Pancreatitis

General overview

Pancreatitis is an inflammation of the pancreas caused by autodigestion of the pancreas from the enzymes it excretes. This process of autodigestion is most often caused by gallstones, with alcohol consumption being the second most common cause. Pancreatitis affects approximately 70 out of every 100,000 people.  Most people with pancreatitis are 45-75 years old, and it is more common in men than women.

Pancreatitis can be fatal. A patient presenting to the emergency department will most often be admitted to the hospital. With acute pancreatitis, a healthy individual will often recover in one to two weeks without serious complications.  In severe cases, however, medical management may take one to two months, often with recurrence. When a patient has multiple acute recurrences, it is referred to as chronic pancreatitis. The multiple intermittent attacks that come with chronic pancreatits can contribute to the eventual breakdown and loss of the gland.
Pathogenesis of acute pancreatitis

The pancreas is a gland located in the upper posterior abdomen. It has two primary functions: the first is insulin production for stabilization of blood sugar, and the second function is the secretion of digestive enzymes used to metabolize carbohydrates, fats and proteins. The digestive enzymes are programmed to become active at the proper time when arriving at the sphincter of oddi just before the opening to the duodenum. Pancreatitis occurs when the enzymes either activate earlier than planned or their pathway becomes blocked, forcing them to back up in the pancreas leading to autodigestion and necrosis.

Autoimmune pancreatitis occurs when the timing of enzyme activation is premature but no cause can be associated with it.  This is a relatively new classification of pancreatitis and is extremely rare. It is usually associated with young adults who are inflicted with an inflammatory bowel disease such as Crohn’s disease.

When the cause is a blockage, it is most often due to gallstones.  The common bile duct and the pancreatic duct join together at the sphincter of oddi. When gallstones form and enter the common bile duct they can block the opening to the duodenum causing the pancreatic juices to back up.

Alcohol consumption causes approximately 35% of all acute pancreatitis cases.  The reason for this is not fully agreed upon by physicians and scientists, but it is believed that alcohol in the cells cause the enzyme to activate prematurely.  Alcohol may also increase the protein content and decrease the bicarbonate levels, the result of which is the formation of protein plugs in the duct that block pancreatic outflow.

Signs and Symptoms

Early recognition of pancreatitis is critical. Whether a patient will be admitted to the hospital for management of symptoms or surgical intervention is decided based on the severity of symptoms. A patient may present with any or all of the following:

• Upper abdominal pain that radiates to the back. The pain typically begins as a dull ache with sudden onset. The pain will progress gradually to a constant uncomfortable ache.

• Nausea and vomiting

• Diarrhea

The patient may present with the following upon physical assessment:

• Jaundice

• Abdominal tenderness

• Fever

• Hypotension

• Diminished or absent bowel sounds

• Diminished breath sounds especially in the left lower lobe

• Dyspnea

• Diaphoresis

• Anorexia, cachexia

Signs of severe necrotizing pancreatitis are less often seen but are extremely important to recognize.

• Grey-Turner’s sign – a reddish brown discoloration along the flank

• Ruddy erythema – caused by pancreatic exudate being leaked from the compromised pancreas

• Cullen sign – a blue discoloration around the patient’s umbilicus

Diagnostic Evidence

Once the signs of pancreatitis have been recognized with assessment, laboratory testing will confirm findings.  The most common labs used are:

• Serum amylase and lipase

• Blood Glucose

• Serum cholesterol and triglyceride

• C-reactive protein

• Complete blood count

• Immunoglobulin G-4

• Blood urea nitrogen

• Serum lactic dehydrogenase

• Arterial blood gas values                                                                                                                                                                                                                

Imaging may be used to provide details about a patient with pancreatitis when a diagnosis is in doubt, or in cases of suspected severe pancreatitis.  The following types of imaging may be useful:

• Endoscopic ultrasonography

• Computerized Tomography (CT) Guided Biopsy

• Endoscopic retrograde cholangiopancreatography (ERCP)

• Magnetic resonance cholangiopancreatography (MRCP)

• CT guided aspiration and drainage

Genetic testing may also offer some answers for some patients when the cause of pancreatitis is believed to be genetic.

Complications

Pseudocysts are a common complication of pancreatitis.  Pseudocysts are small pockets of pancreatic juices.  They resemble blisters on the pancreas. They may not cause problems immediately but they can cause indigestion and stomach pain if untreated. If a pseudocyst bursts open it can lead to bleeding and cause infection.

Another more serious complication is called necrotizing infectious pancreatitis. This occurs when a piece of the pancreas dies and the necrotic tissue becomes infected with bacteria. This occurs most often in the second or third week after the pancreatitis began. The infected, necrotic tissue can lead to other systemic complications such as bacteremia.

Acute respiratory distress syndrome (ARDS), pleural effusions, gastrointestinal hemorrhage, and renal failure have all also been linked to pancreatitis.

Systemic inflammatory response syndrome (SIRS) is another inflammatory process that can develop. The body becomes overwhelmed, hemodynamic stability is compromised and death rapidly ensues.

Treatment

Acute pancreatitis will often go away on its own after some time. Nursing care for these patients includes the following:

• Pain management by means of opioids administered in IV (intravenous) form

• Hydration through an IV or central line

• Strict NPO (nothing by mouth) and bowel rest

• TPN (total parenteral nutrition) administered through a central line

Giving the pancreas a chance to rest is the single most effective intervention.  If the patient has no food or drink by mouth, the pancreas may get enough time to recuperate since no digestive enzymes are produced and the pancreas can rest and recover. The patient should be able to begin eating within a few days. In cases of chronic or severe pancreatitis, surgical intervention may be required to remove the cause of the blockage in the pancreas.

Prognosis

About 80% of people that receive medical treatment for acute pancreatitis recover in 1-2 weeks. These patients usually recover completely without recurrence or impaired pancreatic function. Twenty percent of acute cases will go on to become chronic with frequent recurrence and multiple complications. Hospital stays for these patients are often 1-2 months rather than weeks and nutritional status becomes critical .  Three percent of patients with acute pancreatitis die from the complications.  If they develop necrotic pancreatitis that number increases to a 20% mortality rate.

References:

Khoury, G. Emergent Management of Pancreatitis. UpToDate. Retrieved from http://emedicine.medscape.com/article/775867-overview. 

Pancreatitis. Retrieved from http://www.mayoclinic.org/diseases-conditions/pancreatitis/diagnosis-tre…

Trikudanathan, G. et. al. (2014.) Interventions for necrotizing pancreatitis: an overview of current approaches. Expert Review of Gastroenterology & Hepotology, 7(5), 463-75. Retrieved from http://www.tandfonline.com/doi/full/10.1586/17474124.2013.811055. 

Vege, SS. Patient education: Acute pancreatitis (Beyond the Basics). UpToDate. Retrieved from https://www.uptodate.com/contents/acute-pancreatitis-beyond-the-basics?s…