Pancreatitis Overview and Causes

Pancreatitis Overview

• Pancreatitis is an acute inflammatory process in the pancreas, varying in severity from mild swelling to severe tissue death (necrosis).
• The pancreas, located in the retroperitoneal space and left upper quadrant, has both endocrine and exocrine functions.
• Exocrine function involves producing enzymes like lipase to digest proteins, carbohydrates, and fats.
• Endocrine function involves releasing hormones such as insulin and glucagon.
• Inflammation can disrupt hormone production, potentially leading to complications like diabetes, especially in chronic cases.
• Inflammation can be mild or severe. Pancreatic necrosis can occur.

Causes and Types of Pancreatitis

• Acute pancreatitis can be triggered by:
  • Alcohol abuse is a common cause.
  • High cholesterol levels.
  • Gallbladder disease (cholecystitis) and biliary tract problems.
  • Autodigestion of the pancreas (pancreatic enzymes damaging the pancreas), injury to pancreatic cells, activation of pancreatic enzymes.
  • Cholestasis (gallbladder inflammation) - if gallbladder is affected pancreas is impacted too.
• Chronic pancreatitis involves persistent damage often stemming from alcohol abuse, altering glucagon and insulin function, potentially causing diabetes.

Clinical Manifestations

• Pain is a hallmark symptom. Severe, sharp, piercing pain in the upper abdomen (left upper quadrant and epigastrium), radiating to the back; sudden onset, severe, deep, piercing, and steady. Pain is aggravated by eating and lying down, and not relieved by vomiting.
• Other symptoms include:
  • Flushing, bluish discoloration (cyanosis), shortness of breath (dyspnea), abdominal swelling, nausea, vomiting, decreased or absent bowel sounds.
  • Low-grade fever, leukocytosis (increased white blood cells), hypotension (low blood pressure), tachycardia (rapid heart rate), jaundice, abdominal tenderness, and abnormal lung sounds (crackles).
• Hemorrhage can lead to Cullen's sign (discoloration around the umbilicus) and Grey Turner's sign (discoloration along the flanks).
• Leaks from the pancreas can affect the lungs, causing respiratory complications such as shortness of breath and cyanosis.

Complications

• Local complications:
  • Pseudocysts: Fluid-filled sacs that form outside the pancreas.
  • Abscesses: Pockets of pus within the pancreas; pain, fever, high WBC count, require surgical drainage.
• Systemic complications:
  • Pulmonary: Pleural effusions, atelectasis, pneumonia.
  • Cardiovascular: Hypotension.
  • Neurological: Tetany (caused by hypocalcemia).
• Shrove's and Trousseau's signs are linked to calcium levels in pancreatitis.

Diagnostic Tests and Treatments

• Diagnostic tests:
  • Blood tests: Amylase, lipase levels, liver enzymes, blood glucose, triglycerides, bilirubin, and serum calcium levels are critical.
  • Imaging: Abdominal X-rays, endoscopy.
• Treatment:
  • Pain management: Morphine or dilaudid are often used.
  • Fluid and electrolyte replacement: Crucial to counteract fluid loss and electrolyte imbalance. Lactated Ringer's solution is used for aggressive hydration.
  • Supportive care:
    • NPO (nothing by mouth), NG tube (nasogastric tube) for reduced stomach acid, prevention and treatment of infection.
    • Removal of the precipitating cause is vital, especially if gallstones are present.
  • Surgical interventions:
    • Unresponsive cases; abscesses, pseudocysts, severe peritonitis; ERCP, endoscopic sphincterotomy, laparoscopic cholecystectomy.
    • Early ambulation is encouraged.
• Nutritional support:
  • Initially, NPO with IV fluids, gradually transitioning to a high-carbohydrate, low-fat, high-protein diet.
  • Starting with ice chips, gradually progressing to water, liquids, and bland foods.
• Medication:
  • Pain relievers (IV Morphine or Dilaudid), antispasmodics, carbonic anhydrase inhibitors, antacids, histamine H2-receptor blockers, nitroglycerin or papaverine (additional medications).
• Monitor triglycerides when administering IV lipids.

Nursing Considerations

• Monitor vital signs.
• Closely track fluid intake and output.
• Early ambulation is encouraged.
• Address potential hypocalcemia promptly. Calcium and magnesium supplements may be needed. Symptoms of hypocalcemia include tetany (jerking, irritability, twitching), numbness around the lips/fingers, and positive Shrove's and Trousseau's signs.