ACUTE PANCREATITIS

ACUTE PANCREATITIS

1. PATHOPHYSIOLOGY

   • PRECIPITATING FACTORS: ALCOHOL CONSUMPTION, BILIARY TRACT OBSTRUCTION, TUMOR, MUMPS VIRUS
     • ACTIVATION OF PANCREATIC ENZYMES INSIDE THE PANCREATIC DUCTS
       • AUTODIGESTION OF PANCREATIC TISSUE
         • 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
   • Van Meter & Hubert, 2014

2. ASSESSMENT

   • CLINICAL MANIFESTATIONS
     • Abrupt onset of Severe Epigastric and Left Upper Quadrant Pain that may radiate to back
     • Nausea, vomiting, and fever
     • Decreased bowel sounds, abdominal distention, and rigidity
     • Tachycardia, hypotension, cold clammy skin
     • Possible Jaundice
     • Retroperitoneal bleeding
       • Turner’s sign (Flank ecchymosis)
       • Cullen’s sign (periumbilical ecchymosis)
   • LeMone et. al, 2015

3. DIAGNOSIS

   • SERUM LIPASE TEST
     • 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
   • ULTRASONOGRAPHY
     • 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)
   • Magnetic resonance cholangiopancreatography (MRCP)
     • 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
   • COMPUTED TOMOGRAPHY (CT)
     • 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
   • Greenberg, J. A., et al, 2015

4. MANAGEMENT AND TREATMENT

   • FLUID THERAPY
     • Initial management
       • Fluid replacement, optimization of electrolytes and provide caloric intake
         • Crystalloid, colloid fluids or combination
           • RINGER'S LACTATE (Prefered)
   • ANTIBIOTIC THERAPY
     • Active against Gram negative bacteria
       • IMIPINEM
       • CLINDAMYCIN
       • PIPERACILLIN
       • FLUOROQUINOLONES
       • METRONIDAZOLE
   • NUTRITION
     • Oral food and fluids are withheld during acute episodes
       • Reduce pancreatic secretions and promote rest of the organs
     • Enteral Nutrition (severe)
       • Maintains intestinal motility, which preserves the gut barrier function and subsequently reduces the risk of secondary infections
         • Nasogastric
         • Nasojejunal
     • Oral food or fluids are begun once serum amylase levels have return to normal, bowel sounds are present and pain disappears
       • SOFT DIET
         • LOW FAT SOLID DIET
           • FULL SOLID DIET
   • SURGICAL INTERVENTION
     • Endoscopic trans duodenal sphincterectomy
     • Cholecystectomy
   • Shah, A.P., Mourad, M.M., & Bramhall, S.R., 2018

5. NURSING CARE

   • Perform health history and Physical assessment
     • Determine presence of clinical manifestations
       • Monitor for severity and for any further complications
   • Health Promotion
     • Educate patient on the risks/factors in developing pancreatitis
   • Focus on managing pain, promoting nutrition and maintaining fluid balance
   • Develop activity goals
   • Discuss dietary restrictions
   • LeMone et. al, 2015

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