Learning Objectives:At the end of this lecture, you will be able to:1. Compare approaches to management of cholelithiasis.2. Use the nursing process as a framework for care ofpatients with cholelithiasis and those undergoinglaparoscopic or open cholecystectomy.JOFRED M. MARTINEZ, RN
3. Differentiate between acute and chronic pancreatitis.4. Use the nursing process as a framework for care ofpatients with acute pancreatitis.5. Describe the nutritional and metabolic effects ofsurgical treatment of tumors of the pancreas.Learning Objectives (Cont’d.):
CHOLECYSTITIS• Acute inflammation of the gallbladder causes pain,tenderness, and rigidity of the upper right abdomen thatmay radiate to the midsternal area or right shoulder andis associated with nausea, vomiting, and the usual signsof an acute inflammation.• An empyema of the gallbladder develops if thegallbladder becomes filled with purulent fluid.• Calculous cholecystitis is the cause of more than 90% ofcases of acute cholecystitis. In calculous cholecystitis, agallbladder stone obstructs bile outflow.Disorders of the Gallbladder
DEFINITION OF TERMS• Cholecystitis: inflammation of the gallbladder• Cholelithiasis: the presence of calculi in the gallbladder• Cholecystectomy: removal of the gallbladder• Cholecystostomy: opening and drainage of thegallbladder• Choledochotomy: opening into the common duct• Choledocholithiasis: stones in the common duct• Choledocholithotomy: incision of common bile duct forremoval of stones• Choledochoduodenostomy: anastomosis of commonduct to duodenumDisorders of the Gallbladder
DEFINITION OF TERMS• Choledochojejunostomy: anastomosis of commonduct to jejunum• Lithotripsy: disintegration of gallstones by shock waves• Laparoscopic cholecystectomy: removal ofgallbladder through endoscopic procedure• Laser cholecystectomy: removal of gallbladder usinglaserDisorders of the Gallbladder
CHOLELITHIASIS• Calculi, or gallstones, usually form in the gallbladderfrom the solid constituents of bile; they vary greatly insize, shape, and composition• They are uncommon in children and young adults butbecome increasingly prevalent after 40 years of age.• The incidence of cholelithiasis increases thereafter tosuch an extent that up to 50% of those over the age of70 and over 50% of those over 80 will develop stones inthe bile tract.Disorders of the Gallbladder
RISK FACTORS FOR CHOLELITHIASIS• Obesity• Women, especially those who have had multiplepregnancies or who are of Native American or U.S.Southwestern Hispanic ethnicity• Frequent changes in weight• Rapid weight loss (leads to rapid development ofgallstones and high risk of symptomatic disease)• Treatment with high-dose estrogen (ie, in prostatecancer)• Low-dose estrogen therapy—a small increase in the riskof gallstonesDisorders of the Gallbladder
RISK FACTORS FOR CHOLELITHIASIS• Ileal resection or disease• Cystic fibrosis• Diabetes mellitusDisorders of the Gallbladder
CLINICAL MANIFESTATIONS• Gallstones may be silent, producing no pain and onlymild gastrointestinal symptoms.• The symptoms may be acute or chronic.• Epigastric distress, such as fullness, abdominaldistention, and vague pain in the right upper quadrant ofthe abdomen, may occur.• This distress may follow a meal rich in fried or fattyfoods.Disorders of the Gallbladder
CLINICAL MANIFESTATIONSPAIN AND BILIARY COLIC• If a gallstone obstructs the cystic duct, the gallbladderbecomes distended, inflamed, and eventually infected.• The patient develops a fever and may have a palpableabdominal mass.• The patient may have biliary colic with excruciating upperright abdominal pain that radiates to the back or rightshoulder, is usually associated with nausea and vomiting,and is noticeable several hours after a heavy meal.• The patient moves about restlessly, unable to find acomfortable position. In some patients the pain is constantrather than colicky.Disorders of the Gallbladder
CLINICAL MANIFESTATIONSJAUNDICE• Jaundice occurs in a few patients with gallbladderdisease and usually occurs with obstruction of thecommon bile duct.• The bile, which is no longer carried to the duodenum, isabsorbed by the blood and gives the skin and mucousmembrane a yellow color.• This is frequently accompanied by marked itching of theskin.Disorders of the Gallbladder
CLINICAL MANIFESTATIONSCHANGES IN URINE AND STOOL COLOR• The excretion of the bile pigments by the kidneys givesthe urine a very dark color.• The feces, no longer colored with bile pigments, aregrayish, like putty, and usually described as clay-colored.VITAMIN DEFICIENCY• Obstruction of bile flow also interferes with absorption ofthe fatsoluble vitamins A, D, E, and K.• Therefore, the patient may exhibit deficiencies of thesevitamins if biliary obstruction has been prolonged.Disorders of the Gallbladder
ASSESSMENT AND DIAGNOSTIC FINDINGS• An abdominal x-ray may be obtained if gallbladder diseaseis suggested to exclude other causes of symptoms.• Ultrasonography has replaced oral cholecystography asthe diagnostic procedure of choice because it is rapid andaccurate and can be used in patients with liver dysfunctionand jaundice.• Cholescintigraphy is used successfully in the diagnosis ofacute cholecystitis. In this procedure, a radioactive agent isadministered intravenously.• Cholecystography is still used if ultrasound equipment isnot available or if the ultrasound results are inconclusive.Disorders of the Gallbladder
