Chapter 56: Pancreatitis

KEY CONCEPTS

ACUTE PANCREATITIS

• Factors that can contribute to acute pancreatitis should be identified and corrected, including discontinuation of medications that could be potential causes.

• Patients with acute pancreatitis should receive aggressive fluid replacement to reduce the risks of persistent systemic inflammatory response syndrome (SIRS) and organ failure.

• Parenteral opioid analgesics are used to control abdominal pain associated with acute pancreatitis despite a lack of high quality evidence to support the practice.

• Use of prophylactic antibiotics is not recommended in patients with acute pancreatitis without signs or symptoms of infection, including those with predicted severe acute pancreatitis or necrotizing pancreatitis.

CHRONIC PANCREATITIS

• Chronic pain, malabsorption with resultant steatorrhea, and diabetes mellitus are the hallmark symptoms and complications of chronic pancreatitis.

• Pain from chronic pancreatitis may initially be treated with nonopioid analgesics, but adjuvant agents may be necessary as the disease progresses.

• Pancreatic enzyme and fat-soluble vitamin supplementation are the primary treatments for malabsorption due to chronic pancreatitis.

• Enteric-coated pancreatic enzyme supplements are the preferred dosage form in the treatment of malabsorption and steatorrhea due to chronic pancreatitis.

• The addition of a histamine-2 receptor antagonist or proton pump inhibitor to pancreatic enzyme supplementation may increase the effectiveness of enzyme therapy for malabsorption and steatorrhea due to chronic pancreatitis.

Patient Care Process for Pancreatitis

Collect

• Patient characteristics (eg, age, sex, pregnant)

• Patient history (past medical—hyperlipidemia, recent surgery, gallstone disease or ERCP; social—dietary habits, alcohol use, tobacco use)

• Current and recent (for acute pancreatitis; see Table 56-2) medications

• Medication allergies

• Review of systems for the abdomen and gastrointestinal system (eg, abdominal pain, nausea and vomiting, stool frequency and consistency for chronic pancreatitis; see Tables 56-3 and 56-5)

• Objective data

  • Acute pancreatitis (see Table 56-3)

    • Vital signs (eg, BP, heart rate, temperature, respiratory rate)

    • Labs (eg, CBC, Chem-7, calcium, albumin, amylase, lipase, transaminases, bilirubin, triglycerides)

    • Microbiology results

    • Intake/output

  • Chronic Pancreatitis (see Table 56-5)

    • Physical exam (eg, weight; assessment for neuropathy, nephropathy, and retinopathy with diabetes)

    • Labs (eg, fasting serum glucose, bilirubin, transaminases, pancreatic function tests, calcium, albumin)

Assess

• Acute pancreatitis

  • Causative medications (see Table 56-2)

  • Nutrition and fluid status

  • Abdominal pain: location, radiation, severity, onset

  • Infectious etiologies

  • Continuous hemodynamic monitoring

• Chronic pancreatitis

  • Alcohol and tobacco use

  • Abdominal pain

  • Trends in weight, nutrition status, serum glucose, and stool consistency and frequency (assess for constipation if patient taking opioids)

Plan^*

• Acute pancreatitis

  • Fluid support including choice and dose

  • Discontinue suspected causal medications

  • Nutrition support including route and caloric requirements

  • Pain management with specific medication choice, route, and dose

  • Antimicrobial therapy regimen for suspected or identified infection(s)

• Chronic pancreatitis

  • Tailored lifestyle modifications (eg, abstinence from alcohol, smoking cessation; see Fig. 56-4)

  • Nutrition support and dietetic counseling

  • Therapy ...