Unit-4 Manish Saraswat (M.Sc.) Notes B.Sc.2nd Yr

PANCREATITIS

DEFINITION-Pancreatitis is a disease in which the pancreas becomes inflamed. Pancreatic damage happens when the digestive enzymes are activated before they are released into the small intestine and begin attacking the pancreas.

(digestive enzymes- amylase, which aids in the digestion of carbohydrates; trypsin, which aids in the digestion of proteins; and lipase, which aids in the digestion of fats.) TYPES OF PANCREATITIS THEM CAUSES - , acute pancreatitis and chronic pancreatitis.Acute pancreatitis- Acute pancreatitis is a sudden inflammation that lasts for a short time. It may range from mild discomfort to a severe, life-threatening illness. Most people with acute pancreatitis recover completely after getting the right treatment.

Chronic pancreatitis- Chronic pancreatitis is long-lastinginflammation of the pancreas. It most often happens after an episode of acute pancreatitis. Heavy alcohol drinking is another big cause. Damage to the pancreas from heavy alcohol use may not cause symptoms for many years, but then the person may suddenly develop severe pancreatitis symptomsA number of causes have been identified for acute pancreatitis and chronic pancreatitis, including:

Alcoholism(40%) Gallstones(30%) Abdominal surgery Adverse effect of certain medications: including ACE inhibitors, thiazine diuretics,

furosemide (Lasix), tetracyclines, and sulfonamides Cigarette smoking Cystic fibrosis Pancreatic trauma or pancreatic duct obstruction, such as penetrating or blunt external

trauma, intraoperative manipulation and pancreatic ductal overdistention during endoscopic retrograde cholangiopancreatography (ERCP)

Family history of pancreatitis High calcium levels in the blood (hypercalcemia), which may be caused by an overactive

parathyroid gland (hyperparathyroidism) High triglyceride levels in the blood (hypertriglyceridemia) Infection such as mumps  Injury to the abdomen Pancreatic cancer

PATHOPHYSIUOLOGY- Due to the causes

The enzymes become activated while still in the pancreas.

Enzymes to irritate the cells of pancreas, causing inflammation and the signs and symptoms

associated with acute pancreatitis.

Repeated bouts (attacks) of acute pancreatitis, damage to the pancreas

To chronic pancreatitis.

Scar tissue may form in the pancreas, causing loss of function.

A poorly functioning pancreas can cause digestion problems and diabetes.

SIGN AND SYMPTONS-

ACUTE PANCREATITIS SIGNS AND SYMPTOMS INCLUDE: Upper abdominal pain Abdominal pain that radiates to your back or left shoulder Abdominal pain that feels worse after eating Nausea Vomiting Tenderness when touching the abdomen Bluish-gray discoloration of periumbilical area and abdomen (Cullen’s sign) Bluish-gray discoloration of flank areas (Turner’s sign)

CHRONIC PANCREATITIS SIGNS AND SYMPTOMS INCLUDE:

Upper abdominal pain Losing weight without trying Oily(fatty) stools (steatorrhea) Liver  problems (jaundice) Gnawing continuous abdominal pain with acute exacerbations

OTHER SIGN AND SYMPTOMS- Epigastric pain due to inflammation and stretching of pancreatic duct • Patient in knee-chest position for comfort—reduces tension on abdomen • Nausea and vomiting• Ascites• Weight loss• Blood glucose elevation • Fatigue

COMPLICATIONS Atelectasis Coma Destruction of pancreas Diabetes acidosis

Diabetes Mellitus (if islets of Langerhans are damaged) GI bleeding Massive hemorrhage Pancreatic abscess Pneumonia Pulmonary effusion Shock Pseudocyst. Acute pancreatitis can cause fluid and debris to collect in cyst-like

pockets in pancreas. A large pseudocyst that ruptures can cause complications such as internal bleeding and infection.

Infection. Acute pancreatitis can make your pancreas vulnerable to bacteria and infection. Pancreatic infections are serious and require intensive treatment, such as surgery to remove the infected tissue.

