Acute Pancreatitis

Pancreas is a heterocrine gland, both an exocrine portion. It is found in the abdominal cavity inferior to the stomach. Its head is surrounded by the curve of the duodenum and the tail extends over to the spleen. It composes of the islets of Langerhans, tissue of the pancreas that produces hormones, which has four kinds of cell identified: A-cells, which produce glucagons (helps the conversion of glycogen to glucose and raises blood sugar); B-cells, which produce insulin (lowers blood sugar); D-cells, which produce somatostatin (growth hormone-inhibiting hormone that suppress the release of other hormones form the pancreas and hormones of the digestive tract and reduces the rate at which triglyceride are absorbed from the intestine after a fatty meal); and F-cells, which produce PP or pancreatic peptide (inhibits the release of digestive secretions of the pancreas abuse of such organ like excessive alcohol intake and salty foods may lead to a serious life-threatening condition of the pancreas.) (Anatomy and Physiology by Shirley Burke p 467-468).

Acute pancreatitis is an inflammatory process of the pancreas. It caused by a premature activation of pancreatic enzyme that destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. Its severity depends on the extent of inflammation and tissue destruction. It may range from mild involvement evidenced by edema and inflammation to NHP or necrotizing hemorrhagic pancreatitis (Medical Surgical Nursing 5th ed. by Ignatavicius p 1402-1403).

To know more about this disease, this case study includes the following:

•Normal anatomy and physiology•Risk factors and pathophysiology•Physical Assessment and review of system•Diagnostic tests•Pharmacology or medications•Nursing Care Plans•Medical-Surgical Management•Discharge Plan and Health Education Plan; and•Prognosis

Pancreas is an organ located behind the stomach and next to the liver and the gall bladder.  Pancreatic juices contain Enzymes, which help digest or break down food proteins.  Normally the juices leave the pancreas via a duct like channel and join the

common bile duct, which carries the secretions from the gallbladder, and pour the mixture into the duodenal portion of the

stomach.

Pancreas is also the site where hormones such as Insulin, Glucagon and somatostatin are produced.

http://whydidtheinsulindie.files.wordpress.com/2008/01/normal_pancreas.jpg

ACUTE PANCREATITIS

PREDISPOSING FACTORSBiliary Tract disorder

GallstoneTrauma

Post ERCPIdiopathy

Other causes (infection, hereditary)

PRECIPITATING FACTORSAlcoholism

Drug Interaction (Steroids and thiazide diuretics)

Obstruction/pancreatic duct hypertension

Production and release of pancreatic enzymes

Direct Toxic Injury to

Pancreatic Cells Premature activation

of trypsin

EdemaNecrosis

Hemorrhage

Activation of other

enzymes

Bile/pancreatic duct Reflux

KallikreinLipasePhospholipase AElastase

EdemaVascular permeabilitySmooth muscle contraction

Vasodilation

Shock

Fat NecrosisFat necrosis cell membrane disruption

Necrosis of blood vessels

and ductal fibers

Hemorrhage

SignsFever

Weight lossGeneral Malaise

TachycardiaAbdominal tenderness,

guarding, hypoactive BSJaundice

Severe: hemodynamic, irritability, hematemesis

SymptomsDull, mid epigastricUnusually sudden

onsetNausea and

vomiting

Initiating Event

Injury to acinar cells impairs release of

proenzymes (in zymogen)

Premature activation of Enzymes

Release of trypsin

Autodigestion

Inflammation

Necrosis

Complications

SIRSAcute Respiratory Distress syndromeDiabetes mellitus

Pancreatic infectionHypovolemia or septic

shockHemorrhage

Acute Renal FailurePseudocyst

Pancreatic AbscessParalytic iIeus

Multi organ System

SYSTEM

Respiratory systemAtelectasis, pneumonia, pleural

effusion, ERDS, hypoxia, tachypnea, dyspnea, diffuse pulmonary infiltrates.

Endocrine system Diabetes mellitus, hyperglycemia, hypocalcaemia

Gastrointestinal systemNausea and vomiting, abdominal pain, abdominal distention, decreased peristalsis, jaundice

Cardiovascular systemHypotension, hypovolemia/shock,

cyanosis, tachycardia, myocardial depression, intravascular coagulation

Integumentary system Cold, clammy skin

Excretory system Renal failure

TEST PURPOSENURSING

CONSIDERATIONS

NORMAL VALUES

ABNORMAL RESULTS

1. Serum amylase

Levels of amylase in a blood sample

Most commonly used test to aid tahe diagnosis of acute pancreatitis.