ASSESSMENT AND DIAGNOSTIC FINDINGSENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY• This permits direct visualization of structures that couldonce be seen only during laparotomy.• The examination of the hepatobiliary system is carriedout via a side-viewing flexible fiberoptic endoscopeinserted into the esophagus to the descendingduodenum.• Fluoroscopy and multiple x-rays are used during ERCPto evaluate the presence and location of ductal stones.Disorders of the Gallbladder
Disorders of the Gallbladder
NURSING IMPLICATIONS• The procedure requires a cooperative patient to permitinsertion of the endoscope without damage to thegastrointestinal tract structures, including the biliary tree.• Before the procedure, the patient is given an explanationof the procedure and his or her role in it.• The patient takes nothing by mouth for several hoursbefore the procedure.• Moderate sedation is used with this procedure, so thesedated patient must be monitored closely.• Medications such as glucagon or anticholinergics mayalso be necessary to eliminate duodenal peristalsis tomake cannulation easier.Disorders of the Gallbladder
NURSING IMPLICATIONS• The nurse observes closely for signs of respiratory andcentral nervous system depression, hypotension,oversedation, and vomiting (if glucagon is given).• During ERCP, the nurse monitors intravenous fluids,administers medications, and positions the patient.• After the procedure, the nurse monitors the patient’scondition, observing vital signs and monitoring for signsof perforation or infection.• The nurse also monitors the patient for side effects ofany medications received during the procedure and forreturn of the gag and cough reflexes after the use oflocal anesthetics.Disorders of the Gallbladder
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY• Percutaneous transhepatic cholangiography involves theinjection of dye directly into the biliary tract.• This procedure can be carried out even in the presence ofliver dysfunction and jaundice. It is useful for distinguishingjaundice caused by liver disease (hepatocellular jaundice)from that caused by biliary obstruction, for investigating thegastrointestinal symptoms of a patient whose gallbladderhas been removed, for locating stones within the bile ducts,and for diagnosing cancer involving the biliary system.• This sterile procedure is performed under moderatesedation on a patient who has been fasting; the patientreceives local anesthesia and intravenous sedation.Disorders of the Gallbladder
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY• Coagulation parameters and platelet count should benormal to minimize the risk for bleeding.• Broad-spectrum antibiotics are administered during theprocedure due to the high prevalence of bacterialcolonization from obstructed biliary systems.Disorders of the Gallbladder
MEDICAL MANAGEMENT• The major objectives of medical therapy are to reducethe incidence of acute episodes of gallbladder pain andcholecystitis by supportive and dietary managementand, if possible, to remove the cause of cholecystitis bypharmacologic therapy, endoscopic procedures, orsurgical intervention.• Most of the nonsurgical approaches, including lithotripsyand dissolution of gallstones, provide only temporarysolutions to the problems associated with gallstones.• Removal of the gallbladder (cholecystectomy) throughtraditional surgical approaches was considered thestandard approach to management.Disorders of the Gallbladder
MEDICAL MANAGEMENT• There is now widespread use of laparoscopiccholecystectomy (removal of the gallbladder through asmall incision through the umbilicus).• As a result, surgical risks have decreased, along withthe length of hospital stay and the long recovery periodassociated with the standard surgical cholecystectomy.Disorders of the GallbladderMorphine typically is not ordered because it cancause biliary spasms.
MEDICAL MANAGEMENTNUTRITIONAL AND SUPPORTIVE THERAPY• The diet immediately after an episode is usually limitedto low-fat liquids.• The patient can stir powdered supplements high inprotein and carbohydrate into skim milk.• Cooked fruits, rice or tapioca, lean meats, mashedpotatoes, non–gas-forming vegetables, bread, coffee, ortea may be added as tolerated.• The patient should avoid eggs, cream, pork, fried foods,cheese and rich dressings, gas-forming vegetables, andalcohol.Disorders of the Gallbladder
MEDICAL MANAGEMENTNUTRITIONAL AND SUPPORTIVE THERAPY• It is important to remind the patient that fatty foods maybring on an episode.• Dietary management may be the major mode of therapyin patients who have had only dietary intolerance to fattyfoods and vague gastrointestinal symptoms.Disorders of the Gallbladder
MEDICAL MANAGEMENTPHARMACOLOGIC THERAPY• Ursodeoxycholic acid (UDCA) and chenodeoxycholicacid (chenodiol or CDCA) have been used to dissolvesmall, radiolucent gallstones composed primarily ofcholesterol. It acts by inhibiting the synthesis andsecretion of cholesterol, thereby desaturating bile.Disorders of the GallbladderElderly clients can experience confusion andeven seizures when given meperidine (Demerol)for pain control!
