nursing case study on pancreatitis

Pancreatitis

Learn about the nursing care management of patients with pancreatitis in this nursing study guide .

Table of Contents

• What is Pancreatitis? 

Classification

Pathophysiology, statistics and epidemiology, clinical manifestations, complications, assessment and diagnostic findings, medical management, surgical management, nursing assessment, planning & goals, nursing interventions, discharge and home care guidelines, documentation, practice quiz: pancreatitis, what is pancreatitis.

Pancreatitis, which is the inflammation of the pancreas , can be acute or chronic in nature. It may be caused by edema , necrosis or hemorrhage . In men, this disease is commonly associated with alcoholism, peptic ulcer , or trauma ; in women, it’s associated with biliary tract disease. Prognosis is usually good when pancreatitis follows biliary tract disease, but poor when the factor is alcoholism. The mortality rate may go as high as 60% when the disease is associated with necrosis and hemorrhage. (Schilling McCann, 2009)

Pancreatitis ranges from a mild, self-limited disorder to a severe, rapidly fatal disease that does not respond to any treatment.

• Pancreatitis is an inflammation of the pancreas and is a serious disorder.
• Pancreatitis can be a medical emergency associated with a high risk of life-threatening complications and mortality.
• Pancreatitis is commonly described as autodigestion of the pancreas.

The most basic classification system divides the disorder into acute and chronic forms.

• Acute pancreatitis. Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop.
• Chronic pancreatitis . Chronic pancreatitis is an inflammatory disorder characterized by progressive destruction of the pancreas.

Self-digestion of the pancreas caused by its own proteolytic enzymes, particularly trypsin, causes acute pancreatitis.

• Entrapment. Gallstones enter the common bile duct and lodge at the ampulla of Vater.
• Obstruction. The gallstones obstruct the flow of the pancreatic juice or causing reflux of bile from the common bile duct into the pancreatic duct.
• Activation. The powerful enzymes within the pancreas are activated.
• Inactivity. Normally, these enzymes remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum.
• Enzyme activities. Activation of enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.
• Reflux. These enzymes enter the bile duct, where they are activated and together with bile, back up into the pancreatic duct, causing pancreatitis.

Pancreatitis affects people of all ages, but the mortality rate associated with pancreatitis increases with advancing age.

• Approximately 185, 000 cases of pancreatitis occur in United States each year.
• 150, 000 of these cases are the result of cholelithiasis or sustained alcohol abuse .
• The overall mortality rate of patients with pancreatitis is 2% to 10%.
• Even though the frequency is about 5000 new cases per year in the United States, with a mortality rate of about 10%, it is yet unknown about the number of clients who have recurrent acute pancreatitis or chronic pancreatitis. (Black, 2009)
• The incidence of pancreatitis varies in different countries and also depends on the cause (e.g., alcohol, gallstones, metabolic factors, drugs). In the United States, acute pancreatitis is related to alcohol consumption more commonly than gallstones (second most common); in England, the opposite is true. (Black, 2009)

Mechanisms causing pancreatitis are usually unknown but it is commonly associated with autodigestion of the pancreas.

• Alcohol abuse. Eighty percent of the patients with pancreatitis have biliary tract disease or a history of long-term alcohol abuse.
• Bacterial or viral infection . Pancreatitis occasionally develops as a complication of mumps virus .
• Duodenitis. Spasm and edema of the ampulla of Vater can probably cause pancreatitis.
• Medications. The use of corticosteroids, thiazide diuretics , oral contraceptives , and other medications have been associated with increased incidences of pancreatitis.

The signs and symptoms of pancreatitis include:

• Severe abdominal pain. Abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care and this results from irritation and edema of the inflamed pancreas.
• Boardlike abdomen. A rigid or boardlike abdomen may develop and cause abdominal guarding.
• Ecchymosis. Ecchymosis or bruising in the flank or around the umbilicus may indicate severe pancreatitis.
• Nausea and vomiting . Both are also common in pancreatitis and the emesis is usually gastric in origin but may also be bile stained.
• Hypotension . Hypotension is typical and reflects hypovolemia and shock caused by the large amounts of protein-rich fluid into the tissues and peritoneal cavity.

Complications that arise in pancreatitis include the following:

• Fluid and electrolyte disturbances. These are common complications because of nausea, vomiting , movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever , and use of gastric suction.
• Pancreatic necrosis. This is a major cause of morbidity and mortality in patients with pancreatitis because of resulting hemorrhage, septic shock, and multiple organ failure.
• Septic shock. Septic shock may occur with bacterial infection of the pancreas.

The diagnosis of pancreatitis is based on a history of abdominal pain, the presence of known risk factors, physical examination findings, and diagnostic findings.

• Serum amylase and lipase levels. These are used in making a diagnosis, although their elevation can be attributed to many causes, and serum lipase remains elevated for a longer period than amylase.
• WBC count. The WBC count is usually elevated.
• X-ray studies. X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that can cause similar symptoms.
• Ultrasound. Ultrasound is used to identify an increase in the diameter of the pancreas.
• Blood studies. Hemoglobin and hematocrit levels are used to monitor the patient for bleeding .
• CT scan :  Shows an enlarged pancreas, pancreatic cysts and determines the extent of edema and necrosis.
• Ultrasound of abdomen: May be used to identifying pancreatic inflammation, abscess, pseudocysts, carcinoma, or obstruction of biliary tract
• Endoscopic retrograde cholangiopancreatography:  Useful to diagnose fistulas, obstructive biliary disease, and pancreatic duct strictures/anomalies (the procedure is contraindicated in an acute phase).
• CT–guided needle aspiration : Done to determine whether the infection is present.
• Abdominal x-rays: May demonstrate dilated loop of small bowel adjacent to the pancreas or another intra-abdominal precipitator of pancreatitis, presence of free intraperitoneal air caused by perforation or abscess formation, pancreatic calcification.
• Upper GI series:  Frequently exhibits evidence of pancreatic enlargement/inflammation.
• Serum amylase:  Increased because of obstruction of normal outflow of pancreatic enzymes (normal level does not rule out disease). May be five or more times normal level in acute pancreatitis.
• Serum lipase:  usually elevates along with amylase, but stays elevated longer.
• Serum bilirubin :  Elevation is common (may be caused by alcoholic liver disease or compression of common bile duct).
• Alkaline phosphatase:  Usually elevated if pancreatitis is accompanied by biliary disease.
• Serum albumin and protein:  May be decreased (increased capillary permeability and transudation of fluid into extracellular space).
• Serum calcium:  Hypocalcemia may appear 2–3 days after onset of illness (usually indicates fat necrosis and may accompany pancreatic necrosis).
• Potassium :  Hypokalemia may occur because of gastric losses; hyperkalemia may develop secondary to tissue necrosis, acidosis, renal insufficiency.
• Triglycerides :  Levels may exceed 1700 mg/dL and may be a causative agent in acute pancreatitis.
• LDH/AST:  May be elevated up to 15 times normal because of biliary and liver involvement.
• CBC:  WBC count of 10,000–25,000 is present in 80% of patients. Hb may be lowered because of bleeding. Hct is usually elevated (hemoconcentration associated with vomiting or from effusion of fluid into pancreas or retroperitoneal area).
• Serum glucose :  Transient elevations of more than 200 mg/dL are common, especially during initial/acute attacks. Sustained hyperglycemia reflects widespread cell damage and pancreatic necrosis and is a poor prognostic sign.
• Partial thromboplastin time (PTT):  Prolonged if coagulopathy develops because of liver involvement and fat necrosis.
• Urinalysis:  Glucose, myoglobin, blood, and protein may be present.
• Urine amylase:  Can increase dramatically within 2–3 days after onset of attack.
• Stool :  Increased fat content (steatorrhea) indicative of insufficient digestion of fats and protein.

Management of pancreatitis is directed towards relieving symptoms and preventing or treating complications.

• Pain management. Adequate administration of analgesia ( morphine , fentanyl , or hydromorphone ) is essential during the course of pancreatitis to provide sufficient relief and to minimize restlessness, which may stimulate pancreatic secretion further.
• Intensive care. Correction of fluid and blood loss and low albumin levels is necessary to maintain fluid volume and prevent renal failure .
• Respiratory care. Aggressive respiratory care is indicated because of the high-risk elevation of the diaphragm , pulmonary infiltrates and effusion, and atelectasis .
• Biliary drainage. Placement of biliary drains (for external drainage) and stents (indwelling tubes) in the pancreatic duct through endoscopy has been performed to reestablish drainage of the pancreas.

