Acute pancreatitis

Anatomy

• Retroperitoneal organ
that lies in the upper
quadrants of the
abdomen

• It has head body and

tail
The pancreas has both exocrine (production of digestive enzymes)
and endocrine (production of insulin and glucagon) functions.
The cells of the pancreas, called acini, secrete the major pancreatic
enzymes essential for normal digestion
The endocrine functions of the pancreas are accomplished by groups
of alpha and beta cells that compose the islets of Langerhans.
Beta cells secrete insulin, and alpha cells secrete glucagon. Both are
essential to carbohydrate metabolism
 Definition

Acute pancreatitis is inflammation of the pancreas resulting

from premature activation of pancreatic exocrine enzymes,
such as trypsin, phospholipase A, and elastase within the
pancreas and initiate autodigestion of the gland.
 Incidence

Acute pancreatitis is most common in middle aged man

and women
It affects male and female equally
Types
 Chronic pancreatitis

Chronic pancreatitis is a continuous prolonged,

inflammatory and fibrosing process of the pancreas.
Progressively destroyed as it is replaced with fibrotic tissue.
Stricture and calcification may also occur in pancreas
 Pathophysiology

Normally, pancreatic enzymes (trypsin, chymotrypsin, and

elastase)are secreted into the duodenum, where they are
activated.
The most common theory regarding the development of
pancreatitis is that an injury or disruption of pancreatic
acinar cells allows leakage of the pancreatic enzymes into
pancreatic tissue.
The leaked enzymes become activated in the tissue and
start the process of autodigestion.
The activated enzymes break down tissue and cell
membranes, causing edema, vascular damage, hemorrhage,
necrosis, and fibrosis.
These now toxic enzymes and inflammatory mediators are
released into the bloodstream and cause injury to vessel
and organ systems, such as the hepatic and renal systems.
SEVERITY STAGE 1: Pancreatic Injury
Mild – Edema
– Inflammation
STAGE 2: Local Effects
– Retroperitoneal edema
– Ileus
STAGE 3: Systemic Complications
– Hypotension/shock
– Metabolic disturbances
– Sepsis/organ failure
Severe
Etiology
 Etiology…..cont

Common bile duct obstruction

Tumors of the pancrease
Infections
Medications:
- Estrogen
- Corticosteroids
- Thiazide diuretics
- Frusemide
- Octreotide
 Clinical presentation

Pancreatic Inflammation:
Acute pain: severe, relentless, knifelike; midepigastrium or
periumbilical
• Abdominal guarding
• Nausea
• Rebound tenderness
• Vomiting
• Abdominal distention
• Hypoactive bowel sounds
Fluid Volume Deficit
• Hypotension
• Tachycardia
• Mental status changes
• Cool, clammy skin
• Decreased urine output
Impaired Gas Exchange
• Decreasing Pao2 (PaO2< 60mmHg and SaO2 <90%)
In severe cases:
Ascites
Jaundice
Palpable abdominal masses
Bluish discoloration of the flanks (Grey turners sign) and
around the umbilical area (cullen’s sign) due to
retroperitoneal haemorrhage.
 Diagnosis

Based on the clinical examination, laboratory and the

radiological test
Laboratory test
 Others:
- CRP increased
- ABG: Hypoxemia
Radiological tests:
- CT/MRI
- Endoscopic retrograde cholangiopancreatography(ERCP)
- ECG
 Complications

Pulmonary
- Hypoxemia
- Atelectesis, Pneumonia, Pleural effusion
- Acute respiratory distress syndrome
Cardiovascular
- Hypovolemic shock
- Cardiac dysrrhythmias
Hematological
- Coagulation abnormalities
- Disseminated intravascular coagulation
Gastrointestinal
- Gastrointestinal bleeding
- Pancreatic pseudocyst
- Pancreatic abscess
Renal
- Azotemia
- Oliguria
- Acute renal failure
Metabolic:
- Hypocalcemia
- Hyperlipidemia
- Hyperglycemia
- Metabolic acidosis
 Prognosis

