Liceo de Cagayan University

R.N. Pelaez, Kauswagan Cagayan de Oro City

College of Nursing

NCM 103
A Report on

DISTURBANCES IN ACCESSORY ORGANS

(Digestive and Gastrointestinal Function and Metabolism)

In Partial Fulfillment of
NCM 103 Semi-Finals

Submitted to:
MRS. ANECIA SO, RN, MAN
Medical Surgical Semi-Final Instructor

Submitted by:
Besario, Allisa
Caparas, Bien Jules
Gines, Rjane Anne
Ines, Rizamie
Torregosa, Cyrus Dan
Ubarco, Cleinton
NCM 103-Reporters

September 01, 2010

 TABLE OF CONTENTS

I. Liver Cirrhosis
 Introduction
 Causes
 Signs and Symptoms
 Pathophysiology
 Nursing Management
 Medical and Surgical Management
 Health Teachings

II. Pancreatitis
 Introduction
 Causes
 Signs and Symptoms
 Pathophysiology
 Nursing Management
 Medical and Surgical Management
 Health Teachings

III. Gallbladder Disease

A. Cholelithiasis
 Introduction
 Causes
 Signs and Symptoms
 Pathophysiology
 Nursing Management
 Medical and Surgical Management
 Health Teachings

B. Cholecystitis
 Introduction
 Causes
 Signs and Symptoms
 Pathophysiology
 Nursing Management
 Medical and Surgical Management
 Health Teachings

IV. Bibliography and Journals

 ACUTE AND CHRONIC PANCREATITIS

INTRODUCTION

Pancreas, solid, slender conglomerate gland lying transversely across the

posterior wall of the abdomen. It consists of head, neck, body and tail. It varies in length
from 15 to 20 cm (6 to 8 in) and has a breadth of about 3.8 cm (about 1.5 in) and a
thickness of from 1.3 to 2.5 cm (0.5 to 1 in). Its usual weight is about 85 gm (about 3
oz), and its head lies in the concavity of the duodenum.

The pancreas has both an exocrine and an endocrine secretion. The exocrine
secretion is made up of a number of enzymes that are discharged into the intestine to
aid in digestion. The secretions which are very alkaline because of their high
concentration of sodium bicarbonate, are capable of neutralizing the highly acid gastric
juice that enters the duodenum. The enzymes include amylase, which aids the digestion
of carbohydrates; trypsin, which aids in the digestion of proteins; and lipase, which aids
the digestion of fats. Hormones originating in the gastrointestinal tract stimulate the
secretion of these exocrine pancreatic juices. The hormone secretin is the major
stimulus for increased bicarbonate secretion from the pancreas, and the major stimulus
for digestive enzyme secretion is the hormone CCK-PZ. The vagus nerve also
influences exocrine pancreatic enzyme.

The islet of Langerhans, the endocrine part of the pancreas, is collections of cells
embedded in the pancreatic tissue. They compose of alpha, beta and delta cells. The
hormone produced by the beta cells is called insulin (lowers blood glucose by permitting
entry of glucose into the cells of liver, muscles and other tissues, where it is stored as
glycogen or used for energy); the alpha cells secrete glucagon (raise the blood glucose
by converting glycogen to glucose in the liver) and the delta cells secrete somatostatin
(exerts a hypoglycemic effect by interfering the release of growth hormone from the
pituitary and glucagon from the pancreas).

Pancreatitis is the inflammation of the pancreas. It occurs in acute or chronic

forms; acute form has 10 % mortality. Acute pancreatitis can be a medical emergency
associated with a high risk for life-threatening complications and mortality, whereas
chronic pancreatitis often goes undetected until 80% or 90% of the exocrine and
endocrine tissue is destroyed. Acute pancreatitis does not usually lead to chronic
pancreatitis unless complications develop. However, chronic pancreatitis can be
characterized by acute episodes. Typically the patients are men 40-45 years of age with
a history of alcoholism or women 50-55 years of age with a history of gallstone
pancreatitis.

Although the mechanism causing pancreatic inflammation are unknown,

pancreatitis is common described as autodigestion of the pancreas. It is believed that
the pancreatic duct becomes temporarily obstructed, accompanied by hypersecretion of
the exocrine enzymes of the pancreas. These enzymes enter the bile duct, where they
are activated and, together with bile, back up (reflux) into the pancreatic duct, causing
pancreatitis.

