Etiology
An acute inflammatory process of the pancreas
Degree of inflammation varies from mild to edema to severe necrosis
Most common in middle-age
African American rate three times higher than for whites
Acute PancreatitisEtiology and Pathophysiology Primary etiologic factors are
Biliary tract disease Most common: Gallbladder disease
Alcoholism
* May stimulate production of digestive
enzymes
Acute PancreatitisEtiology and Pathophysiology Caused by auto digestion of pancreas
Etiologic factorsInjury to pancreatic cells
Activate pancreatic enzymes
(AP) Acute PancreatitisEtiology and PathophysiologyTrypsinogen
Normally released into the small intestine, where it is activated to trypsin
In AP, activated trypsin is present or released in pancreas thus auto digestion of pancreas
Acute PancreatitisEtiology and Pathophysiology Edematous pancreatitis
Mild and self-limiting
Necrotizing pancreatitisDegree of necrosis correlates with severity of manifestations
Acute PancreatitisClinical Manifestations
Abdominal pain is predominant symptomPain located in LUQ
Pain may be in the midepigastrium
Commonly radiates to the back
Sudden onset
Severe, deep, piercing, steady
Aggravated by eating
Not relieved by vomiting
Acute PancreatitisClinical Manifestations
Cyanosis, DyspneaEdemaN/V, Bowel sounds decreased or absentLow-grade fever, LeukocytosisHypotension, TachycardiaJaundice FlushingAbdominal tenderness, distentionAbnormal lung sounds - CracklesGrey Turner’s or Cullen’s sign
Acute PancreatitisComplications (local)
Pseudocyst Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions
Abdominal pain
Palpable epigastric mass
Nausea, vomiting, and anorexia
Elevated serum amylase
Acute Pancreatitis Complications (local)
Pancreatic abscessA large fluid-containing cavity within pancreas
Results from extensive necrosis in the pancreas
Upper abdominal pain
Abdominal mass
High fever
Leukocytosis
Acute PancreatitisComplications : Systemic
Main systemic complicationsPulmonary
Pleural effusion
Atelectasis
Pneumonia
CardiovascularHypotension
Tetany (caused by hypocalcemia)
Acute PancreatitisDiagnostic Studies
History and physical examinationLaboratory tests
Serum amylaseSerum lipase2-hour urinary amylase and renal amylase clearanceBlood glucoseSerum calciumTriglycerides
Acute PancreatitisDiagnostic Studies
Flat plate of abdomenAbdominal/endoscopic ultrasoundEndoscopic retrograde cholangiopancreatography (ERCP)Chest x-rayCECT of pancreasMagnetic resonance cholangiopancreatography (MRCP)
Acute Pancreatis:Goals of Care
Relieve pain
Prevent or alleviate shock
Reduce pancreatic secretions
Maintain fluid and electrolyte balance
Remove precipitating cause
Acute Pancreatitis: Treatment and Nursing Care
1. Pain management– IV morphine– Combined with antispasmodic agent
2. Prevention of Shock - Plasma or volume expanders• - LR solution
3. Suppress pancreatic enzymes - NPO, NG suction, antacids, H2 receptor antagonist
4. Antibiotics
Acute PancreatitisTreatment and Nursing Care
Surgical therapy – if related to gallstones
ERCP
Endoscopic sphincterotomy
Stent placement
Laparoscopic cholecystectomy
Acute PancreatitisTreatment and Nursing Care
Nutritional therapyNPO status initially
IV lipids - monitor triglycerides
Enteral or parenteral feeding
Small, frequent feedings if allowed
High-carbohydrate, low-fat, high-protein
Acute PancreatitisNursing Diagnoses
Acute pain
Deficient fluid volume
Imbalanced nutrition: Less than body requirements
Ineffective therapeutic regimen management
Acute Pancreatitis:Home Care
Follow up care Dietary teaching
High-carbohydrate, low-fat dietAbstinence from alcohol,
Patient/family teaching * Signs of infection, high blood glucose,
steatorrhea
Chronic PancreatitisDefinition
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
Chronic PancreatitisEtiology and PathophysiologyMay follow acute pancreatitis
May occur in absence of any history of acute condition
Two major typesChronic obstructive pancreatitis
Chronic calcifying pancreatitis
Chronic PancreatitisEtiology and Pathophysiology
Chronic obstructive pancreatitisAssociated with biliary disease
Most common cause– Inflammation of the sphincter of Oddi associated with
cholelithiasis
Other causes includeCancer of ampulla of Vater, duodenum, or pancreas
Chronic PancreatitisEtiology and PathophysiologyChronic calcifying pancreatitis
Also called alcoholic inducedInflammation and sclerosis
Mainly in the head of the pancreas and around the pancreatic duct
*** Ducts are obstructed with protein precipitates which block the pancreatic duct causing it to calcify then fibrosed and atrophied.
Chronic PancreatitisClinical Manifestations
Abdominal painLocated in the same areas as in AP Heavy, gnawing feeling; burning and cramp-like
Malabsorption with weight lossConstipationMild jaundice with dark urineSteatorrheaFrothy urine/stoolDiabetes mellitus
Chronic PancreatitisClinical Manifestations
Complications includePseudocyst formation
Bile duct or duodenal obstruction
Pancreatic ascites
Pleural effusion
Splenic vein thrombosis
Pseudoaneurysms
Pancreatic cancer
Chronic PancreatitisDiagnostic Studies
Laboratory testsSerum amylase/lipase
May be ↑ slightly or not at all
↑ Serum bilirubin
↑ Alkaline phosphatase
Mild leukocytosis
Elevated sedimentation rate
Chronic PancreatitisDiagnostic Studies
CT
MRI
MRCP
Transabdominal ultrasound
Endoscopic ultrasound
Secretin stimulation test
ERCP
Chronic PancreatitisGoals of Care
Prevention of attacksDuring acute attack follow acute therapy
Relief of pain
Control of pancreatic exocrine and endocrine insufficiency
Bland, low-fat, high-carbohydrate diet
Chronic PancreatitisTreatment and Nursing Care Cont.
Bile salts
Control of diabetes
No alcohol
Pancreatic enzyme replacement
Acid-neutralizing and acid-inhibiting drugs
Chronic PancreatitisTreatment and Nursing Care
SurgeryIndicated when biliary disease is present or if obstruction or pseudocyst develops
Divert bile flow or relieve ductal obstruction
Chronic PancreatitisHome/Ambulatory Care
Focus is on chronic care and health promotion
Dietary controlNo alcohol
Control of diabetes
Taking pancreatic enzymes
Patient and family teaching