There are several approaches available for surgery . The major surgical procedures are the following:

• Side-to-side pancreaticojejunostomy (ductal drainage). Indicated when dilation of pancreatic ducts is associated with septa and calculi. This is the most successful procedure with success rates ranging from 60% to 90%.
• Caudal pancreaticojejunostomy (ductal drainage). Indicated for uncommon causes of proximal pancreatic ductal stenosis not involving the ampulla.
• Pancreaticoduodenal (right-sided) resection (ablative) (with preservation of the pylorus) (Whipple procedure). Indicated when major changes are confined to the head of the pancreas. Preservation of the pylorus avoids usual sequelae of gastric resection.
• Pancreatic surgery. A 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 to 3 days to remove necrotic debris.

Nursing Management

The patient who is admitted to the hospital with a diagnosis of pancreatitis is acutely ill and needs expert nursing care.

Nursing assessment of a patient with pancreatitis involves:

• Assessment of current nutritional status and increased metabolic requirements.
• Assessment of respiratory status.
• Assessment of fluid and electrolyte status.
• Assessment of sources of fluid and electrolyte loss.
• Assessment of abdomen for ascites.

Based on the assessment data, the nursing diagnoses for a patient with pancreatitis include:

• Acute pain related to edema, distention of the pancreas, and peritoneal irritation.
• Imbalanced nutrition : less than body requirements related to inadequate dietary intake, impaired pancreatic secretions, and increased nutritional needs.
• Ineffective breathing pattern related to splinting from severe pain, pulmonary infiltrates, pleural effusion, and atelectasis.

Main article: 8+ Pancreatitis Nursing Care Plans

Planning and goals developed for a patient with pancreatitis involve:

• Relief of pain and discomfort.
• Improvement in nutritional status.
• Improvement in respiratory function.
• Improvement in fluid and electrolyte status.

Performing nursing interventions for a patient with pancreatitis needs expertise and efficiency.

• Relieve pain and discomfort. The current recommendation for pain management in this population is parenteral opioids including morphine, hydromorphone, or fentanyl via patient-controlled analgesia or bolus.
• Improve breathing pattern . The nurse maintains the patient in a semi-Fowler’s position and encourages frequent position changes.
• Improve nutritional status. The patient receives a diet high in carbohydrates and low in fats and proteins between acute attacks.
• Maintain skin integrity . The nurse carries out wound care as prescribed and takes precautions to protect intact skin from contact with drainage.

Evaluation of a successful plan of care for a patient with pancreatitis should include:

• Relieved pain and discomfort.
• Improved nutritional status.
• Improved respiratory function.
• Improved fluid and electrolyte status.

A prolonged period is needed to regain the strength of a patient who has experienced pancreatitis and to return to the previous level of activity.

• Teaching. Teaching needs to be repeated and reinforced because the patient may have difficulty in recalling many of the explanations and instructions are given.
• Prevention. The nurse instructs the patient about the factors implicated in the onset of pancreatitis and about the need to avoid high-fat foods, heavy meals, and alcohol.
• Identification of complications. The nurse should give verbal and written instructions about the signs and symptoms of pancreatitis and possible complications that should be reported promptly to the physician.
• Home care. The nurse would be able to assess the patient’s physical and psychological status and adherence to the therapeutic regimen .

Nursing documentation of the case of a patient with acute pancreatitis involves the following:

• Client’s description of response to pain and acceptable level of pain.
• Prior medication use.
• Caloric intake.
• Individual cultural or religious restrictions and personal preferences.
• Respiratory pattern, breath sounds, and use of accessory muscles.
• Laboratory values.
• Use of respiratory aids or supports.
• Plan of care.
• Teaching plan.
• Response to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes.
• Modifications to plan of care.
• Long-term needs.

Here’s a 5-item practice quiz for this Pancreatitis Study Guide. Please visit our nursing test bank for more NCLEX practice questions .

1. Pancreatitis is commonly characterized by:

A. Edema and inflammation. B. Pleural effusion. C. Sepsis . D. Disseminated intravascular coagulopathy.

2. A major symptom of pancreatitis that brings the patient to medical care is:

A. Severe abdominal pain. B. Fever. C. Jaundice. D. Mental agitation.

3. The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

A. Serum calcium. B. Serum lipase. C. Serum bilirubin. D. Serum amylase.

4. Nursing measures for pain relief for pancreatitis include:

A. Encouraging bed rest to decrease metabolic rate. B. Teaching the patient about the correlation between alcohol intake and pain. C. Withholding oral feedings to limit the release of secretin. D. All of the above.

5. Which of the following diagnostic studies could identify an increase in the diameter of the pancreas?

A. X-ray. B. Hemoglobin and hematocrit levels. C. Ultrasound. D. Serum amylase.

Answers and Rationale

1. Answer: A. Edema and inflammation.

• A: Pancreatitis is most often characterized by edema and inflammation of the pancreas.
• B: Pleural effusion occurs in some patient with pancreatitis yet not too often.
• C: Sepsis is one of the complications of pancreatitis.
• D: DIC may occur in patients with pancreatitis yet is uncommon.

2. Answer: A. Severe abdominal pain.

• A: Abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care and this result from irritation and edema of the inflamed pancreas.
• B: Fever is one of the symptoms of pancreatitis.
• C: Jaundice is one of the symptoms of pancreatitis.
• D: Mental agitation is one of the symptoms of pancreatitis.

3. Answer: B. Serum lipase.

• B: Serum lipase is elevated within 24 hours of the onset of the symptoms and remains elevated for a longer period than serum amylase.
• A: Serum calcium may be taken to detect hypocalcemia .
• C: Serum bilirubin may also be taken to detect elevation in bilirubin levels.
• D: Serum amylase is not as prolonged as serum lipase.

4. Answer: D. All of the above.

• D: All of the interventions mentioned are appropriate for a patient with pancreatitis.
• A: The patient is maintained on bed rest to decrease metabolic rate and reduce the secretion of pancreatic and gastric enzymes.
• B: Alcohol is one of the causes of pain in pancreatitis.
• C: Oral feedings are withheld to decrease the secretion of secretin.

5. Answer: C. Ultrasound.

• C: Ultrasound is used to identify an increase in the diameter of the pancreas.
• A: X-ray may be taken yet it does not identify an increase in the diameter of the pancreas.
• B: Hemoglobin and hematocrit levels may be taken yet it does not identify an increase in the diameter of the pancreas.
• D: Serum amylase may be taken yet it does not identify an increase in the diameter of the pancreas.

Posts related to Pancreatitis:

• 8+ Pancreatitis Nursing Care Plans

3 thoughts on “Pancreatitis”

actually, Serum amylase is the first thing that is elevated within 24 hours of the onset of the symptoms. At least that’s what our book states. Medical-Surgical Nursing, Assessment and management of clinical problems, Lewis

My professor said lipase is more sensitive to pancreas and is better indicator.

Yeah that’s how mine too is indicated

Leave a Comment Cancel reply

Pancreatitis Review for NCLEX Prep and Nursing School | Nursing Case Study

What are you struggling with in nursing school?

NURSING.com is the BEST place to learn nursing. With over 2,000+ clear, concise, and visual lessons, there is something for you!

Learning about Pancreatitis

Pancreatitis is a serious and potentially life-threatening condition that nursing students must be well-versed in to provide effective care. It involves inflammation of the pancreas, a vital organ responsible for producing digestive enzymes and hormones like insulin.

Acute pancreatitis can be caused by factors such as gallstones or excessive alcohol consumption, while chronic pancreatitis is often linked to long-term alcohol abuse. Understanding the risk factors, nursing assessment, and management associated with pancreatitis is crucial for early recognition and timely intervention. 

Pancreatitis, characterized by the inflammation of the pancreas, presents a painful and potentially serious health concern. Often stemming from gallstones or heavy alcohol use, the pancreas becomes inflamed, impacting its ability to produce enzymes crucial for digestion and insulin regulation. Individuals with pancreatitis experience intense abdominal pain, nausea, vomiting, and fever.

While mild cases may resolve with rest and dietary adjustments, severe cases can lead to complications like infection, tissue damage, and even organ failure. Early diagnosis and medical intervention are vital in managing pancreatitis and preventing its escalation. Addressing underlying causes, adopting a healthier lifestyle, and adhering to medical guidance can contribute to the management and well-being of those affected.

Pancreatitis Overview

1. Inflammation of the pancreas 2. Autodigestion of the pancreas results from long-term damage

General Information on Pancreatitis

1. Causes            a. Alcohol abuse, gallbladder disease, obstruction of the ducts, hyperlipidemia, peptic ulcer disease (PUD) 2. Types           a. Acute – occurs suddenly with most clients recovering fully           b. Chronic – usually due to long-standing alcohol abuse with loss of pancreatic function

Nursing Assessment for Pancreatitis 

Therapeutic management for pancreatitis.