To evaluate possible pancreatic injury caused by abdominal trauma or injury.

- The patient need not fast before test but must abstain alcohol.

- If severe abdominal pain occur, obtain sample before therapeutic intervention.

- Handle sample gently to prevent hemolysis.

26 to 102 units/L(SI, o.4 to 1.74)

A marked increase (more than three times the upper limit of normal) in the level strongly suggests acute pancreatitis.

After the onset of acute pancreatitis, levels of amylase in the blood rise within six to 12 hours, peak within 12 to 48 hours and remain elevated for three to five days in uncomplicated attacks.

Moderate serum elevations may accompany obstruction of the common bile duct, pancreatic duct, pancreatic injury, pancreatic cancer and acute salivary gland disease.

Impaired kidney function may increase serum levels.

Decreased levels can occur in patients with chronic pancreatitis, pancreatic cancer, cirrhosis, hepatitis and toxemia of pregnancy

2. Serum lipase Determines levels of lipase in a blood sample

Elevated serum lipase levels help to confirm the pancreatic origin of elevated serum amylase levels.

- instruct patient to fast overnight before test.

- Handle sample gently to prevent hemolysis.

less than 160 units/L

(SI,<2.72 µkat/L)

Increased levels suggest acute pancreatitis or pancreatic duct obstruction. After an acute attack, levels remain elevated for up to 14 days.

Increased levels may occur in other pancreatic injuries such as perforated peptic ulcer with chemical pancreatitis caused by gastric juices & in patients with high intestinal obstruction, pancreatic cancer, or renal disease with impaired secretion.

3. Ultrasonography (Pancreas)

To aid in the diagnosis of pancreatitis, pseudocysts, and pancreatic carcinoma.for initial evaluation when biliary causes are suspected.The sensitivity of this study in detecting pancreatitis is 62 to 95 percent.

-instruct patient to fast for 8 to 12 hours before the test to reduce bowel gas.-Instruct to abstain from smoking before the test to eliminate the risk of swallowing air while inhaling, which interferes with test results.

Pancreas demonstrates a coarse, uniform echo pattern (reflecting tissue density) and is usually more echogenic than the adjacent liver.

Alterations in the size, contour and parenchymal texture of the pancreas suggest possible pancreatic disease.An enlarged pancreas with decreased echogenicity and distinct borders suggests pancreatitis.A well-defined mass with an essentially echo-free interior suggests a pseudocyst.An ill-defined mass with scattered internal echoes, or a mass in the head of the pancreas (obstructing the common bile duct) and a large noncontracting gallbladder suggest pancreatic carcinoma.

4. Ultrasonography (Gallbladder & Biliary system)

particularly useful for identifying gallstones in the gallbladder or in the ducts that drain the gallbladder as the cause of acute pancreatitis

However, this test cannot identify the more serious abnormalities associated with moderate and severe pancreatitis

- provide a fat-free meal in the evening before the test.

- Tell patient that he must fast for 8 to 12 hours before the procedure.

- During the scan, instruct to exhale deeply and hold his breath, when requested.

Gallbladder is sonolucent and pear-shaped; its outer walls normally apper sharp and smooth.

The common bile duct has a linear apperance but is sometimes obscured by overlying bowel gas.

Mobile, echogenic areas, usually linked to an acoustic shadow, suggest gallstones within gallbladder lumen or the biliary system.

May not be visible when the gallbladder is shrunken or filled with gallstones.

A fine layer of echoes that slowly gravitates to the dependent portion of the gallbladder as the patient changes position, suggests biliary sludge within the gallbladder lumen.

A dilated biliary system and usually a dilated gallbladder suggest obstructive jaundice.

5. Abdominal X-ray

reveal a normal appearance of the digestive tract or abnormalities (paralysis of regions of the small intestine and spasm of part of the colon) that are characteristic of acute pancreatitis

may also point to other conditions that mimic acute pancreatitis, such as blockage of the intestine and a tear in the intestinal wall.

The bowel gas pattern (stomach, small and large bowel) and soft tissue densities (liver, spleen, kidneys, and bladder) are normal in size, shape, and location.

