definition, classification, etiology, pathophysiology, clinical manifestations, diagnosis, management of pancreatitis, pancreatic cysts & pancreatic cancer

1. PANCREATIC DISORDERS
By,
Y. V. Vanaja
Lecturer
Vijay Marie College of Nursing

2. PANCREATITIS

3. Introduction
Pancreatitis is inflammation of the pancreas and it is a serious disorder. The most
basic classification system used to describe or categorize the various stages and forms
of pancreatitis divides the disorder into
• Acute pancreatitis
• Chronic pancreatitis
 Acute pancreatitis can be a medical emergency associated with a high risk for
life-threatening complications and mortality
 Chronic pancreatitis often goes undetected until 80% to 90% of the exocrine and
endocrine tissue is destroyed.
 Acute pancreatitis does not lead to chronic pancreatitis unless complications
develop.
 Chronic pancreatitis is characterized by acute episodes

4. Pancreatitis
Acute
pancreatitis
Chronic
pancreatitis

5. Definition
Pancreatitis is defined as the inflammation of the pancreas and it is described as
autodigestion of the pancreas.
“Brunner”
Incidence:
Typically men 40 to 45 years of age with a history of alcoholism
Women- 50 to 55 years of age with a history of biliary disease

6. Acute pancreatitis
Definition:
 Acute pancreatitis is an acute inflammatory process of the pancreas. The degree of the
inflammation varies from mild edema to the severe hemorrhagic necrosis. “Lewis”
 Acute pancreatitis is a serious and, at times, life-threatening inflammatory process of the
pancreas. This process caused by premature activation of the excessive pancreatic enzymes
that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the
pancreas .
“Ignatavicious”
 Acute pancreatitis ranges from a mild, self- limiting disorder to a severe, rapidly fatal
disease that does not respond to any treatment
“ Brunner “

7. Etiology
• Biliary tract disease with gallstones accounts for the half of the cases of obstructive
pancreatitis
• Trauma from surgical manipulation after biliary tract, pancreatic, gastric, and duodenal
procedures such as cholecystectomy, whipple procedure and partial gastrectomy
• Trauma – external
• Pancreatic obstruction- tumors, cysts
• Metabolic disturbances – Eg – hyperlipidemia
• Renal disturbances – failure or transplantation
• Familial, inherited pancreatitis
• Penetration gastric or duodenal ulcers
• Viral infections, such as coxsackievirus b infection
• Alcoholism
• Toxicities of drugs
• Pancreatitis also occurs after ERCP

9. Pathophysiology

10. Clinical manifestations
• Severe abdominal pain in the mid- gastric area or left upper quadrant
• Pain is described as intense, Boring and continuous, acute in onset, it generally more severe after meals
and is unrelieved by antacids.
• Pain may be accompanied by abdominal distention
• Palpable abdominal mass and decreased peristalsis.
• A rigid or board like abdomen may develop
• Ecchymosis (bruising) in the flank or around the umbilicus may indicate severe pancreatitis
• Nausea and vomiting
• Fever
• Jaundice
• Mental confusion and agitation may also occur
• Hypotension
• Tachycardia
• Cyanosis
• Cold and clammy skin
• Acute renal failure
• Respiratory distress and hypoxia

11. • Patient may develop diffuse pulmonary infiltrates
• dyspnea
• Tachypnea
• Abnormal blood gas values
• Bowel sounds are decreased or absent
Cardinal signs
• Grey turner spots or sign: a bluish flank discoloration
• Cullen’s sign : bluish periumblical discoloration
• Fox sign : bruising is seen over the inguinal ligament
• Abdominal guarding : spasm of the abdominal wall muscles

12. Complications of Acute pancreatitis
2 significant local complications of pancreatitis are pseudocyst and abscess
Pseudocyst:
it is a cavity with or surrounding the outside of the pancreas.
The pesudocyst is filled with necrotic products and liquid secretions, such as plasma, pancreatic enzymes and
inflammatory exudates.
Pancreatic abscess : is a large fluid containing cavity with in the pancreas
Systemic complications:
Pulmonary- pleural effusion, atelectasis, and pneumonia
Cardiovascular – hypotension
Tetany due to hypocalcemia
Trypsin can activate prothrombin and plasminogen, increasing the patient’s risk fro intravascular thrombi, pulmonary
emboli

14. Diagnosis
 History collection
 Serum amylase
 Serum lipase
 Serum bilirubin & alakaline phosphatase levels
 Blood glucose
 ESR
 CBC
 BUN
 Serum calcium
 Triglycerides
 Abdominal ultrasound
 Endoscopic ultrasound
 CT scan of the pancreas
 MRI
 ERCP
 Chest X ray

