Etiology

Alcohol abuse and obstruction of the pancreatic duct by gallstones are the most common causes of the disease; less often, pancreatitis results from exposure to drugs (e.g., thiazide diuretics or pentamidine), hypertriglyceridemia, hypercalcemia, abdominal trauma, or viral infections (e.g., mumps or coxsackievirus).

Treatment

The patient receives nothing by mouth until pain, nausea, and vomiting have resolved and diagnostic markers (e.g., serum lipase level) show evidence of normalizing. Standard supportive measures include the administration of fluids and electrolytes, sometimes in massive quantities if dehydration or third-spacing of fluids in the abdomen occurs.

CAUTION!

Prognosis

Several techniques are used to determine how well (or how poorly) patients with pancreatitis will progress during their illness and whether they may benefit from intensive care. The best of these is the Acute Physiology and Chronic Health Evaluation (APACHE II) system; it grades patients with pancreatitis on the basis of 14 measurable physiological parameters, including the patient's body temperature, heart rate, mean arterial pressure, respiratory rate, serum creatinine and sodium levels, arterial pH, white blood cell count, Glasgow coma scale, and age.

Other methods for determining the severity of illness in pancreatitis rely on abnormalities seen on computed tomography (CT) imaging or the measurement of other physiological criteria, including the serum calcium and glucose levels, fluid deficit, and liver function.

Patient care

Intravenous fluids, antiemetics, and pain relievers are administered parenterally. A nasogastric tube may be inserted and placed on low, intermittent suctioning for patients with intractable nausea and vomiting or to reduce hydrochloric acid levels or relieve distention. Required nutritional support is best provided by jejunal enteral feedings that maintain gut integrity. These are as effective as parenteral feeding is and have the benefit of reducing the potential for infection and hypoglycemia. Total parenteral nutrition may be needed for patients with evidence of severe pancreatitis. Such patients may be critically ill and will require close monitoring of vital signs, oxygenation and ventilation, body temperature, cardiac and hemodynamic status, fluid and electrolytes, balance, body weight, serum calcium levels, renal function, level of consciousness, peripheral circulation, possible delirium, and possible multiorgan system failure. Severe pancreatitis often results in a prolonged and complicated hospitalization. Throughout the illness, range-of-motion exercises, correct positioning, prophylaxis against deep venous thrombosis, oral hygiene, and other physical support measures prevent debilitation and complications of prolonged illness. Both patient and family may need support, esp. in the presence of complications (pulmonary, cardiovascular, renal, immune, and coagulation abnormalities). After pancreatitis has resolved, alcoholic patients should be encouraged to seek help from Alcoholics Anonymous or other supportive programs. Follow-up with a gastroenterologist, primary care provider, or nutritionist may be helpful during convalescence and recovery. Patients should return for prompt reevaluation if they have nausea, vomiting, epigastric pain, fevers, or jaundice after discharge.

Symptoms

The pain may be mild or severe, tending to radiate to the back. Jaundice, weakness, emaciation, malabsorption of proteins and fats, and diarrhea are present.

Protein, Blood, Total and Fractions

Common use

Specimen

Normal findings

Description

This procedure is contraindicated for

N/A

Indications

• Evaluation of edema, as seen in patients with low total protein and low albumin levels
• Evaluation of nutritional status

Potential diagnosis

Increased in

• α₁-Globulin proteins in acute and chronic inflammatory diseases
• α₂-Globulin proteins occasionally in diabetes, pancreatitis, and hemolysis
• β-Globulin proteins in hyperlipoproteinemias and monoclonal gammopathies
• γ-Globulin proteins in chronic liver diseases, chronic infections, autoimmune disorders, hepatitis, cirrhosis, and lymphoproliferative disorders
• Total protein:
  • Dehydration (related to hemoconcentration)
  • Monoclonal and polyclonal gammopathies (related to excessive γ-globulin protein synthesis)
  • Myeloma (related to excessive γ-globulin protein synthesis)
  • Sarcoidosis (related to excessive γ-globulin protein synthesis)
  • Some types of chronic liver disease
  • Tropical diseases (e.g., leprosy) (related to inflammatory reaction)
  • Waldenström’s macroglobulinemia (related to excessive γ-globulin protein synthesis)

