Essay: Care and Management of Pancreatitis

Introduction
The essay will show effectiveness of the care implemented across a range of patient
presentations with pancreatitis that will be analysed with consideration given to the
processes of assessment, monitoring and interventions, planning, delivering and
evaluation of care. From the presenting data, it will be discussed and interpreted with the
complete clinical picture, recognising care and protocols, using clinical judgement and
other factors that influences care delivery on the acute and critical care patient.
The patient is a 56 y/o male who was admitted to hospital with abdominal pain and
distention. In order to protect his identity according to Article 5 of the NMC code 2012,
he is referred as Peter.
General Management and Care
Pancreatitis is inflammation of the pancreas, the organ that secretes digestive enzymes
into the gastrointestinal tract that secretes insulin and glucagon. It could be caused by
gallstones which blocks the pancreatic duct outlet, chronic alcohol use, trauma,
medications,infections, tumours and genetic abnormalities (Davis CP. 2012). This disease
occurs when the pancreas suddenly becomes inflamed then gets better. Some patients
have more than one attack of acute pancreatitis but recover fully after each one. Alcohol
abuse and gallstones are the two most common causes of acute pancreatitis. In rare cases,
acute pancreatitis could result from an infection such as mumps. While asking about a
patients medical history and conducting a thorough physical examination, the doctor has
already ordered a blood test to assist in the diagnosis.
Pain usually starts in the upper abdomen that lasts for a few days. The pain is so
severe and sometimes constant, radiates to the back and other areas. It could be sudden
and intense or it may start as a mild pain and get worse after eating. The abdomen may be
swollen and very tender. Patients with pancreatitis usually look and feel very sick, this
may include nausea,vomiting, fever and increased pulse rate. About 20% of acute
pancreatitis cases are severe. Patients may become dehydrated and have low blood
pressure. Sometimes the heart, lungs and kidneys fail. In most severe cases, bleeding may
occur in the pancreas leading to shock and sometimes death.
Peter presented signs and symptoms of vomiting, abdominal distention and pain on
arrival to accident and emergency. Unable to sit still or can not find a position that makes
him comfortable. Blood tests were sent to look for elevated levels of pancreatic enzymes
at least three times the normal amount of amylase and lipase (Gomez D. Addison A. De
Rosa A. 2012). Stool tests were also sent to measure the level of fat that could suggest
digestive system is not absorbing nutrients adequately.
Computerised tomography (CT) is a non invasive X-Ray that produces three
dimensional pictures of the parts of the body and scan to look for gallstones and assess
the extent of pancreas inflammation. Abdominal ultrasound can be used to look for
inflammations and endoscopic ultrasound where a thin flexible lighted tube is pushed
down the throat through the stomach and into the small intestine to look for blockages in
the pancreatic duct. Magnetic resonance imaging is another diagnostic test that produces
cross section images of the parts of the body to look for abnormalities in the gallbladder,
pancreas and ducts (Uk guidelines for the management of pancreatitis 2005).
Once the condition is stabilised in hospital and inflammation in the pancreas is
controlled, doctors can treat the underlying cause of pancreatitis. Initial treatment on
Peter was to control inflammation and fasting or nil by mouth was put in place where he
was not allowed to eat for a couple of days in order to give the pancreas a chance to
recover. Once the inflammation is controlled, he may be allowed to drink clear liquids
and eating bland foods then in time to go back to normal diet. If pancreatitis still persists
and pain when eating, a nasogastric tube was recommended to help with nutrition. It is
assumed that enteral feeding may help maintain the gut mucosal barrier and so reduce the
absorption of endotoxin (Petrov MS, Loveday BP 2009).
Intravenous fluids are also prescribed as the body devotes energy and fluids to
repairing the pancreas when dehydrated. Benefits of Ringer’s lactate compared with other
types of fluids had systemic inflammatory response syndrome, and C reactive protein
levels were lower although clinical outcomes did not differ (Wu Bu, Hwang JQ 2011).
Infusion rate during the first 24 hours should be sufficient to restore circulating volume
and urine output (Tenner S., Baillie J. 2013). Consensus opinion is that 2.5 to 4 liters in 24
hours will be sufficient for most patients but volumes infused should be also determined
by patients clinical response. Patients response to fluid resuscitation should be assessed
by non invasive response monitoring which is the HR, blood pressure and urine output.
At present, there is no indication for use of antibiotics. If it is clinically suspected or
found, antibiotic treatment should be guided by sensitivity of cultured organisms when
available and by the duration and severity of septic symptoms.
Pancreatitis can cause severe pain and pain medications are prescribed to help control
pain. Respiratory function may be impaired by restriction of abdominal wall movement.
Paracetamol or non steroidal anti inflammatory such as ibuprofen and with proton
pump inhibitor, omeprazole to protect gastric ulcers. If NSAIDS or paracetamol prove to
be ineffective with pain, an opiate based painkiller such as codeine or tramadol is
prescribed. Side effects of this types of medications includes constipation, vomiting and
drowsiness. If severe pain, morphine or pethidine is prescribed. Amitriptyline is also
recommended to help with pain.
Clinical features of abdominal pain and vomiting together with elevation of plasma
concentrations of pancreatic enzymes are the cornerstones of diagnosis. The diagnosis of
acute pancreatitis should not rely on arbitrary limits of values 3 or 4 times greater than
normal, but values should be interpreted in light of the time since the onset of abdominal
pain (Toouli J. Brook-Smith M. 2002).
