Description

Pancreatitis, which is the inflammation of the pancreas, can be acute or chronic in nature.
It may be caused by edema, necrosis or hemorrhage. In men, this disease is commonly
associated to alcoholism, peptic ulcer or trauma; in women, it’s associated to biliary tract
disease. Prognosis is usually good when pancreatitis follows biliary tract disease, but
poor when the factor is alcoholism. Mortality rate may go as high as 60% when the
disease is associated from necrosis and hemorrhage. (Schilling McCann, 2009)

Pancreatitis ranges from a mild, self-limited disorder to a severe, rapidly fatal disease that
does not respond to any treatment.

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 Pancreatitis is an inflammation of the pancreas and is a serious disorder.

 Pancreatitis can be a medical emergency associated with a high risk of life-
threatening complications and mortality.
 Pancreatitis is commonly described as autodigestion of the pancreas.

Classification

The most basic classification system divides the disorder into acute and chronic forms.

 Acute pancreatitis. Acute pancreatitis does not usually lead to chronic

pancreatitis unless complications develop.
 Chronic pancreatitis. Chronic pancreatitis is an inflammatory disorder
characterized by progressive destruction of the pancreas.

Pathophysiology
Self-digestion of the pancreas caused by its own proteolytic enzymes, particularly
trypsin, causes acute pancreatitis.

 Entrapment. Gallstones enter the common bile duct and lodge at the ampulla
of Vater.
 Obstruction. The gallstones obstruct the flow of the pancreatic juice or causing
a reflux of bile from the common bile duct into the pancreatic duct.
 Activation. The powerful enzymes within the pancreas are activated.
 Inactivity. Normally, these enzymes remain in an inactive form until the
pancreatic secretions reach the lumen of the duodenum.
 Enzyme activities. Activation of enzymes can lead to vasodilation, increased
vascular permeability, necrosis, erosion, and hemorrhage.
 Reflux. These enzymes enter the bile duct, where they are activated and
together with bile, back up into the pancreatic duct, causing pancreatitis.

Statistics and Epidemiology

Pancreatitis affects people of all ages, but the mortality rate associated with pancreatitis
increases with advancing age.

 Approximately 185, 000 cases of pancreatitis occur in United States each year.
 150, 000 of these cases are the result of cholelithiasis or sustained
alcohol abuse.
 The overall mortality rate of patients with pancreatitis is 2% to 10%.
 Even though the frequency is about 5000 new cases per year in the United
States, with a mortality rate of about 10%, it is yet unknown about the number
clients who have recurrent acute pancreatitis or chronic pancreatitis. (Black,
2009)
 The incidence of pancreatitis varies in different countries and also depends on
the cause (e.g., alcohol, gallstones, metabolic factors, drugs). In United States,
acute pancreatitis is related to alcohol consumption more commonly than to
gallstones (second most common); in England, the opposite is true. (Black,
2009)
Causes

Mechanisms causing pancreatitis are usually unknown but it is commonly associated with
autodigestion of the pancreas.

 Alcohol abuse. Eighty percent of the patients with pancreatitis have biliary
tract disease or a history of long term alcohol abuse.
 Bacterial or viral infection. Pancreatitis occasionally develops as a
complication of mumps virus.
 Duodenitis. Spasm and edema of the ampulla of Vater can probably cause
pancreatitis.
 Medications. The use of corticosteroids, thiazide diuretics, oral contraceptives,
and other medications have been associated with increased incidences of
pancreatitis.

Clinical Manifestations

The signs and symptoms of pancreatitis include:

 Severe abdominal pain. Abdominal pain is the major symptom of

pancreatitis that causes the patient to seek medical care and this result from
irritation and edema of the inflamed pancreas.
 Boardlike abdomen. A rigid or boardlike abdomen may develop and cause
abdominal guarding.
 Ecchymosis. Ecchymosis or bruising in the flank or around the umbilicus may
indicate severe pancreatitis.
 Nausea and vomiting. Both are also common in pancreatitis and the emesis is
usually gastric in origin but may also be bile stained.
 Hypotension. Hypotension is typical and reflects hypovolemia and shock
caused by the large amounts of protein-rich fluid into the tissues and peritoneal
cavity.

