Pancreatitis: Causes, Risks, and Prevention

• Pancreatitis involves the autodigestion of the pancreas by its own digestive enzymes, which get activated prematurely.
• Each year, approximately 275,000 cases of pancreatitis occur in the United States, with a mortality rate of 1.6 per 100,000.
• Inflammation in the pancreas leads to duct obstruction, increased pressure, and potential rupture, causing enzyme release into pancreatic tissue.
• Pancreatitis can cause inflammation, necrosis, and hemorrhage within the pancreas.
• Acute pancreatitis is an inflammatory process resulting from activated pancreatic enzymes digesting the pancreas, varying from mild to severe necrotizing hemorrhagic pancreatitis.
• Chronic pancreatitis is a progressive disease involving inflammation and fibrosis of the pancreas categorized as chronic calcifying, chronic obstructive, autoimmune, idiopathic, or hereditary.

Health Promotion and Disease Prevention

• Avoid excessive alcohol consumption.
• Maintain a low-fat diet.

Risk Factors

• Gallstones can block the meeting point of the common bile duct and pancreatic duct.
• The primary cause of chronic pancreatitis is alcohol use disorder.
• Increased alcohol consumption during vacations or holidays is linked to acute pancreatitis.
• ERCP can be a postprocedure complication.
• Other risk factors include gastrointestinal surgery, metabolic disturbances like hyperlipidemia and hypercalcemia, kidney failure or transplant, genetic predisposition, trauma, penetrating ulcers, medication toxicity, viral infections like coxsackievirus B and HIV, cigarette smoking.

Expected Findings

• Symptoms include a sudden onset of severe, constant pain described as "boring" that goes through the body.
• Pain is typically epigastric, radiating to the back, left flank, or left shoulder.
• Lying down worsens the pain.
• Eating may worsen discomfort, particularly in acute cases.
• Relief can be found by assuming a fetal position or sitting upright and bending forward.
• Other symptoms include nausea, vomiting, and weight loss.

Physical Findings

• Ecchymoses (bruising) may appear on the flanks due to blood-stained exudates seeping into tissues.
• Cullen’s sign presents as a bluish-gray discoloration around the umbilicus.
• The abdomen may be distended and rigid, indicating peritonitis.
• Generalized jaundice may be observed.
• Bowel sounds may be absent or decreased, suggesting paralytic ileus.
• Warm, moist skin and fruity breath can indicate hyperglycemia.
• Hypocalcemia may lead to tetany.
• Trousseau’s sign manifests as a hand spasm when a blood pressure cuff is inflated.
• Chvostek’s sign is facial twitching when the facial nerve is tapped.

Laboratory Tests

• Serum amylase levels increase within 24 hours and remain elevated for 2 to 3 days; persistent elevation may indicate a pancreatic abscess or pseudocyst.
• Blood lipase increases slowly and remains elevated longer than amylase.
• Urine amylase can remain elevated for up to 1 week.
• Elevated enzyme levels indicate pancreatic cell injury.
• White blood cell count is increased due to infection and inflammation.
• Platelet count is decreased.
• Blood calcium and magnesium levels are decreased due to fat necrosis.
• Blood liver enzymes and bilirubin are increased with biliary dysfunction.
• Blood glucose is increased due to decreased insulin production.
• Erythrocyte sedimentation rate is elevated.

Diagnostic Procedures

• A CT scan with contrast is a reliable diagnostic tool for acute pancreatitis.

Nursing Care

• Rest the Pancreas
• Keep the patient NPO until pain-free.
• For severe cases, consider enteral or parenteral nutrition.
• When resuming diet, offer bland, high-protein, low-fat foods without stimulants like caffeine, served in small, frequent meals.
• Administer antiemetics as needed.
• Use a nasogastric tube for gastric decompression in cases of severe vomiting or paralytic ileus.
• No alcohol consumption or smoking.
• Limit stress

Pain Management

• Position the patient for comfort, such as in a fetal position, side-lying, with the head of the bed elevated, or sitting up and leaning forward.
• Administer prescribed analgesics and other medications.
• Monitor respiratory status and vital signs.
• Monitor blood glucose levels and administer insulin as needed.
• Monitor hydration status.
• Monitor IV fluids and electrolyte replacements.

Medications

• Opioid analgesics
  • Morphine or hydromorphone manage acute pain.
  • Meperidine is discouraged due to the risk of seizures, especially in older adults.
• Histamine Receptor Antagonists:
  • Cimetidine decreases gastric acid secretion.
  • Take 1 hour before or after antacids.
• Proton Pump Inhibitors:
  • Omeprazole decreases gastric acid secretion.
  • Monitor for hypomagnesemia.
• Pancreatic Enzymes:
  • Pancrelipase aids in digestion of fats and proteins when taken with meals and snacks.

Pancrelipase

• Monitor and report any persistent side effects like headache, cough, dizziness, or sore throat.
• Contents of capsules can be sprinkled on nonprotein foods.
• Drink a full glass of water after taking pancrelipase.
• Wipe lips and rinse mouth after taking medication.
• Take pancrelipase after antacid or histamine receptor antagonists.
• Take pancrelipase with every meal and snack.

Therapeutic Procedures

• ERCP creates an opening in the sphincter of Oddi if gallstones cause pancreatitis.

Interprofessional Care

• Dietary referral for postpancreatitis diet and nutritional supplements when oral intake is resumed.
• Home health services for nutritional needs, wound care, and assistance with ADLs.
• Substance-related support groups for clients or family members with alcohol use disorder.

Client Education

• Abstain from alcohol if pancreatitis is induced by alcohol use disorder.
• Avoid high-fat foods or heavy meals to prevent acute pancreatitis.

Complications

• Hypovolemia
  • Up to 6 L of fluid can be third-spaced due to retroperitoneal loss.
  • Monitor electrolytes, hypotension, and tachycardia.
  • Assist with IV fluid and electrolyte replacement.

Pancreatic infection

• Pseudocyst (outside pancreas); abscess (inside pancreas)
  • Leakage of fluid out of damaged pancreatic duct
  • Manifestations: Fever, epigastric mass, nausea, vomiting, jaundice
  • Monitor for rupture and hemorrhage.
  • Maintain sump tube if placed for drainage of cyst.
  • Monitor skin around tube for breakdown.

Type 1 Diabetes Mellitus

• Lack or absence of insulin (due to destruction of pancreatic beta cells)
• Monitor blood glucose and administer insulin.

Left Lung Effusion and Atelectasis

• Can precipitate pneumonia
• Causes: Pancreatic ascites
• Monitor for hypoxia and assist with ventilatory support.

Coagulation Defects

• Disseminated intravascular coagulopathy
• Causes: Release of thromboplastic endotoxins
• Monitor coagulation studies and for bleeding.

Multi-System Organ Failure

• Inflammation of pancreas is believed to trigger systemic inflammation
• Cause: Necrotizing hemorrhagic pancreatitis
• Administer treatments and monitor for organ failure.

Pancreatitis involves the pancreas' autodigestion by its enzymes, activated prematurely. Inflammation leads to duct obstruction and enzyme release. Prevention includes avoiding excessive alcohol and maintaining a low-fat diet.