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Die Intensivgallenblase als Schockorgan

Symptome und Therapie

The intensive care gallbladder as shock organ

Symptoms and therapy

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Zusammenfassung

Die akute akalkulöse Cholezystitis (AAC) ist mit einer Inzidenz von 0,2–0,4 % bei Patienten, die mehr als 2 Tage auf einer Intensivstation überwacht werden müssen, kein sehr seltenes Erkrankungsbild und ist bei schnellem Voranschreiten mit einer hohen Morbidität und Mortalität verbunden. Die unspezifische klinische Symptomatik der AAC, die situationsbedingten erschwerten Untersuchungsbedingungen wie auch die multikausal und variabel veränderten laborchemischen Parameter lassen eine Diagnosesicherung nur in Zusammenschau der erhobenen bildmorphologischen Untersuchungen, unter Ausschluss der differenzialdiagnostischen Erkrankungsbilder, zu. Aufgrund der mit dem Erkrankungsbild vergesellschafteten hohen Morbidität und Mortalität ist eine rasche Diagnosefindung entscheidend, damit eine entsprechende Therapie eingeleitet werden kann. Die Therapie der AAC ist dabei stark an die klinische Konstitution des Patienten angelehnt. Liegen keine klinischen Kontraindikationen vor, ist ein operatives Therapievorgehen im Sinn einer Cholezystektomie durchzuführen. Wenn aus operativ-technischen Gründen ein laparoskopisches Vorgehen möglich ist, so ist dieses bei ähnlicher peri- und postoperativer Komplikationsrate durchaus gerechtfertigt. Liegt keine Operabilität des Patienten vor, sollte zügig eine interventionelle perkutane Cholezystostomie durchgeführt werden. Ist diese aus technisch-anatomischen Gründen oder bei Vorliegen von Kontraindikationen nicht möglich, ist bei entsprechender Expertise die endoskopische transpapilläre Gallengangsdrainageeinlage durchführbar. Kommt es durch die Gallenflüssigkeitsableitung zu keiner Besserung des Beschwerdebildes innerhalb von 72 h, muss die Reevaluation zur Durchführung eines operativen Eingriffs erfolgen. Bei einer definitiven Kontrolle der Symptome bei 90 % der Patienten nach erfolgreicher perkutaner Cholezystostomie in einem Nachsorgeintervall von mehr als einem Jahr bleibt der Stellenwert der sekundären Cholezystektomie früh-elektiv oder spät-elektiv offen.

Abstract

Acute acalculous cholecystitis (AAC) represents a severe disease in critically ill patients. The pathogenesis of acute necroinflammatory gallbladder disease is multifactorial and intensive care unit (ICU) patients show multiple risk factors. In addition AAC is difficult to diagnose because of the vague physical and non-specific technical findings. Only the combination of clinical and technical findings including the challenging physical examination of critically ill patients, laboratory results and ultrasound or computed tomography (CT) scan, will lead to the diagnosis. The condition of AAC has a rapid progress to gallbladder necrosis, gangrene and perforation and these complications are reflected in the high morbidity and mortality rates, therefore, therapy should be promptly initiated. If there are no clinical contraindications for an operative approach cholecystectomy is the definitive treatment and both open and laparoscopic procedures have been used. In unstable, critically ill patients percutaneous cholecystostomy should be immediately performed. In addition, transpapillary endoscopic drainage is also possible if there are contraindications for percutaneous cholecystostomy. Patients who fail to improve or deteriorate following interventional drainage should be reconsidered for cholecystectomy. Due to the fact that more than 90  % of patients treated with percutaneous cholecystostomy showed no recurrence of symptoms during a period of more than 1 year, it is still unclear if percutaneous cholecystostomy is the definitive treatment of AAC for unstable patients or if delayed cholecystectomy is still necessary.

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  1. Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn (AöR), Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland

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Rimkus, C., Kalff, J. Die Intensivgallenblase als Schockorgan. Chirurg 84, 197–201 (2013). https://doi.org/10.1007/s00104-012-2358-y

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