What client problem has a priority for the client diagnosed with acute pancreatitis?

This NCLEX review will discuss pancreatitis (acute and chronic).

As a nursing student, you must be familiar with acute and chronic pancreatitis and how to care for patients who are experiencing these conditions.

These type of questions may be found on NCLEX and definitely on nursing lecture exams.

Don’t forget to take the pancreatitis quiz.

You will learn the following from this NCLEX review:

• Key points about acute and chronic pancreatitis
• Pathophysiology
• Signs and Symptoms
• How it is diagnosed
• Nursing Interventions for Pancreatitis

Lecture on Pancreatitis

What is Pancreatitis? Inflammation of the pancreas that can lead to digestion of the pancreas by its own enzymes and/or irreversible structural damage to the organ.

Two types of Pancreatitis: Acute and Chronic

Where is it located in the body? It is found in the upper abdomen behind the stomach and next to the duodenum. Inside the pancreas are special cells that secrete enzymes (acinar) and hormones (islets of Langerhans).  These cells perform exocrine and endocrine functions.

Endocrine Function:

The endocrine cells called Islet of Langerhans cells produce insulin, glucagon, somatostatin, and pancreatic polypeptide (all play a role in metabolism of nutrients and balancing blood sugar). These substances enter the blood stream via a network of blood vessels surrounding the pancreas.

Exocrine Function:

Another type of cells are called Acinar cells which secrete digestive enzymes into the pancreatic ducts which flow through the ampulla of vater (this is where the pancreatic duct and common bile duct form together) into the duodenum via the major duodenal papilla (also called the papilla of vater) which is surround by the sphincter of Oddi (which is a muscular valve that controls the release of digestive enzymes and prevents reflux of stomach contents into the pancreas and bile duct).

The enzymes secreted by the Acinar cells include:

• amylase: breaks down carbs to glucose
• protease: breaks down proteins to amino acids
• lipase: breaks down fats

***NOTE: while the digestive enzymes are in the pancreas they are not activated until they enter the duodenum where a biochemical change occurs with the assistance of stomach acid.

Another substance that enters through the ampulla of vater is bile which is from the gallbladder via the common bile duct. The bile will aid in digestion by increasing the absorption of fats.

In addition, lining the small pancreatic ducts are epithelial cells which secrete bicarbonate.

When inflammation of the pancreas occurs the organs can’t deliver enzymes and hormones properly. The pancreas swells and leaks digestive enzymes.  So, the patient can experience the following (depending on the severity):

• Blood sugar issues
• Ascites
• Malabsorption (weight loss problems)
• GI issues (diarrhea, pain, oily stools)
• Shock…multi-organ failure respiratory distress
• Internal Bleeding…hemorrhage
• Structure changes of the pancreas: fibrosis, cysts (filled with infection, rupture, hemorrhage), abscesses, duct changes

Key Points about the Two Types of Pancreatitis:

Acute Pancreatitis:

Sudden inflammation of the pancreas due to something that has triggered the digestive enzymes to become activated inside the organ (there will be a high amylase and lipase level in the blood). The pancreas starts to digest itself and swell. As the pancreas digests itself, the tissue dies and cysts or abscesses can form out of the dead tissue (which can rupture or hemorrhage).

In addition, due to the location of the pancreas and how it surrounds the other organs the inflammation and activated digestive enzymes can spread to other organs and damage vessels/organs (ex: lungs) which can lead to internal bleeding, respiratory distress etc.

It comes on quickly and if treated promptly it can be reversed. Typically there is limited structural damage to the pancreas because it can be reversed with proper treatment (not the case with chronic pancreatitis). It can be fatal (can easily lead to chronic pancreatitis) and can last for several days.

Most common causes are gallstones and high amount of alcohol consumption.

