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Die Intensivgallenblase als Schockorgan

Symptome und Therapie

The intensive care gallbladder as shock organ

Symptoms and therapy

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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Literatur

  1. Ahvenjarvi L, Koivukangas V, Jartti A et al (2011) Diagnostic accuracy of computed tomography imaging of surgically treated acute acalculous cholecystitis in critically ill patients. J Trauma 70(1):183–188

    PubMed  Article  Google Scholar 

  2. Avalos ME, Cerulli MA, Lee RS (1992) Acalculous acute cholecystitis due to Salmonella typhi. Dig Dis Sci 37(11):1772–1775

    PubMed  Article  CAS  Google Scholar 

  3. Barie PS (1993) Acalculous and postoperative cholecystitis. In: Barie PS, Shires GT (Hrsg) Surgical intensive care. Little, Brown, Boston, pp 837–857

  4. Barie PS, Eachempati SR (2003) Acute acalculous cholecystitis. Curr Gastroenterol Rep 5(4):302–309

    PubMed  Article  Google Scholar 

  5. Becker CG, Dubin T, Glenn F (1980) Induction of acute cholecystitis by activation of factor XII. J Exp Med 151(1):81–90

    PubMed  Article  CAS  Google Scholar 

  6. Boland GW, Slater G, Lu DS et al (2000) Prevalence and significance of gallbladder abnormalities seen on sonography in intensive care unit patients. Am J Roentgenol 174(4):973–977

    Article  CAS  Google Scholar 

  7. Borzellino G, Sauerland S, Minicozzi AM et al (2008) Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results. Surg Endosc 22(1):8–15

    PubMed  Article  Google Scholar 

  8. Campanile FC, Catena F, Coccolini F et al (2011) The need for new „patient-related“ guidelines for the treatment of acute cholecystitis. World J Emerg Surg 6(1):44. doi:10.1186/1749–7922-6-44

    PubMed  Article  Google Scholar 

  9. Caputo P, Rossi G, Faccini M, Carzaniga P (2009) Overcoming of a „surgical dogma“ in acute cholecystitis treated in postponed emergency. Ann Ital Chir 80(4):287–292

    PubMed  Google Scholar 

  10. Chung YH, Choi ER, Kim KM et al (2012) Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis? J Clin Gastroenterol 46(3):216–219

    PubMed  Article  Google Scholar 

  11. Falor AE, Zobel M, Kaji A et al (2012) Admission variables predictive of gangrenous cholecystitis. Am Surg 78(10):1075–1078

    PubMed  Google Scholar 

  12. Ginat D, Saad WE (2008) Cholecystostomy and transcholecystic biliary access. Tech Vasc Interv Radiol 11(1):2–13

    PubMed  Article  Google Scholar 

  13. Griniatsos J, Petrou A, Pappas P et al (2008) Percutaneous cholecystostomy without interval cholecystectomy as definitive treatment of acute cholecystitis in elderly and critically ill patients. South Med J 101(6):586–590

    PubMed  Article  Google Scholar 

  14. Gurusamy KS, Samraj K (2006) Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev (4):CD005440

    Google Scholar 

  15. Ha JP, Tsui KK, Tang CN et al (2008) Cholecystectomy or not after percutaneous cholecystostomy for acute calculous cholecystitis in high-risk patients. Hepatogastroenterology 55(86–87):1497–1502

    Google Scholar 

  16. Hamp T, Fridrich P, Mauritz W et al (2009) Cholecystitis after trauma. J Trauma 66(2):400–406

    PubMed  Article  Google Scholar 

  17. Han IW, Jang JY, Kang MJ et al (2012) Early versus delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage. J Hepatobiliary Pancreat Sci 19(2):187–193

    PubMed  Article  Google Scholar 

  18. Hegazi RA, Wischmeyer PE (2011) Clinical review: optimizing enteral nutrition for critically ill patients–a simple data-driven formula. Crit Care 15(6):234

    PubMed  Article  Google Scholar 

  19. Huffman JL, Schenker S (2010) Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol 8(1):15–22

    PubMed  Article  Google Scholar 

  20. Ganpathi IS, Diddapur RK, Eugene H, Karim M (2007) Acute acalculous cholecystitis: challenging the myths. HPB (Oxford) 9(2):131–134