No growths, abnormal amounts of fluid (ascites), or foreign objects are seen. Normal amounts of air and fluid are seen in the intestines. Normal amounts of stool are seen in the large intestine

The size, shape, or location of the bladder or kidneys may be abnormal. Kidney stones may be seen in the kidney, ureters, bladder, or urethra.

Abnormal growths, such as large tumors, or ascites may be seen

In some cases, gallstones can be seen on an abdominal X-ray.

The walls of the intestines may look abnormal or thick

A collection of air inside the belly cavity but outside the intestines (caused by a hole in the stomach or intestines) may be seen.

6. Chest X-ray To evaluate any abnormalities on the chest.

The diaphragm looks normal in shape and location

No abnormal collection of fluid or air is seen, and no foreign objects are seen.

The lungs look normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs.

The pleural spaces also look normal.

elevation of diaphragm, collection of fluid in the chest cavity collapse of the base of the lungs and inflammation of the lungs.

7. Computed tomography scan (pancreas)

for diagnosing acute pancreatitis (most useful radiology test)

for determining the extent of pancreatitis.

can identify:- enlargeme

nt or abnormal contours of the pancreas,

- inflammation of the tissues surrounding the pancreas,

- collection of fluid around the pancreas,

- and collection of gas in the pancreas or in the tissues behind the pancreas.

- instruct patient to fast after administration of oral contrast medium.

- Check patient’s history for recent barium studies and for hypersensitivity to iodine, seafood, or contrast media.

- Describe possible adverse reactions to the medium (nausea, flushinf, dizziness, sweating) and tell to report these symptoms.

The pancreatic parenchyma displays a uniform density, especially when an I.V. contrast medium is used.

The gland thickens from tail and has a smooth surface.

Changes in the pancreatic size and shape suggests carcinoma and pseudocysts.

Localized swelling of the head/body/tail of pancreas suggests carcinoma.

Acute pancreatitis, either edematous (interstitial) or necrotizing (hemorrhagic), produces diffuse enlargement of the pancreas.

In acute edematous pancreatitis, parenchyma density is uniformly decreased.

In acute necrotizing pancreatitis, the density is non-uniform because of the presence of necrosis and hemorrhage. The areas of tissue necrosis have diminished density.

In acute pancreatitis, inflammation typically spreads into the peripancreatic fat.

Pseudocysts, may be unilocal, multi-local, appear as sharply circumscribed, low-density areas that may contain debris.

Baseline CT scanning is indicated in the following situations: (1) the diagnosis is in doubt;

(2) severe pancreatitis is suspected because of high fever (higher than 38.8° C [102°F]), distension and leukocytosis; or

(3) the patient has an elevated severity score as determined by the MOSF or APACHE II criteria

CT Severity Index (Balthazar Score) in Acute Pancreatitishelpful in assessing complications related to acute pancreatitis or as a

follow-up study in patients who are clinically deteriorating.

CT Grade Score

CT GradeAppearance on CT CT Grade Points

Grade A Normal CT 0 points

Grade B Focal or diffuse enlargement of the pancreas 1 point

Grade C Pancreatic gland abnormalities and peripancreatic inflammation 2 points

Grade D Fluid collection in a single location 3 points

Grade E Two or more fluid collections and / or gas bubbles in or adjacent to pancreas 4 points

Necrosis score

Necrosis PercentagePoints

No necrosis 0 points

0 to 30% necrosis 2 points

30 to 50% necrosis 4 points

Over 50% necrosis 6 points

CT severity index = (points for grade) + (points for degree of pancreatic necrosis)  Interpretation: minimum score 0 maximum score 10

severity index mortality complications

0-1 0% 0%

2-3 3% 8%

4-6 6% 35%

7-10 17% 92%

8. Endoscopic retrograde cholangiopancreatography

To evaluate obstructive jaundice

This procedure is sometimes done to enable endoscopic sphincterectomy and remove impacted stones

To diagnose cancer of the pancreas and biliary ducts.

To locate calculi and stenosis in the pancreatic ducts and hepatobiliary tree.

- inform physician about the patient’s hypersensitivity to iodine, seafood or iodinated contrast media.

- Tell patient to fast after midnight before the test.

- Explain to patient that procedure is invasive (oral insertion) and takes 1-1 ½ hours or longer.

- Explain to patient that he may have sore throat 3-4 days after the procedure.