Complications
Complications that arise in pancreatitis include the following:

 Fluid and electrolyte disturbances. These are common complications because

of nausea, vomiting, movement of fluid from the vascular compartment to the
peritoneal cavity, diaphoresis, fever, and use of gastric suction.
 Pancreatic necrosis. This is a major cause of morbidity and mortality in
patients with pancreatitis because of resulting hemorrhage, septic shock, and
multiple organ failure.
 Septic shock. Septic shock may occur with bacterial infection of the pancreas.

Assessment and Diagnostic Findings

The diagnosis of pancreatitis is based on a history of abdominal pain, the presence of

known risk factors, physical examination findings, and diagnostic findings.

 Serum amylase and lipase levels. These are used in making diagnosis,
although their elevation can be attributed to many causes, and serum lipase
remain elevated for a longer period than amylase.
 WBC count. The WBC count is usually elevated.
 X-ray studies. X-ray studies of the abdomen and chest may be obtained to
differentiate pancreatitis from other disorders that can cause similar symptoms.
 Ultrasound. Ultrasound is used to identify an increase in the diameter of the
pancreas.
 Blood studies. Hemoglobin and hematocrit levels are used to monitor the
patient for bleeding.
 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).
 CT–guided needle aspiration: Done to determine whether infection is present.
 Abdominal x-rays: May demonstrate dilated loop of small bowel adjacent to
pancreas or other intra-abdominal precipitator of pancreatitis, presence of free
intraperitoneal air caused by perforation or abscess formation, pancreatic
calcification.
 Upper GI series: Frequently exhibits evidence of pancreatic
enlargement/inflammation.
 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: Elevation is common (may be caused by alcoholic liver
disease or compression of common bile duct).
 Alkaline phosphatase: 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: Hypocalcemia may appear 2–3 days after onset of illness
(usually indicates fat necrosis and may accompany pancreatic necrosis).
 Potassium: Hypokalemia may occur because of gastric losses; hyperkalemia
may develop secondary to tissue necrosis, acidosis, renal insufficiency.
 Triglycerides: Levels may exceed 1700 mg/dL and may be causative agent in
acute pancreatitis.
 LDH/AST: May be elevated up to 15 times normal because of biliary and liver
involvement.
 CBC: WBC count of 10,000–25,000 is present in 80% of patients. Hb may be
lowered because of bleeding. Hct is usually elevated (hemoconcentration
associated with vomiting or from effusion of fluid into pancreas or
retroperitoneal area).
 Serum glucose: Transient elevations of more than 200 mg/dL are common,
especially during initial/acute attacks. Sustained hyperglycemia reflects
widespread cell damage and pancreatic necrosis and is a poor prognostic sign.
 Partial 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: Can increase dramatically within 2–3 days after onset of
attack.
 Stool: Increased fat content (steatorrhea) indicative of insufficient digestion of
fats and protein.

Medical Management

Management of pancreatitis is directed towards relieving symptoms and preventing or

treating complications.

 Pain management. Adequate administration

of analgesia (morphine, fentanyl, or hydromorphone) is essential during the
course of pancreatitis to provide sufficient relief and to minimize restlessness,
which may stimulate pancreatic secretion further.
 Intensive care. Correction of fluid and blood loss and low albumin levels is
necessary to maintain fluid volume and prevent renal failure.
 Respiratory care. Aggressive respiratory care is indicated because of the
high risk elevation of the diaphragm, pulmonary infiltrates and effusion, and
atelectasis.
 Biliary drainage. Placement of biliary drains (for external drainage)
and stents (indwelling tubes) in the pancreatic duct through endoscopy has
been performed to reestablish drainage of the pancreas.

