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Diagnostik und Therapie der akuten Pankreatitis

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Diagnosis and treatment of acute pancreatitis

Current recommendations

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Zusammenfassung

Die akute Pankreatitis ist potenziell lebensbedrohlich. Durch den z. T. fulminanten Verlauf ist das Zeitfenster für Diagnostik und Therapie kurz. Unter Berücksichtigung aktueller Leitlinien und mit Hilfe einer elektronischen Literatursuche wurden 12 Schlüsselfragen der Diagnostik und Therapie der akuten Pankreatitis zu beantworten versucht: Die Diagnose kann allein durch Anamnese, Klinik und Serumlipasebestimmung gestellt werden. Zum Nachweis einer biliären Genese sind Cholestaseparameter und Oberbauchsonographie ausreichend. Für die frühe Prognose eines schweren Verlaufs sind die Erhöhung von Blutzucker, Hämatokrit (Hkt) und Harnstoff (BUN, „blood urea nitrogen“) wegweisend. Die Bedeutung von erhöhtem Hkt und BUN legt eine frühe zielgerichtete Volumensubstitution nahe. Zur Schmerztherapie sind meist Opiate erforderlich. Metaanalysen belegen therapeutische Effekte der ERC (endoskopische retrograde Cholangiographie) bei biliärer Pankreatitis, der Antibiose bei nekrotisierender Pankreatitis und der frühzeitigen enteralen Ernährung. Auch beim Nachweis von Nekrosen ist ein konservatives Vorgehen gerechtfertigt. Bleibt dieses erfolglos, kann die chirurgische Therapie sinnvoll sein.

Abstract

Acute pancreatitis is a potentially life-threatening illness, with a short time frame for diagnosis and treatment. A number of recent experimental and clinical multicentre trials as well as meta-analyses have provided more far-reaching recommendations compared to previous guidelines. To answer 12 key questions, we performed a review of recent literature and current guidelines. Diagnosis can be made on the basis of history, physical examination and serum lipase alone. Cholestatic parameters and upper abdominal ultrasound enable verification of biliary etiology. Poor prognostic indicators include elevated blood sugar, BUN and hematocrit. The latter suggests early, adequate volume replacement, which should be tailored to the clinical picture, echocardiography and/or modern hemodynamic parameters. In addition to opiate analgesia, meta-analyses support the use of endoscopic retrograde cholangiography in pancreatitis of biliary origin, antibiotics in necrotizing pancreatitis and early enteral feeding. Even where necrosis is present, conservative management (radiologically or endoscopically placed drains) is appropriate.

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Literatur

  1. Abou-Assi S, Craig K, O’Keefe SJ (2002) Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 97(9):2255–2262

    Article  PubMed  Google Scholar 

  2. Arvanitakis M, Delhaye M, De Maertelaere V et al (2004) Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 126:715–723

    Article  PubMed  Google Scholar 

  3. Ayub K, Imada R, Slavin J (2004) Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev 18:CD003630

    Google Scholar 

  4. Bagshaw SM, Ghali WA (2005) Theophylline for prevention of contrast-induced nephropathy: a systematic review and meta-analysis. Arch Intern Med 165:1087–1093

    Article  PubMed  Google Scholar 

  5. Balthazar EJ (2002) Complications of acute pancreatitis: clinical and CT evaluation. Radiol Clin North Am 40:1211–1227

    Article  PubMed  Google Scholar 

  6. Banks PA, Freeman ML, The Practice Parameters Committee of the American College of Gastroenterology (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101:2379–2400

    Article  PubMed  Google Scholar 

  7. Baron TH, Thaggard WG, Morgan DE, Stanley RJ (1996) Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 111:755–756

    Article  PubMed  CAS  Google Scholar 

  8. Besselink MG, Santvoort HC van, Buskens E et al (2008) Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 371:651–659

    Article  PubMed  Google Scholar 

  9. Bradley EL 3rd, Allen K (1991) A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis. Am J Surg 161:19–25

    Article  PubMed  Google Scholar 

  10. Brown A, Orav J, Banks PA (2000) Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas 20:367–372

    Article  PubMed  CAS  Google Scholar 

  11. Brown A, Baillargeon JD, Hughes MD, Banks PA (2002) Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis? Pancreatology 2:104–107