85-90% mild, self-limited

Usually resolves in 3-7 days
10-15% severe requiring ICU admission
Mortality may approach 50% in severe cases
 Management

Conservative therapy:
- Fluid resuscitation: Colloids, crystalloids, or blood products.
- High-dose fresh frozen plasma is indicated to replace lost
circulating proteins.
- Packed RBCs incase of hemorrhagic pancreatitis
- Pain management: IV morphine, antispasmodic
- NG suction
- Keep patient in NPO
 Pharmacological therapy:
- Meperidine hydrochloride: relief of pain. Use of morphine
controversial
- Antispasmodic
- In severe cases, vasopressors to support blood pressure
- antacids: neutralizations of gastric hydrochloride
Histamine (H2) receptor antagonists (ranitidine)
Proton pump inhibitors: omeprazole
- Calcium: if hypocalcemia tetany occur
- Prophylactic broad spectrum antibiotics to combat sepsis
- Regular insulin to combat hyperglycemia
Surgical therapy:
May be done via laparoscopic technique
Pancreatic resection for acute necrotizing pancreatitis
Surgical treatment of a pseudocyst can be performed
through internal or external drainage, or needle aspiration.
Management of the cause: cholecystectomy in case of
gallstones
 Management of the complications:
- Oxygen administration
- Some patient may need intubation to ensure adequate
ventilation
- Early recognition and treatment of a pancreatic
pseudocyst
- Manage coagulopathies
 Nursing management

Nursing assessment
Vital signs
Intake and output
Signs of dehydration
Abdominal girth
Pain level
Nutritional status
 Nursing diagnosis

Fluid volume deficit related to loss of fluid into peritoneal

cavity; dehydration from nausea and vomiting; fever;
nasogastric suction; and defects in coagulation
Pain related to interruption of blood supply to the
pancreas; edema and distention of the pancreas; and
peritoneal irritation
Altered nutrition (less than body requirements) related to
altered production of digestive enzymes
 Nursing intervention

Fluid resuscitation:
- Monitor intake and output
- Colloids, crystalloids, or blood products administration.
- High-dose fresh frozen plasma is indicated to replace lost
circulating proteins.
- Assess signs of hyperglycemia and administer insulin as
prescribed.
 Pain management
- Assess pain using pain scale
- Provide analgesics, antispasmodic as prescribed
- Assess anxiety and administer sedatives as prescribed
- Patient may be advised to sit in an upright position or
slighly forward leaning position to decrease abdominal
discomfort.
- Keep surrounding quiet and restful
 Rest the pancreas:
- Encourage bed rest. Bed rest decreases pancreatic exocrine
secretion
- Maintain NPO status
- Provide nutrition enterally using a jejunal tube to prevent
pancreatic enzyme secretion.
 Improving breathing pattern
– Place the patient in semi-Fowler’s position .
– Administer oxygen therapy
– Frequent position changes to prevent atelectasis (lung
collapse) and pooling respiratory secretions.
– Frequent deep breathing, coughing exercises, and
incentive spirometry to improve respiratory function.
` `
Symtomatic management:
- Antipyretics incase of fever
- Calcium supplements incase of hypocalcemia
Improving nutritional status

– Assessment of patient nutritional status (History of

weight loss, body mass index (BMI)
– Administration of enteral or parenteral nutrition.
– Monitoring blood glucose level every 4-6 hours
– When oral feeding is allowed, provides high
carbohydrate low protein low fat diet initially.
– Educating the patient about the importance of avoiding
heavy meals and alcohol.
 Treat multisystem failure:
- Institute measure to prevent sepsis
- Evidence of poor oxygenation, including any mental
changes is reported promptly
- Oxygen administration

Health education:
- Avoidance of the alcohol
- Lifestyle modifications
Thank you