  21. Itoi T, Sofuni A, Itokawa F et al (2008) Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in whom percutaneous transhepatic approach is contraindicated or anatomically impossible (with video). Gastrointest Endosc 68(3):455–460

    PubMed  Article  Google Scholar 

  22. Itoi T, Coelho-Prabhu N, Baron TH (2010) Endoscopic gallbladder drainage for management of acute cholecystitis. Gastrointest Endosc 71(6):1038–1045

    PubMed  Article  Google Scholar 

  23. Janowitz P, Kratzer W, Zemmler T et al (1994) Gallbladder sludge: spontaneous course and incidence of complications in patients without stones. Hepatology 20(2):291–294

    PubMed  Article  CAS  Google Scholar 

  24. Johnson EE, Hedley-Whyte J (1975) Continuous positive-pressure ventilation and choledochoduodenal flow resistance. J Appl Physiol 39(6):937–942

    PubMed  CAS  Google Scholar 

  25. Joseph T, Unver K, Hwang GL et al (2012) Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol 23(1):83–88.e1

    PubMed  Article  Google Scholar 

  26. Kalliafas S, Ziegler DW, Flancbaum L, Choban PS (1998) Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. Am Surg 64(5):471–475

    PubMed  CAS  Google Scholar 

  27. Kamimura T, Mimori A, Takeda A et al (1998) Acute acalculous cholecystitis in systemic lupus erythematosus: a case report and review of the literature. Lupus 7(5):361–363

    PubMed  Article  CAS  Google Scholar 

  28. Kaminski DL, Feinstein WK, Deshpande YG (1994) The production of experimental cholecystitis by endotoxin. Prostaglandins 47(3):233–245

    PubMed  CAS  Google Scholar 

  29. Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E (1998) Randomized trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 351:321–325

    PubMed  Article  CAS  Google Scholar 

  30. Kubota K, Abe Y, Inamori M et al (2005) Percutaneous transhepatic gallbladder stenting for recurrent acute acalculous cholecystitis after failed endoscopic attempt. J Hepatobiliary Pancreat Surg 12(4):286–289

    PubMed  Article  Google Scholar 

  31. Lichtenstein DA (2007) Point-of-care ultrasound: infection control in the intensive care unit. Crit Care Med 35(5):S262–S267

    PubMed  Article  Google Scholar 

  32. Limdi JK, Hyde GM (2003) Evaluation of abnormal liver function tests. Postgrad Med J 79(932):307–312

    PubMed  Article  CAS  Google Scholar 

  33. Low SW, Iyer SG, Chang SK et al (2009) Laparoscopic cholecystectomy for acute cholecystitis: safe implementation of successful strategies to reduce conversion rates. Surg Endosc 23:2424–2429

    PubMed  Article  Google Scholar 

  34. Mariat G, Mahul P, Prév t N et al (2000) Contribution of ultrasonography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients. Intensive Care Med 26(11):1658–1663

    PubMed  Article  CAS  Google Scholar 

  35. Melloul E, Denys A, Demartines N et al (2011) Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter? World J Surg 35(4):826–833

    PubMed  Article  CAS  Google Scholar 

  36. Mirvis SE, Vainright JR, Nelson AW et al (1986) The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. Am J Roentgenol 147(6):1171–1175

    Article  CAS  Google Scholar 

  37. Mirvis SE, Whitley NO, Miller JW (1987) CT diagnosis of acalculous cholecystitis. J Comput Assist Tomogr 11(1):83–87

    PubMed  Article  CAS  Google Scholar 

  38. Molenat F, Boussuges A, Valantin V, Sainty JM (1996) Gallbladder abnormalities in medical ICU patients: an ultrasonographic study. Intensive Care Med 22(4):356–358

    PubMed  Article  CAS  Google Scholar 

  39. Morse BC, Smith JB, Lawdahl RB, Roettger RH (2010) Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg 76(7):708–712

    PubMed  Google Scholar 

  40. Mutlu GM, Mutlu EA, Factor P (2001) GI complications in patients receiving mechanical ventilation. Chest 119(4):1222–1241