    Article  PubMed  CAS  Google Scholar 

  12. Brunkhorst FM, Engel C, Bloos F et al (2008) Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358:125–139

    Article  PubMed  CAS  Google Scholar 

  13. Buechler MW, Gloor B, Muller CA et al (2000) Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 232:619–626

    Article  Google Scholar 

  14. Dellinger EP, Tellado JM, Soto NE et al (2007) Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg 245:674–683

    Article  PubMed  Google Scholar 

  15. Dervenis C, Johnson CD, Bassi C (1999) Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini Consensus Conference. Int J Pancreatol 25:195–210

    PubMed  CAS  Google Scholar 

  16. Eatock FC, Chong P, Menezes N et al (2005) A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol 100(2):432–439

    Article  PubMed  CAS  Google Scholar 

  17. Fan ST, Lai EC, Mok FP et al (1993) Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 328:228–232

    Article  PubMed  CAS  Google Scholar 

  18. Foelsch UR, Nitsche R, Ludtke R et al (1997) Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis. N Engl J Med 336:237–242

    Article  Google Scholar 

  19. Forsmark CE, Baillie J (2007) AGA institute technical review on acute pancreatitis. Gastroenterology 132:2022–2044

    Article  PubMed  CAS  Google Scholar 

  20. Freeny PC, Hauptmann E, Althaus SJ et al (1998) Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol 170:969–975

    PubMed  CAS  Google Scholar 

  21. Fritz S, Hartwig W, Lehmann R et al (2008) Prophylactic antibiotic treatment is superior to therapy on-demand in experimental necrotising pancreatitis. Crit Care 12:R141

    Article  PubMed  Google Scholar 

  22. Gardner TB, Vege SS, Chari ST et al (2009) Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 9:770–776

    Article  PubMed  Google Scholar 

  23. Goepfert MSG, Reuter DA, Akyol D et al (2007) Goal-directed fluid management reduces vassopressor and catecholamine use in cardiac surgery patients. Intensive Care Med 33:96–103

    Article  PubMed  Google Scholar 

  24. Gumaste VV, Roditis N, Mehta D et al (1993) Serum lipase levels in nonpancreatic abdominal pain versus acute pancreatitis. Am J Gastroenterol 88:2051–2055

    PubMed  CAS  Google Scholar 

  25. Harrison DA, D’Amico G, Singer M (2007) The pancreatitis outcome prediction (POP) score: a new prognostic index for patients with severe acute pancreatitis. Crit Care Med 35:1703–1708

    Article  PubMed  Google Scholar 

  26. Heinrich S, Schäfer M, Rousson V, Clavien PA (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154–168

    Article  PubMed  Google Scholar 

  27. Huber W, Eckel F, Hennig M et al (2006) Prophylaxis of contrast-induced nephropathy in ICU-patients: acetylcysteine, theophylline or both? A randomised study. Radiology 239:793–804

    Article  PubMed  Google Scholar 

  28. Huber W, Schmid RM (2007) Akute Pankreatitis: Evidenzbasierte Diagnostik und Therapie. Dtsch Arztebl 104:A-1832/B-1615/C-1555

    Google Scholar 

  29. Huber W, Umgelter A, Schuster T, Schmid RM (2007) The pancreatitis outcome prediction (POP) score: how about hematocrit and leukopenia? Crit Care Med 35:2670–2671

    Article  PubMed  Google Scholar 

  30. Huber W, Umgelter A, Reindl W et al (2008) Volume assessment in patients with necrotizing pancreatitis: a comparison of intrathoracic blood volume index, central venous pressure, and hematocrit, and their correlation to cardiac index and extravascular lung water index. Crit Care Med 36:2348–2354

    Article  PubMed  Google Scholar 

  31. Huber W, Rockmann F (2008) Invasive und nichtinvasive Möglichkeiten des haemodynamischen Monitorings. Intensivmed 45:337–359

    Article  Google Scholar 

  32. Huber W, Schmid RM (2010) Prognose und Monitoring bei akuter Pankreatitis. Intensivmed Notfallmed 47:243–250

    Article  Google Scholar 

  33. Kahl S, Zimmermann S, Pross M et al (2004) Procaine hydrochloride fails to relieve pain in patients with acute pancreatitis. Digestion 69:2–4

    Article  Google Scholar 

  34. Isenmann R, Runzi M, Kron M et al (2004) Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology 126:997–1004

    Article  PubMed  CAS  Google Scholar 

  35. Jakobs R, Adamek MU, Bubnoff AC von, Riemann JF (2002) Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study. Scand J Gastroenterol 35:1319–1323