Acute pancreatitis ranges from mild, self limited disorder to severe, rapidly fatal
disease that does not respond to any treatment. Mild acute pancreatitis is characterized
by edema and inflammation confined to the pancreas. Minimal organ dysfunction is
present, and return to normal function usually occurs within 6 months. Although this is
considered the milder form of pancreatitis, the patient is acutely ill and at risk for
hypovolemic shock, fluid and electrolyte disturbances and sepsis. A more widespread
and complete enzymatic digestion of the gland characterizes severe acute pancreatitis.
Enzymes damage the local blood vessels, and bleeding and thrombosis can occur. The
tissue may become necrotic, with damage extending into the retroperitoneal tissues.
Local complications consist of pancreatic cysts or abscesses and acute fluid collections
in or near the pancreas. Patients who develop systemic complications with organ
failure, such as pulmonary insufficiency with hypoxia, shock, renal failure, and
gastrointestinal bleeding, are also characterized as having severe acute pancreatitis.
This disorder is seen in approximately 20% of all the patients with acute pancreatitis
and has a mortality rate of 15%-20%.

Chronic pancreatitis is an inflammatory disorder that is characterized by

progressive anatomic and functional destruction of the pancreas. As cells are replaced
by fibrous tissue with repeated attacks of pancreatitis, pressure within the pancreas
increases. The end result is mechanical obstruction of the pancreatic and common bile
ducts and the duodenum. Additionally, there is atrophy of the epithelium of the ducts,
inflammation, and destruction of the secreting cells of the pancreas.

Alcohol consumption in Western societies and malnutrition worldwide are the

major cause of chronic pancreatitis. Excessive and prolonged consumption of alcohol
accounts for approximately 70%-80% of all cases of chronic pancreatitis. The incidence
of pancreatitis is 50 times greater in people with alcoholism than in those who do not
abuse alcohol. Long term alcohol consumption causes hypersecretion of protein in the
pancreatic secretions, resulting in protein plugs and calculi within the pancreatic ducts.
Alcohol also has direct toxic effect on the cells of the pancreas. Damage to the cells is
more likely to occur and to be more severe in patients whose diets are poor in protein
content and either very high or very low in fat.
 NURSING MANAGEMENT

Relieving Pain and Discomfort

Because the pathologic process responsible for pain is autodigestion of the

pancreas, the objectives of therapy are to relieve pain and decrease secretion of the
pancreatic enzymes. The pain of acute pancreatitis is often very severe, necessitating
the liberal use of analgesics. The current recommendation for pain management is
parenteral morphine. Alternatively, hydromorphone may be used. Oral feedings may be
withheld to decreases the formation and secretion of secretin. The patient is maintained
on parenteral fluids and electrolytes to restore and maintain fluid balance. Nasogastric
suction may be used to relieve nausea and vomiting or to treat abdominal distention and
paralytic ileus. The nurse provides frequent oral hygiene and care to decrease
discomfort from the nasogastric tube and relieve dryness of the mouth.

Patient is maintained on bed rest to decrease the metabolic rate and reduce the
secretion of pancreatic and gastric enzymes. If the patient experiences increasing
severity of pain, the nurse reports this to the physician, because the patient may be
experiencing hemorrhage of the pancreas or the dose of the analgesic may be
inadequate.

The patient with acute pancreatitis often has a clouded sensorium because of
severe pain, fluid and electrolyte disturbances and hypoxia. Therefore, the nurse
provides frequent and repeated but simple explanations about the need for withholding
fluids, maintenance of gastric suction and bed rest.

Improving Breathing Pattern

The nurse maintains the patient in a semi-Fowler’s position to decrease pressure

on the diaphragm by the distended abdomen and to increase respiratory expansion.
Frequent changes of position are necessary to prevent atelectasis and pooling of
respiratory secretions. Pulmonary assessment and monitoring of pulse oximetry or
arterial blood gases are essential to detect changes in respiratory status so that early
treatment can be initiated. The nurse instructs the patient in techniques of coughing and
deep breathing and in the use of incentive spirometry to improve respiratory function
and encourages and assists the patient to perform these activities every hour.

Improving Nutritional Status

The patient with acute pancreatitis is not permitted food or oral fluid intake.
However, it is important to assess the patient’s nutritional status and to note the factors
that alter the patient’s nutritional requirements. Laboratory test results and daily weights
are useful to monitor the nutritional status.

Enteral and parenteral nutrition may be prescribed. In addition to administering

enteral and parenteral nutrition, the nurse monitors the serum glucose levels every 4-6
hours. As the acute symptoms subside, the nurse gradually reintroduces oral feedings.
Between acute attacks, the patient receives a diet that is high in carbohydrates and low
in fats and proteins. The patient should avoid heavy meals and alcoholic beverages.