NONSURGICAL REMOVAL OF GALLSTONESDISSOLVING GALLSTONES• Several methods have been used to dissolve gallstonesby infusion of a solvent (mono-octanoin or methyl tertiarybutyl ether [MTBE]) into the gallbladder.• The solvent can be infused through the following routes:a tube or catheter inserted percutaneously directly intothe gallbladder; a tube or drain inserted through a T-tubetract to dissolve stones not removed at the time ofsurgery; an ERCP endoscope; or a transnasal biliarycatheter.• This method of dissolution of stones is not widely usedin patients with gallstone disease.Disorders of the Gallbladder
NONSURGICAL REMOVAL OF GALLSTONESSTONE REMOVAL BY INSTRUMENTATION• A catheter and instrument with a basket attached arethreaded through the T-tube tract or fistula formed at thetime of T-tube insertion; the basket is used to retrieveand remove the stones lodged in the common bile duct.• A second procedure involves the use of the ERCPendoscope. After the endoscope is inserted, a cuttinginstrument is passed through the endoscope into theampulla of Vater of the common bile duct.Disorders of the Gallbladder
NONSURGICAL REMOVAL OF GALLSTONESEXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY• Extracorporeal shockwavetherapy has been used fornonsurgical fragmentation of gallstones.• This noninvasive procedure uses repeated shock wavesdirected at the gallstones in the gallbladder or commonbile duct to fragment the stones.• After the stones are gradually broken up, the stonefragments pass from the gallbladder or common bileduct spontaneously, are removed by endoscopy, or aredissolved with oral bile acid or solvents.Disorders of the Gallbladder
NONSURGICAL REMOVAL OF GALLSTONESINTRACORPOREAL LITHOTRIPSY• A laser pulse is directed under fluoroscopic guidancewith the use of devices that can distinguish betweenstones and tissue.• The laser pulse produces rapid expansion anddisintegration of plasma on the stone surface, resultingin a mechanical shock wave.• Electrohydraulic lithotripsy uses a probe with twoelectrodes that deliver electric sparks in rapid pulses,creating expansion of the liquid environmentsurrounding the gallstones.Disorders of the Gallbladder
Disorders of the Gallbladder
Disorders of the Gallbladder
SURGICAL MANAGEMENTLAPAROSCOPIC CHOLECYSTECTOMY• Laparoscopic cholecystectomy is performed through asmall incision or puncture made through the abdominalwall in the umbilicus.• The abdominal cavity is insufflated with carbon dioxideto assist in inserting the laparoscope and to aid thesurgeon in visualizing the abdominal structures.• The fiberoptic scope is inserted through the smallumbilical incision.Disorders of the Gallbladder
Disorders of the Gallbladder
SURGICAL MANAGEMENTCHOLECYSTECTOMY• In this procedure, the gallbladder is removed through anabdominal incision after the cystic duct and artery areligated.• In some patients a drain may be placed close to thegallbladder bed and brought out through a puncturewound if there is a bile leak.Disorders of the Gallbladder
SURGICAL MANAGEMENTMINI-CHOLECYSTECTOMY• Mini-cholecystectomy is a surgical procedure in whichthe gallbladder is removed through a small incision.CHOLEDOCHOSTOMY• Choledochostomy involves an incision into the commonduct, usually for removal of stones. After the stones havebeen evacuated, a tube usually is inserted into the ductfor drainage of bile until edema subsides.CHOLECYSTOSTOMY• The gallbladder is surgically opened, the stones and thebile or the purulent drainage are removed, and adrainage tube is secured with a purse-string suture.Disorders of the Gallbladder
SURGICAL MANAGEMENTPERCUTANEOUS CHOLECYSTOSTOMY• Under local anesthesia, a fine needle is inserted throughthe abdominal wall and liver edge into the gallbladderunder the guidance of ultrasound or computedtomography.• Bile is aspirated to ensure adequate placement of theneedle, and a catheter is inserted into the gallbladder todecompress the biliary tract.Disorders of the GallbladderAlcohol use accounts for 80% of chronicpancreatitis; however, do not automatically assumethat someone who has pancreatitis is an alcoholic.
Disorders of the PancreasACUTE PANCREATITIS• Acute pancreatitis ranges from a mild, self-limitingdisorder to a severe, rapidly fatal disease that does notrespond to any treatment.• Mild acute pancreatitis is characterized by edema andinflammation confined to the pancreas.• Minimal organ dysfunction is present, and return tonormal usually occurs within 6 months.• Although this is considered the milder form ofpancreatitis, the patient is acutely ill and at risk forhypovolemic shock, fluid and electrolyte disturbances,and sepsis.
