ACUTE PANCREATITIS

PATHOPHYSIOLOGY
1. PRECIPITATING FACTORS: ALCOHOL CONSUMPTION, BILIARY TRACT OBSTRUCTION, TUMOR, MUMPS VIRUS
  1. ACTIVATION OF PANCREATIC ENZYMES INSIDE THE PANCREATIC DUCTS
    1. AUTODIGESTION OF PANCREATIC TISSUE
      1. TISSUE NECROSIS AND SEVERE INFLAMMATION OF PANCREAS
        Enzymes and cell contents leak into general circulation and may cause:
        SHOCK
        DISSEMINATED INTRAVASCULAR COAGULATION
        ADULT RESPIRATORY DISTRESS SYNDROME
        Active enzymes leak into peritoneal cavity and continue to destroy tissue with massive inflammation
        SEVERE PAIN
        HEMORRHAGE AND SHOCK
        PERITONITIS AND HYPOVOLEMIC SHOCK
2. Van Meter & Hubert, 2014
ASSESSMENT
1. CLINICAL MANIFESTATIONS
  1. Abrupt onset of Severe Epigastric and Left Upper Quadrant Pain that may radiate to back
  2. Nausea, vomiting, and fever
  3. Decreased bowel sounds, abdominal distention, and rigidity
  4. Tachycardia, hypotension, cold clammy skin
  5. Possible Jaundice
  6. Retroperitoneal bleeding
    1. Turner’s sign (Flank ecchymosis)
    2. Cullen’s sign (periumbilical ecchymosis)
2. LeMone et. al, 2015
DIAGNOSIS
1. SERUM LIPASE TEST
  1. 3-fold elevation of serum lipase from the upper limit of normal (NORMAL VALUE: 14-280 units/L)is required to make the diagnosis of acute pancreatitis
2. ULTRASONOGRAPHY
  1. Performed in all patients at baseline to evaluate the biliary tract and in particular to determine if the patient has gallstones and/or a stone in the common bile duct (CBD)
3. Magnetic resonance cholangiopancreatography (MRCP)
  1. Recommended only in patients in whom there is elevation of liver enzymes and in whom the CBD is either not visualized adequately or is found to be normal on ultrasound
4. COMPUTED TOMOGRAPHY (CT)
  1. Performed selectively when patient presents with substantial abdominal pain and a broad differential diagnosis that includes acute pancreatitis, or in patients with suspected local complications of acute pancreatitis
5. Greenberg, J. A., et al, 2015
MANAGEMENT AND TREATMENT
1. FLUID THERAPY
  1. Initial management
    1. Fluid replacement, optimization of electrolytes and provide caloric intake
      1. Crystalloid, colloid fluids or combination
        RINGER'S LACTATE (Prefered)
2. ANTIBIOTIC THERAPY
  1. Active against Gram negative bacteria
    1. IMIPINEM
    2. CLINDAMYCIN
    3. PIPERACILLIN
    4. FLUOROQUINOLONES
    5. METRONIDAZOLE
3. NUTRITION
  1. Oral food and fluids are withheld during acute episodes
    1. Reduce pancreatic secretions and promote rest of the organs
  2. Enteral Nutrition (severe)
    1. Maintains intestinal motility, which preserves the gut barrier function and subsequently reduces the risk of secondary infections
      1. Nasogastric
      2. Nasojejunal
  3. Oral food or fluids are begun once serum amylase levels have return to normal, bowel sounds are present and pain disappears
    1. SOFT DIET
      1. LOW FAT SOLID DIET
        FULL SOLID DIET
4. SURGICAL INTERVENTION
  1. Endoscopic trans duodenal sphincterectomy
  2. Cholecystectomy
5. Shah, A.P., Mourad, M.M., & Bramhall, S.R., 2018
NURSING CARE
1. Perform health history and Physical assessment
  1. Determine presence of clinical manifestations
    1. Monitor for severity and for any further complications
2. Health Promotion
  1. Educate patient on the risks/factors in developing pancreatitis
3. Focus on managing pain, promoting nutrition and maintaining fluid balance
4. Develop activity goals
5. Discuss dietary restrictions
6. LeMone et. al, 2015

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ACUTE PANCREATITIS

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