Improving Skin Integrity

The patient is at risk for skin breakdown because of poor nutritional status,
enforced bed rest and restlessness, which may result in pressure ulcers and breaks in
tissue integrity. In addition, the patient who has undergone surgery may have multiple
drains or an open surgical incision and is at risk for skin breakdown and infection. The
nurse carefully assesses the wound, drainage sites, and skin for signs of infection,
inflammation, and breakdown. The nurse carries out wound care as prescribed and
takes precautions to protect intact skin from contact with drainage. It is important to turn
the patient every 2 hours; use of specialty beds may be indicated to prevent skin
breakdown.

Monitoring and Managing Potential Complications

Fluid and electrolyte disturbances are common complications because of nausea

and vomiting, movement of fluid from the vascular compartment to the peritoneal cavity,
diaphoresis, fever and the use of gastric suction. The nurse assesses the patient’s fluid
and electrolyte status by noting skin turgor and moistness of mucous membranes. The
nurse weighs the patient daily and carefully measures fluid intake and output, including
urine output, nasogastric secretion and diarrhea. In addition, it is important to assess for
other factors that may affect fluid and electrolyte status, including increase body
temperature and wounds drainage. The abdominal girth daily ascites is suspected.

Fluids are administered intravenously and may be accompanied by infusion of

blood or blood products to maintain the blood volume and to prevent or treat
hypovolemic shock. It is important to keep emergency medications readily available
because of the risk for circulatory collapse and shock. The nurse promptly reports blood
pressure and reduced urine output, because these signs may indicate hypovolemia and
shock or renal failure. Low serum calcium and magnesium levels may occur and require
prompt treatment.

Pancreatic necrosis is a major cause of morbidity and mortality of patients with

acute pancreatitis. The patient who develops necrosis is at risk for hemorrhage, septic
shock, and multiple organ failure. The patient may undergo diagnostic procedures to
confirm pancreatic necrosis, surgical debridement or insertion of multiple drains may be
performed. The patient with pancreatic is usually critically ill and requires expert medical
and nursing management, including hemodynamic monitoring in the ICU.

In addition to carefully monitoring vital signs and other signs and symptoms, the
nurse is responsible for administering prescribes fluids, medications and blood
products; assisting with supportive management such as ventilator; preventing
additional complications; and attending to the patient’s physical and physiologic care.
 Shock and multiple organ failure may occur with acute pancreatitis. Hypovolemic
shock may occur as a result of hypovolemia and sequestering of fluid in the peritoneal
cavity. Hemorrhagic shock may occur with hemorrhagic pancreatitis. Septic shock may
occur with bacterial infection of the pancreas. Cardiac dysfunction may occur as a result
of fluid and electrolyte disturbance, acid-base imbalances and the release of toxic
substance into the circulation.

The nurse closely monitors the patient for early signs of neurologic,
cardiovascular, renal and respiratory dysfunction. The nurse must be prepared to
respond quickly to rapid changes in the patient’s status, treatments, and therapies. In
addition, it is important to inform the family about the status and progress of the patient
and to allow them to spend time with the patient.

MEDICAL MANAGEMENT

Acute Pancreatitis

Management of acute pancreatitis is directed toward relieving symptoms and

preventing or treating complications. All oral intake is withheld, to inhibit stimulation of
the pancreas and its secretion of enzymes. Parenteral nutrition is usually an important
part of the therapy, particularly in debilitated patients, because of the extreme metabolic
stress associated with acute pancreatitis. Patients who do not tolerate enteral feeding
require parenteral nutrition. Nasogastric suction may be used to relieve nausea and
vomiting and to decrease painful abdominal distention and paralytic ileus. H-2
antagonists such as cimetidine and ranitidine may be prescribed to decrease pancreatic
activity by inhibiting secretion of hydrogen chloride. Proton pump inhibitors may be used
for patients who do not tolerate H2 antagonists or for whom this therapy is ineffective.

Pain Management:

-adequate administration of analgesia, pain relief may require parenteral opioids

suchas morphine; Meperidine had been the drug of choice, Hydromorphone may be
also effective. Antiemetic agents may be prescribed to prevent vomiting

Intensive Care:

-correction of fluid and blood loss and low albumin levels is necessary to
maintain fluid volume and prevent renal failure. The patient is usually acutely ill and is
monitored in the ICU, where hemodynamic monitoring and arterial blood gas monitoring
are initiated. Antibiotic agents may be prescribed if infection is present. Insulin may be
required if hyperglycemia occurs.
 Respiratory Care:

-aggressive respiratory care is indicated because of the high risk for elevation of
the diaphragm, pulmonary infiltrates and effusion and atelectasis. Hypoxemia occurs in
a significant number of patients with acute pancreatitis, even with normal x-ray findings.
Respiratory care may range from close monitoring of arterial 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
has been performed to reestablish drainage of the pancreas. This has resulted in
decreased pain and increased weight gain.