15. NonSurgical Management
Management of patient with acute pancreatitis is directed toward relieving symptoms and
preventing or treating complications
All oral intake is withheld to inhibit pancreatic stimulation and secretion of pancreatic
enzymes
Parenteral nutrition & Iv replacement of calcium and magnesium
NG tube suction may be used to relieve nausea and vomiting and to decrease the HCL
Histamine- 2 antagonists like ranitidine & proton pump inhibitors like omeprazole
Pain management:
Administration of analgesics – morphine, Meperidine, & iv or transdermal fentanyl
Intensive care:
• Help the patient to assume side lying position may decrease the abdominal pain of the
pancreatitis
• Correction of fluid and blood loss and low albumin levels is necessary to maintain fluid
volume and renal failure

16.  Antibiotic therapy
 Peritoneal lavage or dialysis has been used to remove kinin and phospholipase.
 Respiratory care
 monitoring Blood gases to use of humidified oxygen to intubation and mechanical ventilation
 Biliary Drainage:
 Placement of biliary drains and stents in the pancreatic duct through endoscopy - to reestablish drainage of
pancreas
Surgical management:
• If the pancreatitis is cause by gallstones an ERCP with sphincterostomy may be performed on an emergency basis
• Laparocopic cholecystectomy
• Laparoscopy may be done to drain an abscess or pseudocysts or abscess can be treated by percutaneous drainage under CT
guidance

17. Chronic pancreatitis

18. Introduction:
it is a benign inflammatory process and fibrosing disorder
characterized by
• irreversible morphologic changes,
• Progressive and
• permanent loss of exocrine and endocrine function

19. DEFINITION
1) Chronic pancreatitis is an inflammatory disorder characterized by progressive anatomic and functional
destruction of the pancreas
“Brunner’’
2) Chronic pancreatitis is a progressive disease of the pancreas that has remissions and exacerbations.
Inflammation and fibrosis of the tissue contribute to pancreatic insufficiency and diminished function of
the organ “Ignatavicious”
3) Chronic pancreatitis is progressive destruction of the pancreas with fibrotic replacement of pancreatic
tissue. Strictures and calcifications may also occur in the pancreas. “Lewis”

20. Classification of Chronic pancreatitis
• Chronic calcifying pancreatitis
• Chronic obstructive pancreatitis
• Autoimmune pancreatitis
• Idiopathic pancreatitis
Chronic calcifying pancreatitis:
• Chronic calcifying pancreatitis id also called as alcohol- induced pancreatitis
• In chronic pancreatitis there is inflammation and sclerosis, mainly in the head of the pancreas
and around the pancreatic duct.

21. Chronic obstructive pancreatitis;
• Develops from inflammation , spasm and obstruction of the sphincter of oddi, often
from cholelithiasis.
• Inflammatory sclerotic lesions occur in the head of the pancreas and around the ducts
causing an obstruction and back flow of secretions.

22. Autoimmune pancreatitis;
• Is a chronic inflammatory process in which immunoglobulins invade the
pancreas.
• Other organs also may infiltrated , including the lungs and liver.
Idiopathic and hereditary chronic pancreatitis;
May be associated with SPINK1 & CFTR gene mutations
The protein encoded by the SPINK1 gene is a trypsin inhibitor.
The CFTR gene is associated with cystic fibrosis

23. Etiology
• Alcohol consumption
• Malnutrition
• autoimmune disease,
• a narrow pancreatic duct,
• a blockage of the pancreatic duct by either gallstones or pancreatic
stones
• cystic fibrosis, which is a hereditary disease that causes mucus to build
up in your lungs
• genetics
• high blood levels of calcium
• a high level of triglyceride fats in your blood
• Recurrent acute pancreatitis

25. Pathophjysiology
Chronic calcifying pancreatitis;
Alcohol
Pancreatic secretions precipitate as insoluble proteins that plug the pancreatic ducts & flow of pancreatic juices
As the protein plugs become more widespread, the cellular lining of the ducts changes and ulcerates
This inflammatory process causes fibrosis of the pancreatic tissue.
Intraductal calcification and marked pancreatic destruction develop.
The organ becomes hard and firm as result of cell atrophy and pancreatic insufficiency

26. Clinical manifestations
• Abdominal Pain accompanied by vomiting
• abdominal tenderness
• ascites
• Exocrine insufficiency occurs in 80% to 90%
• anorexia
• steatorrhea,
• constipation
• Endocrine insufficiency - diabetes mellitus
• Jaundice or cholangitis
• Weight loss & muscle wasting- due to fat malabsorption
• Protein malabsorption – ‘starvation’ edema of the feet, legs and hands
•

28. Diagnostic Studies
Serum amylase
Serum lipase
Serum bilirubin
CBP
Stool examination
Secretin stimulation test – to assess pancreatic function
ERCP
MRI,
CT
Ultrasound
Glucose tolerance test – to evaluate pancreatic islet function