1. Suppress Pancreatic secretions through NPO diet and NG tube insertion to decompress the stomach 2. IV hydration 3. TPN for prolonged exacerbations to provide adequate nutrition 4. Endoscopic Retrograde Cholangiopancreatography (ERCP) to remove gallstones→ Camera inserted to visualize common bile duct 5. Surgery            a. Whipple – remove a portion of pancreas (for mass or tumor)            b. Pancreatectomy – remove the pancreas, which will require Insulin, glucagon, and pancreatic enzyme supplementation           c. Cholecystectomy – if the source is gallbladder disease 6. Medications for pain and to control symptoms→ Analgesics, H2 blockers, proton pump inhibitors, insulin, and anticholinergics

Nursing Case Study for Pancreatitis

Patient profile:.

• Severe, persistent upper abdominal pain radiating to the back 
• Nausea and vomiting 
• Elevated heart rate and low blood pressure
• Physical Examination: Mr. Goldman displayed tenderness and guarding in the upper abdomen 
• Laboratory Tests: Elevated serum amylase and lipase levels, indicative of pancreatic enzyme release 
• Abdominal CT scan: Confirmed inflammation of the pancreas, confirming acute pancreatitis

Medical History: Mr. Goldman had a history of chronic alcohol use and a recent diagnosis of gallstones  Diagnosis:  Mr. Goldman was diagnosed with acute pancreatitis, an inflammatory condition of the pancreas   Treatment Plan: 

1. NPO Status and Bowel Rest: Mr. Goldman was kept NPO (nothing by mouth) to reduce pancreatic stimulation and rest the digestive system. 2. Pain Management: Administered analgesics and positioned Mr. Goldman comfortably to alleviate abdominal pain. 3. Intravenous Fluids: Provided aggressive fluid resuscitation to maintain hydration and support blood pressure  4. Nutritional support: Collaborated with a dietician to introduce enteral nutrition gradually once the inflammation subsided  5. Alcohol Cessation Support: Offered counseling and support to address Mr. Goldman’s alcohol use and promote lifestyle changes.

With diligent nursing care and medical management, Mr. Goldman’s pancreatitis improved. His abdominal pain decreased, and his vital signs stabilized. Gradually, he tolerated a liquid diet and showed signs of clinical improvement.

Conclusion and Free Download

This Pancreatitis review provides essential knowledge for approaching the NCLEX with confidence. Understanding its prevention, management, and interventions empowers nurses to provide effective care and save lives.

Looking for more must-know NCLEX review topics? Download our free eBook, "NCLEX Flash Notes: 77 Must-Know Nursing Topics for the NCLEX," by simply providing your email address below. I'll send you a complimentary copy straight to your inbox!

You CAN Do This

Happy Nursing!

Hepatitis Overview for Nursing School and the NCLEX Exam

What you need to know about appendicitis for the nclex + free download, similar blog posts.

Cholecystitis NCLEX Review for Nursing Students + Free Download

The Struggles of Ulcerative Colitis for Nursing Students + free download

Peptic Ulcer Disease NCLEX Review for Nursing Students + Free Download

Apply       Visit       Give       |      Alumni       Parents       Offices       TCNJ Today       Three Bar Menu

Pancreatitis Unfolding Case

Author: Gerry Altmiller, EdD, APRN, ACNS-BC, ANEF, FAAN

Title: Associate Professor

Institution: The College of New Jersey

Email: [email protected]

Competency Category(s) Safety

Learner Level(s) Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s) Clinical Setting

Strategy Type Case Studies

Learning Objectives

This case study is designed to develop student knowledge of the (1) human factors and other basic safety design principles as well as commonly used unsafe practices and to develop knowledge of (2) potential and actual impact of national patient safety resources, initiatives and regulations. It is designed to increase skill regarding (1) strategies to reduce risk of harm to self or others, (2)reduce reliance on memory, and (3) to focus attention on safety in care settings. This case study focues on attitudes that (1) value the contribution of standardization/reliability to safety, (2) value their own role in preventing errors, and (3) value the relationship between national safety campaigns and implementation in local practices and practice settings.

Strategy Overview

This strategy is an unfolding case study of a patient with pancreatitis admitted as an in-patient. It provides an opportunity for students to learn about caring for a patient with pancreatitis while utilizing national safety standards for the patient’s care.

Evaluation Description

TCNJ Today || Parents || Alumni

Campus Life

A-Z | Directory | Map | Offices

Facebook     Twitter     LinkedIn     Instagram     YouTube

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Diagnosis & Evidence-Based Management

Diagnosis of pancreatitis can be made based on clinical findings on a physical exam; identification of associated disorders, like gallstones or alcohol use; laboratory findings; and imaging techniques, such as CT scan, MRI, and ultrasonography (McCance & Huether, 2014).

Acute Pancreatitis

Acute pancreatitis is difficult to diagnose due to several other disorders presenting with similar laboratory and clinical symptoms. The primary diagnostic marker for acute pancreatitis is serum lipase. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and decrease within 8 to 14 days. Serum amylase levels are elevated as well, but are not an indicator of severity or specificity of the disease. Serum trypsin levels are very specific in indicating pancreatitis, but the test is not widely available. Severity can be predicted and measured by C-reactive protein, procalcitonin, blood urea nitrogen (BUN), and Bedside Index of Severity in Acute Pancreatitis (McCance & Huether, 2014). Table 3 below shows the criteria for BISAP.

Although there is no specific treatment for pancreatitis, the goal is to stop autodigestion and prevent further systemic complications. In the first 24 hours, it is important to have hemodynamic monitoring and parenteral fluids to restore blood volume and prevent hypotension and shock. Narcotics may be used to relieve pain. Meperidine hydrochloride (Demerol) is used instead in cases of chronic alcohol use affecting the sphincter of Oddi, which controls flow of bile from the common bile duct to the duodenum and prevents reflux of duodenal contents. Demerol is used because it causes less spasm of the sphincter. Nasogastric suctioning may not be needed for mild pancreatitis, but may help relieve pain and prevent paralytic ileus (loss of parastaltic motor activity in the intestine) in nauseated and/or vomiting individuals (McCance & Huether, 2014).

Enteral nutrition via a jejunal tube feeding may be helpful in cases of severe acute pancreatitis. Jejunal tube feedings may decrease pancreatic enzyme secretion, prevent gut bacterial overgrowth, and maintain gut barrier function. Drugs, like H2 receptor antagonists, that decrease gastric acid production can decrease stimulation of the pancreas by secretin (regulates secretions in the stomach, live, and pancreas). Necrotizing pancreatitis requires surgical resection, and possibly antibiotics to control infection (McCance & Huether, 2014).

Chronic Pancreatitis

Chronic pancreatitis is due to repeated exacerbations of acute pancreatitis leading to chronic changes. Treatment includes preventing disease progression though lifestyle modifications to stop smoking and alcohol use. Analgesics, endoscopic therapy, nerve block, and surgical drainage of cysts or partial resection of the pancreas can be used for pain management. Corticosteroids can be used to treat autoimmune chronic pancreatitis (McCance & Huether, 2014).

This website is intended for healthcare professionals

• { $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Alpi KM, Evans JJ. Distinguishing case study as a research method from case reports as a publication type. J Med Libr Assoc. 2019; 107:(1)1-5 https://doi.org/10.5195/JMLA.2019.615

Diagnostic and statistical manual of mental disorders IV.Washington (DC): American Psychiatric Association; 1994

Arif-Rahu M, Grap MJ. Facial expression and pain in the critically ill non-communicative patient: state of science review. Intensive Crit Care Nurs. 2010; 26:(6)343-352 https://doi.org/10.1016/j.iccn.2010.08.007

British Pain Society. Outcome measures. 2019. https://tinyurl.com/yfyzwevy (accessed 21 February 2022)

Dougherty L, Lister S, West-Oram A. The Royal Marsden manual of clinical nursing procedures, 9th edn. Student edn. Chichester: John Wiley and Sons; 2015

Hicks AM, Chou J, Capanu M, Lowery MA, Yu KH, O'Reilly EM. Pancreas adenocarcinoma: ascites, clinical manifestations, and management implications. Clin Colorectal Cancer. 2016; 15:(4)360-368 https://doi.org/10.1016/j.clcc.2016.04.014

Ilic M, Ilic I. Epidemiology of pancreatic cancer. World J Gastroenterol. 2016; 22:(44)9694-9705 https://doi.org/10.3748/wjg.v22.i44.9694

Joint Formulary Committee. British National Formulary. 2022a. https://bnf.nice.org.uk/drug/pancreatin.html (accessed 21 February 2022)

Joint Formulary Committee. British National Formulary. 2022b. https://bnf.nice.org.uk/drug/morphine.html (accessed 21 February 2022)

Jungquist CR, Smith K, Nicely KL, Polomano RC. Monitoring hospitalized adult patients for opioid-induced sedation and respiratory depression. Am J Nurs. 2017; 117:(3)S27-S35 https://doi.org/10.1097/01.NAJ.0000513528.79557.33

Karcioglu O, Topacoglu H, Dikme O, Dikme O. A systematic review of the pain scales in adults: which to use?. Am J Emerg Med. 2018; 36:(4)707-714 https://doi.org/10.1016/j.ajem.2018.01.008

