Acute pancreatitis: presentation and diagnostics
Acute pancreatitis is autodigestion of the pancreas by its own activated enzymes, and in adults the two dominant causes are gallstones and alcohol use. The pain is severe, constant, boring epigastric or left upper quadrant pain radiating straight through to the back, worse after eating or lying supine and relieved by sitting up and leaning forward or drawing the knees to the chest. Nausea, vomiting that does not relieve the pain, abdominal distension, hypoactive bowel sounds and low-grade fever accompany it.
Laboratory findings drive many items. Serum lipase rises within hours, stays elevated for up to two weeks and is the more specific marker; amylase rises early but is less specific. Supporting findings include leukocytosis, hyperglycaemia from impaired insulin release, elevated triglycerides, hypocalcaemia from fat saponification, and elevated bilirubin when a stone obstructs the duct. Contrast-enhanced computed tomography confirms severity and complications.
Two skin signs signal bleeding into retroperitoneal tissue: Cullen's sign is bluish discolouration around the umbilicus and Grey Turner's sign is bluish discolouration of the flanks. Both indicate haemorrhagic pancreatitis, a life-threatening development, and their appearance in a stem always makes assessment of perfusion and immediate provider notification the correct action.
| Feature | Acute pancreatitis | Cholecystitis |
|---|---|---|
| Pain location | Epigastric, radiating to back | Right upper quadrant, to right shoulder |
| Relieving position | Leaning forward, knees to chest | No classic relieving position |
| Key labs | Lipase, amylase, glucose, calcium | Bilirubin, alkaline phosphatase, white cells |
| Classic sign | Cullen's and Grey Turner's signs | Murphy's sign |
| Imaging | CT abdomen | Right upper quadrant ultrasound |
| Definitive treatment | Supportive; treat cause | Cholecystectomy |
Nursing management of pancreatitis
The pancreas is rested. The client is kept NPO in the acute phase so that enzyme secretion is not stimulated, with nasogastric suction added when vomiting or ileus is present. Aggressive intravenous fluid replacement is central because third spacing into the retroperitoneum can produce hypovolaemic shock; urine output, blood pressure, heart rate and haematocrit are followed closely.
Pain control uses opioid analgesia, and the exam expects adequate dosing rather than withholding. Position the client on their side with the knees flexed and the head of the bed elevated, or sitting forward over a table, and provide quiet, low-stimulation surroundings. Antiemetics, oral care while NPO and small frequent low-fat meals when feeding resumes complete the plan.
Complication surveillance is what separates a passing answer from a distractor. Monitor calcium and watch for perioral numbness, tingling, Chvostek's sign, Trousseau's sign and tetany. Monitor glucose because endocrine function may be impaired. Watch respiratory status for pleural effusion and acute respiratory distress syndrome, and watch for signs of infected necrosis or pseudocyst — rising fever, worsening pain and a palpable epigastric mass.
- •NPO with nasogastric suction in severe disease
- •Aggressive isotonic fluids and strict intake and output
- •Opioid analgesia with side-lying, knees-flexed positioning
- •Monitor calcium, glucose, magnesium and respiratory status
- •No alcohol, no caffeine, no large or fatty meals on discharge
- •Pancreatic enzyme replacement is taken with every meal and snack in chronic disease
Cholecystitis and cholelithiasis
Cholecystitis is gallbladder inflammation, usually caused by an obstructing stone. Risk is summarized by the classic four Fs — female, forty, fertile and overweight — with rapid weight loss, oral contraceptives and a high-fat diet adding risk. Pain is right upper quadrant, may radiate to the right scapula or shoulder, and is often triggered two to four hours after a fatty meal. Nausea, vomiting, low-grade fever, indigestion and belching are common.
Murphy's sign — the client stops inspiration abruptly when the examiner palpates below the right costal margin — supports the diagnosis. When the common bile duct is obstructed, bile cannot reach the intestine and the client develops jaundice, dark amber urine, clay-coloured stools, steatorrhoea and pruritus, with elevated direct bilirubin and alkaline phosphatase. Prolonged obstruction impairs vitamin K absorption and prolongs prothrombin time, which matters before surgery.
Laparoscopic cholecystectomy is the usual treatment. Postoperatively the nurse manages referred shoulder pain from residual carbon dioxide by encouraging ambulation and left side-lying with the knees up, promotes deep breathing and early mobility, and monitors the incisions. When a T-tube is present after open surgery, it drains bile, the bag is kept below the level of the gallbladder, output is measured and expected to decrease over days, and the tube is clamped before meals only as ordered to assess tolerance.
Diet teaching and long-term care
Diet answers are consistent across both conditions and easy points. After acute pancreatitis the client resumes eating with small, frequent, low-fat, high-carbohydrate meals, avoids alcohol permanently, limits caffeine and stops smoking. In chronic pancreatitis, pancreatic enzyme replacement is taken with every meal and snack, swallowed whole rather than crushed, and effectiveness is judged by reduced steatorrhoea and stable weight; fat-soluble vitamin supplementation is often needed.
After cholecystectomy, most clients tolerate a normal diet over time but do best beginning with low-fat choices and gradually reintroducing fat as tolerated, since bile now drips continuously rather than being stored and released in a bolus. Small frequent meals reduce bloating and diarrhoea in the early weeks.
Teaching also covers when to call. Fever, worsening or unrelieved pain, persistent vomiting, jaundice, clay-coloured stools, dark urine or wound drainage all require prompt evaluation. Clients on long-term enzyme therapy or with pancreatic endocrine damage need glucose monitoring and follow-up laboratory review.