Disorders of the PancreasCLINICAL MANIFESTATIONS• Severe abdominal pain is the major symptom ofpancreatitis that causes the patient to seek medicalcare.• Abdominal pain and tenderness and back pain resultfrom irritation and edema of the inflamed pancreas thatstimulate the nerve endings.• Pain is frequently acute in onset, occurring 24 to 48hours after a very heavy meal or alcohol ingestion, and itmay be diffuse and difficult to localize.• Abdominal guarding is present.
Disorders of the PancreasACUTE PANCREATITIS• A more widespread and complete enzymatic digestion ofthe gland characterizes severe acute pancreatitis.• The tissue becomes necrotic, and the damage extendsinto the retroperitoneal tissues.• Local complications consist of pancreatic cysts orabscesses and acute fluid collections in or near thepancreas.• Systemic complications, such as acute respiratorydistress syndrome, shock, disseminated intravascularcoagulopathy, and pleural effusion, can increase themortality rate to 50% or higher.
Disorders of the PancreasCLINICAL MANIFESTATIONS• A rigid or board-like abdomen may develop and isgenerally an ominous sign; the abdomen may remainsoft in the absence of peritonitis.• Ecchymosis in the flank or around the umbilicus mayindicate severe pancreatitis.• Nausea and vomiting are common in acute pancreatitis.• The emesis is usually gastric in origin but may also bebile-stained.• Fever, jaundice, mental confusion, and agitation alsomay occur.
Disorders of the PancreasCLINICAL MANIFESTATIONS• Hypotension is typical and reflects hypovolemia andshock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity.• The patient may develop tachycardia, cyanosis, andcold, clammy skin in addition to hypotension.• Acute renal failure is common.• Respiratory distress and hypoxia are common, and thepatient may develop diffuse pulmonary infiltrates,dyspnea, tachypnea, and abnormal blood gas values.• Myocardial depression, hypocalcemia, hyperglycemia,and disseminated intravascular coagulopathy (DIC) mayalso occur with acute pancreatitis.
Disorders of the PancreasMEDICAL MANAGEMENT• All oral intake is withheld to inhibit pancreatic stimulationand secretion of pancreatic enzymes.• Parenteral nutrition is usually an important part oftherapy, particularly in debilitated patients, because ofthe extreme metabolic stress associated with acutepancreatitis.• Nasogastric suction may be used to relieve nausea andvomiting, to decrease painful abdominal distention andparalytic ileus, and to remove hydrochloric acid so that itdoes not enter the duodenum and stimulate thepancreas.
Disorders of the PancreasMEDICAL MANAGEMENT• Histamine-2 (H2) antagonists (eg, cimetidine [Tagamet]and ranitidine [Zantac]) may be prescribed to decreasepancreatic activity by inhibiting HCl secretion.
Disorders of the PancreasPAIN MANAGEMENT• Adequate pain medication is essential during the courseof acute pancreatitis to provide sufficient pain relief andminimize restlessness, which may stimulate pancreaticsecretion further.• Morphine and morphine derivatives are often avoidedbecause it has been thought that they cause spasm ofthe sphincter of Oddi; meperidine (Demerol) is oftenprescribed because it is less likely to cause spasm of thesphincter.• Antiemetic agents may be prescribed to preventvomiting.
Disorders of the PancreasINTENSIVE CARE• Correction of fluid and blood loss and low albumin levelsis necessary to maintain fluid volume and prevent renalfailure.• The patient is usually acutely ill and is monitored in theintensive care unit, where hemodynamic monitoring andarterial blood gas monitoring are initiated.• Antibiotic agents may be prescribed if infection ispresent; insulin may be required if significanthyperglycemia occurs.
Disorders of the PancreasRESPIRATORY CARE• Aggressive respiratory care is indicated because of thehigh risk for elevation of the diaphragm, pulmonaryinfiltrates and effusion, and atelectasis.• Hypoxemia occurs in a significant number of patientswith acute pancreatitis even with normal x-ray findings.• Respiratory care may range from close monitoring ofarterial blood gases to use of humidified oxygen tointubation and mechanical ventilation.
Disorders of the PancreasBILIARY DRAINAGE• Placement of biliary drains (for external drainage) andstents (indwelling tubes) in the pancreatic duct throughendoscopy has been performed to reestablish drainageof the pancreas. This has resulted in decreased painand increased weight gain.
Disorders of the PancreasSURGICAL INTERVENTION• The patient who undergoes pancreatic surgery mayhave multiple drains in place postoperatively as well asa surgical incision that is left open for irrigation andrepacking every 2 to 3 days to remove necrotic debris.
