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Management der dekompensierten Leberzirrhose auf der Intensivstation

  • O. Lerschmacher
  • A. Koch
  • K. Streetz
  • C. Trautwein
  • F. TackeEmail author
Leitthema

Zusammenfassung

Die Leberzirrhose ist die Endstrecke chronischer meist über Jahrzehnte verlaufender Lebererkrankungen. Komplikationen der Leberzirrhose haben ein hohes Letalitätsrisiko, aber ihre Prognose lässt sich durch optimales intensivmedizinisches Management erheblich verbessern. Bei Erstdiagnose und bei Dekompensation sind strukturierte diagnostische Maßnahmen erforderlich, um die Ätiologie zu erkennen und Komplikationen nachzuweisen. Die akute Varizenblutung wird durch endoskopische Intervention, vasoaktive Substanzen, Antibiotika, supportive intensivmedizinische Behandlung und ggf. durch einen im Notfall eingesetzten transjugulären intrahepatischen portosystemischen Shunt (TIPS) behandelt. Bei Aszites muss eine spontane bakterielle Peritonitis ausgeschlossen bzw. unmittelbar antibiotisch behandelt werden. Bei hepatorenalem Syndrom ist die Kombinationstherapie aus Vasokonstriktoren und Humanalbumin etabliert. Differenzialdiagnosen bei respiratorischer Insuffizienz umfassen neben Pneumonie, Lungenembolie oder kardialer Dekompensation auch das hepatopulmonale Syndrom, die portopulmonale Hypertonie oder den hepatischen Hydrothorax. Bei dekompensierter Leberzirrhose ist stets die Indikation und Möglichkeit der Lebertransplantation zu evaluieren. Leberersatzverfahren haben derzeit höchstens eine Rolle als Überbrückungsverfahren bis zur definitiven Transplantation.

Schlüsselwörter

Portale Hypertension Hämorrhagie Aszites Hepatische Enzephalopathie Hepatorenales Syndrom 

Management of decompensated liver cirrhosis in the intensive care unit

Abstract

Liver cirrhosis is the end-stage of long-standing chronic liver diseases. The occurrence of complications from liver cirrhosis increases the mortality risk, but the prognosis can be improved by optimal management in the intensive care unit (ICU). Defined diagnostic algorithms allow the etiology and presence of typical complications upon presentation to the ICU to be identified. Acute variceal bleeding requires endoscopic intervention, vasoactive drugs, antibiotics, supportive intensive care measures and, where necessary, urgent transjugular intrahepatic portosystemic shunt (TIPS) procedure. Spontaneous bacterial peritonitis needs to be diagnosed and immediately treated in patients with ascites. Hepatorenal syndrome should be treated by albumin and terlipressin. In case of respiratory failure, differential diagnosis should not only consider pneumonia, pulmonary embolism and cardiac failure, but also hepatic hydrothorax, portopulmonary hypertension and hepatopulmonary syndrome. The feasibility of liver transplantation should be always discussed in patients with decompensated cirrhosis. Artificial liver support devices may only serve as a bridging procedure until transplant.

Keywords

Hypertension, portal Hemorrhage Ascites Hepatic encephalopathy Hepatorenal syndrome 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt. O. Lerschmacher, A. Koch und K. Streetz geben an, dass kein Interessenkonflikt besteht. C. Trautwein erhielt Vortragshonorare von den Firmen Gilead, Bristol-Myers Squibb, Roche, Falk, MSD Sharp & Dohme und Janssen. F. Tacke erhielt Vortragshonorare von den Firmen Gilead, Bristol-Myers Squibb, Roche, Falk, MSD Sharp & Dohme und Janssen.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • O. Lerschmacher
    • 1
  • A. Koch
    • 1
  • K. Streetz
    • 1
  • C. Trautwein
    • 1
  • F. Tacke
    • 1
    Email author
  1. 1.Medizinische Klinik IIIUniversitätsklinikum RWTH-AachenAachenDeutschland

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