    Google Scholar 

  36. Kalfarentzos F, Kehagias J, Mead N et al (1997) Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 84:1665–1669

    Article  PubMed  CAS  Google Scholar 

  37. Keim V, Teich N, Fiedler F et al (1998) A comparison of lipase and amylase in the diagnosis of acute pancreatitis in patients with abdominal pain. Pancreas 16:45–49

    Article  PubMed  CAS  Google Scholar 

  38. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829

    Article  PubMed  CAS  Google Scholar 

  39. Kumar A, Anel R, Bunnell E et al (2004) Pulmonary arterial occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 32:691–699

    Article  PubMed  Google Scholar 

  40. Lankisch PG, Burchard-Reckert S, Lehnick D (1999) Underestimation of acute pancreatitis: patients with only a small increase in amylase/lipase levels can also have or develop severe acute pancreatitis. Gut 44(4):542–544

    Article  PubMed  CAS  Google Scholar 

  41. Lankisch PG, Mahlke R, Blum T et al (2001) Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol 96:2081–2085

    Article  PubMed  CAS  Google Scholar 

  42. Lankisch PG, Blum T, Bruns A et al (2001) Has blood glucose level measured on admission to hospital in a patient with acute pancreatitis any prognostic value? Pancreatology 1:224–229

    Article  PubMed  CAS  Google Scholar 

  43. Lankisch PG, Assmus C, Maisonneuve P et al (2002) Epidemiology of pancreatic diseases in Lüneburg county. A study in a defined German population. Pancreatology 2:469–477

    Article  PubMed  CAS  Google Scholar 

  44. Lankisch PG, Warnecke B, Bruns D et al (2002) The APACHE II score is unreliable to diagnose necrotizing pancreatitis on admission to hospital. Pancreas 24:217–222

    Article  PubMed  Google Scholar 

  45. Malbrain MLNG, Deeren D, De Potter TJR (2005) Intra-abdominal hypertension in the critically ill: it is time to pay attention. Curr Opin Crit Care 11:156–171

    Article  PubMed  Google Scholar 

  46. Mao EQ, Tang YQ, Fei J et al (2009) Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J (Engl) 122:169–173

    Google Scholar 

  47. Mao EQ, Fei J, Peng YB et al (2010) Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chin Med J (Engl) 123:1639–1644

    Google Scholar 

  48. Marik PE, Zaloga GP (2004) Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 328:1407

    Article  PubMed  Google Scholar 

  49. McClave SA, Greene LM, Snider HL et al (1997) Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enteral Nutr 21:14–20

    Article  PubMed  CAS  Google Scholar 

  50. Mier J, Leon EL, Castillo A et al (1997) Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 173:71–75

    Article  PubMed  CAS  Google Scholar 

  51. Moretti A, Papi C, Aratari A et al (2008) Is early endoscopic retrograde cholangiopancreatography useful in the management of acute biliary pancreatitis? A meta-analysis of randomized controlled trials. Dig Liver Dis 40:379–385

    Article  PubMed  CAS  Google Scholar 

  52. Munoz-Bongrand N, Panis Y et al (2001) Serial computed tomography is rarely necessary in patients with acute pancreatitis: a prospective study in 102 patients. J Am Coll Surg 146–152

  53. Neoptolemos JP, Carr-Locke DL, London NJ et al (1988) Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet 2(8618):979–983

    Article  PubMed  CAS  Google Scholar 

  54. Ney MV, Maluf-Filho F, Sakai Zilberstein B et al (2005) Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct. Arq Gastroenterol 42:239–243

    Article  PubMed  Google Scholar 

  55. Nowak A, Marek TA, Nowakowska-Dulawa E et al (1998) Biliary pancreatitis needs endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for cure. Endoscopy 30:A256–A259

    Article  PubMed  CAS  Google Scholar 

  56. Olah A, Pardavi G, Belagyi T et al (2002) Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition 18:259–262

    Article  PubMed  Google Scholar 

  57. Osman D, Ridel C, Ray P et al (2007) Cardiac filling pressures are not appropriate to predict haemodynamic response to volume challenge. Crit Care Med 35:64–68

    Article  PubMed  Google Scholar 

  58. Pederzoli P, Bassi C, Vesentini S, Campedelli A (1993) A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 176:480–483

    PubMed  CAS  Google Scholar 

  59. Perez A, Whang EE, Brooks DC et al (2002) Is severity of necrotizing pancreatitis increased in extended necrosis and infected necrosis? Pancreas 25:229–233

    Article  PubMed  Google Scholar 

  60. Phillip V, Huber W, Hagemes F et al (in press) Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany. Clin Gastroenterol Hepatol in press