Chronic Pancreatitis:

Chronic inflammation of the pancreas (can be from repeated episodes of acute pancreatitis but most commonly due to years of alcohol abuse) that has led to irreversible damage to the structure of pancreas which may lead to:

• loss of the function of the endocrine and exocrine cells (digestion and blood glucose problems)
• damaged ducts
• fibrosis
• pancreas may become enlarged or shrunk
• cysts and calcification….patient doesn’t get better and damage is irreversible

More in-depth look at the Main Causes of Pancreatitis:

Acute pancreatitis:

Main causes gallstones and high alcohol consumption

What are Gallstones? Gallstones are hardened deposits of undissolved cholesterol, salts, or bilirubin that can block the bile duct which will cause pancreatic juices to build up in the pancreas (remember the bile duct and pancreatic duct share the ampulla of vater so bile and enzymes can flow via the papilla of vater into the duodenum). If a blockage presents it can increase pressure in the pancreatic ducts which can activate the digestive enzymes….hence leading to pancreatitis.

High Alcohol Consumption: Alcohol damages the cells of the pancreas specifically the acinar cells along with duct cells (remember they produce bicarbonate and fluids), and that can lead to pancreatic duct occlusion due to the thickening of the fluid that lines the pancreatic ducts and this can lead to the activation of the enzyme cells inside the pancreas.

other causes infection, tumor, medications, trauma

Chronic pancreatitis:

Main cause is heavy-long term alcohol consumption

Recurrent episodes of acute pancreatitis from alcohol consumption leads to the damage of the pancreatic ducts/acinar cells and this can lead to scar tissue to form. The chronic inflammation of pancreatitis slowly destroys the pancreas overtime (patient needs to avoid alcohol completely).

Another cause:

Cystic fibrosis: Patients with this condition are lacking the protein CFTR. This plays a role in the movement of chloride ions to help balance salt and water in the epithelial cells that line the ducts of the pancreas. Due to the lack of this protein, there is a decreased production of bicarbonate secretion by the epithelial cells. Therefore, this causes thick mucus in the pancreatic ducts that leads to blockage of the pancreatic ducts and the enzymes activate and damage the pancreas.

Overtime, the pancreas experiences fibrosis of the pancreas’ tissue and no longer produces digestive enzyme to help with food digestion. The patient will need supplements of pancreatic digestive enzymes.

other causes: hypercalcemia, hyperlipidemia etc.

How is Pancreatitis Diagnosed?

• Blood tests: amylase, lipase, electrolytes (abnormal)
• CT or ultrasound: imaging of the pancreas
• ERCP (Endoscopic Retrograde Cholangio-Pancreatography): use to diagnose and sometimes treat the cause of pancreatitis. It assesses the pancreas, bile ducts, and gallbladder with a small scope. In addition, it can be used to help remove gallstones, dilate the blocked ducts with a stent or balloon, drain cysts etc.

Signs and Symptoms of Pancreatitis

**signs and symptoms can differ between acute vs chronic

Acute Pancreatitis:

• Abdominal Pain: Sudden, very painful mid-epigastric pain or left upper quadrant which can be felt in the back as well due to the location of the pancreas
• Pain worst when lying flat…WHY? Due to the location of the pancreas and how it is behind the peritoneum. Remember the peritoneum is a membrane lining the abdominal cavity that covers the abdominal organs. So when the pancreas is swollen/ inflamed  and the person lies flat, this pulls the peritoneum tighter over the pancreas and causes increased pain.
• May report the pain started after consuming greasy/high fat meal or alcohol.
• Fever, increased HR, decreased BP
• Nausea and vomiting
• Hyperglycemia
• Increased amylase and lipase
• Cullen’s and Grey-Turner’s Sign (seen with SEVERE cases of acute pancreatitis)
  • What causes Cullen’s and Grey-Turner’s Sign? They represent retroperitoneal bleeding from the leakage of digestive enzymes into the surrounding tissues which is causing bleeding and it is leaking down in to the flanks and umbilicus.
    • Cullen’s Sign: bluish coloration around the belly button.
      • Remember the “C” in the word Cullen for the word Circle. Your belly button forms a circle.
    • Grey-Turner’s Sign: bluish discoloration on the flanks
      • Remember the word “Turner” as how you would say it…..“TURN HER”….hence turn her on her side and you will find the bluish discoloration.

