Acute Pancreatitis

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.

ACUTE PANCREATITIS PREDISPOSING FACTORS Biliary Tract disorder Gallstone Trauma Post ERCP Idiopathy Other causes (infection, hereditary)

PRECIPITATING FACTORS Alcoholism Drug Interaction (Steroids and thiazide diuretics)

Obstruction/pancreatic duct hypertension

Direct Toxic Injury to Pancreatic Cells

Edema Necrosis Hemorrhage

Bile/pancreatic duct Reflux Premature activation of trypsin Activation of other enzymes

Production and release of pancreatic enzymes

Elastase

Necrosis of blood vessels and ductal fibers

Phospholipase A

Fat necrosis cell membrane disruption

Hemorrhage

Signs Fever Weight loss General Malaise Tachycardia Abdominal tenderness, guarding, hypoactive BS Jaundice Severe: hemodynamic, irritability, hematemesis

Lipase

Fat Necrosis

Kallikrein

Edema Vascular permeability Smooth muscle contraction Vasodilation Shock

Symptoms Dull, mid epigastric Unusually sudden onset Nausea 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 SIRS Acute Respiratory Distress syndrome Diabetes mellitus Pancreatic infection Hypovolemia or septic shock Hemorrhage Acute Renal Failure Pseudocyst Pancreatic Abscess Paralytic iIeus Multi organ System

SYSTEM Respiratory system

Endocrine system

Gastrointestinal system

Cardiovascular system

Integumentary system Excretory system

Atelectasis, pneumonia, pleural effusion, ERDS, hypoxia, tachypnea, dyspnea, diffuse pulmonary infiltrates.

Diabetes mellitus, hyperglycemia, hypocalcaemia Nausea and vomiting, abdominal pain, abdominal distention, decreased peristalsis, jaundice Hypotension, hypovolemia/shock, cyanosis, tachycardia, myocardial depression, intravascular coagulation Cold, clammy skin Renal failure

TEST

PURPOSE

1. Serum amylase

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NURSING NORMAL VALUESABNORMAL RESULTS CONSIDER ATIONS

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.

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The patient 26 to 102 units/L need not fast (SI, o.4 to 1.74) before test but must abstain alcohol. If severe abdominal pain occur, obtain sample before therapeutic intervention. Handle sample gently to prevent hemolysis.

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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

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Determines levels of lipase in a blood sample Elevated serum lipase levels help to confirm the pancreatic origin of elevated serum amylase levels.

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instruct patient to fast overnight before test. Handle sample gently to prevent hemolysis.

less than 160 units/L (SI,<2.72 µkat/L)

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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 Pancreas patient to demonstrates a fast for 8 to coarse, uniform 12 hours echo pattern before the (reflecting tissue test to density) and is reduce usually more bowel gas. echogenic than the -Instruct to adjacent liver. abstain from smoking before the test to eliminate the risk of swallowing air while inhaling, which interferes with test results.

•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. Ultrasonogra phy (Gallbladder & Biliary system)

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particularl y useful for identifying gallstones in the gallbladder or in the ducts that drain the gallbladder as the cause of acute pancreatiti s However, this test cannot identify the more serious abnormalit ies associated with moderate and severe pancreatiti s

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provide a Gallbladder is • fat-free sonolucent meal in and pearthe shaped; its evening outer walls • before the normally test. apper Tell sharp and • patient smooth. that he The common must fast bile duct for 8 to 12 has a hours linear before the apperance • procedure but is . sometimes During the obscured scan, by instruct to overlying exhale bowel gas. deeply and hold his breath, when requested .

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 •

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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.

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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

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To evaluate any abnormalities on the chest.

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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) •

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for diagnosing acute pancreatitis (most useful radiology test) for determining the extent of pancreatitis. can identify: enlargem ent or abnormal contours of the pancreas, inflamma tion of the tissues surroundi ng the pancreas, collection of fluid around the pancreas, and collection of gas in the pancreas or in the tissues behind the pancreas.

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instruct The patient to fast after administ ration of oral contrast medium. Check The patient’ s history for recent barium studies and for hyperse nsitivity to iodine, seafood, or contrast media. Describe possible adverse reaction s to the medium (nausea, flushinf, dizzines s, sweatin g) and tell to report these sympto ms.

pancreatic parenchyma displays a uniform density, especially when an I.V. contrast medium is used. gland thickens from tail and has a smooth surface.

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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 Pancreatitis helpful in assessing complications related to acute pancreatitis or as a follow-up study in patients who are clinically deteriorating.

CT Grade Score Appearance 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

CT Grade

Necrosis score Points Necrosis Percentage

Interpretation:

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) 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 cholangiopancreat • ography

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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.

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• 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 Filling defects, strictures hepatobiliary ducts and irregular deviations of usually join and the pancreatic ducts empty through the suggests possible duodenal papilla; pancreatic cysts and separate orifices are pseudocysts, pancreatic sometimes present. tumors, chronic Contrast medium pancreatitis, pancreatic uniformly fills the fibrosis, calculi or pancreatic duct, papillary stenosis. • hepatobiliary tree Hepatobiliary tree filling and gallbladder. defects, strictures or Duodenal papilla irregular deviations appears as a small suggests possible calculi, red or pale erosion cancer of the bile ducts & protruding into the biliary cirrhosis. lumen. 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

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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

MEPERIDINE CLASSIFICATION: 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 arrest RESPIRATORY: dyspnea DRUG 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

1. meperidine ( Demerol)

150 mg PO q 3- 4 h

Nursing Instructions • •

2. cimitidine (Tagamet)

400 mg PO bid with meals

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3.cefuroxime (Zinacef)

250 mg PO bid

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4. ranitidine (Zantac)

• • 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.

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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 caffeinecontaining 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 1.

Specific health teaching • •

Educate client of the effects of alcohol drinking.

2. Encourage to take a well - balanced diet.

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3. Encourage a healthy lifestyle

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4. Educate patient in pain management

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

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.

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.

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 1.Educate client of the effects of alcohol drinking.

Specific health teaching •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•Eat smaller meals. •Limit fat in your diet. Encourage a diet. 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

4. Educate patient in pain management

•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.

•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.