Kenner BJ. Early detection of pancreatic cancer. Pancreas. 2018; 47:(4)363-367 https://doi.org/10.1097/MPA.0000000000001024

Kornhaber R, Walsh K, Duff J, Walker K. Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review. J Multidiscip Healthc. 2016; 9:537-546 https://doi.org/10.2147/JMDH.S116957

Lee J, Lakha SF, Mailis A. Efficacy of low-dose oral liquid morphine for elderly patients with chronic non-cancer pain: retrospective chart review. Drugs Real World Outcomes. 2015; 2:(4)369-376 https://doi.org/10.1007/s40801-015-0048-z

Mayr M, Schmid RM. Pancreatic cancer and depression: myth and truth. BMC Cancer. 2010; 10 https://doi.org/10.1186/1471-2407-10-569

Morasco B, Lovejoy T, Hyde S, Shull S, Dobscha S. Limitations of pain numeric rating scale scores collected during usual care: need for enhanced assessment. Journal of Pain. 2018; 19:(3)S57-S58 https://doi.org/10.1016/j.jpain.2017.12.145

Morphine. 2022. https://www.ncbi.nlm.nih.gov/books/NBK526115/

National Institute for Health and Care Excellence. Depression in adults: recognition and management. Clinical guideline CG90. 2009. https://www.nice.org.uk/guidance/cg90/chapter/Appendix-Assessing-depression-and-its-severity (accessed 21 February 2022)

National Institute for Health and Care Excellence. PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites. 2018. https://www.nice.org.uk/guidance/mtg9/chapter/3-Clinical-evidence (accessed 21 February 2022)

Nursing and Midwifery Council. The code. 2018. https://www.nmc.org.uk/standards/code/read-the-code-online (accessed 21 February 2022)

Pancreatic Cancer UK. Pancreatic cancer statistics. 2022. https://tinyurl.com/2p8pfdns (accessed 3 March 2022)

Porter LS, Fish L, Steinhauser K. Themes addressed by couples with advanced cancer during a communication skills training intervention. J Pain Symptom Manage. 2018; 56:(2)252-258 https://doi.org/10.1016/j.jpainsymman.2018.04.004

Rawla P, Sunkara T, Gaduputi V. Epidemiology of pancreatic cancer: global trends, etiology and risk factors. World J Oncol. 2019; 10:(1)10-27 https://doi.org/10.14740/wjon1166

Riva P, Wirth JH, Williams KD. The consequences of pain: the social and physical pain overlap on psychological responses. Eur J Soc Psychol. 2011; 41:(6)681-687 https://doi.org/10.1002/ejsp.837

Rooij T de, Klompmaker S, Hilal MA, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol. 2016; 13:(4)227-238 https://doi.org/10.1038/nrgastro.2016.17

Rudralingam V, Footitt C, Layton B. Ascites matters. Ultrasound. 2017; 25:(2)69-79 https://doi.org/10.1177/1742271X16680653

Pain management: part 1. 2014. https://www.bjfm.co.uk/pain-managment-part-1 (accessed 21 February 2022)

Sessler CN, Grap MJ, Ramsay MAE. Evaluating and monitoring analgesia and sedation in the intensive care unit. Crit Care. 2008; 12 https://doi.org/10.1186/cc6148

Stevenson C, Grieves M, Stein-Parbury J. Symbolic interactionism as a theoretical tool for understanding interpersonal relationships in nursing. In: Stevenson C, Grieves M, Stein-Parbury J (eds). Philadelphia (PA): Elsevier Churchill Livingstone; 2004

Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of the brief pain inventory for chronic nonmalignant pain. J Pain. 2004; 5:(2)133-137 https://doi.org/10.1016/j.jpain.2003.12.005

Triantafillou S, Saeb S, Lattie EG, Mohr DC, Kording KP. Relationship between sleep quality and mood: ecological momentary assessment study. JMIR Ment Health. 2019; 6:(3) https://doi.org/10.2196/12613

Depression definition and DSM-5 diagnostic criteria. 2020. https://www.psycom.net/depression-definition-dsm-5-diagnostic-criteria/ (accessed 21 February 2022)

Underhill M, Hong F, Lawrence J, Blonquist T, Syngal S. Relationship between individual and family characteristics and psychosocial factors in persons with familial pancreatic cancer. Psychooncology. 2018; 27:(7)1711-1718 https://doi.org/10.1002/pon.4712

Vijayvergia N, Denlinger C. Lifestyle factors in cancer survivorship: where we are and where we are headed. J Pers Med. 2015; 5:(3)243-263 https://doi.org/10.3390/jpm5030243

Widmaier E, Raff H, Strang K. Vander's human physiology, 15th edn. New York: McGraw-Hill Education; 2018

Geriatric depression: the use of antidepressants in the elderly. 2011. https://www.bcmj.org/articles/geriatric-depression-use-antidepressants-elderly (accessed 21 February 2022)

World Medical Association. WMA declaration of Helsinki. Ethical principles for medical research involving human subjects. 2008. https://tinyurl.com/2p99x377 (accessed 21 February 2022)

Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013; 144:(6)1252-1261 https://doi.org/org/10.1053/j.gastro.2013.01.068

Assessment and management of a person experiencing pain from pancreatic cancer ascites: a case study

Siouxsie Otterwell

Second-year Student Nurse, Florence Nightingale School of Nursing and Midwifery, King's College London

View articles · Email Siouxsie

Mark J Baker

Lecturer, Florence Nightingale School of Nursing and Midwifery, King's College London

View articles

The most common type of pancreatic cancer is pancreatic adenocarcinoma, which affects the exocrine ducts. There are many risk factors associated with pancreatic cancer, including smoking, obesity, poor diet, diabetes, inactivity and genetics. In the UK, pancreatic cancer is the 10th most common cancer with a poor prognosis, with only 24% of people surviving the first year after diagnosis and 7% surviving for 5 years. The lives of those with the condition are impacted in a number of ways. This case study of a patient with pancreatic cancer explores the nursing assessment, management and evaluation of care provided from a student nurse perspective under the supervision of a qualified nurse.

This case study examines the care of a person with pancreatic cancer who was admitted to a private surgical ward for insertion of an ascitic drain. The article presents a student nurse's perspective of the nursing assessment, management and evaluation of the care provided to the patient. The student was supervised by a qualified nurse. A holistic patient-centred approach was adopted for the provision of patient care, incorporating a physical and psychological nursing assessment, management and evaluation. The decisions made by the student nurse, under the supervision of the qualified nurse, were based on evidence from the patient assessment, nursing literature, clinical guidance and hospital policies to support the care provided. The case study illustrates the care of a single patient and therefore the conclusions cannot be generalised ( Alpi and Evans, 2019 ).

Overview of pancreatic cancer

The pancreas is located behind the stomach and has exocrine and endocrine glands with several functions, including breaking down carbohydrates, acids, fats and proteins and hormonal secretion of insulin, glucagon and somatostatin for the regulation of blood glucose ( Widmaier et al, 2018 ). The most common type of pancreatic cancer is pancreatic adenocarcinoma, which affects 9 out of 10 patients, with the primary cancer starting in the exocrine ducts of the pancreas ( Underhill et al, 2018 ).

The cause of pancreatic cancer is still not fully understood; however, according to Hicks et al (2016) there are several risk factors based on lifestyle choices, such as smoking, obesity, poor diet, diabetes and inactivity. There may also be a genetic element. There are no current screening methods for this disease, only prevention by reduction of lifestyle risk factors ( Ilic and Ilic, 2016 ). Yadav and Lowenfels (2013) suggested that increased risks for developing pancreatic cancer include individuals who have had chronic pancreatitis, or a family history of chronic pancreatitis.

In 2018, there were 10 449 people living with pancreatic cancer in the UK, according to Pancreatic Cancer UK (2022) , making it the 10th most common cancer. It is estimated that, in England, only 25.9% of people survive the first year after diagnosis and 7% survive 5 years ( Pancreatic Cancer UK, 2022 ). Globally, in 2018, there were 458 918 newly diagnosed cases of pancreatic cancer and case numbers are expected to rise ( Rawla et al, 2019 ).

Living with pancreatic cancer impacts on all aspects of an individual's life: physically, psychologically, emotionally, socially and financially. There are few signs and symptoms of pancreatic cancer but it can be asymptomatic, meaning it is often not diagnosed until the cancer is advanced, which leads to a poor prognosis despite treatment ( Underhill et al, 2018 ). When diagnosed with any type of cancer, many patients tend to feel isolated as they do not want their family and friends to worry about them, and they face challenges related to communication with adult children, friends and coworkers about illness-related issues, and maintaining normality in these relationships ( Porter et al, 2018 ).

