Acute Pancreatitis PDF

2/14/24, 10:33 AM Realizeit for Student Introduction Pancreatitis (inflammation of the pancreas) is a serious disorder. The most basic classification system used to describe or categorize the various stages and forms of pancreatitis divides the disorder into acute and chronic forms. Acute pancreatit...

2/14/24, 10:33 AM Realizeit for Student Introduction Pancreatitis (inflammation of the pancreas) is a serious disorder. The most basic classification system used to describe or categorize the various stages and forms of pancreatitis divides the disorder into acute and chronic forms. Acute pancreatitis can be a medical emergency associated with a high risk of life-threatening complications and mortality, whereas chronic pancreatitis often goes undetected because classic clinical and diagnostic findings are not always present in the early stages of the disease (Feldman et al., 2016; Papadakis & McPhee, 2020; Srinivasan & Friedman, 2018). By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost (Feldman et al., 2016; Goldman & Shaffer, 2019; Papadakis & McPhee, 2020; Srinivasan & Friedman, 2018). Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop. However, chronic pancreatitis can be characterized by acute episodes. Although the mechanisms causing pancreatic inflammation are unknown, pancreatitis is commonly described as autodigestion of the pancreas. It is believed that the pancreatic duct becomes temporarily obstructed, accompanied by hypersecretion of the exocrine enzymes of the pancreas. These enzymes enter the bile duct, where they are activated and, together with bile, back up (reflux) into the pancreatic duct, causing pancreatitis. Acute Pancreatitis Acute pancreatitis ranges from a mild, self-limited disorder to a severe, rapidly fatal disease that does not respond to any treatment. These two main types of acute pancreatitis (mild and severe) are classified as interstitial edematous pancreatitis and necrotizing pancreatitis, respectively. Interstitial pancreatitis affects the majority of patients. It is characterized by a lack of pancreatic or peripancreatic parenchymal necrosis with diffuse enlargement of the gland due to inflammatory edema (Faghih et al., 2019; Olson et al., 2019). The edema and inflammation in interstitial pancreatitis is confined to the pancreas itself. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months. Although this is considered the milder form of pancreatitis, the patient is acutely ill and at risk for hypovolemic shock, fluid and electrolyte disturbances, and sepsis. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 1/6 2/14/24, 10:33 AM Realizeit for Student In the more severe form, necrotizing pancreatitis, there is tissue necrosis in either the pancreatic parenchyma or in the tissue surrounding the gland. This type can be sterile or infected; if the parenchyma is involved, this is a marker for more severe disease (Brunicardi, 2019; Faghih, et al., 2019; Olson et al., 2019). A more widespread and complete enzymatic digestion of the gland characterizes necrotizing pancreatitis. Enzymes damage the local blood vessels, and bleeding and thrombosis can occur. The tissue may become necrotic, with damage extending into the retroperitoneal tissues. Local complications include pancreatic cysts or abscesses and acute fluid collections in or near the pancreas. Patients who develop systemic complications with organ failure, such as pulmonary insufficiency with hypoxia, shock, kidney disease, and GI bleeding, are also characterized as having severe acute pancreatitis. Pathophysiology Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. These patients usually have had undiagnosed chronic pancreatitis before their first episode of acute pancreatitis. Gallstones enter the CBD and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the CBD into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum (Brunicardi, 2019; Faghih et al., 2019; Norris, 2019; Olson et al., 2019). Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage (Brunicardi, 2019; Faghih et al., 2019; Norris, 2019; Olson et al., 2019; Townsend et al., 2016). Other less common causes of pancreatitis include bacterial or viral infection, with pancreatitis occasionally developing as a complication of mumps viral infection. Spasm and edema of the ampulla of Vater, caused by duodenitis, can probably produce pancreatitis. Blunt abdominal trauma, peptic ulcer disease, ischemic vascular disease, hyperlipidemia, hypercalcemia, and the use of corticosteroids, thiazide diuretics, oral contraceptives, and other medications have also been associated with an increased incidence of pancreatitis. Acute pancreatitis may develop after surgery on or near the pancreas or after instrumentation of the pancreatic duct. In addition to alcohol consumption, use of tobacco products is a risk factor for the development of acute and chronic pancreatitis (Aune, Yahya, Norat, et al., 2019). Acute idiopathic pancreatitis accounts for up to 10% of the cases of acute pancreatitis. Some postulate that these cases may be related to occult microlithiasis (small stones in the bile) (Goodchild, https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 2/6 2/14/24, 10:33 AM Realizeit for Student Chouhan, & Johnson, 2019; Olson et al., 2019; Townsend et al., 2016). In addition, there is a