Digestive System: Issues With The Functioning Of A Pancreas

Pancreatitis accounts for more than 200,000 hospitalizations in America each year (Quinlan, 2014). Pancreatitis is the inflammation and irritation of the cells of the pancreas, resulting from activated digestive enzymes (Ignatavicius, Workman, Blair, Rebar, & Winkelman, 2016). When the pancreas is inflamed, it is unable to work properly Pancreatic enzymes are typically activated in the small intestine. The pancreatic enzymes not only destroy pancreatic cells, but also ductal tissue resulting in fibrosis of the pancreas and autodigestion (Ignatavicius et al., 2016). Pancreatitis can be deadly if left untreated and acute pancreatitis has a mortality rate of approximately ten percent (Acute Pancreatitis, 2018).

The pancreas is both an endocrine gland functioning in the endocrine system and an exocrine gland functioning in the digestive system. Diabetes or digestive issues also result from a poorly functioning pancreas (Pancreatitis, 2018). There are two types of pancreatitis: acute pancreatitis and chronic pancreatitis. Chronic pancreatitis can be due to an obstruction of the sphincter of Oddi, an autoimmune issue, a hereditary issue, or as a result of alcoholism. Chronic pancreatitis occurs after repeated occurrences of acute pancreatitis (Ignatavicius et al., 2016). Scar tissue forms in the pancreas after repeated episodes causing loss of function. Individuals with chronic pancreatitis are at a higher risk for developing pancreatic cancer (Pancreatitis, 2018).

There are some individuals that are at a higher risk for pancreatitis. Women, especially during the months following childbirth, are at higher risk for acute pancreatitis. Acute pancreatitis in men is particularly common after indulging during the holidays or while on vacation due to increased alcohol consumption (Ignatavicius et al., 2016). Risk factors include: Hypertriglyceridemia, hypercalcemia, hyperparathyroidism, infection, cystic fibrosis, smoking, alcoholism, gallstones, abdominal surgery or injury to the abdomen, pancreatic cancer, and a family history of pancreatitis (Pancreatitis, 2018). Pancreatitis can also be caused by pancreatic obstruction or toxicities of drugs (Ignatavicius et al., 2016). The underlying cause of pancreatitis may affect the treatment plan.

The health care provider will diagnose patients with pancreatitis after a thorough assessment and diagnostic studies. Most patients with acute pancreatitis complain of severe, constant abdominal pain with a boring quality. The provider may notice a gray-blue discoloration of the skin in the abdominal region. This skin discoloration is the result of pancreatic enzymes leaking from the peritoneal cavity to the cutaneous tissue (Ignatavicius et al., 2016). Acute patients will also experience nausea, vomiting, diarrhea, sweating, rapid heart rate, and fever (Pancreatitis, 2018). It is imperative to thoroughly assess and monitor patients presenting with pancreatitis since they may go into shock.

Those with acute pancreatitis are also at a higher risk for pneumonia, atelectasis, and left lung pleural effusions. Patients with chronic pancreatitis may exhibit additional symptoms. Chronic pancreatitis patients may have worsening abdominal pain during a flare up, polydipsia, polyphagia, and polyuria. One of the most common symptoms of chronic pancreatitis is frequent, foul smelling, fatty stools known as steatorrhea (Ignatavicius et al., 2016). In addition to their assessment, the health care provider may order an abdominal ultrasound, a contrast-enhanced CT scan, and diagnostic laboratory tests. Abdominal ultrasound does not always produce clear results; thus, the need for further investigation with a CT scan.

Patients with acute pancreatitis may have an increased serum amylase, elastase, trypsin, and lipase due to pancreatic cell injury. Other laboratory considerations include: elevated serum glucose, decreased serum calcium and magnesium, elevated bilirubin, elevated alanine aminotransferase, elevated aspartate aminotransferase, and elevated leukocyte count. For patients with chronic pancreatitis, they may have elevated serum glucose levels; a slightly elevated serum amylase and lipase level; and elevated bilirubin and alkaline phosphate levels (Ignatavicius et al., 2016).