Disorders of the Pancreas
Disorders of the PancreasPOSTACUTE MANAGEMENT• Antacids may be used when acute pancreatitis begins toresolve.• Oral feedings low in fat and protein are initiatedgradually.• Caffeine and alcohol are eliminated from the diet.• If the episode of pancreatitis occurred during treatmentwith thiazide diuretics, corticosteroids, or oralcontraceptives, these medications are discontinued.
Disorders of the PancreasPOSTACUTE MANAGEMENT• Follow-up of the patient may include ultrasound, x-raystudies, or ERCP to determine whether the pancreatitisis resolving and to assess for abscesses andpseudocysts.
Disorders of the PancreasPOSTACUTE MANAGEMENT• Follow-up of the patient may include ultrasound, x-raystudies, or ERCP to determine whether the pancreatitisis resolving and to assess for abscesses andpseudocysts.
The Patient with Acute PancreatitisASSESSMENT• The nurse assesses the presence of pain, its location,its relationship to eating and to alcohol consumption,and the effectiveness of pain relief measures.• It also is important to assess the patient’s nutritional andfluid status and history of gallbladder attacks andalcohol use.• A history of gastrointestinal problems, including nausea,vomiting, diarrhea, and passage of fatty stools, iselicited.NURSING PROCESS:
The Patient with Acute PancreatitisASSESSMENT• The nurse assesses the abdomen for pain, tenderness,guarding, and bowel sounds, noting the presence of aboard-like or soft abdomen.• It also is important to assess respiratory status,respiratory rate and pattern, and breath sounds.• Normal and adventitious breath sounds and abnormalfindings on chest percussion, including dullness at thebases of the lungs and abnormal tactile fremitus, aredocumented.
The Patient with Acute PancreatitisASSESSMENT• The nurse assesses the emotional and psychologicalstatus of the patient and family and their coping,because they are often anxious about the severity of thesymptoms and the acuity of illness.
The Patient with Acute PancreatitisNURSING DIAGNOSES• Acute pain related to inflammation, edema, distention ofthe pancreas, and peritoneal irritation• Ineffective breathing pattern related to severe pain,pulmonary infiltrates, pleural effusion, atelectasis, andelevated diaphragm• Imbalanced nutrition, less than body requirements,related to reduced food intake and increased metabolicdemands• Impaired skin integrity related to poor nutritional status,bed rest, and multiple drains and surgical wound
The Patient with Acute PancreatitisPLANNING AND GOALS• The major goals for the patient include relief of pain anddiscomfort, improved respiratory function, improvednutritional status, maintenance of skin integrity, andabsence of complications.
The Patient with Acute PancreatitisNURSING INTERVENTIONS• RELIEVING PAIN AND DISCOMFORT• IMPROVING BREATHING PATTERN• MAINTAINING OPTIMAL NUTRITIONAL STATUS• IMPROVING SKIN INTEGRITY• MONITORING AND MANAGING POTENTIALCOMPLICATIONS• PROMOTING HOME AND COMMUNITY-BASEDCARE
The Patient with Acute PancreatitisPOTENTIAL COMPLICATIONSPotential complications may include the following:• Fluid and electrolyte disturbances• Necrosis of the pancreas• Shock and multiple organ dysfunction
The Patient with Acute PancreatitisEVALUATIONEXPECTED PATIENT OUTCOMESExpected patient outcomes may include:1. Reports relief of pain and discomforta. Uses analgesics and anticholinergics as prescribed,without overuseb. Maintains bed rest as prescribedc. Avoids alcohol to decrease abdominal pain2. Experiences improved respiratory functiona. Changes position in bed frequentlyb. Coughs and takes deep breaths at least every hour
The Patient with Acute PancreatitisEVALUATIONEXPECTED PATIENT OUTCOMESExpected patient outcomes may include:c. Demonstrates normal respiratory rate and pattern,full lung expansion, normal breath soundsd. Demonstrates normal body temperature andabsence of respiratory infection3. Achieves nutritional and fluid and electrolyte balancea. Reports decrease in number of episodes of diarrheab. Identifies and consumes high-carbohydrate, low-protein foods
The Patient with Acute PancreatitisEVALUATIONEXPECTED PATIENT OUTCOMESc. Explains rationale for eliminating alcohol intaked. Maintains adequate fluid intake within prescribedguidelinese. Exhibits adequate urine output4. Exhibits intact skina. Skin is without breakdown or infectionb. Drainage is contained adequately
The Patient with Acute PancreatitisEVALUATIONEXPECTED PATIENT OUTCOMES5. Absence of complicationsa. Demonstrates normal skin turgor, moist mucousmembranes, normal serum electrolyte levelsb. Exhibits stabilization of weight, with no increase inabdominal girthc. Exhibits normal neurologic, cardiovascular, renal,and respiratory function
Disorders of the PancreasCHRONIC PANCREATITIS• Chronic pancreatitis is an inflammatory disordercharacterized by progressive anatomic and functionaldestruction of the pancreas.• As cells are replaced by fibrous tissue with repeatedattacks of pancreatitis, pressure within the pancreasincreases.• The end result is mechanical obstruction of thepancreatic and common bile ducts and the duodenum.• Additionally, there is atrophy of the epithelium of theducts, inflammation, and destruction of the secretingcells of the pancreas.