Breathing problems. Acute pancreatitis can cause chemical changes in your body that affect your lung function, causing the level of oxygen in blood to fall to dangerously low levels. (Adult respiratory distress syndrome/acute respiratory distress syndrome due to abnormally permeability of the alveolocapillay membrane)

Kidney failure.  Malnutrition. Both acute and chronic pancreatitis can cause pancreas to produce

fewer of the enzymes that are needed to break down and process nutrients from the food eat. This can lead to malnutrition, diarrhea and weight loss, even though may be eating the same foods or the same amount of food.

Pancreatic cancer. Long-standing inflammation in pancreas caused by chronic pancreatitis is a risk factor for developing pancreatic cancer.

DIAGNOSTIC STUDIES CT scan: Shows an enlarged pancreas, pancreatic cysts and determines extent of

edema and necrosis. Ultrasound of abdomen: May be used to identify pancreatic inflammation, abscess,

pseudocysts, carcinoma, or obstruction of biliary tract Endoscopic retrograde cholangiopancreatography: Useful to diagnose fistulas,

obstructive biliary disease, and pancreatic duct strictures/anomalies (procedure is contraindicated in acute phase).

Needle aspiration: Done to determine whether infection is present. Abdominal x-rays. Serum amylase: Increased because of obstruction of normal outflow of pancreatic

enzymes (normal level does not rule out disease). May be five or more times normal level in acute pancreatitis.

Serum lipase: usually elevates along with amylase, but stays elevated longer. Serum bilirubin level test: Elevation is common (may be caused by alcoholic liver

disease or compression of common bile duct). Alkaline phosphatase level test: Usually elevated if pancreatitis is accompanied by

biliary disease. Serum albumin and protein: May be decreased (increased capillary permeability

and transudation of fluid into extracellular space). Serum calcium level test: Hypocalcemia may appear 2–3 days after onset of illness

(usually indicates fat necrosis and may accompany pancreatic necrosis). Serum potassium level test: Hypokalemia may occur because of gastric losses;

hyperkalemia may develop secondary to tissue necrosis, acidosis, renal insufficiency.

Triglycerides Test: Levels may exceed 1700 mg/dL and may be causative agent in acute pancreatitis.

SGPT (Serum Glutamic Pyruvic Transminase)/SGOT (Serum Glutamic Oxaloacetic Transaminase) TEST-.may be elevated Up To 15 Times normal because of biliary and liver involvement.

CBC Serum glucosePartial thromboplastin time (PTT): Prolonged if coagulopathy

develops because of liver involvement and fat necrosis. Urinalysis: Glucose, myoglobin, blood, and protein may be present. Urine amylase test: Can increase dramatically within 2–3 days after onset of attack. Stool test: Increased fat content (steatorrhea) indicative of insufficient digestion of

fats and protein. Endoscopic ultrasound to look for inflammation and blockages in the pancreatic duct

or bile duct Magnetic resonance imaging (MRI) to look for abnormalities in the gallbladder,

pancreas and ducts.

COLLABORATION MANAGEMENTMEDICAL MANAGEMENT:A client experiencing pancreatitis can be admitted to the hospital for health care. Initial steps to control inflammation of the pancreas and help increase the comfort of the client include:

Fasting Pain medications Intravenous fluids Exogenous insulin therapy may be necessary because of destruction of islet tissue.

FASTINGFasting is indicated until acute inflammation subsides (ie, cessation of abdominal tenderness and pain, normalization of serum amylase, return of appetite, feeling better). Fasting can last from a few days in mild pancreatitis to several weeks. In severe cases, TPN should be initiated within the first few days to prevent undernutrition.PAIN MEDICATIONS-

Pain relief requires parenteral opioids, which should be given in adequate doses. Although morphine may cause the sphincter of Oddi to contract, this is of doubtful clinical significance. Antiemetic agents (eg,prochlorperazine 5 to 10 mg IV q 6 h) should be given to alleviate vomiting.