Pancreatitis is typically treated with pain control, bowel rest, and fluid administration. Abdominal pain associated with pancreatitis is severe; thus, the priority intervention is controlling the patient’s pain (Quinlan, 2014). Opioids, for acute pancreatitis, may be ordered by the health care provider and administered for pain relief. Morphine or hydromorphone are used to treat pain, in acute patients; meperidine is not the first choice to treat pain because it can cause seizures. After the acute phase, nonopioid analgesics are utilized to manage pain in patients with chronic pancreatitis. Initially, the patient will have nothing by mouth (NPO) to rest their pancreas and reduce pancreatic enzyme secretion. In acute patients, a nasogastric tube may be inserted so that gastric decompression can prevent gastric juices from entering the duodenum; proton pump inhibitors, such as omeprazole, and histamine receptor antagonists, such as ranitidine, also help decrease gastric acid secretion.

When an acute patient is recovering they will eat frequent, small high protein, high carbohydrate, low spice, low fat meals to promote healing. Chronic patients should follow a similar diet and avoid foods or beverages that aggravate their symptoms. Prevention is an important aspect of treatment for chronic patients. Pancreatic-enzyme replacement therapy (PERT), is used for patients with chronic pancreatitis. These enzymes should reduce the number of fatty stools. The health care provider may also prescribe proton pump inhibitors or sodium bicarbonate to neutralize stomach acid and increase the effectiveness of enzyme therapy (Ignatavicius et al., 2016).

Surgical intervention is available but is typically not needed for acute or chronic pancreatitis. However, an endoscopic retrograde cholangiopancreatography (ERCP) with a sphincterotomy may be needed if acute pancreatitis was caused by gallstones. If that procedure is not successful, a cholecystectomy may be performed. For patients with chronic pancreatitis, an endoscopic pancreatic necrosectomy and natural orifice transluminal endoscopic surgery may be performed to remove necrotic pancreatic tissue. Pancreatic transplantation is also a surgical option, but rarely performed; this procedure is typically reserved for patients with severe diabetes. An acute or chronic patient may have a laparoscopic surgery performed to drain the abscess or pseudocyst (Ignatavicius et al., 2016).

Patient scenario: John, a forty-year-old male, presents in the emergency department with acute abdominal pain in the left upper quadrant. His current temperature is 99.7 orally, his pulse is 102, his blood pressure is 129/82, respirations are fifteen, and his oxygen saturation is 93% with room air. Bowel sounds are present but hypoactive. John states the pain began yesterday and the pain feels as if it is going straight through his body. He is on vacation with his wife and has enjoyed visiting local restaurants. He describes himself as a moderate drink but states he has had an alcoholic beverage with most meals while on vacation. John mentions he drank heavily one night during their trip while at a concert. He has experienced nausea and vomiting but initially attributed those symptoms to his alcohol consumption.

The doctor in the emergency room performs an assessment and has orders labs to be drawn as well as an abdominal ultrasound and contrast-enhanced CT scan. Lab results show John’s amylase levels are over three times the normal level at 548 U/L (Acute Pancreatitis, 2018). Amylase levels typically rise within the first 12 to 24 hours of acute pancreatitis. John’s lipase levels are elevated at 279 U/L, however, typically lipase levels rise later amylase levels. Additionally, his white blood count is 14,000/mm, blood glucose is 190mg/dL, BUN is 20mg/dL, and triglycerides are 2300 mg/dL. These elevated lab values confirm the doctor’s concern and indicate acute pancreatitis. The abdominal ultrasound CT scan ruled out a pancreatic pseudocyst and gallstones; it is unlikely the patient will need surgery (Ignatavicius et al., 2016).

The doctor orders fluids for the patient and morphine to be administered intravenously. The doctor wants to keep the patient hydrated and manage their pain. The patient is admitted to the hospital for acute pancreatitis. Under the doctor’s order, the patient is NPO for 48 hours so that the patient’s digestive system can rest and heal (Acute Pancreatitis, 2018). Once the inflammation is controlled, the patient eats small, frequent, bland meals. If the patient had been unable to tolerate eating food, the doctor would have ordered a feeding tube. Once the patient is discharged from the hospital, he is able return to a regular diet. The doctor referred the patient to a dietician and encouraged him to avoid overindulging in alcohol and eat low-fat, high nutrient meals. The patient was further educated on pancreatitis risks prior to discharge; he is now aware excessive drinking damages the pancreas (Quinlan, 2014).

Individuals that suffer from acute pancreatitis, like the patient previously mentioned, are more at risk for developing chronic pancreatitis. For chronic patients, it is important to be aware of, and avoid, triggers to minimize the risk of flare ups. Pancreatitis is a serious condition and those with symptoms should seek immediate medical attention. However, with adequate medical care it is possible to have a positive patient outcome.