Disorders of the PancreasCHRONIC PANCREATITIS• Excessive and prolonged consumption of alcoholaccounts for approximately 70% of the cases.• The incidence of pancreatitis is 50 times greater inalcoholics than in the nondrinking population.• Damage to these cells is more likely to occur and to bemore severe in patients whose diets are poor in proteincontent and either very high or very low in fat.
Disorders of the PancreasCLINICAL MANIFESTATIONS• Chronic pancreatitis is characterized by recurringattacks of severe upper abdominal and back pain,accompanied by vomiting.• Weight loss is a major problem in chronic pancreatitis:more than 75% of patients experience significant weightloss, usually caused by decreased dietary intakesecondary to anorexia or fear that eating will precipitateanother attack.• Malabsorption occurs late in the disease, when as littleas 10% of pancreatic function remains.
Disorders of the PancreasCLINICAL MANIFESTATIONS• As a result, digestion, especially of proteins and fats, isimpaired.• The stools become frequent, frothy, and foul-smellingbecause of impaired fat digestion, which results in stoolswith a high fat content.
Disorders of the PancreasASSESSMENT AND DIAGNOSTIC FINDINGS• ERCP is the most useful study in the diagnosis of chronicpancreatitis.• Various imaging procedures, including magnetic resonanceimaging, computed tomography, and ultrasound, havebeen useful in the diagnostic evaluation of patients withsuspected pancreatic disorders.• A glucose tolerance test evaluates pancreatic islet cellfunction, information necessary for making decisions aboutsurgical resection of the pancreas.• In contrast to the patient with acute pancreatitis, serumamylase levels and the white blood cell count may not beelevated significantly.
Disorders of the PancreasMEDICAL MANAGEMENT• Endoscopy to remove pancreatic duct stones and stentstrictures may be effective in selected patients tomanage pain and relieve obstruction.• Management of abdominal pain and discomfort is similarto that of acute pancreatitis; however, the focus isusually on the use of nonopioid methods to managepain.• The physician, nurse, and dietitian emphasize to thepatient and family the importance of avoiding alcoholand other foods that the patient has found tend toproduce abdominal pain and discomfort.
Disorders of the PancreasMEDICAL MANAGEMENT• Diabetes mellitus resulting from dysfunction of thepancreatic islet cells is treated with diet, insulin, or oralantidiabetic agents.• Pancreatic enzyme replacement is indicated in thepatient with malabsorption and steatorrhea.
Disorders of the PancreasSURGICAL MANAGEMENT• Pancreaticojejunostomy (also referred to as Roux-en-Y) with a side-to-side anastomosis or joining of thepancreatic duct to the jejunum allows drainage of thepancreatic secretions into the jejunum.• Other surgical procedures may be performed fordifferent degrees and types of disease, ranging fromrevision of the sphincter of the ampulla of Vater, tointernal drainage of a pancreatic cyst into the stomach,to insertion of a stent, to wide resection or removal ofthe pancreas.
Disorders of the PancreasSURGICAL MANAGEMENT• A Whipple resection (pancreaticoduodenectomy) hasbeen carried out to relieve the pain of chronicpancreatitis.• Autotransplantation or implantation of the patient’spancreatic islet cells has been attempted to preserve theendocrine function of the pancreas in patients who haveundergone total pancreatectomy.
Disorders of the PancreasPANCREATIC CYSTS• As a result of the local necrosis that occurs at the time ofacute pancreatitis, collections of fluid may form in thevicinity of the pancreas. These become walled off byfibrous tissue and are called pancreatic pseudocysts.• Diagnosis of pancreatic cysts and pseudocysts is madeby ultrasound, computed tomography, and ERCP.
Disorders of the PancreasCANCER OF THE PANCREAS• Cigarette smoking, exposure to industrial chemicals ortoxins in the environment, and a diet high in fat, meat, orboth are associated with pancreatic• Diabetes mellitus, chronic pancreatitis, and hereditarypancreatitis are also associated with pancreatic cancer.• The pancreas can also be the site of metastasis fromother tumors.
Disorders of the PancreasCLINICAL MANIFESTATIONS• Pain, jaundice, or both are present in more than 90% ofpatients and, along with weight loss, are consideredclassic signs of pancreatic carcinoma.• Other signs include rapid, profound, and progressiveweight loss as well as vague upper or midabdominalpain or discomfort that is unrelated to anygastrointestinal function and is often difficult to describe.• Such discomfort radiates as a boring pain in themidback and is unrelated to posture or activity. Reliefmay be obtained by sitting up and leaning forward, oraccentuated when lying supine.
