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Gallensteine

Von der molekularen Pathogenese zur leitlinienbasierten Prävention und Therapie

Gallstones

From molecular pathogenesis to guideline-based prevention and therapy

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Zusammenfassung

15–20% der deutschen Bevölkerung haben Gallensteine, und jährlich werden in Deutschland mehr als 190.000 Cholezystektomien wegen symptomatischer Gallensteine durchgeführt. 90% sind Cholesterinsteine, die infolge einer vermehrten Cholesterinsekretion der Leber in einer hypomotilen Gallenblase entstehen. Die Cholesterinhypersekretion wird auf exogene Faktoren (z. B. hochkalorische, kohlenhydratreiche Ernährung und Bewegungsmangel) und genetische Risikofaktoren (z. B. Genvariante des hepatischen Cholesterintransporters ABCG5/G8) zurückgeführt. Pro Jahr entwickeln 1–3% der Steinträger Koliken; die Komplikationsrate (Cholezystitis, Cholangitis, Pankreatitis) liegt um den Faktor 10 niedriger. Die laparoskopische Cholezystektomie ist sowohl bei unkomplizierter Cholezystolithiasis als auch bei der akuten Cholezystitis die Therapie der Wahl. Sie führt bei identischen Komplikationsraten zu kürzeren Krankenhausverweil- und Rekonvaleszenzzeiten. Die vor Kurzem aktualisierte S3-Leitlinie zur Diagnose und Therapie von Gallensteinen empfiehlt bei gleichzeitig bestehender Choledocholithiasis das therapeutische Splitting mit präoperativer ERC und Steinextraktion; bei zweifelhaftem Befund sollten Endosonographie –alternativ eine Magnetresonzcholangiographie – vorgeschaltet werden.

Abstract

In Germany, 15–20% of individuals develop gallstones, and more than 190,000 cholecystectomies are performed for symptomatic stones annually. Overall, 90% of gallstones are cholesterol stones, which are due to increased hepatic cholesterol secretion and gallbladder hypomotility. Cholesterol hypersecretion is attributed to exogenous risk factors, such as a hypercaloric carbohydrate-rich diet and physical inactivity, as well as to lithogenic genes, such as common gene variants of the hepatic cholesterol transporter ABCG5/G8. Of stone carriers, 1–3% per year develop symptoms (biliary colic), and the rate of complications (cholecystitis, cholangitis, pancreatitis) ranges from 0.1% to 0.3% per year. Today laparoscopic cholecystectomy represents the standard of care for most symptomatic stones with and without complications because it leads to shorter hospital stays and recovery times than open cholecystectomy but has similar complication rates. The recently updated German S3 guidelines for diagnosis and treatment of gallstones recommends preoperative endoscopic retrograde cholangiography and stone extraction in cases of simultaneous bile duct and gallbladder stones; if the probability of bile duct stones is moderate, endoscopic ultrasound – or magnetic resonance cholangiography – should precede cholecystectomy.

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Literatur

  1. Ayub K, Imada R, Slavin J (2004) Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev: CD003630

    Google Scholar 

  2. Boerma D, Rauws EA, Keulemans YC et al. (2002) Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial. Lancet 360: 761–765

    Article  PubMed  Google Scholar 

  3. Brink MA, Slors JF, Keulemans YC et al. (1999) Enterohepatic cycling of bilirubin: a putative mechanism for pigment gallstone formation in ileal Crohn’s disease. Gastroenterology 116: 1420–1427

    Article  CAS  PubMed  Google Scholar 

  4. Buch S, Schafmayer C, Völzke H et al. (2007) A genome-wide association scan identifies the hepatic cholesterol transporter ABCG8 as a susceptibility factor for human gallstone disease. Nat Genet 46: 994–999

    Google Scholar 

  5. Statistisches Bundesamt (2007) Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik), Diagnosen und Prozeduren der vollstationären Patienten und Patientinnen in Krankenhäusern 2005. Fachserie 12, Reihe 6.4. Statistisches Bundesamt, Wiesbaden

  6. Choi M, Moschetta A, Bookout AL et al. (2007) Identification of a hormonal basis of gallbladder filling. Nat Med 12: 1253–1255