    PubMed  Article  CAS  Google Scholar 

  41. Myrianthefs P, Evodia E, Vlachou I et al (2012) Is routine ultrasound examination of the gallbladder justified in critical care patients? Crit Care Res Pract 2012:565617

    PubMed  Google Scholar 

  42. Nikfarjam M, Niumsawatt V, Sethu A et al (2011) Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis. HPB (Oxford) 13(8):551–558

    Google Scholar 

  43. Pelinka LE, Schmidhammer R, Hamid L et al (2003) Acute acalculous cholecystitis after trauma: a prospective study. J Trauma 55(2):323–329

    PubMed  Article  Google Scholar 

  44. Pitt HA, King W 3rd, Mann LL et al (1983) Increased risk of cholelithiasis with prolonged total parenteral nutrition. Am J Surg 145(1):106–112

    PubMed  Article  CAS  Google Scholar 

  45. Puc MM, Tran HS, Wry PW, Ross SE (2002) Ultrasound is not a useful screening tool for acute acalculous cholecystitis in critically ill trauma patients. Am Surg 68(1):65–69

    PubMed  Google Scholar 

  46. Ryu JK, Ryu KH, Kim KH (2003) Clinical features of acute acalculous cholecystitis. J Clin Gastroenterol 36(2):166–169

    PubMed  Article  Google Scholar 

  47. Savoca PE, Longo WE, Zucker KA et al (1990) The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study. Ann Surg 211(4):433–437

    PubMed  Article  CAS  Google Scholar 

  48. Shea JA, Berlin JA, Escarce JJ et al (1994) Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 154(22):2573–2581

    PubMed  Article  CAS  Google Scholar 

  49. Spira RM, Nissan A, Zamir O et al (2002) Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg 183(1):62–66

    PubMed  Article  Google Scholar 

  50. Theodorou P, Maurer CA, Spanholtz TA et al (2009) Acalculous cholecystitis in severely burned patients: incidence and predisposing factors. Burns 35(3):405–411

    PubMed  Article  CAS  Google Scholar 

  51. Taoka H (1991) Experimental study on the pathogenesis of acute acalculous cholecystitis, with special reference to the roles of microcirculatory disturbances, free radicals and membrane-bound phospholipase A2. Gastroenterol Jpn 26(5):633–644

    PubMed  CAS  Google Scholar 

  52. Trowbridgski RL, Rutkowski NK, Shojania KG (2003) Does this patient have acute cholecystitis? JAMA 289(1):80–86

    Article  Google Scholar 

  53. Tulchinsky M, Ziessman HA, Maurer AH (2012) Current standard technique for cholecystokinin cholescintigraphy. Am J Roentgenol 198(1):W93 (author reply W94)

    Article  Google Scholar 

  54. Breda Vriesman AC van, Engelbrecht MR, Smithuis RH, Puylaert JB (2007) Diffuse gallbladder wall thickening: differential diagnosis. Am J Roentgenol 188(2):495–501

    Article  Google Scholar 

  55. Venkataramani A, Strong RM, Anderson DS et al (1998) Abnormal duodenal bile composition in patients with acalculous chronic cholecystitis. Am J Gastroenterol 93(3):434–441

    PubMed  Article  CAS  Google Scholar 

  56. Wang AJ, Wang TE, Lin CC et al (2003) Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis. World J Gastroenterol 9(12):2821–2823

    PubMed  Google Scholar 

  57. Weissmann HS, Berkowitz D, Fox MS et al (1983) The role of technetium-99m iminodiacetic acid (IDA) cholescintigraphy in acute acalculous cholecystitis. Radiology 146(1):177–180

    PubMed  CAS  Google Scholar 

  58. Yamashita Y, Takada T, Kawarada Y et al (2007) Surgical treatment of patients with acute cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg 14(1):91–97

    PubMed  Article  Google Scholar 

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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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  • DOI: https://doi.org/10.1007/s00104-012-2358-y

Schlüsselwörter

  • Akute Cholezystitis
  • Diagnosesicherung
  • Cholezystektomie
  • Laparoskopisches Vorgehen
  • Endoskopische transpapilläre Gallengangsdrainageneinlage

Keywords

  • Acute cholecystitis
  • Diagnosis
  • Cholecystectomy
  • Laparascopic approach
  • Endoscopic transpapillary gallbladder duct drainage