Surgical Intervention:

-although surgery is often risk because the acutely ill patient is a poor surgical
risk, it may be performed to assist in the diagnosis of pancreatitis (diagnostic
laparotomy), to establish pancreatic drainage, or to resect or debride a necrotic
pancreas. The patient who undergoes pancreatic surgery may have multiple drains in
place postoperatively, as well as a surgical incision that is left open for irrigation and
repacking every 2-3 days to remove necrotic debris.

Post-acute Management:

-antacids after acute pancreatitis begins to resolve; oral feedings that are low in
fat and protein are initiated gradually; caffeine and alcohol are eliminated from the diet;
follow up may include ultrasound, x-ray studies to determine whether the pancreatitis is
resolving and to assess for abscesses and pseudocyst.

Chronic Pancreatitis

The management of chronic pancreatitis depends on its probable cause in each

patient. Treatment is directed toward preventing and managing acute attacks, relieving
pain and discomfort, and managing exocrine and endocrine insufficiency of pancreatitis.

Nonsurgical Management

Nonsurgical approaches may be indicated for the patient who refuses surgery,
who is a poor surgical risk or whose disease and symptoms do not warrant surgical
intervention. Endoscopy to remove pancreatic duct stones and strictures may be
effective in selected patients to manage pain and relieve obstruction.

Management of the abdominal and discomfort is similar to the acute pancreatitis;

however the focus is usually on the use of nonopioid methods to manage the pain.
Persistent, unrelieved pain is often the most difficult aspect of management. The
physician, nurse and dietitian emphasize to the family and patient the importance of
avoiding alcohol and foods that have produced abdominal pain and discomfort in the
past. The health care team stresses to the patient that no other treatment is likely to
relive pain if the patient continues to consume alcohol.

Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated
with diet, insulin or oral antidiabetic agents. The hazard of severe hypoglycemia with
alcohol consumption is stressed to the patient and family. Pancreatic enzyme
replacement is indicated for the patient with malabsorption and steatorrhea. A proton
pump inhibitor is administered with enzyme therapy to reduce gastric acid activation of
enzymes.

Surgical Management

Surgery is carried out to relieve abdominal pain and discomfort, restore drainage
of pancreatic secretions and reduce the frequency of acute attacks of pancreatitis. The
type of surgery that is performed depends on the anatomic and functional abnormalities
of the pancreas, the presence of diabetes, exocrine insufficiency, biliary stenosis, and
pseudocysts of the pancreas. Other considerations for surgery election include the
patient’s likelihood for continued use of alcohol and the likelihood that the patient will be
able to manage the endocrine or exocrine changes that are expected after surgery.

Pancreaticojejunoscopy (Roux-en-Y), which a side to side anastomosis or

joining of the pancreatic duct to the jejunum, allow drainage of the pancreatic secretions
into the jejunum. Pain relief occurs within 6 months in more than 80% of the patients
who undergo this procedure, but pain returns in a substantial number of patients as the
disease progresses.

Other surgical procedures may be performed for different degrees and types of
underlying disorders. These procedures include revision of the sphincter of the ampulla
of Vater, internal drainage of the pancreatic cyst into the stomach, insertion of a stent,
and wide resection or removal of the pancreas. A Whipple resection
(pancreaticoduodenectomy) can be carried out to relieve the pain of chronic
pancreatitis.

Autotransplantation or implantation of the patient’s pancreatic islet cells has

been attempted to preserve the endocrine function of the pancreas in patients who have
undergone total pancreatectomy. Moving the pancreas to another location within the
abdomen with revised vascular and enteric anastamoses may provide relief from pain
and preserve endocrine function. Testing and refinement of these procedures continue
in an effort to improve outcomes.

When chronic pancreatitis develops as a result of gallbladder disease, the

obstruction is treated by surgery to explore the common duct and remove the stones;
usually, the gallbladder is remove at same time. In addition, an attempt is made to
improve the drainage of the common bile duct and the pancreatic duct by dividing the
sphincter of Oddi, a muscle that is located at the ampulla of Vater (sphincterotomy). A
T-tube surgical procedure is usually placed in the common bile duct, requiring a
drainage system to collect the bile postoperatively. Nursing care after such surgery is
similar to that indicated after other biliary tract surgery.