An NGT is required only if significant vomiting persists or ileus is present.Parenteral H 2 blockers or proton pump inhibitors are given(rentidine)

Efforts to reduce pancreatic secretion with drugs (eg, anticholinergics (atropine sulfate), glucagon, somatostatin.

In Severe acute pancreatitis should be treated in an ICU, particularly in patients with hypotension, oliguria In the ICU, vital signs and urine output are monitored hourly; cbc, glucose, and electrolytes are reassessed every 8 h; ABG is determined as needed; central venous pressure line or catheter measurements are determined every 6 h if the patient is hemodynamically unstable or if fluid requirements are unclear. CBC, platelet count, coagulation parameters, total protein with albumin, BUN, creatinine, Ca, and Mg are measured daily.

INTRAVENOUS FLUIDS Adequate fluid resuscitation is essential; up to 6 to 8 L/day of fluid containing

appropriate electrolytes may be required. Inadequate fluid therapy increases the risk of pancreatic necrosis

Prerenal azotemia(presence of increased amounts of nitrogenous waste products) should be treated by increased fluid replacement. Renal failure may require dialysis (usually peritoneal). Administer pancreatic enzymes with meals

EXOGENOUS INSULIN THERAPY MAY BE NECESSARY BECAUSE OF

DESTRUCTION OF ISLET TISSUE.

Hypoxemia is treated with humidified O 2 via mask or nasal prongs. If hypoxemia persists or adult respiratory distress syndrome develops, assisted ventilation may be required. Glucose > 170 to 200 mg/dL (9.4 to 11.1 mmol/L) should be treated cautiously with sc or IV insulin and carefully monitored.

SURGICAL INTERVENTIONS- The surgery performed depends on the anatomic and functional abnormalities of the pancreas, including the location of disease within the pancreas, diabetes, exocrine insufficiency, biliary stenosis, and pseudocysts of the pancreas. Other factors taken into consideration in determining whether surgery is to be performed and what procedure is indicated include the patient’s continued use of alcohol and the likelihood that the patient will be able to manage the endocrine or exocrine changes that are expected after surgery.There are several approaches av ailable for surgery. The major surgical procedures are the following:-

Side-to-side pancreaticojejunostomy (ductal drainage). a side-to-side anastomosis or joining of the pancreatic duct to the jejunum allows drainage of the pancreatic secretions into the jejunum. This is the most successful procedure with success rates ranging from 60% to 90%.

Caudal pancreaticojejunostomy (ductal drainage). is a surgical technique used in the treatment of chronic pancreatitis. It involves a  anastomosis of the pancreatic tail and the jejunum

Pancreaticoduodenal (right-sided) resection (ablative) (with preservation of the pylorus) (Whipple procedure)- The Whipple procedure (pancreatoduodenectomy) is an operation to remove a portion of the pancreas, as well as a portion of the small intestine (duodenum), the gallbladder and part of the bile duct. The remaining organs are reattached to allow you to digest food.

Surgery may be performed to assist in the diagnosis of pancreatitis (diagnostic laparotomy), to establish pancreatic drainage, or to resect or débride a necrotic pancreas. The patient who undergoes pancreatic surgery may have multiple drains in place postoperatively as well as a surgical incision that is left open for irrigation and repacking every 2 to 3 days to remove necrotic debris

(multiple sump tubes are used after pancreatic surgery triple-lumen tubes consist of ports that provide tubing for irrigation, air venting, and drainage.)

PREVENTIVE MEASURES: Stop drinking alcohol. If you're unable to stop drinking alcohol on your own, ask your

doctor for help. Your doctor can refer you to local programs to help you stop drinking. Stop smoking. If you smoke, quit. If you don't smoke, don't start. If you can't quit on

your own, ask your doctor for help. Medications and counseling can help you stop smoking.

Choose a low-fat diet. Choose a diet that limits fat and emphasizes fresh fruits and vegetables, whole grains, and lean protein.

Drink more fluids. Pancreatitis can cause dehydration, so drink more fluids throughout the day. It may help to keep a water bottle or glass of water with you.