small incidence of hereditary pancreatitis. The mortality rate of patients with acute pancreatitis is 2% to 10% because of shock, anoxia, hypotension, or fluid and electrolyte imbalances. This mortality rate may also be related to the 10% to 30% of patients with severe acute disease characterized by pancreatic and peripancreatic necrosis (Goodchild et al., 2019; Olson et al., 2019; Townsend et al., 2016). Pancreatitis may result in complete recovery, may recur without permanent damage, or may progress to chronic pancreatitis. The patient who is admitted to the hospital with a diagnosis of pancreatitis is acutely ill and needs expert nursing and medical care. Clinical Manifestations Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Increased tension on the pancreatic capsule and obstruction of the pancreatic ducts also contribute to the pain. Typically, the pain occurs in the midepigastrium. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion, and it may be diffuse and difficult to localize. It is generally more severe after meals and is unrelieved by antacids. Pain may be accompanied by abdominal distention; a poorly defined, palpable abdominal mass; decreased peristalsis; and vomiting that fails to relieve the pain or nausea. The patient appears acutely ill. Abdominal guarding is present. A rigid or boardlike abdomen may develop, usually indicating peritonitis (Goodchild et al., 2019; Olson et al., 2019). Ecchymosis (bruising) in the flank or around the umbilicus may indicate severe pancreatitis. Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur. Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. In addition to https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 3/6 2/14/24, 10:33 AM Realizeit for Student hypotension, the patient may develop tachycardia; cyanosis; and cold, clammy skin. Acute kidney injury is common. Respiratory distress and hypoxia are common, and the patient may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. Myocardial depression, hypocalcemia, hyperglycemia, and disseminated intravascular coagulation may also occur with acute pancreatitis. Assessment and Diagnostic Findings The diagnosis of acute pancreatitis is based on the fulfillment of two out of the three following criteria: a history of upper abdominal pain, biochemical changes with serum amylase or lipase levels greater than three times the upper limit of normal, or typical findings on imaging (CT, magnetic resonance imaging [MRI] or ultrasonography). The presence of known risk factors is also helpful for diagnostic purposes (Feldman et al., 2016; Goodchild et al., 2019; Olson et al., 2019; Z.orniak, Beyer, & Mayerle, 2019). In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase. Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels. The white blood cell count is usually elevated; hypocalcemia is present in many patients and correlates well with the severity of pancreatitis. Transient hyperglycemia and glucosuria and elevated serum bilirubin levels occur in some patients with acute pancreatitis. X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that can cause similar symptoms and to detect pleural effusions. Ultrasound studies, contrast-enhanced CT scans, and MRI scans are used to identify an increase in the diameter of the pancreas and to detect pancreatic cysts, abscesses, or pseudocysts. Hematocrit and hemoglobin levels are used to monitor the patient for bleeding. Peritoneal fluid, obtained through paracentesis or peritoneal lavage, may contain increased levels of pancreatic enzymes. ERCP is rarely used in the diagnostic evaluation https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 4/6 2/14/24, 10:33 AM Realizeit for Student of acute pancreatitis, because the patient is acutely ill; however, it may be valuable in the treatment of gallstone pancreatitis. The severity of acute pancreatitis is difficult to predict early in the course of the disease, but mortality can be predicted based on clinical and laboratory data. According to the revised Atlanta Classification, there are three degrees of severity: (1) mild with the absence of organ failure and no local or systemic complications, (2) moderately severe with the presence of transient organ failure or local or systemic complications, and (3) severe acute pancreatitis characterized by persistent organ failure (>48 hours) (Banks, Bollen, Dervenis, et al., 2013; Z.orniak et al., 2019). Several risk stratification systems aim to predict persistent organ failure and complications. The Acute Physiology and Chronic Health Evaluation II (APACHE II), Ranson Criteria for Pancreatitis Mortality, and Bedside Index of Severity in Acute Pancreatitis (BISAP) are scoring systems that assess clinical and biochemical factors to determine the severity of acute pancreatitis. Laboratory values such as C-reactive protein, procalcitonin, and blood urea nitrogen (BUN) may also carry some predictive value (Z.orniak et al., 2019). Early prediction of the severity of acute pancreatitis is important for guiding early treatment, choosing the optimal level of care, and identifying patients who might benefit from transfer to a center that specializes in the care of this disease (Z.orniak et al., 2019). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 5/6 2/14/24, 10:33 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 6/6