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ACUTE AND CHRONIC PANCREATITIS
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- 2. Elongated andtapered organ . A pale grey gland weighing about 60 grams and about 12-15 cm long Situated in the epigastric and left hypochondriac regions of the abdominal cavity
- 3. Parts Head-the widest right part of the organ and lies in the curve of the duodenum Body- tapered left side extends slightly upward lies behind stomach. Tail- narrowed end part lies infront of the kidney and just reaches the spleen.
- 4. FUNCTIONS Endocrine functions -Islet oflangerhens -Alphacells glucagon(20%) -Beta cells insulin(75%) -Delta cells somatostatin Exocrine functions Pancreatic juice -Amylase -Lipase -Trypsin -Chymotrypsin Carboxypeptidase
- 6. Exocrine cells consists of a large number of lobules made up of small acini, which consist of secretory cells. Each lobule is drained by a tiny duct and these unite eventually to form the pancreatic duct. pancreatic duct joins the common bile duct to form hepato pancreatic ampulla. The duodenal opening of the ampulla is controlled by the hepatopancreatic sphincter of the duodenal papilla.
- 8. The functionof the exocrine pancreas is to produce pancreatic juice containing enzymes,that digest carbohydrates, proteins and fats.
- 9. Pancreatic juice: Secreted by exocrine pancreas . Consists of: Water Mineral salts Enzymes: Amylase Lipase Inactivated enzyme precursor including Trypsinogen Chymotrypsinogen
- 10. Functions Digestionof protein: Trypsinogen and chymotrypsinogen are inactive enzyme precursors activated by enterokinase to enzymes trypsin and chymotrypsin which convert polypeptide to tripeptides and dipeptides. Digestion of carbohydrates Amylase converts polysaccharides(starches) to disaccharides. Digestion of fats: Lipase converts fats to fatty acids and glycerol.to aid the action of fats , bile salts emulsify fats.
- 11. Control ofsecretions : When the partially digested contents of the stomach reach the small intestine, two hormones ,secretin and cholecystokinin are produced by endocrine cells in the walls of the duodenum and these hormones stimulates the secretion of pancreatic juice.
- 12. Endocrine functions consists of clusters of cells, known as the pancreatic islets scattered throughout the gland. they are directly secreted into the blood stream and circulate throughout the body. Alpha cells secrete glucagon Beta cells secret insulin Delta cells secrete somatostatin.
- 13. Functions ofinsulin Reduces blood glucose levels Secretion is stimulated by increased blood glucose level,e.g after eating a meal Functions of glucagon Increases blood glucose level. Secretion is stimulated by low blood glucose levels and exercise, and decreased by somatostatin and insulin. Functions of somatostatins Inhibits the secretion of insulin and glucagon in addition to inhibiting the secretion of GH from the anterior pituitary.
- 14. Definition Pancreatitisis the inflammation of the pancreas. pancreatitis is commonly described as autodigestion of the pancreas.
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- 16. Acute pancreatitis It is an acute inflammatory process of the pancreas. The degree of inflammation varies from mild edema to severe hemorrhagic necrosis.
- 17. Incidence Acutepancreatitis is most common in middle aged men and women. It affects male and female equally.
- 20. Phospholipase fat necrosis Elastasehaemorrhage Activates proteases which causes autodigestion of pancreas,and activation of other proteolytic enzymes. Trypsinogen CK trypsin Activation of pancreatic enzymes Etiological factors(Gallstone,ethanol,trauma etc)
- 21. The pathophysiologicinvolvement of acute pancreatitits ranges from edematous pancreatitis (which is self limiting )to necrotizing pancreatitis.
- 22. Severe abdominalpain is predominanat symptoms Pain located in upper quadrant and midepigastrium Severe, deep piercing and continuous or steady in nature
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- 24. ◦ Crackles present over lungs ◦Illeus with marked abdominal distension
- 25. Greys turner spots(bluish flank discolouration) Cullen’s sign(a bluish periumblical area)
- 26. Tachycardia andjaundice Bowel sound may be decreased or absent Shock may be arise due to haemorrhage, toxemia from activated enzymes. Hypovolemia as a result of fluid shift.
- 27. Chronic pancreatitisis a continuous, prolonged , inflammatory and fibrosing process of the pancreas. Progressively destroyed as it is replaced with fibrotic tissue. Strictures and calcification may also occur in pancreas
- 29. Pathophysiology The2 major types are chronic obstructive pancreatitits and chronic calcifying pancreatitis.
- 30. Toxic effectof alcohol causes obstruction of duct with protein precipitates.the precipitates block the pancreatic duct and eventually calcify which is followed by fibrosis and glandular atrophy. Pseudocyst and abscesses commonly develop.
- 31. Clinical manifestation Upper abdominal pain Losing weight without trying Oily, smelly stools (steatorrhea)
- 32. Infections: Inacute pancreatitis, the pancreas is susceptible to bacteria that can cause infections.. Pseudocyst:Debris and fluid that can collect in pockets of the pancreas. If this cyst-like pocket ruptures, infection and bleeding can result. Diabetes: Due to damage of the insulin producing cells.