    Article  Google Scholar 

  7. Grünhage F, Acalovschi M, Tirziu S et al. (2007) Increased gallstone risk in humans conferred by common variant of hepatic ATP binding cassette transporter for cholesterol. Hepatology 46: 793–801

    Article  PubMed  Google Scholar 

  8. Gurusamy KS, Samraj K (2006) Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev: CD005440

    Google Scholar 

  9. Katsika D, Grjibovski A, Einarsson C et al. (2005) Genetic and environmental influences on symptomatic gallstone disease: a Swedish study of 43,141 twin pairs. Hepatology 41: 1138–1143

    Article  CAS  PubMed  Google Scholar 

  10. Keus F, Jong JA de, Gooszen HG, Laarhoven CJ van (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev: CD006231

    Google Scholar 

  11. Lammert F, Neubrand MW, Bittner R et al. (2007) S3-Leitlinie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten und der Deutschen Gesellschaft für Viszeralchirurgie zur Diagnostik und Behandlung von Gallensteinen. Z Gastroenterol 11: 971–1001

    Article  Google Scholar 

  12. Lammert F, Sauerbruch T (2005) Mechanisms of disease: the genetic epidemiology of gallbladder stones. Nat Clin Pract Gastroenterol Hepatol 2: 423–433

    Article  CAS  PubMed  Google Scholar 

  13. Lau JY, Leow CK, Fung TM et al. (2006) Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients. Gastroenterology 130: 96–103

    Article  PubMed  Google Scholar 

  14. Martin DJ, Vernon DR, Toouli J (2006) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev: CD003327

    Google Scholar 

  15. Nealon WH, Bawduniak J, Walser EM (2004) Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg 239: 741–749

    Article  PubMed  Google Scholar 

  16. Oria A, Cimmino D, Ocampo C et al. (2007) Early endoscopic intervention versus early conservative management in patients with acute gallstone pancreatitis and biliopancreatic obstruction. A randomized clinical trial. Ann Surg 245: 10–17

    Article  PubMed  Google Scholar 

  17. Rabenstein T, Radespiel-Troger M, Hopfner L et al. (2005) Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones. Eur J Gastroenterol Hepatol 17: 629–639

    Article  PubMed  Google Scholar 

  18. Rosmorduc O, Hermelin B, Boelle PY et al. (2003) ABCB4 gene mutation-associated cholelithiasis in adults. Gastroenterology 125: 452–459

    Article  PubMed  Google Scholar 

  19. Sandler RS, Everhart JE, Donowitz M et al. (2002) The burden of selected digestive diseases in the United States. Gastroenterology 122: 1500–1511

    Article  PubMed  Google Scholar 

  20. Stephen AE, Berger DL (2001) Carcinoma in the porcelain gallbladder: a relationship revisited. Surgery 129: 699–703

    Article  CAS  PubMed  Google Scholar 

  21. Thistle JL, Cleary PA, Lachin JM et al. (1984) The natural history of cholelithiasis: the National Cooperative Gallstone Study. Ann Intern Med 101: 171–175

    CAS  PubMed  Google Scholar 

  22. Venneman NG, Renooij W, Rehfeld JF et al. (2005) Small gallstones, preserved gallbladder motility, and fast crystallization are associated with pancreatitis. Hepatology 41: 738–746

    Article  CAS  PubMed  Google Scholar 

  23. Verma D, Kapedia A, Eisen GM, Adler DG (2006) EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 64: 248–254

    Article  PubMed  Google Scholar 

  24. Völzke H, Baumeister SE, Alte D et al. (2005) Independent risk factors for gallstone formation in a region with high cholelithiasis prevalence. Digestion 71: 97–105

    Article  PubMed  Google Scholar 

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  1. Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Deutschland

    F. Lammert & T. Sauerbruch

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  1. F. Lammert
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  2. T. Sauerbruch
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Correspondence to F. Lammert.

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Lammert, F., Sauerbruch, T. Gallensteine. Gastroenterologe 2, 461–476 (2007). https://doi.org/10.1007/s11377-007-0119-0

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  • DOI: https://doi.org/10.1007/s11377-007-0119-0

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