- Avoid alcohol 24 hours after the tes.

- Monitor vital signs throughout the test.

- Withhold food and fluids until gag reflex returns.

- Monitor for complications after the test.

Pancreatic and hepatobiliary ducts usually join and empty through the duodenal papilla; separate orifices are sometimes present.

Contrast medium uniformly fills the pancreatic duct, hepatobiliary tree and gallbladder.

Duodenal papilla appears as a small red or pale erosion protruding into the lumen.

Filling defects, strictures and irregular deviations of the pancreatic ducts suggests possible pancreatic cysts and pseudocysts, pancreatic tumors, chronic pancreatitis, pancreatic fibrosis, calculi or papillary stenosis.

Hepatobiliary tree filling defects, strictures or irregular deviations suggests possible calculi, cancer of the bile ducts & biliary cirrhosis.

Note: The risks of performing ERCP with sphincterotomy include precipitating an acute episode of pancreatitis, introducing infection and causing hemorrhage and perforation.

9. Fine needle aspiration 

a thin needle is used to collect tissue and/or fluid in and around the pancreas, usually with CT guidance. (This is recommended if the patient has a persistent fever or if areas of dying tissue in the pancreas - called necrotizing pancreatitis - fails to improve or worsens despite treatment.)

The small sample of pancreatic tissue/fluid that is removed is sent for laboratory analysis, including staining for bacteria and culture.

This analysis can help determine if the damaged pancreatic tissue has become infected. If infection is present in dead pancreatic tissue, further treatment may involve removal of the dead tissue by surgery

MEDICAL – SURGICAL MANAGEMENT

MEDICAL MANAGEMENT SURGICAL MANAGEMENT

MEPERIDINECLASSIFICATION: CNS agent, NARCOTIC AGONIST ANALGESIC.INDICATIONS: DEMEROL is indicated for the relief of moderate to

severe pain.MECHANISM OF ACTION: Binds to opiate receptors in the CNS,

causing inhibition of ascending pain pathways, altering the perception of and response to pain; produces generalized CNS depression.

ADVERSE REACTIONS: CNS: Fatigue, drowsiness, dizziness, nervousness, headache, restlessness,

malaise, confusion, mental depression, hallucinations, paradoxical CNS stimulation, increased intracranial pressure, seizure (associated with metabolite accumulation)

CV: cardiovascular collapse, cardiac arrestRESPIRATORY: dyspneaDRUG INTERACTION: Cimitidine cause additive sedation, and CNS depression.Selegiline, furazolidone may cause excessive and prolonged CNS

depression, convulsions, and cardiovascular collapse.MANAGEMENT:>Give narcotic analgesics in the smallest effective dose and for the least

period of time compatible with patient’s needs.>Monitor vital signs closely.>Instruct the patient not to smoke and walk without assistance after

receiving the drug.>Do not take other CNS depressant or drink alcohol because of their

additive effects.>Do not breast feed while using this drug. Oral intake is restricted and parental nutrition is started within 3 days

to prevent catabolism. In cases of intractable vomiting or ileus, nasogastric suction is

beneficial to prevent vomiting, manage ileus, and provide pancreatic rest.

Source: http://www.umm.edu/altmed/drugs/meperidine-081500.htm#Patient%20Education

INDICATIONS:>Operative intervention is indicated in four specific circumstances: Uncertainty of diagnosis Treatment of pancreatic necrosis and pancreatic abscess Correction of associated biliary tract disease Progressive clinical deterioration despite optimal supportive care.>Suregeries for acute pancreatitis are: Laparotomy Subtotal Pancreatectomy Whipple’s operation Exploratory laparotomy Cholecystectomy and intraoperative cholangiography>Preoperative Care Close monitoring of WBC count, hematocrit, serum electrolytes, serum

calcium, serum creatinine, BUN, AST, LDH, ABG’s> Postoperative Care Monitor the client for manifestations of hypoglycemia and

hyperglycemia. When the client begins to eat, watch for the development of diarrhea

and steartorrhea, which indicate that insufficient pancreatic enzymes are present.

Source:Medical Surgical Nursing 6th ed. By Black p. 1196, 1198

Medications Dosage/Frequency Nursing Instructions

1. meperidine ( Demerol)

2. cimitidine (Tagamet)

3.cefuroxime (Zinacef)

4. ranitidine (Zantac)

150 mg PO q 3- 4 h

400 mg PO bid with meals

250 mg PO bid

150 mg PO bid

Avoid alcohol, antihistamine drugs and OTC drugs.