Disorders of the PancreasCLINICAL MANIFESTATIONS• The formation of ascites is common.• An important sign, when present, is the onset ofsymptoms of insulin deficiency: glucosuria,hyperglycemia, and abnormal glucose tolerance.• Meals often aggravate epigastric pain, which usuallyoccurs before the appearance of jaundice and pruritus.
Disorders of the PancreasASSESSMENT AND DIAGNOSTIC FINDINGS• Magnetic resonance imaging and computed tomographyare used to identify the presence of pancreatic tumors.• Gastrointestinal x-ray findings may demonstratedeformities in adjacent viscera caused by the impingingpancreatic mass.• Percutaneous fine-needle aspiration biopsy of thepancreas is nused to diagnose pancreatic tumors andconfirm the diagnosis in patients whose tumors are notresectable, eliminating the stress and postoperative painof ineffective surgery.
Disorders of the PancreasASSESSMENT AND DIAGNOSTIC FINDINGS• Percutaneous transhepatic cholangiography is anotherprocedure that may be performed to identify obstructionsof the biliary tract by a pancreatic tumor.• Several tumor markers (eg, CA 19-9, CEA, DU-PAN-2)may be used in the diagnostic workup, but they arenonspecific for pancreatic carcinoma.• Angiography, computed tomography, and laparoscopymay be performed to determine whether the tumor canbe removed surgically.• Intraoperative ultrasonography has been used todetermine if there is metastatic disease to other organs.
Disorders of the PancreasMEDICAL MANAGEMENT• If the patient undergoes surgery, intraoperative radiationtherapy (IORT) may be used to deliver a high dose ofradiation to the tumor with minimal injury to othertissues.• IORT may also be helpful in relief of pain.• Interstitial implantation of radioactive sources has alsobeen used, although the rate of complications is high.• A large biliary stent inserted percutaneously or byendoscopy may be used to relievemjaundice.
Disorders of the PancreasNURSING MANAGEMENT• Pain management and attention to nutritionalrequirements are important nursing measures toimprove the level of comfort.• Skin care and nursing measures are directed towardrelief of pain and discomfort associated with jaundice,anorexia, and profound weight loss.• Specialty mattresses are beneficial and protect bonyprominences from pressure.• Pain associated with pancreatic cancer may be severeand may require liberal use of opioids; patient controlledanalgesia should be considered for the patient withsevere, escalating pain.
Disorders of the PancreasNURSING MANAGEMENT• Because of the poor prognosis and likelihood of shortsurvival, end-of-life preferences are discussed andhonored.• If appropriate, the nurse refers the patient to hospicecare.
Disorders of the PancreasTUMORS OF THE HEAD OF THE PANCREAS• Sixty to eighty percent of pancreatic tumors occur in thehead of the pancreas.• Tumors in this region of the pancreas obstruct thecommon bile duct where the duct passes through thehead of the pancreas to join the pancreatic duct andempty at the ampulla of Vater into the duodenum.• The tumors producing the obstruction may arise fromthe pancreas, the common bile duct, or the ampulla ofVater.
Disorders of the PancreasCLINICAL MANIFESTATIONS• The obstructed flow of bile produces jaundice, clay-coloredstools, and dark urine.• Malabsorption of nutrients and fat-soluble vitamins mayresult from obstruction by the tumor to entry of bile in thegastrointestinal tract.• Abdominal discomfort or pain and pruritus may be noted,along with anorexia, weight loss, and malaise.• The jaundice of this disease must be differentiated fromthat due to a biliary obstruction caused by a gallstone inthe common duct, which is usually intermittent and appearstypically in obese patients, most often women, who havehad previous symptoms of gallbladder disease.
Disorders of the PancreasASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnostic studies may include duodenography,angiography by hepatic or celiac artery catheterization,pancreatic scanning, percutaneous transhepaticcholangiography, ERCP, and percutaneous needlebiopsy of the pancreas.• Results of a biopsy of the pancreas may aid in thediagnosis.
Disorders of the PancreasMEDICAL MANAGEMENT• A diet high in protein along with pancreatic enzymes isoften prescribed.• Preoperative preparation includes adequate hydration,correction of prothrombin deficiency with vitamin K, andtreatment of anemia to minimize postoperativecomplications.• Parenteral nutrition and blood component therapy arefrequently required.• A biliary-enteric shunt may be performed to relieve thejaundice and, perhaps, to provide time for a thoroughdiagnostic evaluation.