Chronic Pancreatitis

• Abdominal pain: Chronic epigastric pain that is persistent (can have no pain because the pancreas is not producing enzymes because of the extent of the damage)
• Pain becomes worst after drinking alcohol or eating a greasy/fatty meal
• May have a mass and swelling in abdomen due to pseudocyst formation on the pancreas
• Diarrhea with stool that is called Steatorrhea: oily/fatty stools due to the lack of pancreatic enzymes to help digest fats
• Weight loss: because no enzymes to help digest the food
• Signs and symptoms of Jaundice: yellowing of skin and eyes…damage to the common bile duct which helps remove bile from the liver so the bile builds up
• Dark urine: due to the excessive bile in the body
• Signs and symptoms of Diabetes Mellitus: the pancreas’ islet of Langerhans that secrete insulin are NOT working

Nursing Interventions for Pancreatitis

Goal: rest the pancreas (prevent it from being stimulated to produce digestive enzymes), control pain, monitor for complications, administer medications per MD order (pancreatic enzymes, antibiotics and stomach acid blockers), diet education

• Maintain NPO status (to let pancreas rest…once symptoms subside reintroduce solids food very carefully..start with liquids..no fat per MD order)
• Maintain IV hydration….TPN may be ordered (if taking a while to heal) for nutrition per MD order
• Insert NG tube and maintain per MD order (used to remove stomach contents and gas)
• Monitor blood sugars: hyperglycemia
• Monitor stools: oily/greasy? And their frequency…if they are taking pancreatic enzymes, the number of oily/greasy stools should decrease
• Monitor nutrition: daily weights, intake and output (urine color…can turn dark brown)
• Administering pain medication per MD order for pain (usually IV route due to severity)…Typically, NO Morphine because it can cause spasm of sphincter of Oddi
• Nonpharmacological methods for pain: leaning forward or sitting up (no supine positioning)
• Administering drugs to decrease acid secretion to help prevent the activation of digestive enzymes (similar to the drugs used in Peptic Ulcer Disease and GERD): PPIs, H2 blockers, antacids per MD order
• Administering Pancreatic enzymes “Creon/Pancreatin”
  • helps the body break down carbs, proteins, and fats because the body is not sufficiently producing digestive enzymes anymore (patient should have decreased steatorrhea)
    • Give right before a meal so it can work properly, usually comes in capsules. However, some patients can’t swallow…may need to open capsule and mix it in something like applesauce or something similar that is ACIDIC.
    • Avoid mixing with alkaline foods like ice cream, pudding, milk etc. because these foods can destroy the enzymes…remember these enzyme thrive in acidic conditions similar to your stomach.
• Education on diet
  • AVOID alcohol or greasy/fatty food
  • Low fat, bland small meals rather than large, high protein, stay hydrated
  • Limit sugar and avoid refined carbs (high fructose corn syrups, breads) but concentrate on complex carbs like fruits, vegetables, grain….body will release less insulin, especially if patient develops diabetes…need complex carbs, high protein

More NCLEX Reviews

References:

1. “Gallstones | NIDDK”. National Institute of Diabetes and Digestive and Kidney Diseases. Web. 18 Apr. 2017.
2. “Pancreatitis | Medlineplus”. Medlineplus.gov. Web. 17 Apr. 2017.
3. “Pancreatitis | NIDDK”. National Institute of Diabetes and Digestive and Kidney Diseases. Web. 17 Apr. 2017.
4. “Questions And Answers: Delayed-Release Pancreatic Enzyme Product Receives FDA Approval”. Fda.gov. Web. 18 Apr. 2017.