Adult Medical- Adult Medical- Surgical Nursing Surgical Nursing Gastro-intestinal Module: Gastro-intestinal Module: PancreatitisPancreatitis

The Pancreas: The Pancreas: Exocrine Function Exocrine Function

SecretionSecretion of of digestivedigestive enzymesenzymes, high in , high in protein and electrolytes:protein and electrolytes:

Amylase (CHO digestion)Amylase (CHO digestion) Lipase (fat)Lipase (fat) Trypsinogen and Enterokinase → Trypsin Trypsinogen and Enterokinase → Trypsin

(protein)(protein)

DuctDuct cellscells: Sodium Bicarbonate (alkaline to : Sodium Bicarbonate (alkaline to neutralise acidity of the chyme) neutralise acidity of the chyme)

The Pancreas: The Pancreas: Endocrine FunctionEndocrine Function

AlphaAlpha cellscells: Secretion of glucagon (CHO : Secretion of glucagon (CHO metabolism): causes breakdown of glycogen to metabolism): causes breakdown of glycogen to release glucose for energy on demandrelease glucose for energy on demand

ββ cellscells: Secretion of insulin (CHO metabolism): : Secretion of insulin (CHO metabolism): storage of glucose as glycogen in liverstorage of glucose as glycogen in liver

DeltaDelta cellscells: Secretion of somatostatin which : Secretion of somatostatin which raises blood glucose (opposes growth hormone)raises blood glucose (opposes growth hormone)

Pancreatitis: ClassificationPancreatitis: Classification

Acute PancreatitisAcute Pancreatitis

Chronic PancreatitisChronic Pancreatitis

Acute PancreatitisAcute Pancreatitis

Acute PancreatitisAcute Pancreatitis

Acute inflammation, autodigestion and Acute inflammation, autodigestion and destruction of pancreatic tissue from destruction of pancreatic tissue from hypersecretion of proteolytic enzymes hypersecretion of proteolytic enzymes especially trypsinespecially trypsin

May be mild → severe, life-threateningMay be mild → severe, life-threatening 10% mortality rate10% mortality rate

The inflammatory process is often related to The inflammatory process is often related to underlying disease of the biliary tract, as gall-underlying disease of the biliary tract, as gall-stones or long-term alcohol abusestones or long-term alcohol abuse

Acute Pancreatitis: Acute Pancreatitis: AetiologyAetiology

Gall stonesGall stones High fat dietHigh fat diet ObesityObesity Alcohol abuseAlcohol abuse Viral or bacterial infectionViral or bacterial infection

Acute Pancreatitis: Acute Pancreatitis: PathophysiologyPathophysiology

Some blockage of the pancreatic duct →Some blockage of the pancreatic duct → Hypersecretion of enzymes Hypersecretion of enzymes ThereThere isis aa reflux reflux of enzymes with bile into the of enzymes with bile into the

pancreas → self-digestion and pancreatitispancreas → self-digestion and pancreatitis May be mild oedema and inflammation confined May be mild oedema and inflammation confined

to the pancreas to the pancreas oror

A huge outpouring of proteolytic secretions and A huge outpouring of proteolytic secretions and necrosis of pancreatic tissue which can spread necrosis of pancreatic tissue which can spread to surrounding tissues to surrounding tissues

Acute Pancreatitis:Acute Pancreatitis:Pathophysiology (cont)Pathophysiology (cont)

The condition may lead to systemic The condition may lead to systemic shockshock:: Hypovolaemia: Hypovolaemia: Large amounts of protein-rich fluid in the tissues Large amounts of protein-rich fluid in the tissues

and peritoneal cavity (drawing water from the and peritoneal cavity (drawing water from the circulation by osmosis)circulation by osmosis)

Acute renal failureAcute renal failure Pulmonary effusionPulmonary effusion Respiratory distress Respiratory distress DICDIC

Acute Pancreatitis: Acute Pancreatitis: Clinical ManifestationsClinical Manifestations

Severe epigastric pain and referred back pain Severe epigastric pain and referred back pain especially after a meal, unrelieved by antacids (↑ especially after a meal, unrelieved by antacids (↑ tension within the pancreatic capsule and obstruction tension within the pancreatic capsule and obstruction of ducts)of ducts)

Nausea, vomiting (gastric contents or bile)Nausea, vomiting (gastric contents or bile) Tenderness, guarding, rigid board-like abdomen Tenderness, guarding, rigid board-like abdomen

(peritonitis) (peritonitis) Fever Fever Mental confusion, restlessnessMental confusion, restlessness BruisingBruising Jaundice, bulky fatty pale stool Jaundice, bulky fatty pale stool

Acute Pancreatitis: Acute Pancreatitis: DiagnosisDiagnosis

History and clinical pictureHistory and clinical picture Serum electrolytes, LFTSerum electrolytes, LFT ↑ ↑ SerumSerum Amylase*Amylase*/ / Lipase Lipase (diagnostic)(diagnostic) CBC (↑ WCC), ↑ ESR, ↑ CRPCBC (↑ WCC), ↑ ESR, ↑ CRP Serum bilirubin (often raised)Serum bilirubin (often raised) Random blood glucose (often raised)Random blood glucose (often raised) Serum calcium ↓; ABG if complications Serum calcium ↓; ABG if complications Ultrasound/ Xray: Ultrasound/ Xray: NONO invasive procedure invasive procedure