Disorders of the PancreasMEDICAL MANAGEMENT• Total pancreatectomy (removal of the pancreas) maybe performed if there is no evidence of direct extensionof the tumor to adjacent tissues or regional lymphnodes.• A pancreaticoduodenectomy (Whipple’s procedure orresection) is used for potentially resectable cancer of thehead of the pancreas. This procedure involves removalof the gallbladder, distal portion of the stomach,duodenum, head of the pancreas, and common bile ductand anastomosis of the remaining pancreas andstomach to the jejunum.
Disorders of the PancreasMEDICAL MANAGEMENT• When the tumor cannot be excised, the jaundice may berelieved by diverting the bile flow into the jejunum byanastomosing the jejunum to the gallbladder, aprocedure known as cholecystojejunostomy.• The postoperative management of patients who haveundergone a pancreatectomy or apancreaticoduodenectomy is similar to the managementof patients after extensive gastrointestinal and biliarysurgery.• A nasogastric tube and suction and parenteral nutritionallow the gastrointestinal tract to rest while promotingadequate nutrition.
Disorders of the PancreasNURSING MANAGEMENT• Preoperatively and postoperatively, nursing care isdirected toward promoting patient comfort, preventingcomplications, and assisting the patient to return to andmaintain as normal and comfortable a life as possible.• The nurse closely monitors the patient in the intensivecare unit after surgery; the patient will have multipleintravenous and arterial lines in place for fluid and bloodreplacement as well as for monitoring arterial pressures,and is on a mechanical ventilator in the immediatepostoperative period.
Disorders of the PancreasNURSING MANAGEMENT• It is important to give careful attention to changes in vitalsigns, arterial blood gases and pressures, pulseoximetry, laboratory values, and urine output.• The nurse must also consider the patient’s compromisednutritional status and risk for bleeding.• Although the patient’s physiologic status is the focus ofthe health care team in the immediate postoperativeperiod, the patient’s psychological and emotional statemust be considered, along with that of the family.• The patient has undergone major and risky surgery andis critically ill; thus, anxiety and depression may affectrecovery.
Disorders of the PancreasNURSING MANAGEMENT• The immediate and long-term outcome of this extensivesurgical resection is uncertain, and the patient andfamily require emotional support and understanding inthe critical and stressful preoperative and postoperativeperiods.
Disorders of the PancreasPANCREATIC ISLET TUMORS• At least two types of tumors of the pancreatic islet cellsare known: those that secrete insulin (insulinoma) andthose in which insulin secretion is not increased(―nonfunctioning‖ islet cell cancer).• Insulinomas produce hypersecretion of insulin andcause an excessive rate of glucose metabolism. Theresulting hypoglycemia may produce symptoms ofweakness, mental confusion, and seizures.• The 5-hour glucose tolerance test is helpful indiagnosing insulinoma and in distinguishing it from othercauses of hypoglycemia.
Disorders of the PancreasSURGICAL MANAGEMENT• When a tumor of the islet cells has been diagnosed,surgical treatmentmwith removal of the tumor usually isrecommended.• In some patients, symptoms may be produced by simplehypertrophy of this tissue rather than a tumor of the isletcells. In such cases, a partial pancreatectomy (removalof the tail and part of the body of the pancreas) isperformed.
Disorders of the PancreasNURSING MANAGEMENT• In preparing the patient for surgery, the nurse must bealert for symptoms of hypoglycemia and be ready toadminister glucose as prescribed if symptoms occur.• Postoperatively, the nursing management is the same asthat after other upper abdominal surgical procedures,with special emphasis on monitoring serum glucoselevels.• Patient teaching is determined by the extent of surgeryand the alterations in pancreatic function that result.
Disorders of the PancreasHYPERINSULINISM• Hyperinsulinism results from overproduction of insulin bythe pancreatic islets.• Symptoms resemble those of excessive doses of insulinand are attributable to the same mechanism, an abnormalreduction in blood glucose levels.• Clinically, it is characterized by episodes during which thepatient experiences unusualmhunger, nervousness,sweating, headache, and faintness; in severe cases,seizures and episodes of unconsciousness may occur.• The findings at the time of surgery or at autopsy mayindicate hyperplasia of the islets of Langerhans or a benignor malignant tumor involving the islets and capable ofproducing large amounts of insulin.
Disorders of the PancreasHYPERINSULINISM• Surgical removal of the hyperplastic or neoplastic tissuefrom the pancreas is the only successful method oftreatment.• About 15% of patients with spontaneous or functionalhypoglycemia eventually develop diabetes mellitus.
Disorders of the PancreasULCEROGENIC TUMORS• Some tumors of the islets of Langerhans are associatedwith hypersecretion of gastric acid that produces ulcersin the stomach, duodenum, and jejunum. The result isreferred to as Zollinger- Ellison syndrome.• The hypersecretion is so great that even after partialgastric resection, enough acid is produced to causefurther ulceration.• In many patients, a total gastrectomy may be necessaryto reduce the secretion of gastric acid sufficiently toprevent further ulceration.