Surgical Management

There are several approaches available for surgery. The major surgical procedures are the
following:

 Side-to-side pancreaticojejunostomy (ductal drainage). Indicated when

dilation of pancreatic ducts is associated with septa and calculi. This is the most
successful procedure with success rates ranging from 60% to 90%.
 Caudal pancreaticojejunostomy (ductal drainage). Indicated for uncommon
causes of proximal pancreatic ductal stenosis not involving the ampulla.
 Pancreaticoduodenal (right-sided) resection (ablative) (with preservation
of the pylorus) (Whipple procedure). Indicated when major changes are
 confined to the head of the pancreas. Preservation of the pylorus avoids usual
sequelae of gastric resection.
 Pancreatic surgery. A 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.

Nursing Management

The patient who is admitted to the hospital with a diagnosis of pancreatitis is acutely ill
and needs expert nursing care.

Nursing Assessment

Nursing assessment of a patient with pancreatitis involves:

 Assessment of current nutritional status and increased metabolic requirements.

 Assessment of respiratory status.
 Assessment of fluid and electrolyte status.
 Assessment of sources of fluid and electrolyte loss.
 Assessment of abdomen for ascites.

Diagnosis

Based on the assessment data, the nursing diagnoses for a patient with pancreatitis
include:

 Acute pain related to edema, distention of the pancreas, and peritoneal

irritation.
 Imbalanced nutrition: less than body requirements related to inadequate
dietary intake, impaired pancreatic secretions, and increased nutritional needs.
 Ineffective breathing pattern related to splinting from severe pain, pulmonary
infiltrates, pleural effusion, and atelectasis.

Planning & Goals

Main article: 8+ Pancreatitis Nursing Care Plans

Planning and goals developed for a patient with pancreatitis involves:

 Relief of pain and discomfort.

 Improvement in nutritional status.
 Improvement in respiratory function.
 Improvement in fluid and electrolyte status.

Nursing Interventions

Performing nursing interventions for a patient with pancreatitis needs expertise and
efficiency.

 Relieve pain and discomfort. The current recommendation for pain

management in this population is parenteral opioids including morphine,
hydromorphone, or fentanyl via patient-controlled analgesia or bolus.
 Improve breathing pattern. The nurse maintains the patient in a semi-
Fowler’s position and encourages frequent position changes.
 Improve nutritional status. The patient receives a diet high in carbohydrates
and low in fats and proteins between acute attacks.
 Maintain skin integrity. The nurse carries out wound care as prescribed and
takes precautions to protect intact skin from contact with drainage.

Evaluation

Evaluation of a successful plan of care for a patient with pancreatitis should include:

 Relieved pain and discomfort.

 Improved nutritional status.
 Improved respiratory function.
 Improved fluid and electrolyte status.

Discharge and Home Care Guidelines

A prolonged period is needed to regain the strength of a patient who has experienced
pancreatitis and to return to the previous level of activity.

 Teaching. Teaching needs to be repeated and reinforced because the patient

may have difficulty in recalling many of the explanations and instructions
given.
 Prevention. The nurse instructs the patient about the factors implicated in the
onset of pancreatitis and about the need to avoid high-fat foods, heavy meals,
and alcohol.
 Identification of complications. The nurse should give verbal and written
instructions about the signs and symptoms of pancreatitis and possible
complications that should be reported promptly to the physician.
 Home care. The nurse would be able to assess the patient’s physical and
psychological status and adherence to the therapeutic regimen.

Documentation

Nursing documentation of the case of a patient with acute pancreatitis involves the
following:

 Client’s description of response to pain and acceptable level of pain.

 Prior medication use.
 Caloric intake.
 Individual cultural or religious restrictions and personal preferences.
 Respiratory pattern, breath sounds, and use of accessory muscles.
 Laboratory values.
 Use of respiratory aids or supports.
 Plan of care.
 Teaching plan.
 Response to interventions, teaching, and actions performed.
 Attainment or progress toward desired outcomes.
 Modifications to plan of care.
 Long term needs.