All patients with acute pancreatitis should have liver function tests and abdominal
ultrasonography within 24 hours of admission to look for gallstones. Sound waves are
sent towards the pancreas through a handheld device that is glided over the abdomen. The
sound waves bounce off the pancreas, gallbladder, liver,and other organs, and their echoes
make electrical impulses that create a picture or a sonogram. If gallstones are causing
inflammation, the sound waves will also bounce off them,showing their location
During acute attacks of pancreatitis, the blood has high levels of digestive enzymes.
The blood may also have abnormal levels of other important electrolytes such as
magnesium, calcium,bicarbonate, potassium and sodium. Patients may also have high
amounts of sugar and lipids. These changes would help in the diagnosis of pancreatitis.
When the pancreas recovers, blood levels of these substances usually return to normal.
The kidneys and lungs may be treated with dialysis and a ventilator to prevent multi
organ failure. Acute pancreatitis can cause fluid and debris to collect in cyst like pockets
in the pancreas. It could rupture and causes internal bleeding and infection. It could also
be vulnerable to bacteria and may require intensive treatment. It causes chemical changes
causing the level of oxygen in your blood to fall to dangerous levels, damages the insulin
producing cells in the pancreas that leads to diabetes.
Because Peter remains to be nauseated and and in a lot of pain, the nasogastric tube
needed to be on free drainage to remove fluid and air. Intravenous fluids were given and
analgesias prescribed. Peter was going into respiratory failure due to the distended
abdomen. Arterial blood gases are as follows ph 7.28 pCo2 7.4 kpa p02 8.4 kpa. Doctors
wanted to start him on Non Invasive ventilation where a tight mask is put around his
mouth and nose and attached on the ventilator to help with breathing. Non invasive
ventilation is a provision of ventilatory support through the patients upper airway using a
mask. The technique is distinguished from those which bypass the upper airway with a
tracheal tube or laryngeal mask. Continuous positive airway pressure in this document
refers to the non invasive application of positive airway pressure which is an effective
treatment for acute hypercapnia respiratory failure. In order for Peter to tolerate the tight
mask, diazepam was given intravenously to calm his nerves and to be able to breathe with
the ventilator(BNF 2014). Another arterial gas was performed and the results are much
improved ph7.35 pCo2 5.1 kpa pO2-9 kpa. The tight mask was left on as Peter was still
tolerating it. Because the mask was controlled by mix air and oxygen, Peter’s mouth was
dry so alot of oral care and moistening was performed and encouraged. Intravenous
fluids were commenced to rehydrate Peter. Antibiotics for specific infections, ct scan if
treatment is necessary. When pain and other symptoms have resolved and blood tests are
normal, oralfluids and then solids can be resumed (Al Omaran M. Albalawi ZH 2010). If
gallstones are the cause then consider common bile duct clearance and cholecystectomy
after recovery preferably during original admission. When there is evidence of significant
pancreatic necrosis, IV antibiotics should be given. Surgery is only required where there
is infection and necrosis. If long standing inflammation in the pancreas is caused by
chronic pancreatitis, there is a risk of developing pancreatic cancer.
Peter underwent a procedure called endoscopic retrograde cholangiopancreatography
(ERCP) which uses a long tube with a camera on the end to examine the pancreas and
bile ducts. The tube is passed down the throat and the camera sends pictures of the
digestive system to a monitor. It aids in diagnosing problems in the bile duct and in
making repairs. Peter was sedated all throughout the procedure.
Radiological facilities should be available to permit ultrasound examination within 24
hours of diagnosis of acute pancreatitis. Specialists unit will have access at any time to
contrast enhances Computed tomography or magnetic resonance imaging, percutaneous
image guided aspiration and drainage techniques and angiography for the early
assessment and treatment of abdominal and other complications. Facilities and expertise
should be available for ERCP to be performed at any time, for common bile duct
evaluation followed by sphincterectomy and stone extraction or stenting as required.
Additional treatments included pain management and Peter was referred to a pain
specialist. Pancreatic enzymes supplements can help the body break down and process
the nutrients in the foods that he eats. Peter was referred to a dietician who can help in
planning low fat meals that are high in nutrients. Once Peter was discharged from
hospital,he was advised by the team to stop drinking alcohol,stop smoking,choose a low
fat diet and drink more fluids.
Conclusion
Acute pancreatitis occurs when the pancreas suddenly becomes inflamed and then
gets better. Some patients have more than one attack but recover fully after each one.
Alcohol abuse and gallstones are the two most common causes of acute pancreatitis.
Other causes may include the use of prescribed drugs,trauma or surgery to the abdomen
or abnormalities of the pancreas or intestines. Treatment depends on how bad the attack is
unless complications occur, if not treated it becomes chronic pancreatitis. The correct
diagnosis of acute pancreatitis should be made on all patients within 48 hours of
admission. The aetiology of pancreatitis should be determined and classified. Patients
with persisting organ failure, signs of sepsis, or deterioration in clinical status after
admission should have CT using a dedicated pancreas protocol. Adequate prompt fluid
resuscitation is crucial in the prevention of systemic complications. Although the
majority of patients will have mild disease that resolves spontaneously, it is difficult to
detect patients at risk of complications early in the hospital admission. Early oxygenation
supplementation may be associated with resolution of organ failure (Brown A.2002).