pancreatitis is an inflammatory disorder characterized by progressive anatomic
and functional destruction of the pancreas. As cells are replaced by fibrous
tissue with repeated attacks of pan-creatitis, 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.
consumption in Western societies and malnutrition worldwide are the major
causes of chronic pancreatitis. Excessive and prolonged consumption of alcohol
accounts for approximately 70% of the cases (Clain & Pearson, 1999). The
incidence of pan-creatitis is 50 times greater in alcoholics than in the
nondrinking population. Long-term alcohol consumption causes hypersecre-tion of
protein in pancreatic secretions, resulting in protein plugs and calculi within
the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of
the pancreas. Damage to these 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.
pancreatitis is characterized by recurring attacks of se-vere upper abdominal
and back pain, accompanied by vomiting. Attacks are often so painful that
opioids, even in large doses, do not provide relief. As the disease progresses,
recurring attacks of pain are more severe, more frequent, and of longer
duration. Some patients experience continuous severe pain; others have a dull,
nagging constant pain. The risk of dependence on opioids is increased in
pancreatitis because of the chronic nature and severity of the pain.
loss is a major problem in chronic pancreatitis: more than 75% of patients
experience significant weight loss, usually caused by decreased dietary intake
secondary to anorexia or fear that eating will precipitate another attack.
Malabsorption occurs late in the disease, when as little as 10% of pancreatic
function re-mains. As a result, digestion, especially of proteins and fats, is
im-paired. The stools become frequent, frothy, and foul-smelling because of
impaired fat digestion, which results in stools with a high fat content. This
is referred to as steatorrhea. As
the disease progresses, calcification of the gland may occur, and calcium
stones may form within the ducts.
is the most useful study in the diagnosis of chronic pan-creatitis. It provides
detail about the anatomy of the pancreas and the pancreatic and biliary ducts.
It is also helpful in obtaining tissue for analysis and differentiating
pancreatitis from other conditions, such as carcinoma. Various imaging
procedures, in-cluding magnetic resonance imaging, computed tomography, and
ultrasound, have been useful in the diagnostic evaluation of patients with
suspected pancreatic disorders. Computed tomog-raphy scanning or ultrasound is
helpful to detect pancreatic cysts.
glucose tolerance test evaluates pancreatic islet cell function, information
necessary for making decisions about surgical resec-tion of the pancreas. An
abnormal glucose tolerance test indica-tive of diabetes may be present. In
contrast to the patient with acute pancreatitis, serum amylase levels and the
white blood cell count may not be elevated significantly.
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.
approaches may be indicated for the patient who re-fuses surgery, who is a poor
surgical risk, or whose disease and symptoms do not warrant surgical
intervention. Endoscopy to re-move pancreatic duct stones and stent strictures
may be effective in selected patients to manage pain and relieve obstruction.
How-ever, such therapy is available only in special centers and is suit-able
for few patients (Bornman & Beckingham, 2001).
of abdominal pain and discomfort is similar to that of acute pancreatitis;
however, the focus is usually on the use of nonopioid methods to manage pain.
Persistent, unrelieved pain is often the most difficult aspect of management
(Bornman Beckingham, 2001). The physician, nurse, and dietitian em-phasize to the
patient and family the importance of avoiding al-cohol and other foods that the
patient has found tend to produce abdominal pain and discomfort. The fact that
no other treatment is likely to relieve pain if the patient continues to
consume alco-hol is stressed to the patient.
mellitus resulting from dysfunction of the pancreatic islet cells is treated
with diet, insulin, or oral antidiabetic agents.
hazard of severe hypoglycemia with alcohol use is stressed to the patient and
family. Pancreatic enzyme replacement is indi-cated in the patient with
malabsorption and steatorrhea (Trolli, Conwell & Zuccaro, 2001).
is generally carried out to relieve abdominal pain and dis-comfort, restore
drainage of pancreatic secretions, and reduce the frequency of acute attacks of
pancreatitis. The surgery performed depends on the anatomic and functional
abnormalities of the pancreas, including the location of disease within the
pancreas, diabetes, exocrine insufficiency, biliary stenosis, and pseudocysts
of the pancreas. Other factors taken into consideration in deter-mining whether
surgery is to be performed and what procedure is indicated include the
patient’s continued use of alcohol and the likelihood that the patient will be
able to manage the en-docrine or exocrine changes that are expected after
Pancreaticojejunostomy (also referred to as Roux-en-Y)with a
side-to-side anastomosis or joining of the pancreatic duct to the jejunum
allows drainage of the pancreatic secretions into the jejunum. Pain relief
occurs by 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 itself
progresses (Tierney et al., 2001).
surgical procedures may be performed for different de-grees and types of
disease, ranging from revision of the sphincter of the ampulla of Vater, to
internal drainage of a pancreatic cyst into the stomach (see Pancreatic Cyst
discussion), to insertion of a stent, to wide resection or removal of the
pancreas. A Whipple resection (pancreaticoduodenectomy) has been carried out to
relieve the pain of chronic pancreatitis.
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 pancreatec-tomy. Testing and refinement of this procedure continue in an
ef-fort to improve outcomes.
chronic pancreatitis develops as a result of gallbladder disease, the obstruction
is treated by surgery to explore the com-mon duct and remove the stones;
usually, the gallbladder is re-moved at the same time. In addition, an attempt
is made to improve the drainage of the common bile duct and the pancre-atic
duct by dividing the sphincter of Oddi, a muscle that is lo-cated at the
ampulla of Vater (this surgical procedure is known as a sphincterotomy). A
T-tube usually is placed in the common bile duct, requiring a drainage system
to collect the bile post-operatively. Nursing care after such surgery is
similar to that in-dicated after other biliary tract surgery.
who undergo surgery for chronic pancreatitis may ex-perience 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 mor-tality after these surgical procedures are high because of the poor
physical condition of the patient before surgery and the con-comitant
occurrence 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.