- 33. Pancreatic abscess(cavityof pus within the pancreas) Respiratory problems(pleural effusion,atrelactasis,pneumonia) SIRS(systemic inflammatory response syndrome)-vasodilation,hypotension,capillary leakage,edema) Malnutrition: Due to lack of absorption. Pulmonary emboli, disseminated intravascular coagulation.
- 34. Primary test Serum amylase Increased (>200 U/L) Serum lipase Elevated Urinary amylase Elevated Secondary tests Blood glucose Hyperglycemia Serum calcium Hypocalcemia Serum triglyceride Hyperlipidemia
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- 36. Abdominal computed tomography(CT) scanning Endoscopic retrograde cholangiopancreatogra phy (ERCP)
- 37. Collaborative care Objective of collaborative care for acute pancreatitits include: Relief of pain Prevention or alleviation of shock Reduction of pancreatic secretions Control of fluid and electrolyte imbalances Prevention or treatment of infections Removal of the precipitating cause
- 38. Conservative therapy Focused on supportive care Pain management(Iv morphine,antispasmodic) Correction of hypovolemia using normal saline and colloids. Use NG suction to reduce vomiting and gastric distension Decrease stimulation of pancreas Avoidance of alcohol. Keep patient in NPO
- 39. Oxygen forhypoxic patients those with acute respiratory distress syndrome.
- 40. Pharmacological therapy Morphine –relief of pain. Nitroglycerine or papaverine-relaxation of smooth muscles and relief of pain. Antispasmodic(dicyclomine,propantheline bromide)-decreased of vagal stimulation,motility,pancreatic outflow. Carbonic anhydrase inhibitor (acetazolamide) reduction in volume and bicarbonate concentration of pancreatic secretions.
- 41. Antacids –neutralizations of gastric hydrochloride. Histamine(H2) receptor antagonists ranitidine proton pump inhibitors (omeprazole) -decrease in HCL and stimulates pancreatic secretion
- 42. Calcium :ifhypocalcemia tetany occur Prophylactic broad spectrum antibiotic Pancreatic enzyme replacement.
- 43. Nutritional management Diet: low in fat and high in protein and carbohydrates Small frequent feeding Pancreatic enzyme supplementation with meals Correct malabsorption of the fat-soluble vitamins (A, D, E, K) and vitamin B12
- 44. Medium-chain triglyceridesin patients with severe fat malabsorption (they are directly absorbed by the small intestine without the need for digestion).
- 45. Surgical therapy Done in case of Abscess Severe peritonitis Acute pseudocyst.
- 46. ERCP plusendoscopic sphincterotomy- performed to remove duct obstruction - eg, gallstone.
- 47. Percutaneous drainageof pseudocyst.
- 48. Choledochojejunostomy- Commonbilde duct is anastomosed into the jejunum where it diverts bile around the ampulla of vater.
- 49. Roux-en Ypancreatojejunostomy.
- 50. 1.Acute pain relatedto distension of pancreas, peritoneal irritation,obstruction of biliary tract. 2. Risk for fluid volume deficit realted to Excessive losses: vomiting, gastric suctioning.
- 51. 3. Imbalanced Nutrition:Less Than Body Requirements related to Vomiting, decreased oral intake; prescribed dietary restrictions,Loss of digestive enzymes and insulin .
- 52. Research evidence Topic :Frequency and risk factors of recurrent pain during refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients. OBJECTIVES : To assess the frequency and the risk factors of pain relapse in patients with acute pancreatitis.
- 53. RESULTS: Thecause of acute pancreatitis was biliary in 47% and alcohol misuse in 31%. During the oral refeeding period, 21% of the patients had pain relapse.
- 54. CONCLUSION: Painrelapse occurred in one fifth of the patients with acute pancreatitis during oral refeeding and was more common in patients with necrotic pancreatitis and with longer periods of pain. The results of this study can be used to predict high risk patients and are a first step in the prevention of pain relapse.
- 55. RESEARCH EVIDENCE TOPIC :Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of Chronic Pancreatitis in the United States. GOALS: The aim of this study was to characterize current trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) in the United States for patients hospitalized with chronic pancreatitis.
- 56. RESULTS: Duringthe study period, 29,318 patients with chronic pancreatitis (mean age 52 y, 57.2% female) underwent ERCP during their hospitalization. CONCLUSIONS: In the United States, ERCP has been an important diagnostic and therapeutic tool for chronic pancreatitis.
- 57. REFERENCES BOOKS Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. Textbook of medical surgical nursing, 12th ed. Newdelhi: Lippincot wolter’s kluwer; p.113-114(vol-1) Lewis Sharan mantik, Heitkemper Margaret Mclean, Shannon Ruff Dirksen,Obrien Patrical, Giddens Jean Foret, Bucher Linda. Medical surgical nursing. 6th ed.Mosby; p.1052-56 Best practices A guide to excellence in nursing care. lippincott William and wikins. P.258-62. )
- 58. JOURNALS LévyP, Heresbach D, Pariente EA, Boruchowicz A, Delcenserie R, Millat B, Moreau J, Le Bodic L, de Calan L, Barthet M, Sauvanet .Frequency and risk factors of recurrent pain during refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients. Gut;1997:20(1) Clark CJ, Fino NF, Clark N, Rosales A, Mishra G, Pawa R. Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of ChronicPancreatitis in the United States. J Clin Gastroenterol;2016:50(5