Acute Pancreatitis: Acute Pancreatitis: Medical Management Medical Management

ICU, possibly ventilator required, O2ICU, possibly ventilator required, O2 Pain relief (narcotic but avoid Morphine)Pain relief (narcotic but avoid Morphine) Anti-emeticAnti-emetic Nil orally; NG aspiration, TPNNil orally; NG aspiration, TPN IV fluids: glucose and electrolyte IV fluids: glucose and electrolyte

replacement, volume expanders; correct replacement, volume expanders; correct protein loss with plasma, albumenprotein loss with plasma, albumen

IV antibiotics; corticosteroids; H2-receptor IV antibiotics; corticosteroids; H2-receptor antagonists or proton-pump inhibitors (↓ HCl)antagonists or proton-pump inhibitors (↓ HCl)

Acute Pancreatitis: Acute Pancreatitis: Nursing CareNursing Care

Rest and pain reliefRest and pain relief Care of ventilation, O2 therapyCare of ventilation, O2 therapy Nil by mouth, NG aspirationsNil by mouth, NG aspirations Care of IV fluids, TPN, fluid balanceCare of IV fluids, TPN, fluid balance Monitor vital signs, CVPMonitor vital signs, CVP Monitor blood gases (ABG), electrolytes, glucose Monitor blood gases (ABG), electrolytes, glucose

(may need insulin) (may need insulin) Mouth care, change position, leg exercises anti-Mouth care, change position, leg exercises anti-

thrombo-embolus stockings (TEDs)thrombo-embolus stockings (TEDs)

Acute Pancreatitis: Acute Pancreatitis: ConvalescenceConvalescence

Gradually increase oral intake Gradually increase oral intake Gradually discontinue TPN (↓ debilitation)Gradually discontinue TPN (↓ debilitation) Low fat dietLow fat diet Continue to monitor electrolytes, Continue to monitor electrolytes,

amylase, lipase, blood glucose (may amylase, lipase, blood glucose (may affect insulin secretion triggering type 2 affect insulin secretion triggering type 2 diabetes) diabetes)

Chronic PancreatitisChronic Pancreatitis

Chronic PancreatitisChronic Pancreatitis

Chronic pancreatitis is characterised by a Chronic pancreatitis is characterised by a progressive destruction of the pancreas progressive destruction of the pancreas and its functionsand its functions

Chronic Pancreatitis: Chronic Pancreatitis: AetiologyAetiology

Main causes are alcohol abuse and Main causes are alcohol abuse and malnutrition (often combined)malnutrition (often combined)

Alcohol causes ↑ protein content in the Alcohol causes ↑ protein content in the pancreatic secretions, leading to protein plugs pancreatic secretions, leading to protein plugs and calculi within the ducts and recurrent and calculi within the ducts and recurrent acute/ sub-acute attacks acute/ sub-acute attacks

Alcohol has a direct toxic effect on the Alcohol has a direct toxic effect on the pancreatic cells, especially when the diet is pancreatic cells, especially when the diet is poor: low protein, high fat poor: low protein, high fat

Chronic Pancreatitis: Chronic Pancreatitis: PathophysiologyPathophysiology

Fibrosis and calcification of the gland from Fibrosis and calcification of the gland from repeated inflammation of acute/ sub-acute repeated inflammation of acute/ sub-acute attacksattacks

Increased pressure within the pancreasIncreased pressure within the pancreas Obstruction of the pancreatic and common bile Obstruction of the pancreatic and common bile

ducts with protein plugs and calcium stonesducts with protein plugs and calcium stones Atrophy of the epithelium of the ductsAtrophy of the epithelium of the ducts Destruction of pancreatic cells Destruction of pancreatic cells

Chronic Pancreatitis: Chronic Pancreatitis: Clinical ManifestationsClinical Manifestations

Intermittent exacerbations of acute/ sub-acute Intermittent exacerbations of acute/ sub-acute inflammation with epigastric and back paininflammation with epigastric and back pain

Weight loss: Weight loss: Anorexia especially if alcohol-related Anorexia especially if alcohol-related Fear of a further painful episodeFear of a further painful episode Clinical features of malabsorption Clinical features of malabsorption Frequent bulky offensive pale stoolsFrequent bulky offensive pale stools Bleeding tendencyBleeding tendency Jaundice Jaundice

Chronic Pancreatitis: Chronic Pancreatitis: DiagnosisDiagnosis

History and clinical pictureHistory and clinical picture Abdominal CT scan may show Abdominal CT scan may show

calcificationscalcifications Serum Amylase may not be raised in Serum Amylase may not be raised in

Chronic PancreatitisChronic Pancreatitis ERCP via endoscopy with biopsy of ERCP via endoscopy with biopsy of

pancreatic tissue (excludes carcinoma)pancreatic tissue (excludes carcinoma) GTT: may affect insulin productionGTT: may affect insulin production

Chronic Pancreatitis: Chronic Pancreatitis: Management and Nursing Management and Nursing ConsiderationsConsiderations

Dietary and lifestyle health education:Dietary and lifestyle health education: Avoid alcoholAvoid alcohol Low fat, moderate protein dietLow fat, moderate protein diet Monitor blood glucose from time to timeMonitor blood glucose from time to time Avoid exhaustion and stress as possibleAvoid exhaustion and stress as possible Blood coagulation studiesBlood coagulation studies Monitor serum calcium, vitamin KMonitor serum calcium, vitamin K