NURSING MANAGEMENT-NURSING INTERVENTIONS

1. Maintain the nasogastric tube for drainage or suctioning.2. Restrict the patient to bed rest, and provide a quiet and restful environment.3. Place the patient in comfortable position that allows maximal chest expansion.4. Keep water and other beverages at bed side, and encourage the patient to drink plenty

of fluids.5. Provide I.V. fluids and parenteral nutrition as ordered.6. Assess the patient’s level of pain.7. Assess pulmonary status at least every 4 hours to detect early signs of respiratory

complications.8. Monitor fluid and electrolyte balance, and report any abnormalities.9. Emphasize the importance of avoiding factors that precipitate acute pancreatitis

especially alcohol.10. Stress the need for a diet high in carbohydrates and low in protein and fats.11. Caution the patient to avoid caffeinated beverages and irritating foods.

NURSING DIAGNOSIS-

1. Acute Pain may be related to Obstruction of pancreatic, biliary ducts, Chemical contamination of peritoneal surfaces by pancreatic exudates/auto digestion of pancreas, Extension of inflammation to the retroperitoneal nerve plexusGOAL- Report pain is relieved/controlled,Follow prescribed therapeutic regimen,Demonstrate use of methods that provide relief.

INTERVENTION- Investigate verbal reports of pain, noting specific location and intensity (0–10 scale).

Note factors that aggravate and relieve pain. Maintain bedrest during acute attack. Provide quiet, restful environment. Promote position of comfort on one side with knees flexed, sitting up and leaning

forward. Provide alternative comfort measures (back rub), encourage relaxation techniques

(guided imagery, visualization), quiet diversional activities (TV, radio). Keep environment free of food odors. Administer analgesics in timely manner (smaller, more frequent doses). Maintain meticulous skin care, especially in presence of draining abdominal wall

fistulas. Administer medication as indicated:Narcotic analgesics: meperidine (Demerol),

fentanyl (Sublimaze), pentazocine (Talwin); Sedatives: diazepam (Valium);antispasmodics: atropine; Antacids: Mylanta, Maalox, Amphojel, Riopan; Cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) Withhold food and fluid as indicated. Maintain gastric suction when used. Prepare for surgical intervention if indicated.

2. Risk for Deficient Fluid Volume risk factors may include Excessive losses: vomiting, gastric suctioning, Alteration of clotting process, hemorrhageGOAL- Maintain adequate hydration as evidenced by stable vital signs, good skin turgor, prompt capillary refill, strong peripheral pulses, and individually appropriate urinary output.INTERVENTION-

Monitor BP and measure CVP if available. Measure I&O including vomiting, gastric aspirate, diarrhea. Calculate 24-hr fluid

balance. Note decrease in urine output (less than 400 mL per 24 hr). Record color and character of gastric drainage, measure pH, and note presence of

occult blood. Weigh as indicated. Correlate with calculated fluid balance. Note poor skin turgor, dry skin and mucous membranes, reports of thirst. Observe and record peripheral and dependent edema. Measure abdominal girth if

ascites present. Investigate changes in sensorium (confusion, slowed responses). Auscultate heart sounds; note rate and rhythm. Monitor and document rhythm,

changes. Inspect skin for petechiae, hematomas, and unusual wound or venipuncture bleeding.

Note hematuria, mucous membrane bleeding, and bloody gastric contents.

Watch out for signs and symptoms of calcium deficiency. Observe and report coarse muscle tremors, twitching, positive Chvostek’s, Trousseau’s sign, tetany, cramps, carpopedal spasm, and seizures.

Keep airway and suction apparatus handy and pad side rails. Administer fluid replacement as indicated (saline solutions, albumin, blood, blood

products, dextran). Monitor laboratory studies (Hb and Hct, Protein, albumin, electrolytes, BUN,

creatinine, urine osmolality and sodium, potassium, coagulation studies). Replace electrolytes (sodium, potassium, chloride, calcium as indicated). Prepare and assist with peritoneal lavage, hemoperitoneal dialysis.