In addition to the first author's personal experience as a student nurse on clinical placement engaging in patient care, under the direction and supervision of a nurse, a range of other data informed the case study, such as a patient interview, examination of the patient's medical records, and engagement with relevant literature ( Figure 1 ).

Voluntary verbal consent was given by the patient in this case study. Written consent was not possible due to the patient's condition at the time. The student nurse obtained permission from the supervising qualified nurse and verbal consent was witnessed. Voluntary informed consent was guided by the World Declaration of Helsinki ( World Medical Association, 2008 ) and the hospital's ethics process. For the purpose of the case study the pseudonym ‘Peter’ was selected in consultation with the patient and the supervising nurse. In keeping with Nursing and Midwifery Council's (2018) Code requirements, all identifiable data about Peter have been altered to protect his confidentiality and anonymity.

Patient overview

Peter is a divorced, white male living in north London, who has sustained a friendship with his ex-wife and two adult children. He claimed he was ‘supported at home’ by his friends and children. He was an accountant in his own family business, working with one of his children. At the time of illness he had taken a step back from working while his son took over the business, which ‘took the pressure off’.

Peter had been diagnosed with type 1 diabetes, at the age of 57 years. Six months later he was diagnosed with pancreatic cancer. Peter said he felt overwhelmed, and lacked understanding of the two conditions and how they interrelated and impacted on each another. Prior to this admission, Peter had been admitted to hospital for a Whipple procedure—the resection of the pancreatic head and surrounding area to include the duodenum, common bile duct and gall bladder ( de Rooij et al, 2016 ). Unfortunately, this procedure was unsuccessful because his cancer was too advanced.

To manage his diabetes, Peter used long-acting insulin glargine, administering 18 units each morning. He said that he ‘never forgets or misses a dose’. Peter also took pancreatin, which is a supplement to compensate for reduced or absent exocrine secretion and assists with the digestion of protein, starch and fat ( Joint Formulary Committee, 2022a ). Peter described difficulty in taking this medication as he took several capsules, depending on the size of his meal. Pancreatin capsules are large and the Joint Formulary Committee (2022a) states that side effects of nausea and loss of appetite are common, which Peter experienced. He described himself as taking a responsible approach to his health and did not drink alcohol or smoke.

Peter's cancer treatment consisted of five cycles of chemotherapy. At the time of admission for insertion of an ascitic drain, he was due to commence the fifth and final cycle. He was hopeful and eager to meet with his oncologist to determine the next steps in treatment. Peter was admitted to the surgical ward for insertion of an ascitic drain because of the build-up of fluid in his abdomen.

Peter was a private patient, which included access to a consultant oncologist and endocrinologist. He was admitted to a private surgical ward for management of ascites because his consultant had made the decision to insert an ascitic drain, with the procedure scheduled for the day after admission. The student nurse met Peter on the ward before he went to theatre for surgery and provided post-surgery care on his return to the ward. This case study explores nursing assessment, management and evaluation, including physical and psychological perspectives, of Peter from a student nurse perspective.

Nursing assessment

In the advanced stages of pancreatic cancer, ascites—the accumulation of fluid in the abdomen—can be common ( Hicks et al, 2016 ). There are several ways of treating this, such as insertion of an ascitic catheter drain, shunt or, in minor distention, diuretic medications ( Rudralingam et al, 2017 ). All these treatments can have the common complication risk of infection ( Hicks et al, 2016 ). Peter's ascitic drain was inserted in theatre early in the morning and when he returned to the ward the drain clamp had not been released as the treating consultant wanted the fluid output to be monitored by the nurse on the ward. The amount of fluid that had accumulated caused pressure on the abdomen, resulting in Peter experiencing acute pain, which was the focus of the nursing assessment.

Verbal or numerical pain rating tools are most appropriate for assessing acute pain, according to Dougherty et al (2015) . Karcioglu et al (2018) described a numerical rating scale (NRS) used in acute settings and this tool was used in the clinical area where Peter was an inpatient. The NRS involves the patient verbally rating their pain along a scale of 0 to 10 ( Table 1 ) ( Karcioglu et al, 2018 ). When the student nurse administered the NRS to assess Peter's pain, he rated it as 8 out of 10, which equates to severe pain.

Source: Karcioglu et al, 2018

According to Karcioglu et al (2018) , the NRS is commonly used in hospitals and patients tend to be familiar with this scale due to its straightforward nature, which also minimises the risk of misinterpretation. Although the NRS is commonly used by nurses assessing patients experiencing acute pain, there are limitations. It does not indicate the location, type, or history of pain to guide the nurse conducting a comprehensive assessment; to supplement NRS data, the nurse is required to ask the patient further questions ( Morasco et al, 2018 ).

The Brief Pain Inventory could have been used to assess Peter's post-procedure pain ( British Pain Society, 2019 ); nevertheless, this tool is reported to be more commonly used for patients experiencing chronic pain ( Tan et al, 2004 ). For those experiencing pain related to their cancer condition, Schofield et al (2014) recommended the use of the Leeds Assessment of Neuropathic Symptoms and Signs. However, this assessment was not used because Peter's pain had resulted from the surgical intervention not his pancreatic cancer. Alternative visual assessments of patients' pain are the Wong-Baker Faces Scale and the Facial Expression Pain Scale ( Arif-Rahu and Grap, 2010 ); both of which are typically used by nurses when a patient is unable to communicate or is unconscious. As Peter was able to communicate, these assessments were not considered appropriate and the NRS was deemed the most effective way of assessing his acute pain.

As well as assessing the physical aspect of Peter's pain, the student nurse also considered the psychosocial aspect of his pain as part of a conducting patient-centred holistic assessment ( Riva et al, 2011 ). When a patient experiences pain, Dougherty et al (2015) indicated that the psychosocial aspect of care should be assessed, such as the patient's mood, wellbeing, and relationships. By using questions to gently probe the patient's feelings, the nurse can gain an understanding about the mindset of the patient. Peter told the student nurse he felt he had a ‘low mood’ due to his long-term condition and he believed his mood state was exacerbated by the acute pain he was experiencing. Although a mental health diagnosis was not recorded in the medical history, the student nurse asked further questions to gather more information about Peter's reported low mood. It was uncertain how long Peter had lived with a low mood, he could not outline a time frame, he just described feeling persistently low in mood in recent days.

The student nurse used the Baseline Assessment Tool for Depression in Adults ( National Institute for Health and Care Excellence (NICE), 2009 ) to conduct a psychosocial assessment. The student nurse explored with Peter his interests, motivation, appetite, ideas of self-worth, insomnia and energy levels. By gathering information about Peter's stated low mood, while providing physical care, the student nurse was able to update the supervising qualified nurse and treating medical officer for a more informed assessment. The Baseline Assessment Tool for Depression in Adults ( NICE, 2009 ) is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) ( American Psychiatric Association, 1994 ), but the assessment criteria are different; the DSM-IV for use by a doctor, whereas the Baseline Assessment Tool for Depression can be used by any health professional ( NICE, 2009 ). According to Truschel (2019), the Baseline Assessment Tool for Depression in Adults ( NICE, 2009 ) is recommended for use across the UK to ensure that health professionals take a standardised approach.

After gathering further data about Peter's self-reported low mood, the student nurse handed over to the supervising nurse and treating medical officer, and Peter was medically assessed. This assessment indicated that Peter was not suffering from depression based on criteria that his symptoms had not persisted for longer than 2 weeks ( NICE, 2009 ). However, Peter was medically assessed as experiencing low mood. The medical and nursing assessment data informed the nursing management of Peter's care needs.

Nursing management

The pain Peter was experiencing was due to the pressure from the fluid build-up in his abdomen. This was managed pharmacologically and non-pharmacologically. The student nurse observed the administration of a prescribed controlled medication for pain relief by the supervising nurse.

The Joint Formulary Committee (2022b) states that adults with acute pain can be prescribed 10 ml of morphine every 4 hours delivered orally or by subcutaneous or intramuscular injection and this can be adjusted according to the patient's response. The medical officer prescribed 5-10 ml of morphine to be delivered orally every 4 hours. The supervising nurse planned to administer 5 ml of morphine as an initial dose, as prescribed and in keeping with recommended dosage for patients in acute pain ( Joint Formulary Committee, 2022b ). Peter was reluctant to take the full dose because he was concerned about being sick or too drowsy when his sons came to visit that evening. The student nurse explained that, should he feel nauseated, the medical team could prescribe an anti-emetic medication and taking the morphine would mean that his pain would be controlled for his sons' visit later in the evening. The management of starting with a low dose and titrating if the pain continues is supported in the literature ( Lee et al, 2015 ).

Peter required observation because of the opiate medication, which can have an adverse effect on respiration, causing respiratory depression, and he was monitored every 30 minutes, in line with good practice ( Jungquist et al, 2017 ). The student nurse was responsible for observing Peter's vital signs: respiration rate, depth of breath and pulse oximetry. Jungquist et al (2017) recommended that vital signs are taken at least once per hour because this is one method of early detection of any further deterioration. Monitoring every 30 minutes provided an opportunity to ensure Peter's pain was being effectively managed.