30. NonSurgical Management
• Pain management
• Pancreatic Enzyme replacement therapy- to prevent malnutrition,
malabsorption &weight loss
• Pancrelipase – contains amount of amylase, lipase and protease
• Record the number and consistency of stools per day to monitor effectiveness
of enzyme therapy
• If patient has diabetes – insulin or oral hypoglycemic agents to control blood
glucose level
• TPN
• H2 blockers or proton pump inhibitors
• Total enteral nutrition TEN, including vitamin and mineral replacement
• Food high in CHO and protein and also assist in healing process
• Teach patients to avoid alcohol

32. Surgical management
• Laparoscopic cholecystectomy or choledochotomy ( incision of common bile
duct)
• Sphincterotomy
• Endoscopic sphincterotomy
• Laparoscopic pancreatectomy
• Endoscopic pancreatic necrosectomy and Natural orifice transluminal
endoscopic surgery
• Pancreaticojejunostomy
• Whipple resection (pancreaticoduodenectomy)
• Pancreas transplantation

33. Pancreatic Cysts

34. Pancreatic cysts are saclike pockets of fluid on or in the pancreas.
As a result of the local necrosis that occurs at the time of acute pancreatitis, collections of fluid may form in the
vicinity of the pancreas. These become walled off by fibrous tissue and are called as pancreatic pseudocysts
Classification
The main categories of pancreatic cysts can be divided into two groups,
nonneoplastic or neoplastic cysts.
Each group includes many different subtypes of cysts, such as
Pseudocysts; A pancreatic pseudocyst is a circumscribed collection of fluid rich in pancreatic enzymes, blood, and
necrotic tissue, typically located in the lesser sac of the abdomen
Serous cystadenomas ; Pancreatic serous cystadenoma is a benign tumour of pancreas. It is usually found in the tail
of the pancreas, and may be associated with von Hippel-Lindau syndrome.
mucinous cystic neoplasms; Mucinous cystic neoplasms (MCNs) usually are large, septated, thick-walled mucinous
cysts that lack communication with the ductal system, and occur almost exclusively in the pancreatic body and tail
of middle-aged women.
Most aren't cancerous, and many don't cause symptoms.
But some pancreatic cysts can be or can become cancerous.
Definition

35. Etiology
• Acute pancreatitis
• Chronic pancreatitis
• Abdominal trauma
Clinical Manifestations of pseudocysts;
• Epigastric pain radiating to the back
• Abdominal fullness
• Nausea
• vomiting
• Haemorrhage
• Infection
• Obstruction of the bowel, biliary tract, or splenic vein
• Abscess
• Fistula formation
• Pancreatic ascites

36. Diagnosis
• Ultrasound
• CT
• ERCP
Management;
Psedocysts may spontaneously resolve or they may rupture and produce haemorrhage.
Surgical intervention is necessary if the pseudocyst does not resolve within 6 to 8 weeks or if
complications develop.
Surgeries include;
Percutaneous drainage using a needle, usually under CT scan guidance
Endoscopic – assisted drainage using an endoscope to locate the pseudocyst
Surgical drainage of the pseudocyst into the stomach or jejunum
To provide external drainage , the surgeon inserts a sump drainage tube to remove pancreatic
secretions and exudate

37. Pancreatic Abscess

38. Pancreatic abscess is a late complication of acute necrotizing pancreatitis, occurring more than 4 weeks
after the initial attack. A pancreatic abscess is a collection of pus resulting from
tissue necrosis, liquefaction, and infection. “Wikipedia’’
Pancreatic abscesses are the most serious complication of acute necrotizing pancreatitis. The abscesses
form from collections of the purulent liquefaction of the necrotic pancreas. “Ignatavicious”
Causes;
• Inflammatory necrosis of the pancreas
• pancreatic pseudocysts that become infected
• penetrating peptic ulcers
• gall stones
• alcohol consumption
• in rare cases, drugs
• blunt trauma
Definition

39. Clinical manifestations
• Fever
• Pleural effusion
• abdominal pain,
• chills
• inability to eat.
• Whereas some patients present an abdominal mass,
• Nausea and vomiting

40. Diagnosis
• History collection
• CBP
• Abdominal CT scans,
• MRIs
• ultrasounds
• Blood culture

41. Management
• Antibiotics ]
• On the other hand, antibiotics are not recommended in patients with pancreatitis, unless the presence of an
infected abscess has been proved.
• Drainage via percutaneous method or laparoscopy should be performed to prevent sepsis.

