Disorders of the Pancreas

Question 1

Functions of the pancreas: Endocrine

Answer 1

secretes products directly into the bloodstream. Insulin from the beta cells. Glucagon in the alpha cells. Somatostatin inhibits pancreatic hormones

Question 2

Functions of the pancreas: Exocrine

Answer 2

releases enzymes into the ducts in the target tissues. Amylase, tripsin and lipase (digestive enzymes)

Question 3

Two types of pancreatitis

Answer 3

Acute
Chronic

Question 4

Acute is caused by: (2)
Most common cause:

Answer 4

Gallstones and Alcohol
Gallstones are the most common cause

Question 5

Acute Pancreatitis

Answer 5

An acute inflammation of the pancreas which varies from mild edema to severe hemorrhagic necrosis

Question 6

Pathophysiology of acute pancreatitis:

Answer 6

auto digestion of the pancreas. Injury to pancreatic cells or activation of the pancreatic enzymes is caused in the pancreas rather than in the intestine. may be due to reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi. Tripsinogen is an inactive enzyme produced by the pancreas it

Question 7

With pancreatitis the patient can be acutely ill at risk for:

Answer 7

1 - sepsis
2 - hypovolemic shock (pancreatic fluid and blood leak into abdominal cavity)
3 - fluid and electrolyte disturbances

Question 8

Clinical Manifestations of Pancreatitis (9)

Answer 8

• Severe abdominal pain (predominant symptom)
• nausea and vomiting
• Low grade fever
• Leukocytosis (high WBCs)
• Abdomen can be rigid or board-like
• Ecchymosis (bruising) in the flank (grey turner’s sign) or around the umbilicus (cullens sign) in severe cases
• bowel sounds may be decreased
• crackles to lungs (causes inflammation throughout whole body)
• stools are often bulky, pale, and foul smelling (fat content is 50-90% - normal is 20%)

Question 9

Characteristics of pain in pancreatitis

Answer 9

sudden onset and severe, aggravated by eating, worse when laying down, 24-48 hours after eating a heavy meal or drinking, pain is not relieved by vomiting.

Question 10

Complications: severe pancreatitis

Answer 10

• complete enzymatic autodigestion of the gland
• tissue becomes necrotic
• damage extends into retroperitoneal tissues

Question 11

Complications: Local complications

Answer 11

• pseudocyst develops. an accumulation of fluid, pancreatic enzymes and tissues debris next to the pancreas.
• pancreatic abscess. a large collection of fluid in the pancreas from pancreatic necrosis.
• must be drained promptly or can cause sepsis

Question 12

Manifestations of the pseudocyst

Answer 12

abdominal pain, palpable epigastric mass, anorexia, N&V, high serum amylase, most will resolve on their own

Question 13

Systemic Complications: Pulmonary

Answer 13

• pleural effusion, atelectasis, and pneumonia
• pulmonary complications are caused by: passage of exudate that contains pancreatic enzymes from the peritoneal cavity. Can travel through diaphragmatic lymph channels which causes the diaphragm to be inflamed which leads to restricted movement of the diaphragm and atelectasis

Question 14

Systemic Complications: Cardiovascular

Answer 14

hypotension because activated trypsin is present i the pancreas and can digest the pancreas and produce bleeding.

Question 15

Systemic Complications: Hypocalcimia

Answer 15

Tetany caused by hypocalcimia. Tetany is involuntary muscle contractions and overly stimulated peripheral nerves
hypocalcimia is a sign of severe disease, caused in part by the combining of calcium and fatty acids during fat necrosis.

Question 16

Complications: Trypsin

Answer 16

A pancreatic enzyme that can activate prothrombin and plasminogen - increasing the risk of pulmonary embolism

Question 17

Diagnostic Tests (6) - lab values

Answer 17

Elevated serum amylase early and remains elevated for 24 hours
Serum lipase is also elevated and helps differentiate pancreatitis from other disorders (more diagnostic of pancreatitis)
WBC - increased
Calcium - decreased
Liver enzymes increased, glucose increased, bilirubin increased
Hct and hemoglobin - check for bleeding

Question 18

Diagnostic Imaging

Answer 18

• Abdominal ultrasound
• Abdominal CT with contrast (used to detect complications)
• MRCP - magnetic resonance image

Question 19

Goals of Collaborative Care for Patient with Acute Pancreatitis - (9)