  61. Pupelis G, Selga G, Austrums E, Kaminski A (2001) Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis. Nutrition 17:91–94

    Article  PubMed  CAS  Google Scholar 

  62. Ranson JH, Rifkind KM, Roses DF et al (1974) Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 139:69–81

    PubMed  CAS  Google Scholar 

  63. Rivers E, Nguyen B, Havstad S et al (2001) Early goal-directed therapy in treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377

    Article  PubMed  CAS  Google Scholar 

  64. Rünzi M, Layer P, Büchler MW et al (2000) Therapie der akuten Pankreatitis. Gemeinsame Leitlinien. Z Gastroenterol 38:571–581

    Article  PubMed  Google Scholar 

  65. Ruenzi M, Niebel W, Goebell H et al (2005) Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 30:195–199

    Article  Google Scholar 

  66. Sainio V, Kemppainen E, Puolakkainen P et al (1995) Early antibiotic treatment in acute necrotising pancreatitis. Lancet 346:663–667

    Article  PubMed  CAS  Google Scholar 

  67. Schwarz M, Isenmann R, Meyer H, Beger HG (1997) Antibiotic use in necrotizing pancreatitis. Results of a controlled study. Dtsch Med Wochenschr 122:356–361

    Article  PubMed  CAS  Google Scholar 

  68. Seifert H, Wehrmann T, Schmitt T et al (2000) Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 356:653–655

    Article  PubMed  CAS  Google Scholar 

  69. Sharma VK, Howden CW (1999) Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis. Am J Gastroenterol 94:3211–3214

    Article  PubMed  CAS  Google Scholar 

  70. Sharma VK, Howden CW (2001) Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas 22:28–31

    Article  PubMed  CAS  Google Scholar 

  71. Siriwardena AK, Mason JM, Balachandra S et al (2007) Randomised, double blind, placebo controlled trial of intravenous antioxidant (N-acetylcysteine, selenium, vitamin C) therapy in severe acute pancreatitis. Gut 56:1439–1444

    Article  PubMed  CAS  Google Scholar 

  72. Steinberg WM, Goldstein SS, Davis ND et al (1985) Diagnostic assays in acute pancreatitis. A study of sensitivity and specificity. Ann Intern Med 102:576–580

    PubMed  CAS  Google Scholar 

  73. Thomson HJ, Obekpa PO, Smith AN, Brydon WG (1987) Diagnosis of acute pancreatitis: a proposed sequence of biochemical investigations. Scand J Gastroenterol 22:719–724

    Article  PubMed  CAS  Google Scholar 

  74. Uhl W, Warshaw A, Imrie C et al (2002) International Association of Pancreatology. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology 2:565–573

    Article  PubMed  Google Scholar 

  75. Van Santvoort HC, Besselink MG, Vries AC de et al (2009) Dutch Acute Pancreatitis Study Group. Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg 250:68–75

    Article  Google Scholar 

  76. Van Santvoort HC, Besselink MG, Bakker OJ et al (2010) Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 362:1491–1502

    Article  Google Scholar 

  77. Vege SS, Whitcomb DC, Travis AC (2011) Clinical manifestations and diagnosis of acute pancreatitis. UpToDate

  78. Vege SS, Whitcomb DC, Travis AC (2011) Treatment of acute pancreatitis. UpToDate

  79. Villatoro E, Mulla M, Larvin M (2010) Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 12(5):CD002941

    Google Scholar 

  80. Windsor AC, Kanwar S, Li AG et al (1998) Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 42:431–435

    Article  PubMed  CAS  Google Scholar 

  81. Wu BU, Johannes RS, Sun X, Tabak Y et al (2008) The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 57:1698–1703

    Article  PubMed  CAS  Google Scholar 

  82. Wu BU, Johannes RS, Sun X et al (2009) Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology 137:129–135

    Article  PubMed  CAS  Google Scholar 

  83. Yadav D, Agarwal N, Pitchumoni CS (2002) A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol 97:1309–1318

    Article  PubMed  CAS  Google Scholar 

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  1. Intensivstation 2/11, II. Medizinische Klinik, Klinikum Rechts der Isar, Ismaningerstraße 22, 81675, München, Deutschland

    W. Huber & R.M. Schmid

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Huber, W., Schmid, R. Diagnostik und Therapie der akuten Pankreatitis. Internist 52, 823–832 (2011). https://doi.org/10.1007/s00108-010-2796-x

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