42. Pancreatic Cancer

43. • Cancer of the pancreas is the leading cause of the deaths in each year in United states.
• Pancreatic tumors usually originate from epithelial cells of the pancreatic ductal system.
• If the tumor is discovered in the early stages the tumor cells may be localized within the
glandular organ.
• Most often the tumor is discovered in the late stages of development and may be a well-
defined mass or is diffusely spread throughout the pancreas.
• The tumor may be primary cancer, or it may result from metastasis from cancers of the lung,
breast, thyroid, kidney or skin.
• Primary cancers are generally adenocarcinomas and grow in a well differentiated patterns.
They grow rapidly and spread to surrounding organs.by direct extension and invasion of
lymphatic and vascular system.
• The highly metastatic lesion may eventually invade the lung, peritoneum, liver, spleen, and
lymph nodes.
Definition:
Pancreatic cancer is a disease in which malignant (cancerous) cells form in the tissues of the pancreas. Pancreatic
cancer occurs within the tissues of the pancreas, which is a vital endocrine organ located behind the stomach.

44. ETIOLOGY
• Cigarette smoking
• Exposure to industrial chemicals or toxins in the environment
• Diet high in fat, meat, or both
• DM
• Chronic pancreatitis
• Hereditary pancreatitis
• Cirrhosis
• obesity

45. Pathophysiology

47. Clinical manifestations
• Upper Abdominal pain often radiates to back
• Anorexia
• Rapid and progressive weight loss
• Nausea
• Jaundice
• Weight loss due to poor digestion and absorption
• Tumors may be palpable abdominal masses, especially in the thin patient.
• Hepatomegaly
• Dark urine
• Clay colored stools
• Glucose intolerance
• Splenomegaly
• GI bleeding
• Ascites

49. Diagnosis
• Serum amylase.
• Serum lipase
• Serum bilirubin
• CEA – carcinoembryonic antigen
• MRI
• CT
• ERCP
• X-ray
• Percutaneous FNAB
• Percutaneous transhepatic cholangiography
• Angiograpghy

50. Management
• Chemotherapy or radiation is used to relieve pain by shrinking the tumor
• It may be used before, after, or instead of surgery
• Chemotherapy ;
• in most cases combining agents has been more successful than single-agent chemotherapy.
• 5-fluorouracil (5-FU) may be given alone or with gemcitabine for locally advanced, or unresectable,
pancreatic cancer.
• Gemcitabine may also be given with capecitabine , docetaxel, and/or erlotinib
• Observe for adverse effects, such as fatigue, rash, anorexia, and diarrhea.
• other targeted therapies being investigated include growth factor inhibitors, anti – angiogenesis
factors, and kinase inhibitors.
• To control pain – opioid analgesics ( morphine)
• Intensive external beam radiation therapy to the pancreas may offer pain relief by shrinking tumor
cells.
• Implantation of radioactive iodine seeds, in combination with systemic or intra arterial administration
of floxuridine

51. For patients experiencing biliary obstruction who are high surgical risks, biliary stents placed percutaneously can ensure
patency to relieve pain.
Surgical Management;
• Partial pancreatectomy – preferred from tumors smaller than3cm in diameter
• Minimal invasive surgery via laparoscopy in the staging, palliative and removal of cancer.
• For larger tumors – radical pancreatectomy or whipple procedure
Preoperative Management;
• Jejunostomy feeding – feedings are started in low concentrations and volumes and are
gradually increased as tolerated
• Provide feeding using a pump to maintain a constant volume and assess for diarrhea
frequency to determine tolerance.
• TPN
• Iv line care to prevent catheter sepsis
• Sterile dressing changes and site observation are important.
• Patient have nothing by mouth fro at least 6 to 8 hrs before surgery.

52. Post operative care
• Observe for multiple potential complications of the open whipple procedure.
• The patient having the laparoscopic whipple surgery or radical pancreatectomy is also less at risk for severe
complications.
• Preventive measures for surgical complications like;
• Diabetes – check blood glucose often
• Hemorrhage – monitor pulse, B.P, Skin color and mental status.
• Wound infection – monitor temperature and assess wounds
• Bowel obstruction – check for bowel sounds and stools
• Intra abdominal abscess – monitor temperature and patients reports of pain
 Immediately after surgery, the patient is NPO and usually has NGT to decompress the stomach.
 In open surgical approaches, biliary drainage tubes are placed during surgery – assess the tubes and drainage
devices for tension or kinking
 Monitor drainage for color, consistency and amount
 Place patient in the semi fowlers’s position to reduce tension on the suture line and anastomosis site

53. The development of fistula is the most common and most serious post operative
complication.
Monitor vital signs, decreased urine output – to detect early signs of hypovolemia
Mainatin sequential compressive devices to prevent DVT
Maitain IV isotonic fluid replacement with colloid replacement
Monitor HB and Haematocrit values – to assess blood loss and need for blood
transfusion
Maintain electrolyte balance