Answer 19

1. Pain relief
2. Other meds (PPI, antispasmotics, IV narcotics (Demerol)
3. prevention/alleviation of shock (monitor for shock, might need plasma volume expanders)
4. Reduction of pancreatic secretions - NPO
5. control of fluid and eletrolyte imblanaces - ensure they have adequate fluid
6. prevention/treatment of infection - WBCs
7. Assess respiratory functioning - ABCs, resp rate, breath sounds, supplemental O2
8. Assess for hypocalcemia - tetany, labs
9. Removal of the precepitating cause (if possible)

Question 20

Nutrition (3)

Answer 20

• initially NPO
• when food is allowed, the diet is usually high in carbs because they are the least stimulating
• Abstain from alcohol

Question 21

Prevention and promotion

Answer 21

• Avoid high fat foods, heavy meals, and alcohol
• Referral to home care if going home
• Referral to alcoholic support groups

Question 22

Chronic Pancreatitis

Answer 22

An inflammatory disorder characterized by progressive anatomic and functional destruction of the pancreas
Pancreatic cells are replaced by fibrous tissue with repeated attacks of pancreatitis

Question 23

Two types of Chronic Pancreatitis

Answer 23

Obstructive
Nonobstructive

Question 24

Obstructive Chronic Pancreatitis

Answer 24

Mechanical obstruction of pancreatic, common bile duct and the duodenum d/t biliary disease

Question 25

Nonobstructive Chronic Pancreatitis

Answer 25

associated with inflammation and sclerosis mainly in the head of the pancreas d/t alcoholism

Question 26

Chronic Pancreatitis: Clinical Manifestations (3)

Answer 26

• Like acute pancreatitis but recurring attacks are more severe, more frequent, and longer duration
• Wt loss - experienced by 74% of patients usually secondary to malabsorption; problems with digestion of fats and proteins, steatorrhea, diabetes mellitus, constipation, mild jaundice with dark urine
• Pain LUQ or epigastric, but heavy, gnawing feeling; burning; cramp like. Not relieved with food or antacids

Question 27

Chronic Pancreatitis: Diagnostic Studies (5)

Answer 27

• Unlike acute pancreatitis, serum amylase and lipase not elevated significantly
• Serum bili, ALP, and WBC elevated
• Stool +ve for high fat content
• Assessment and Dx: ERCP, MRI, CT, ultrasound, glucose, tolerance test

Question 28

Nonsurgical treatment

Answer 28

Endoscopy (remove pancreatic duct stones)
Same for tx for acute pancreatitis
Diabetes mellitus - diet, insulin, or oral antidiabetic agents

Question 29

Chronic Pancreatitis: Collaborative Care - Focus is on:

Answer 29

• prevention of further attacks
• relief of pain
• control of pancreatic endocrine and exocrine insufficiency (diet, pancreatic enzyme replacement and control of diabetes)

Question 30

What is given to control pancreatic insufficiency:

Answer 30

• Enteric-coated enzymes given
• Bile salts are given (to aid absorption of Vit D, A, E, K)
• Diabetes is controlled with insulin/OHA’s

Question 31

Surgical Treatment for Pancreatitis

Answer 31

• poor candidates for surgery, anorexic, poor nutrition and physical condition
• Pancreaticojejunostomy - joins pancreatic duct to jejunum to allow drainage of pancreatic duct (pain relief for 80% in 6 months)
• Insert stents in pancreas

Question 32

Pancreatic Cancer

Answer 32

• most commonly associated with a poor outcome
• in 2020, 6000 Canadians were diagnosed with pancreatic Ca
• peak incidence: 65-75 yrs
• mean survival: 5-12 mos from diagnosis
• 5 yr survival rate: 6%

Question 33

Primary Risk factor for Pancreatic Ca

Answer 33

Cigarette smoking

Question 34

Other causes of Pancreatic Ca

Answer 34

• obesity
• heavy alcohol use
• genetic pre-dispositions

Question 35

Clinical Manifestations of Pancreatic Ca (5)

Answer 35

• abdominal pain
• anorexia
• nausea
• rapid and progressive weight loss
• obstructive jaundice/pruritis

Question 36

Pancreatic Ca: Diagnostic Studies

Answer 36

• CT scan (initial dx): provides info on metastasis and vascular involvement
• ERCP: allows for visualization of the pancreatic duct and biliary system
• Tumour markers: used for dx and monitoring of response to treatment
• CA- 19-9 is the most commonly used tumour marker

Question 37

Collaborative Care: Pancreatic Ca

Answer 37

• Surgical Treatment - whipples resection
• Chemotherapy or Radiotherapy - postop
• Nursing management: symptomatic and similar to the approach with pancreatitis