Non-pharmacological nursing management involved fluid draining to relieve Peter's abdominal pain ( NICE, 2018 ). The student nurse unclamped the drain and completed a fluid balance chart to record that 4000 ml of fluid had drained over the course of 3 hours since surgical insertion.

The student nurse assisted Peter to wash, change into clean clothes and sit out of bed, all of which are recommended strategies to helping improve a patient's feelings of low mood ( Wiese, 2011 ). This type of management aimed to help Peter feel more motivated to renew his interest in activities of daily living and in engaging socially with his family, an approach supported by others ( Kenner, 2018 ). By sitting out of bed, Peter was more active throughout the day, which also aimed to improve his quality of sleep during the night. Insomnia is a known contributing factor to low mood ( Triantafillou et al, 2019 ). Time spent with Peter helping him wash and dress gave the student nurse an opportunity to build a therapeutic nurse-patient relationship, which is considered fundamental in nursing ( Stevenson et al, 2004 ; Kornhaber et al, 2016 ). This nurse-patient relationship enabled the student nurse to engage in an open discussion about how Peter was feeling and explore other possible reasons or triggers for his low mood. Research shows that 76% of patients with pancreatic cancer develop mental health concerns after their diagnosis ( Mayr and Schmid, 2010 ).

Nursing evaluation

Evaluating nursing actions and interactions is a crucial aspect of practice and Peter's care was evaluated by the student nurse, under the supervision of a qualified nurse.

Non-pharmacological evaluation consisted of the ascitic drain being monitored by the student nurse over the shift and 6000 ml was drained over 8 hours and recorded on a fluid balance chart. As the large amount of fluid drained from the peritoneal cavity, the distention of Peter's abdomen decreased ( Rudralingam et al, 2017 ), which resulted in his pain decreasing and improving his ability to mobilise.

The administration of 20 mg of morphine by the supervising qualified nurse over the length of the shift resulted in Peter's acute pain being effectively managed. This was evident by the student nurse repeating the NRS assessment. Peter's pain was initially rated at 8 (severe) and this subsequently reduced to 2 (mild) ( Karcioglu et al, 2018 ). Towards the end of the student's shift Peter described his pain as ‘tolerable’ and indicated that he no longer wanted the morphine administered as he did not want the drowsy side effects. Instead, he preferred to continue with his analgesia of paracetamol as prescribed for pain, 1 g every 4-6 hours orally, which he had been taking prior to admission. For some patients, stopping the morphine could be problematic because, morphine, like many other analgesics, is most effective when taken at prescribed regular intervals. If this is stopped the patient is at risk of their pain returning and needing to recommence the process of pain assessment and management ( Sessler et al, 2008 ). The student nurse explained the mechanism of analgesia to Peter, but he declined the morphine because of its associated drowsiness and nausea, which are common side effects of morphine and other opioids ( Murphy et al, 2022 ).

Peter's motivation to eat and drink, mobilise and engage in conversations in the clinical area were noted to improve as his pain decreased. Good nutrition and mobilising can lead to an increase in energy and motivation, which can have an impact on the mood of people living with cancer ( Vijayvergia and Denlinger, 2015 ).

The student nurse reflected on the care of Peter and concluded that his needs had been met during his stay: his pain and low mood had been acknowledged and recorded, analgesia provided and the cause of the pain treated through draining fluid from his abdomen. He had been given the chance to talk about his feelings and helped to wash, change and mobilise, which improved his mood.

This case study has outlined the fundamental role that a student nurse can have in carrying out the assessment, management and evaluation of a patient for improved health outcomes, such as eliminating pain and improving mood, as demonstrated in the case of Peter. The assessment of acute pain using the NRS was suitable due to the straightforwardness of the tool, and its familiarity, and because it allows immediate understanding of the pain being experienced. There are more advanced methods for pain assessment, but these were not appropriate for use with the patient in this case study. A psychosocial aspect of this patient's case was the patient's low mood, which was associated with his experience of pain and was therefore managed through pain relief and ascites drainage. This allowed the patient to mobilise, wash and eat, all factors that improved his mood.

Receiving surgical treatment for cancer ascites via a drain insertion meant that the patient could be discharged home to wait for his final treatment cycle of chemotherapy for pancreatic cancer.

• Pancreatic adenocarcinoma affects the exocrine ducts
• Surgical intervention for ascites drainage may be required
• A range of post-surgical pharmacological and non-pharmacological nursing interventions can help to improve the lives of those affected
• Person-centred holistic nursing care extends beyond physical care and includes the psychological wellbeing of the patient
• Credible evidence should inform nursing practice to ensure the best possible patient experience

CPD reflective questions

• Think about the symptoms of pancreatic cancer and how these are best managed
• What is the nurse's/student nurse's role in assessing, managing, and evaluating post-surgical acute pain experienced by a patient with pancreatic cancer?
• How can you provide holistic patient-centred care for a patient with pancreatic cancer?

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Lippincott Open Access

Update on the management of acute pancreatitis

Fons f. van den berg.

a Amsterdam UMC location University of Amsterdam, Medical Microbiology & Infection prevention

Marja A. Boermeester

b Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9

c Amsterdam institute for Infection and Immunity

d Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands

Purpose of review

This review provides insight into the recent advancements in the management of acute pancreatitis.

Recent findings

Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal “on-demand” diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.

INTRODUCTION

Acute pancreatitis (AP) is a (initially) sterile inflammation of the pancreas that evokes a systemic inflammatory response syndrome (SIRS) with large heterogeneity in terms of severity. Around 80% of patients experience mild symptoms that merely require supportive therapy with fluids, analgesia, and diet resumption. Nevertheless, a small fraction of patients is being admitted to intensive care units (ICUs) within the first days due to an overwhelming SIRS response causing persistent (multiple) organ failure. Besides supportive care until the inflammation resides, no specific therapies are yet available to mitigate or prevent this.

Despite recent treatment approaches such as the surgical and endoscopic step-up approaches [ 1 , 2 ] that have been adopted in most practices, infected (peri-) pancreatic necrosis remains a challenge for clinicians. A recent nationwide analysis shows that mortality in patients with acute pancreatitis who had been admitted to Dutch ICUs remained unchanged for the last two decades (average 23% hospital mortality) [ 3 ▪ ]. However, all-cause 1-year mortality was higher before 2010 (up to the publication date of the PANTER trial [ 2 ]) for patients with late mortality (after 14 days), suggesting that mainly treatment of late complications has improved.

This review presents an overview of recent clinical trials, while also focusing on novel insights, that will most likely affect the management of acute pancreatitis (Table ​ (Table1 1 ). 

Recommendations based on recent literature

no caption available

EARLY MANAGEMENT

Goal-directed fluid resuscitation is the cornerstone of initial management of acute pancreatitis, although based on very limited evidence. A Spanish trial randomizing patients with acute pancreatitis between aggressive goal directed and moderate resuscitation was halted because patients in the aggressive group experienced more fluid overload (20.5% vs. 6.3%), while not preventing progression to moderate or severe acute pancreatitis [ 4 ▪▪ ]. Another trial comparing aggressive vs. normal resuscitation did not show a difference in clinical outcomes [ 5 ].

Although evidence is scarce, comprising small RCTs with irrelevant clinical primary outcomes, the international guidelines advocate the use of Ringers lactate. The single-center trial of Lee et al. [ 6 ▪ ] meant to put an end to the debate on choice of fluids. They have randomized 121 patients between goal-directed fluid resuscitation with normal saline (NS) or Ringer's lactate (RL). SIRS score at 24 h after administration as primary outcome of the study is not different between NS (23.3%) and RL (27.9%). Secondary outcomes differ significantly in favor of RL, such as median length of hospital stay (3.5 [2–5.9] vs. 4.6 [3–7.4] days), ICU admission (9.8% vs. 25%), and pancreatic necrosis (6.6% vs. 15%). The authors have excluded two thirds of patients with acute pancreatitis. The most common reasons for exclusion were logistical reasons (40%) and liver, renal or cardiac insufficiency (35.2%). Of the patients with mild acute pancreatitis, around 20% progressed to moderate or severe acute pancreatitis, which is comparable to the literature. A recent systematic review confirms that Ringers reduces ICU admission and hospital stay [ 7 ]. Recent randomized unblinded trials of lower quality show reduced CRP levels and less organ failure with RL [ 8 , 9 ]. Despite these major limitations, these studies strengthen the current recommendations regarding the use of RL. Future studies should limit their exclusion criteria and use a clinically relevant (composite) endpoint, for example major complications such as new onset organ failure and pancreatic necrosis. Goal-directed aggressive fluid therapy will most likely be abandoned and be replaced by moderate resuscitation (10 ml/kg bolus in case of hypovolemia, followed by 1.5 ml/kg/h). In patients with severe acute pancreatitis, novel fluid administration strategies such as colonic fluid resuscitation [ 10 ] and pulmonary artery catheter- guided resuscitation [ 11 ] show favorable results but their value remains unclear.