Decreased in

α₁-Globulin proteins in hereditary deficiency α₂-Globulin proteins in nephrotic syndrome, malignancies, numerous subacute and chronic inflammatory disorders, and recovery stage of severe burns β-Globulin proteins in hypo-β-lipoproteinemias and IgA deficiency γ-Globulin proteins in immune deficiency or suppression Total protein:
• Administration of IV fluids (related to hemodilution)
• Burns (related to fluid retention, loss of albumin from chronic open burns)
• Chronic alcoholism (related to insufficient dietary intake; diminished protein synthesis by damaged liver)
• Chronic ulcerative colitis (related to poor intestinal absorption)
• Cirrhosis (related to damaged liver, which cannot synthesize adequate amount of protein)
• Crohn’s disease (related to poor intestinal absorption)
• Glomerulonephritis (related to alteration in permeability that results in excessive loss by kidneys)
• Heart failure (related to fluid retention)
• Hyperthyroidism (possibly related to increased metabolism and corresponding protein synthesis)
• Malabsorption (related to insufficient intestinal absorption)
• Malnutrition (related to insufficient intake)
• Neoplasms
• Nephrotic syndrome (related to alteration in permeability that results in excessive loss by kidneys)
• Pregnancy (related to fluid retention, dietary insufficiency, increased demands of growing fetus)
• Prolonged immobilization (related to fluid retention)
• Protein-losing enteropathies (related to excessive loss)
• Severe skin disease
• Starvation (related to insufficient intake)

Critical findings

N/A

Interfering factors

• Drugs that may increase protein levels include amino acids (if given IV), anabolic steroids, angiotensin, anticonvulsants, corticosteroids, corticotropin, furosemide, insulin, isotretinoin, levonorgestrel, oral contraceptives, progesterone, radiographic agents, and thyroid agents.
• Drugs and substances that may decrease protein levels include acetylsalicylic acid, arginine, benzene, carvedilol, citrates, floxuridine, laxatives, mercury compounds, oral contraceptives, pentastarch, phosgene, pyrazinamide, rifampin, trimethadione, and valproic acid.
• Values are significantly lower (5% to 10%) in recumbent patients.
• Hemolysis can falsely elevate results.
• Venous stasis can falsely elevate results; the tourniquet should not be left on the arm for longer than 60 sec.

Nursing Implications and Procedure

Pretest

• Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
• Patient Teaching: Inform the patient this test can assist in assessing nutritional status related to disease process.
• Obtain a history of the patient’s complaints, including a list of known allergens especially allergies or sensitivities to latex.
• Obtain a history of the patient’s gastrointestinal, hepatobiliary, and immune systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures.
• Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
• Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture.
• Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
• Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

• Potential complications: N/A
• Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
• Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement.
• Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection. Perform a venipuncture.
• Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.
• Promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

• Inform the patient that a report of the results will be made available to the requesting health-care provider (HCP), who will discuss the results with the patient.
• Nutritional Considerations: Educate the patient, as appropriate, that good dietary sources of complete protein (containing all eight essential amino acids) include meat, fish, eggs, and dairy products and that good sources of incomplete protein (lacking one or more of the eight essential amino acids) include grains, nuts, legumes, vegetables, and seeds.
• Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
• Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

• Related tests include albumin, ALP, ACE, anion gap, AST, biopsy liver, biopsy lung, calcium, carbon dioxide, chloride, CBC WBC count and differential, cryoglobulin, fecal analysis, fecal fat, gallium scan, GGT, IgA, IgG, IgM, IFE, liver and spleen scan, magnesium, mediastinoscopy,β ₂-microglobulin, osmolality, protein urine total and fractions, PFT, radiography bone, RF, sodium, TSH, thyroxine, and UA.
• Refer to the Gastrointestinal, Hepatobiliary, and Immune systems tables at the end of the book for related tests by body system.