3. Imbalanced Nutrition: Less Than Body Requirements may be related toVomiting, decreased oral intake; prescribed dietary restrictions,Loss of digestive enzymes and insulin (related to pancreatic outflow obstruction or necrosis/autodigestion)Goal- Demonstrate progressive weight gain toward goal with normalization of laboratory values,Experience no signs of malnutrition,Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.INTERVENTION-

Assess abdomen, noting presence and character of bowel sounds, abdominal distension, and reports of nausea.

Provide frequent oral care. Assist patient in selecting food and fluids that meet nutritional needs and restrictions

when diet is resumed. Observe color, consistency and amount of stools. Note frothy consistency and foul

odor. Note signs of increased thirst and urination or changes in mentation and visual acuity. Test urine for sugar and acetone. Maintain NPO status and gastric suctioning in acute phase. Administer hyperalimentation and lipids, if indicated. Resume oral intake with clear liquids and advance diet slowly to provide high-protein,

high-carbohydrate diet, when indicated. Provide medium-chain triglycerides ( Portagen). Administer medications as indicated:-Vitamins: A,D,E,K; Replacement enzymes: pancreatin (Dizymes), pancrelipase (Viokase, Cotazym). Monitor serum glucose. Provide insulin as appropriate.

4.Risk for Infection risk factors may includeInadequate primary defenses: stasis of body fluids, altered peristalsis, change in pH of secretions,Immunosuppression,Nutritional deficiencies,Tissue destruction, chronic diseaseGOAL- Achieve timely healing, be free of signs of infection,Be afebrile,Participate in activities to reduce risk of infection.INTERVENTION-

Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters and tubes, drains. Change soiled dressings promptly.

Stress importance of good handwashing.

Observe rate and characteristics of respirations, breath sounds. Note occurrence of cough and sputum production.

Encourage frequent position changes, deep breathing, and coughing. Assist with ambulation as soon as stable.

Observe for signs of infection:-Fever and respiratory distress in conjunction with jaundice;Increased abdominal pain, rigidity and rebound tenderness, diminished and absent bowel sounds;Increased abdominal pain and tenderness, recurrent fever (higher than 101°F), leukocytosis, hypotension, tachycardia, and chills.

Obtain culture specimens (blood, wound, urine, sputum, or pancreatic aspirate). Administer antibiotic therapy as indicated: cephalosporins, cefoxitin sodium

(Mefoxin); plus aminoglycosides: gentamicin (Garamycin), tobramycin (Nebcin). Prepare for surgical intervention as necessary.

5.Deficient Knowledge may be related to Lack of exposure/recall,Information misinterpretation; unfamiliarity with information resourcesGOAL-Verbalize understanding of condition/disease process and potential complications,Verbalize understanding of therapeutic needs,Correctly perform necessary procedures and explain reasons for the actions,Initiate necessary lifestyle changes and participate in treatment regimen.INTERVENTION-

Review specific cause of current episode and prognosis. Discuss other causative and associated factors such as excessive alcohol intake,

gallbladder disease, duodenal ulcer, hyper -lipoproteinemias, some drugs (oral contraceptives, thiazides, furosemide [Lasix], isoniazid [INH], glucocorticoids, sulfonamides).

Explore availability of treatment programs and rehabilitation of chemical dependency if indicated.

Stress the importance of follow-up care, and review symptoms that need to be reported immediately to physician (recurrence of pain, persistent fever, nausea and vomiting, abdominal distension, frothy and foul-smelling stools, general intolerance of food).

Review importance of initially continuing bland, low-fat diet with frequent small feedings and restricted caffeine, with gradual resumption of a normal diet within individual tolerance.

Instruct in use of pancreatic enzyme replacements and bile salt therapy as indicated, avoiding concomitant ingestion of hot foods and fluids.

Recommend cessation of smoking. Discuss signs and symptoms of diabetes mellitus (polydipsia, polyuria, weakness,

weight loss).