Nutrition remains a highly debatable subject in early pancreatitis management. Starvation in acute pancreatitis is driving pathogenic processes such as gut failure and bacterial translocation. A recent Spanish trial has compared conventional fasting until biochemical and clinical improvement to immediate resumption of a solid diet at admission [ 12 ▪ ]. This trial has randomized 131 patients with mild/moderate acute pancreatitis; 99% of patients in the early feeding group resumed their diet immediately while this took a mean of 2.8 (1.7) days in the conventional feeding group. Only 1 patient (1.4%) in the early feeding group experienced intolerance for diet vs. 13 (21.6%) in the conventional group. The primary outcome length of hospital stay was significantly lower in the early feeding group [mean 3.4 (1.7) vs. 8.8 (7.9) days]. Also, progression to moderate AP, complications, and IC admissions are lower in the early feeding group. Rai et al. [ 13 ] have conducted a similar randomized controlled trial (RCT) with patients with moderate or severe acute pancreatitis. Mean length of hospital stay was 6.3 (3.5) vs. 7.3 (3.4) days in favor of on-demand oral feeding. The prolonged hospital stay in a conventional feeding strategy is not surprising since length of stay is driven by a fasting period and build-up of the diet. Therefore, length of hospital stay may not be clinically relevant here. Also, both studies use food intolerance as secondary outcome, which may introduce interventional bias since patients may assume that starvation is a necessary part of their treatment and therefore later resume their diet. Finally, both studies do not mention the actual caloric intake per day, which is a better reflection of the nutritional status. Two recent meta-analyses confirmed that early diet resumption is associated with short hospital stay [ 14 , 15 ].

In our clinical practice, generally “the nil per os” strategy has been replaced for some years now by an on-demand oral diet that is offered on admission. In our opinion, nasogastric tube feeding (or nasojejunal tube in case of gastropareses) should be considered if an oral diet has not been resumed within three days. Parental feeding should be reserved for patients that are persistently intolerant to enteral feeding (i.e., due to paralytic ileus). Future research should focus on specialized (or better personalized) nutrition tailored to the disease severity and phase and to the patient's needs.

Pain management

Pain management in pancreatitis is poorly studied and a substantial variation exists between and within clinical practices. Traditionally, pain management is cornered on the use of opiates although nowadays a multimodal approach paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), metamizole, opiates, ketamine and epidural analgesia is commonly used. Two recent meta-analyses have appeared, identifying 6 and 12 RCTs, respectively [ 16 , 17 ]. Both meta-analyses indicate that NSAIDs and opiates are equally effective, but a substantial paucity of data exists. Epidural analgesia may also be an effective opiate sparing modality, although only one RCT has been identified. A recent retrospective analysis of 352 patients with severe acute pancreatitis admitted to the ICU of a Chinese hospital suggests thoracic epidural analgesia may provide protection against adult respiratory distress syndrome (ARDS), acute kidney injury (AKI), and even mortality [ 18 ▪ ]. An unblinded trial has randomized patients between hydromorphone patient-controlled analgesia (PCA) and intramuscular pethidine and showed no difference in pain relief, but an overall worse outcome in the hydromorphone-PCA group resulting in premature termination of the trial [ 19 ].

Although based on low quality and low sample size evidence, a multimodal approach that combines paracetamol, metamizole and simple opiates is recommended. When insufficient, an Acute Pain Service, nowadays available in most hospitals, can be consulted for additional modalities. Epidural analgesia is still infrequently used but shows promise as an opiate-sparing alternative, depending on in-house availability.

Prophylactic antibiotics

Although there are many, often contradiction, studies, current guidelines advise against the routine use of prophylactic antibiotics for treatment of acute pancreatitis since there is no clear benefit. A recent meta-analysis of seven studies again confirmed this by showing that prophylactic carbapenems, the most widespread used treatment for infected necrosis, reduces urinary tract infections, pneumonia and bacteremia, but did not show a beneficial effect on infected necrosis, mortality and other clinically important outcomes [ 20 ]. Also, that meta-analysis has included two retrospective studies that may have biased the results. Although continuously under debate, it seems that prophylactic antibiotics may do more harm than good and therefore is still not recommended.

Pre, pro- and postbiotics

For the last decades it becomes more apparent that the gut microbiome is an important disease modifier in severe inflammatory conditions such as acute pancreatitis. Nevertheless, trials that were aimed to reduce the gut pathobiome (collection of pathogens) though antibiotics or enhance the commensal microbiota with pre or probiotics did not lead to an effective and safe prophylactic treatment for administration in the early, hyperinflammatory phase of acute pancreatitis. Two recent randomized trials showed that synbiotics (Bifilac) in moderate and severe pancreatitis and probiotics (Bacillus subtilis and Enterococcus faecium) in mild pancreatitis, respectively, reduced the length of hospital stay but did not affect clinically important outcomes [ 21 , 22 ]. Chen et al. [ 23 ] have randomized 49 patients with severe acute pancreatitis between soluble dietary fibers (polydextrose) or control. Feeding intolerance, defined as the need to stop or reduce enteral nutrition, is reduced from 72.73% to 29.17% with soluble dietary fibers. However, there was no blinded outcome assessment which introduces important risk of bias.

Postbiotics, bacterial products that are produced from fibers, are attractive targets because of their endogenous nature and safety profile. A recent preclinical study showed promise for the use of butyrate, a short chain fatty acid, in the prevention of severe complications in mice [ 24 ▪ ]. A proof-of-concept trial using micro-encapsulated tributyrin (a butyrate prodrug) as prophylaxis in patients with acute pancreatitis is currently being designed.

Prevention of post-ERCP pancreatitis

A lot of effort has been invested to reduce the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). As mentioned, it is now standard of care to administer rectal NSAIDs. Moreover, a pancreatic duct (PD) stent is placed in case of unintentional PD cannulation. A Japanese propensity-score matched analysis shows that low dose diclofenac (25 mg) in patients with a body weight <50 kg is not effective [ 25 ]. A large international prospective observational study has shown no protective effect of chronic statin and aspirin use [ 26 ]. Besides the routine administration of NSAIDs, prophylactic hyperhydration has gained a lot of attention recently. A large multicenter RCT has randomized patients with moderate or high risk for PEP between standard of care and an aggressive hydration protocol using Ringer's lactate. Although mean fluid administration in the first 24 h is significantly higher in the aggressive hydration compared to control (3562 ml vs. 400 ml), comparable PEP incidence is found (8% vs. 9%) [ 27 ▪ ]. A Japanese trial has found comparable PEP incidence for rectal diclofenac, PD stenting, and a combination of both [ 28 ]. However, at a very low incidence of PEP (1.6%), the study was likely underpowered to detect a potential difference.

No additional prophylactic measures other than a high dose of rectal NSAIDs (100 mg diclofenac) and pancreatic duct stenting in case of unintentional PD cannulation can currently be recommended.

MANAGEMENT OF COMPLICATIONS

Antibiotic treatment.

The prescription of antibiotics is common during acute pancreatitis; up to two third of patients are administered antibiotics during the disease course, often without a culture- or radiologically proven infection. Clinicians who are confronted with fever and elevated inflammatory parameters early in the disease course initiate empirical antibiotics due to the inability to discriminate between SIRS and infection.

Procalcitonin (PCT) is a useful biomarker that is elevated in bacterial infection but not in inflammation. A UK single-center RCT has randomized 260 patients between PCT-guided antibiotic treatment or usual care [ 29 ▪▪ ]. In the intervention group, PCT was measured at days 0, 4 and 7, and thereafter weekly or when a clinical decision was going to be made to initiate or stop antibiotics. When a PCT test indicated >1 ng/ml, the advice was to initiate antibiotics; at <1 ng/ml, the advice was to stop or not to initiate antibiotics. Clinicians deviated from the algorithm in 24 instances, mostly initiating or continuing antibiotics despite a negative PCT test (79%). In the PCT-guided intervention group, therapeutic antibiotic prescription was significantly lower compared to the usual care group (41% vs. 60%). The infection and adverse advents rates were comparable among groups. PCT-guided care may reduce unwarranted antibiotic use without risking severe complications. However, in the subgroup of patients with moderate or severe acute pancreatitis there was no difference in antibiotic prescription among groups, suggesting that PCT-guide care is mainly effective in reducing antibiotic use in the early hyperinflammatory phase. The results do not give insight in what type of patients and in what phase of the disease clinicians decide to adhere or deviate from the algorithm. The indication, choice and duration of antibiotics administration is not described by the authors. A recent Spanish prospective study showed that PCT-guided antibiotic therapy on admission was associated with infectious complications [ 30 ]. It does not seem logical to use PCT levels on admission to guide antibiotic treatment for infections that usually occur after weeks.

