The pancreas has two jobs. The exocrine pancreas secretes digestive enzymes (lipase, amylase, trypsin) and bicarbonate into the duodenum. The endocrine pancreas (islets) secretes insulin and glucagon. Disease can damage either or both.

Acute pancreatitis (AP) — enzymes activate inside the pancreas and digest it ("autodigestion"), triggering local inflammation that may spread into a systemic inflammatory response with capillary leak.

• Most common causes: gallstones and alcohol
• Others: hypertriglyceridemia (usually 1,000 mg/dL, 11.3 mmol/L, or higher), post-ERCP, drugs (e.g., azathioprine, valproate, some diuretics, GLP-1 receptor agonists — clients should report severe abdominal pain), hypercalcemia, trauma, smoking as a risk factor
• Revised Atlanta severity: mild (no organ failure or local complications), moderately severe (transient organ failure under 48 hours or local complications), severe (persistent organ failure over 48 hours)

Chronic pancreatitis — repeated inflammation causes fibrosis and permanent loss of function. Main causes are alcohol and smoking. Results: chronic pain, exocrine insufficiency (steatorrhea, weight loss), and endocrine insufficiency (diabetes).

Pancreatic cancer — mostly ductal adenocarcinoma; poor prognosis because it is usually found late. Risk factors: smoking, age, obesity, chronic pancreatitis, long-standing diabetes, family history and inherited syndromes. New-onset diabetes in an older adult can be an early sign.

Acute pancreatitis

• Severe, constant epigastric or LUQ pain radiating to the back, worse lying flat; relief by sitting up and leaning forward or knees to chest
• Nausea and vomiting, abdominal distension, guarding, hypoactive bowel sounds
• Fever, tachycardia, hypotension (fluid shifting into the retroperitoneum)
• Cullen sign (periumbilical bruising) and Grey Turner sign (flank bruising) — retroperitoneal hemorrhage, severe disease
• Hypocalcemia (calcium binds to areas of fat necrosis): tetany, Chvostek and Trousseau signs
• Hyperglycemia; crackles, dyspnea (pleural effusion, ARDS); jaundice if a stone blocks the common bile duct

Chronic pancreatitis

• Recurrent or persistent epigastric pain — the most common symptom
• Steatorrhea (bulky, greasy, foul-smelling stools), weight loss
• Diabetes symptoms

Pancreatic cancer

• Tumor in the head of the pancreas → painless obstructive jaundice (common bile duct compression): dark urine, clay-colored stools, pruritus; palpable nontender gallbladder (Courvoisier sign)
• Weight loss, anorexia, dull epigastric pain radiating to the back (body/tail tumors), new diabetes, venous thrombosis

Acute pancreatitis is diagnosed when 2 of 3 are present:

1. Typical abdominal pain
2. Serum lipase (or amylase) at least 3 times the upper limit of normal
3. Characteristic imaging findings

Acute pancreatitis (ACG 2024)

• Goal-directed, moderate IV fluid with lactated Ringer's — reassess at frequent intervals (heart rate, BP, urine output, BUN, hematocrit). Aggressive large-volume fluid is no longer advised; it increases fluid overload without benefit
• Early oral feeding within 24–48 hours as tolerated, starting with a low-fat solid diet in mild disease — prolonged NPO ("pancreatic rest") is no longer recommended. If the client cannot eat, enteral tube feeding is preferred over parenteral nutrition
• Pain control is a priority — IV opioids (e.g., hydromorphone, morphine) are appropriate; monitor respiratory status and sedation
• No prophylactic antibiotics, even in severe disease; antibiotics only for documented infection (e.g., infected necrosis, cholangitis)
• Gallstone pancreatitis: cholecystectomy during the same admission for mild disease; urgent ERCP only if cholangitis or persistent bile-duct obstruction
• Hypertriglyceridemia: insulin infusion (with dextrose co-infusion, hourly glucose checks, and potassium monitoring) or plasmapheresis in selected cases; alcohol: cessation counseling and withdrawal monitoring
• Severe disease: ICU care; drainage or necrosectomy for infected necrosis, usually delayed and minimally invasive

