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Acute pancreatitis
- Sudden onset of inflammation of pancreas
- Abd pain
- Pancreatic tissue edema
- Necrosis of pancreatic tissue
- Possible pancreatic hemmorhage
- Results in autodigestion of itself
- Self-limiting if mild
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Severe Acut pancreatitis
- Necrotizing or hemorrhagic pancreatitis
- Extensive necrosis in and around pancreas
- Pancreatic cell necrosis
- Hemmorhage
- Digestive enzymes are release when pancreas dies, eats cells tissues and vessel walls...leads to bleeding
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Pancreatitis pathogenesis
Inital injury of acinar cells, premature enzyme activation (trypsin), overwhelms protective mechanisms, autodigestion of pancreas and surrounding tissues
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Most damaging enzymes
- Phospholipase A: digests cell membranes
- Elastase: digests vessel walls
- Kallikrein: inflammatory mediator secreted by basophils, increases local damage; potentiates hypotension, shock, MODS
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Pancreatitis causes
- Gallstones: most common in females, fatty greasy diet, obstruction of common bile duct
- Chronic alcohol abuse: most common in males, cause spasm of sphincter of Oddi...leads to obstruction
- Idiopathic
- Drug induced: hypersensitivity or toxix metabolism
- Metabolic Problem: hypoglycemia, hypertriglyceridemia (plaque build up, stenosis of vessel, Ca)
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Pancreatitis Clinical presentation
- Pain (constant, dull, collicky, worse when lying supine): radiation to flank, back, or both, heavy meal or drinking triggers pain
- N/V
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Pancreatitis Dx
PE: abd distention, muscle spasms, epigastric pain, LUQ tenderness, fever, tachycardia, jaundice, restless, dehydrated (N/V)
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Amylase
- Most widely used indicator
- Quick and inexpensive
- Lacks sensitivity and specifity
- Peaks 2-12hrs post onset, elevated for 3-5 days
- Tells us more by being negative than it does by being positive
- Highers levels doesn't mean severe
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Lipase
- Greater sensitivity and specifity than amalyse
- Peaks at 24hrs, elevated for 4-8hrs post onset
- Peaks 3x normal
- May remain elevated after amalyse isn't
- If both amylase and lipase elevated, more likely to be pancreatitis
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Trypsin
Most accurate but not commonly used test
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Elastase
Not as accurate as trypsin or lipase
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LFTs
- Not reliable for testing pancreatitis
- Only want to kow if liver dysfunction associated and/or coags
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Labs Dx
- Glucose: increased; >180-200, beta cells out of pancreas aren't functioning well; associated w/ insulin
- Calcium: decreased; associated liver problems bc of low albumin and nutrition
- WBC: increased; 15,000-18,000; inflammation
- BUN: increased; dehydration
- HCT: increased; dehydration, dilutional bc of low fluid
- Albumin: decreased; liver dysfunction, malnutrition
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Steatorrhea
- Pale of gray stool
- Foul smelling
- Caused by deficiency in pancreatic enzymes in the bowel
- Big indicator
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Edoscopic Retrograde Cholangiopancreatography (ERCP)
- Used when biliary obstruction suspected
- Inject dye into ducts to see obstruction in pancreas
- Can precipitate acute pancreatitis
- Hydration and pain control
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ERCP Complications
- Abscess
- Necrosis
- Psedocyst: encapsulated infectious material in organ, can further cause autodigestion of pancreas
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Systemic complications of pancreatitis
- Pulmonary: Hypoxemia, insufficiency/failure, effusions, ARDS (r/t phospholipase A)
- Cardiovascular: hypovolemic shock (trypsin vasodilates)
- Renal: ARF
- Neuro: decreased LOC (pain control is difficult and pancreatic encelphalopathy, decreased perfusion)
- Hematologic: DIC (liver dysfunction, platelets/clotting factors)
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Stabilizing hemodynamic status
- Fluid resuscitation: crystalloids, colloids, plasma expanders, monitor status
- Inotropic therapy: Dopamine
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Controlling Pain
- Difficult to control
- Morphine
- Fentanyl
- Dilaudid
- May not be able to bring pain to 0
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Minimizing pancreatic stimulation
- Rest the GI track
- Meds: antacids, PPIs, anticholinergics
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Meeting nutritional needs
- Initial NPO
- Initiate nutritional support if NPO >5-7 days
- Nasal jejunal feeding: Post ligament of Treitz, preferred tip location
- Improve outcomes
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Curative therapy
- Correct underlying problem: remove gallstone, stop drinking
- Prevent/treat complications: early recognition, close multi-system monitoring
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Nursing Care
- Control of pain: PCA narcotics, monitor for non/therapeutic effects
- Maintain nutrition
- Managing N/V: antiemetic therapy
- Monitor for complications
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