Based on these studies, PCT testing will most likely be implemented in pancreatitis care globally, stimulated by recent Antibiotic Stewardship Programs. Future efforts to limit unwarranted antibiotic use must address the value of algorithms in specific disease phenotypes and disease phases. Moreover, the effects of such algorithms have yet to be evaluated in countries that are restrictive in antibiotic use such as the Netherlands and Scandinavian countries, as in such clinical practices this may even result in an increase instead of decrease in antibiotic administration. Carbapenems such as meropenem and imipenem are most frequently used as empirical antibiotics because of limited evidence showing penetration of pancreatic tissue, however practice variation is large and clear guidelines are lacking.

Management of severe local complications

In the last decades, significant progress has been made in the treatment of infected necrotizing pancreatitis. A range of new interventional procedures have become available, such as the video-assisted retroperitoneal debridement (VARD), transgastric drainage, and necrosectomy. The step-up approach (surgically [ 2 ] or endoscopically [ 1 ]) has become the global standard of care. The 5-year follow up of a trial comparing the endoscopic and surgical step-up shows comparable outcomes, although less pancreatic fistulas with the endoscopic approach [ 31 ▪ ].

It has been recommended to wait for the development of walled-of-necrosis before drainage to prevent complications. Nevertheless, early drainage can potentially prevent a gradually increasing inflammatory response or cytokine storm. In the Dutch POINTER trial, patients with infected necrotizing pancreatitis have been randomized between early (mean 24 days) or late drainage (mean 34 days) [ 32 ▪▪ ]. The Comprehensive Complication Index did not differ among groups but the postponed group overall received less interventions (mean 2.6 vs. 4.4). More importantly, 39% of the postponed group did not receive any intervention at all and were treated with antibiotics alone, while all patients in the early drainage group received an intervention.

The AXIOMA study has added a third treatment arm including patients being drained using a lumen-apposing metal stent [ 33 ▪ ]. The need for transluminal necrosectomy following drainage was equal compared to patients drained with plastic stents in the POINTER trial. The same study group has retrospectively reviewed patients undergoing endoscopic drainage of symptomatic sterile necrotic collections and have found a high success rate (87%) but also a high rate of iatrogenic secondary infections (73%) [ 34 ].

A further course towards a more conservative approach to infected necrotizing pancreatitis using only antibiotics is justified by these recent studies. The optimal choice and duration of antibiotics and radiological follow-up of conservative treatment is unclear and is in need of more data and the development of clear guidelines. The choice of interventional modality is mainly dictated by the location of fluid/necrosis collections and in-house availability of expertise. Optimal treatment warrants centralization of care and multidisciplinary consultation. A sterile necrotic collection only requires drainage when symptomatic and suspicious of undiagnosed infection of that collection, counterbalanced by a high iatrogenic infection rate.

Neostigmine treatment reduces the intra-abdominal pressure and increases stool volume in patients admitted to the ICU. Intra-abdominal hypertension (IAH) is believed to be associated with worse outcome, although no effect on clinically important outcome measures such as new-onset organ failure, mortality, or the need for surgical decompression has been shown. Therefore, the direct benefit for patients of interventions to lower IAH remains unclear [ 35 ].

The standard for mild biliary pancreatitis is a same-admission cholecystectomy, but there is no consensus regarding the optimal timing of cholecystectomy for patients with necrotizing pancreatitis. A large retrospective analysis shows that cholecystectomy was performed at a median of over 3 months following discharge [ 36 ▪ ]. Early (<8 weeks) cholecystectomy might reduce biliary recurrences, however due to the retrospective nature there remains a strong need for a (randomized) trial.

Immunomodulation

Severe acute pancreatitis is characterized by hyperinflammation in the early phase that leads to (multiple) organ failure and high mortality rates. Modulation of this hyperinflammatory response by removing components of the cytokine storm is a (theoretically) attractive approach that is getting more attention lately. Two recent studies have investigated filtration of blood to remove cytokines [ 37 , 38 ]. A meta-analysis of 17 studies shows that high-volume hemofiltration reduces short term (<4 weeks) but not long-term mortality [ 37 ]. A small observational study reports 16 patients with severe acute pancreatitis being treated with Cytosorb, an extracorporeal blood purification device that selectively absorbs cytokines [ 38 ]. In this small series, the treatment improves hemodynamics in comparison with 32 APACHE-II-score matched patients. Therapeutic plasma exchange is sometimes used as a last resort to treat patients with refractory multiple organ failure. Case series data show that despite a temporary improvement of hemodynamics, almost all patients still die within 28 days [ 39 ]. Future innovations may enable us to better treat or even prevent organ failure.

Infected necrotizing pancreatitis most often occurs late in the disease course. Immunoparalysis due to prolonged preceding hyperinflammation may significantly contribute to this late infection. Following a successful pilot study, a Chinese group has performed a large randomized placebo-controlled trial using Thymosin alpha 1, an immunomodulatory natural occurring peptide in the human thymus which is currently utilized in immunocompromised patients and as enhancer of vaccine response [ 40 ]. In contrast to the pilot study results, the RCT shows no difference in clinical outcomes between the intervention and placebo group.

Prophylactic administration of NSAIDs to prevent post-ERCP pancreatitis has become routine care. The presumed working mechanism, reduction of the proinflammatory response through cyclooxygenase (COX) inhibition, may also be a viable option in patients with acute pancreatitis who have a high risk of developing organ failure. A large US retrospective study based on ICD-9 codes suggests that any prior NSAID use is inversely associated with organ failure [ 41 ]. A US RCT has randomized 42 patients with SIRS but without organ failure between a 100 mg loading dose of rectal indomethacin, followed by five doses of 50 mg every 8 h, or placebo [ 42 ]. SIRS score as primary outcome and other markers clinical outcomes are comparable among groups; no beneficial effect is seen.

These disappointing results may very well reflect our fundamental lack of understanding of the pathophysiological mechanisms that underlie (early) organ failure. Recently, using multiomics techniques, 4 subtypes of molecular endotypes have been identified in patients with acute pancreatitis, resembling generalizable endotypes seen in ARDS patients [ 43 ▪ ]. Notably, all patients with persistent organ failure clustered in subtype A despite adding clinical data to the model. Although exploratory, more such studies are needed to study specific disease processes that may be manipulated in future clinical trials.

Early management of acute pancreatitis is continuously improving and includes fluid resuscitation, nutrition, and analgesia. Recent trends are towards a more conservative approach using less fluids, less opiates, and delay interventions as much as possible. Trials that are focused on reducing (early) organ failure through immunomodulation still produce disappointing results. A more fundamental understanding of the early inflammatory response is therefore needed.

Acknowledgements

Financial support and sponsorship, conflicts of interest.

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

• ▪ of special interest
• ▪▪ of outstanding interest

Popular Search Resources for

Interprofessional Case Study Event Elevates Patient Care Strategies

By Office of the President | Apr 2, 2024

The Sixth Annual Interprofessional Case Study event, organized by Downstate's School of Health Professions (SOHP) in collaboration with the College of Nursing and the School of Public Health, took place on March 21. Engaging over 160 students in-person and virtually, the event underscored the importance of healthcare professionals working collaboratively in interdisciplinary teams to improve patient care.

Case-based learning constitutes a crucial component of health education, equipping students with essential clinical skills, fostering active learning, and enriching their understanding of the complexities involved in patient care. Interprofessional education amplifies this by instructing students on how to operate effectively within intricate healthcare settings. The amalgamation of these methodologies provides a comprehensive educational journey to emerge as proficient, collaborative, and patient-focused professionals.

Students from various programs within the School of Health Professions, including Diagnostic Medical Imaging, Health Informatics, Midwifery, Occupational Therapy, Physical Therapy, and Physician Assistant programs, alongside College of Nursing and School of Public Health students, actively contributed insights from their respective disciplines. They collaborated on treatment plans and discussed strategies to address complex health issues, advocate for patients, and identify supportive resources. Faculty from Health Professions, Nursing, and Public Health guided students through this immersive experience.

The Federal Register

The daily journal of the united states government, request access.

Due to aggressive automated scraping of FederalRegister.gov and eCFR.gov, programmatic access to these sites is limited to access to our extensive developer APIs.

If you are human user receiving this message, we can add your IP address to a set of IPs that can access FederalRegister.gov & eCFR.gov; complete the CAPTCHA (bot test) below and click "Request Access". This process will be necessary for each IP address you wish to access the site from, requests are valid for approximately one quarter (three months) after which the process may need to be repeated.

An official website of the United States government.

If you want to request a wider IP range, first request access for your current IP, and then use the "Site Feedback" button found in the lower left-hand side to make the request.