Endoscopic and laparoscopic procedures such as distal pancreatectomy,

longitudinal decompression of the pancreatic duct, and the nerve denervation have
been performed and are being refined. Minimally invasive procedures to treat chronic
pancreatitis may prove to be successful adjuncts in the management of this complex
disorder.

Patients who undergo surgery for chronic pancreatitis may experience weight
gain and improved nutritional status; this may result from reduction in pain associated
with eating rather than from correction of malabsorption. However, morbidity and
mortality after these surgical procedures are high because of the poor physical condition
of the patient before surgery and the concomitant presence of cirrhosis. Even after
undergoing these surgical procedures, the patient is likely to continue to have pain and
impaired digestion secondary to pancreatitis, unless alcohol is avoided completely.
 JOURNAL READING

Predicting Mortality in Patients with Severe Acute Pancreatitis

A simple new scoring system proved both sensitive and specific for mortality.

In patients with severe acute pancreatitis, identifying risk for mortality within 24 hours of
presentation is critical. However, a simple scoring system to predict mortality based on
routine laboratory and diagnostic test results has been lacking.

To provide such a system, investigators developed and prospectively evaluated the

performance of a bedside index for severity in acute pancreatitis (BISAP) in 397
consecutive cases of acute pancreatitis at a tertiary care hospital. BISAP is scored on a
scale of 0 to 5, based on how many of the following characteristics the patient has
within 24 hours of presentation: blood urea nitrogen level >25 mg/dL, impaired mental
status, systemic inflammatory response syndrome, age >60, and pleural effusion on
imaging studies.

Organ failure occurred within 72 hours of presentation in 18% of cases (transient in

74%), and the overall 1-week mortality rate was 3.5%. The higher the BISAP score was,
the greater the mortality rate (P for trend, <0.0001). A score of 3 was determined to be
the optimal cutoff for predicting mortality: Death occurred in 18% of cases with BISAP
scores 3 versus 1% of cases with scores <3. In terms of mortality, a BISAP score 3
had a sensitivity of 71%, a specificity of 83%, a positive predictive value of 18%, and a
negative predictive value (NPV) of 99%. In addition, a BISAP score 3 was significantly
associated with increased risk for organ failure overall (odds ratio, 7.4), persistent organ
failure (OR, 12.7), and pancreatic necrosis (OR, 3.8).

Comment: The main advantage of the BISAP scoring system over others is its
simplicity: Scores can be calculated quickly using easily accessible data. Its NPV for
mortality (99%) is impressive. This study was conducted in a tertiary care setting with
experts in all aspects of patient care. If the results are confirmed in a community setting,
BISAP will likely become the standard prognostic scoring system to identify patients at
risk for mortality and organ failure.

— Stuart Sherman, MD

Published in Journal Watch Gastroenterology September 18, 2009

http://gastroenterology.jwatch.org/cgi/content/full/2009/918/1
 BIBLIOGRAPHY

 Smeltzer. Textbook of Medical-Surgical Nursing. Volume 2, pp. 1345-

1369, 11th Edition. Lippincott and Wilkins 2007.
 Russo MW, Wei JT, Thiny MT, et al. Digestive and liver disease statistics,
2004. Gastroenterology. 2004;126:1448–1453.
 Microsoft® Encarta® 2009. © 1993-2008 Microsoft Corporation. All
rights reserved.

WEBLIOGRAPHY

 Sribd.com

 Wikipedia.com

HEALTH TEACHINGS

The client should be encouraged to learn and use of relaxation techniques including
guided imagery and music therapy are used to shift the focus of the brain away from the
pain, decrease muscle tension, and reduce stress. Tension and stress can also be
reduced through biofeedback. Being massaged or applying backrub is very relaxing and
helps reduce stress.

- Encourage to take a well - balanced diet.

- Encourage a healthy lifestyle.
- Educate patient in pain management.

Teach patient that if acute abdominal pain or biliary tract disease (as evidenced by
jaundice, clay- colored stools, and darkened urine) occurs, she should notify it to the
physician. She may report to the physician after 7 to 10 days to know the indictor of
disease or response progression.

The client should be instructed to avoid alcohol, spicy foods, any caffeine- containing
foods, heavy meals, high fatty foods. Small,frequent feeding of bland diet.
PATHOPHYSIOLOGY