Summary
The importance of the gastro-intestinal system has been neglected for a long time in critically ill patients. Fine and advanced contemporary hypotheses on the role of the gut as the main driver in critical illness, or an undrained abscess in multiple organ failure, or the central organ of surgical stress, however, have changed this view fundamentally. Considering that the gut with its intestinal mucosa, mesenteric lymph nodes and the associated liver is the largest immunologic system of the human organism, its importance in critically ill has become obvious. Acute intraabdominal diseases, sepsis, trauma, mechanical ventilation, drugs or lack of enteral feeding may lead to the clinical picture of mechanical or paralytic ileus or to complete gut failure. On the other hand, a poorly perfused or paralytic gut may induce or enhance sepsis or septic shock, probably via microbial translocation from the intestinal lumen over an altered intestinal barrier. Furthermore, the abdominal compartment syndrome defined by a sustained intraabdominal hypertension results in poor cardiac output, oliguria and atelectasis in the lung associated with impaired respiratory mechanics.
In this short review, we discuss the interactions between the diseased gut and systemic inflammation and infection as well as some important therapeutic principles like pharmacologic modulation of the splanchnic perfusion, early enteral nutrition, and enterocyte specific substrates (glutamine). Another focus lies on the effects of prokinetic drugs like erythromycin, metoclopramide, and parasympthomimetics on gastric, small and large bowel movement. In surgical patients the use of continuous epidural analgesia via a thoracic or lumbar epidural catheter seems to lower the rate of postoperative ileus significantly when compared to conventional analgesia by opiates. Epidural analgesia elegantly combines sufficient analgesia and sympatholysis, which results in an earlier recovery of small and large bowel movements. The life-threatening abdominal compartment syndrome, which may follow severe abdominal trauma, rupture of the abdominal aorta or ileus, is a further important aspect in the management of critically ill patients. When the condition is severe, verified by some objective measurements of the intraabdominal pressure, surgical abdominal decompression is required.
Zusammenfassung
Der Gastrointestinaltrakt mit der Aufgabe des Nahrungstransports, der Nährstoff-, Wasser- und Elektrolytresorption und der Elimination unverdaulicher Nahrungsbestandteile, stellt aufgrund seiner Barrierefunktion zwischen innerem und äußerem Milieu und dem damit einhergehendem permanenten Antigenreiz das größte immunologische Organ des Organismus dar. Akute Erkrankungen des Abdomens, Sepsis, Beatmung oder Medikamente können zum Bild des mechanischen oder paralytischen Ileus oder bis hin zum manifesten Darmversagen führen, respektive kann eine gestörte gastrointestinale Funktion systemischen Entzündungsreaktionen (SIRS, Sepsis) induzieren oder unterhalten.
In dieser Übersichtsarbeit werden die pathophysiologischen Zusammenhänge des Darmversagens beim Intensivpatienten kurz erläutert, wobei insbesondere auf die Wechselwirkungen zwischen Darmversagen und systemischer Inflammation und Infektion fokussiert wird. Auf dieser Basis werden medikamentöse Therapieansätze (z. B. Perfusionssteigerung, Prokinetika, Periduralanalgesie), sowie nutritive Maßnahmen (frühe enterale Ernährung, Glutamin) zur Behandlung des Darmversagens kritisch diskutiert. Ein weiterer Schwerpunkt liegt auf der Beeinflussung der intestinalen Peristaltik durch Prokinetika und kontinuierliche Katheterperiduralanalgesie beim Intensivpatienten und bei Patienten mit ausgedehnten abdominellen chirurgischen Eingriffen („postoperativer Ileus“). Das lebensbedrohliche abdominelle Kompartmentsyndrom, meist hervorgerufen durch schweres abdominelles Trauma, Aortenruptur oder Ileus stellt einen eigenständigen Symptomenkomplex dar. Typischerweise kommt es hier zu einer Reduktion der Perfusion im Splanchnikusgebiet, zur Oligo-Anurie, und zur Atelektasenbildung in der Lunge mit respiratorischer Insuffizienz. Klinische Zeichen und eine objektive Messung des intraabdominellen Drucks sind die Voraussetzung für eine chirurgische Dekompression. Ergänzt werden die Strategien zur Behandlung des akuten Darmversagens durch Aspekte und Hinweise für die klinische Praxis.
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Serie: Die Intensivtherapie bei Sepsis und Multiorganversagen Herausgegeben von L. Engelmann (Leipzig)
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Ragaller, M., Gottschlich, B. Akutes Darmversagen in der Intensivmedizin—. Intensivmed 42, 627–638 (2005). https://doi.org/10.1007/s00390-005-0528-6
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DOI: https://doi.org/10.1007/s00390-005-0528-6
Key words
- Gut failure
- monitoring of the gastrointestinal function
- splanchnic perfusion
- early enteral nutrition
- prokinetic drugs
- peridural analgesia
- abdominal comparment syndrome