Report severe nausea, vomiting constipation, SOB, or DOB to thephysician.

Take drug with meals and at bedtime. Inform the physician about the cigarette

smoking habits of the patient. Report if sore throat, fever, unusual

bruising or bleeding, tarry stools, confusion, severe headache, muscle or joint pain.

Take the full course of medicine even if the patient is feeling better.

Swallow tablets whole; take the medicine with food.

Report to physician if side effects are noted such as stomach upset or diarrhea.

Report to physician if severe diarrhea with blood, pus or mucus; DOB, unusual tiredness, fatigue; unusual bleeding or bruising, unusual itching or irritation

Take drug with meals and at bedtime. Report to physician if side effects are

noticed: diarrhea or constipation, nausea or vomiting and headache.

Report if sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, severe headache, muscle or joint pain.

• Some clients with acute pancreatitis may be severely weakened from their acute illness and need to confine activity to one floor, limiting their stair climbing and other activities until they regain strength.

Therapy• The clients should be encourage to learn and use of relaxation techniques

including guided imagery and music therapy are used to shift the focus of the brain away from the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback. Being massaged or applying backrub is very relaxing and help reduce stress.

Health Teaching• Teach patient about OPD Visits/ Referral• Teach patient that if acute abdominal pain or biliary tract disease (as

evidenced be jaundice, clay- colored stools, and darkened urine) occurs, he should notify it to the physician. He may report to the physician after 7 5to 10 days to know the indictor of disease or response progression.

Diet• The client should be instructed to avoid alcohol, spicy foods, any caffeine-

containing foods, heavy meals, high fatty foods. Small, frequent feeding of bland diet. Spiritual Care• Encourage client to pray in accordance with their beliefs. Ask for help to

God for complete recovery.

General health teaching Specific health teaching

1. Educate client of the effects of alcohol drinking. Instruct client to stop drinking alcohol. Advice client to get treatment for alcoholism if he

finds difficulty from abstaining.

2. Encourage to take a well - balanced diet. Eat smaller meals. Limit fat in your diet. Encourage a healthy diet of fresh

fruits and vegetables, whole grains, and lean protein. Try to get most of your daily calories from complex

carbohydrates found in grains, vegetables and legumes. If you have diabetes, a dietitian can help you plan an appropriate diet.

Drink plenty of liquids. Dehydration may aggravate your pain by further irritating your pancreas.

3. Encourage a healthy lifestyle Encourage patient to stop cigarette smoking. Immunize children against mumps and other childhood

illness. Use proper safety precautions to avoid abdominal trauma. Encourage patient to have a regular exercise.

4. Educate patient in pain management Instruct patient to do relaxation techniques, such as guided

imagery and music therapy to shift the focus of the brain away from pain, decrease muscle tension and reduce stress.

Encourage patient to participate in normal activities Inform patient of the therapeutic effect of heat compress and massage for relaxation and reducing stress.

Instruct patient to talk to the doctor about options for controlling pain.

General health teaching Specific health teaching

1.Educate client of the effects of alcohol drinking.

Instruct client to stop drinking alcohol.Advice client to get treatment for alcoholism if he finds difficulty from abstaining.

2. Encourage to take a well - balanced diet.

Eat smaller meals.Limit fat in your diet. Encourage a healthy diet of fresh fruits and vegetables, whole grains, and lean protein.Try to get most of your daily calories from complex carbohydrates found in grains, vegetables and legumes. If you have diabetes, a dietitian can help you plan an appropriate diet. Drink plenty of liquids. Dehydration may aggravate your pain by further irritating your pancreas.

3. Encourage a healthy lifestyleEncourage patient to stop cigarette smoking. Immunize children against mumps and other childhood illness.Use proper safety precautions to avoid abdominal trauma.Encourage patient to have a regular exercise.

4. Educate patient in pain managementInstruct patient to do relaxation techniques, such as guided imagery and music therapy to shift the focus of the brain away from pain, decrease muscle tension and reduce stress.Encourage patient to participate in normal activities Inform patient of the therapeutic effect of heat compress and massage for relaxation and reducing stress.Instruct patient to talk to the doctor about options for controlling pain.