Chronic pancreatitis

• Complete alcohol and smoking cessation
• Pancreatic enzyme replacement (pancrelipase) with every meal and snack — swallow whole; adverse effects: abdominal pain, hyperuricemia, fibrosing colonopathy at very high doses; porcine origin
• Pain: non-opioid analgesics first, neuropathic agents; opioids cautiously; endoscopic or surgical drainage for duct obstruction; celiac plexus block
• Diabetes (type 3c) often needs insulin; hypoglycemia risk is high because glucagon is also lost — teach the Rule of 15 (see Diabetes Mellitus); fat-soluble vitamin replacement

Pancreatic cancer

• Pancreaticoduodenectomy (Whipple procedure) for resectable head tumors: removes the pancreatic head, duodenum, gallbladder, common bile duct, and sometimes part of the stomach
• Total pancreatectomy causes complete loss of insulin and glucagon — lifelong insulin and enzyme replacement are required; glucose control is often unstable with risk of severe hypoglycemia
• Chemotherapy, biliary stenting for jaundice, palliative care
• Pain: scheduled (around-the-clock) opioids for persistent cancer pain, not only as needed; celiac plexus block; bowel regimen for opioid constipation

Listed in priority order.

1. Breathing — monitor respiratory rate, SpO₂, lung sounds; pleural effusion and ARDS are common in severe AP; semi-Fowler's, deep breathing
2. Circulation / shock — monitor BP, heart rate, urine output (at least 0.5 mL/kg/h), mental status; titrate fluids as ordered and watch for fluid overload (crackles, edema)
3. Pain — assess often; give analgesics on schedule; position sitting up and leaning forward or side-lying with knees flexed
4. Metabolic — monitor glucose (insulin as ordered), calcium (seizure precautions; check Chvostek and Trousseau signs), magnesium, potassium
5. Nutrition — start oral low-fat feeding as ordered once pain and nausea allow; NG tube only for persistent vomiting or ileus; enteral feeding care
6. Alcohol withdrawal — assess for tremor, agitation, hallucinations with a validated scale
7. After Whipple — monitor drain output for pancreatic or bile leak (drain amylase, bile color), bleeding, delayed gastric emptying; glucose control; early ambulation; VTE prophylaxis

• Stop drinking alcohol completely and stop smoking — continued use leads to recurrence and chronic pancreatitis
• Eat small, low-fat meals; increase fat only as tolerated when enzymes are prescribed
• Take enzyme capsules with the first bite of every meal and snack; do not crush or chew; report greasy stools or weight loss
• Check blood glucose as instructed; recognize and treat hypoglycemia and hyperglycemia
• If gallstones caused the attack, have the gallbladder removed as planned — recurrence risk is high otherwise
• Report severe abdominal pain, fever, jaundice, vomiting, or signs of diabetes
• If hypertriglyceridemia caused the attack: follow a low-fat diet, avoid alcohol, control diabetes, and take triglyceride-lowering drugs (e.g., fibrates) as prescribed
• Ask before taking new medications or supplements — several drugs can trigger pancreatitis
• After a Whipple procedure: expect slow return of appetite and possible delayed stomach emptying; eat small frequent meals; keep follow-up for glucose, weight, and enzyme dose adjustment
• For cancer: discuss goals of care early; palliative and hospice services improve symptom control and quality of life

• AP causes: gallstones and alcohol
• Diagnosis: 2 of 3 — pain, lipase ≥ 3× upper limit, imaging; lipase is more specific than amylase
• Pain: epigastric to the back; relieved by sitting up and leaning forward
• Cullen and Grey Turner signs = retroperitoneal bleeding, severe disease
• Hypocalcemia — watch Chvostek and Trousseau signs
• Current care: goal-directed lactated Ringer's, early oral feeding within 24–48 h, no prophylactic antibiotics
• Biggest early threats: shock and respiratory failure (ARDS)
• Pseudocyst is a classic local complication
• Chronic pancreatitis: pain, steatorrhea, diabetes → enzymes with meals, insulin, no alcohol or smoking
• Pancreatic head cancer: painless jaundice; Whipple; total pancreatectomy → lifelong insulin and enzymes
• Cancer pain: around-the-clock analgesia, not as needed only