Pancreatitis Case Study, Pathophysiology, Nursing Care Plans

Pancreatitis, which is the inflammation of the pancreas, can be acute or chronic in nature. It may be caused by edema, necrosis or hemorrhage. In men, this disease is commonly associated to alcoholism, peptic ulcer or trauma; in women, it’s associated to biliary tract disease. Prognosis is usually good when pancreatitis follows biliary tract disease, but poor when the factor is alcoholism. Mortality rate may go as high as 60% when the disease is associated from necrosis and hemorrhage. (Schilling McCann, 2009)

Even though the frequency is about 5000 new cases per year in the United States, with a mortality rate of about 10%, it is yet unknown about the number clients who have recurrent acute pancreatitis or chronic pancreatitis. (Black, 2009)

The incidence of pancreatitis varies in different countries and also depends on the cause (e.g., alcohol, gallstones, metabolic factors, drugs). In United States, acute pancreatitis is related to alcohol consumption more commonly than to gallstones (second most common); in England, the opposite is true. (Black, 2009)

Etiology and Risk Factors

Acute pancreatitis has many causes, such as alcohol abuse, cholelithiasis, abdominal trauma, virus infection, drugs, and metabolic factors. The mechanisms by which these conditions trigger pancreatic inflammation have not been identified.

Acute pancreatitis is thought to result from inappropriate intrapancreatic activation of proteases, which causes autodigestion of the pancreas. Exactly how this occurs is unknown. It is thought that alcohol-induced pancreatitis may include a physiochemical alteration of protein that results in plugs that block the small pancreatic ductules. Biliary pancreatitis occurs when edema or an obstruction blocks the ampulla of Vater, resulting in reflux of bile into pancreatic ducts or direct injury to the acinar cells. Other causes include the following:

• Hyperlipidemia, which may occur secondary to nephritis, castration, or exogenous estrogen administration, or as hereditary hyperlipidemia
• Hypercalcemia arising as a result of hyperparathyroidism
• Cholecystitis and cholelithiasis
• Familial cases with no definite mechanism defined
• Pancreatic tumor
• Pancreatic trauma or pancreatic duct obstruction, such as penetrating or blunt external trauma, intraoperative manipulation, or ampullar manipulation, and pancreatic ductal overdistention during endoscopic retrograde cholangiopancreatography (ERCP)
• Pancreatic ischemia during episodes of hypotensive shock, cardiopulmonary bypass, visceral atheroembolism, or vasculitis
• Drugs; although azathioprine and estrogens have been directly linked with the disease, many other drugs are believed to have an association (e.g., antibiotics, anticonvulsants, thiazide diuretics, sulfonamides, valproic acid)
• Other general causes, such as pancreatic duct obstruction, obesity, duodenal obstruction, viral infection (e.g., mumps), carcinoma, scorpion venom, ERCP, peritoneal dialysis, and factors still to be determined

Complications

• Adult respiratory distress syndrome
• Atelectasis
• Coma
• Destruction of pancreas
• Diabetes acidosis
• Diabetes Mellitus (if islets of Langerhans are damaged)
• GI bleeding
• Massive hemorrhage
• Pancreatic abscess
• Pneumonia
• Pulmonary effusion
• Shock

Signs and Symptoms

Signs and symptoms of pancreatitis vary if it is acute or chronic in nature, depending on what the client is having.

Signs and symptoms of acute pancreatitis include:

• Abdominal pain to the upper quadrants, radiates to the clients back and worsens after meals
• Nausea and vomiting
• Tenderness on the abdomen

Signs and symptoms of chronic pancreatitis include:

• Upper abdominal pain
• Indigestion
• Sudden weight loss
• Steatorrhea (oily, foul smelling stools)

Treatment

Interventions for pancreatitis usually require hospitalization. Once the client’s condition is stabilized in the hospital and inflammation is controlled, doctors can treat the underlying cause of pancreatitis.

Medical Management:

A client experiencing pancreatitis can be admitted to the hospital for health care. Initial steps to control inflammation of the pancreas and help increase the comfort of the client include:

• Fasting
• Pain medications
• Intravenous fluids
• Exogenous insulin therapy may be necessary because of destruction of islet tissue.

Surgical Management:

There are several approaches available for surgery. The major surgical procedures are the following:

• Side-to-side pancreaticojejunostomy (ductal drainage). Indicated when dilation of pancreatic ducts is associated with septa and calculi. This is the most successful procedure with success rates ranging from 60% to 90%.
• Caudal pancreaticojejunostomy (ductal drainage). Indicated for uncommon causes of proximal pancreatic ductal stenosis not involving the ampulla.
• Pancreaticoduodenal (right-sided) resection (ablative) (with preservation of the pylorus) (Whipple procedure). Indicated when major changes are confined to the head of the pancreas. Preservation of the pylorus avoids usual sequelae of gastric resection.

Preventive Measures:

• Alcohol and smoking cessation
• Low fat diet
• Increased fluid intake

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