Zusammenfassung
In der Schwangerschaft kommt es durch einen Anstieg von Östrogenen und Progesteron zu einer erhöhten Lithogenität der Galle mit Inzidenzzunahme von Gallenblasensteinen (bis etwa 12 %) und -sludge (bis etwa 30 %). Von den betroffenen Schwangeren entwickeln aber nur etwa 1–3 % Beschwerden. Eine symptomatische Cholelithiasis (Gallenkolik, akute Cholezystitis, Choledocholithiasis, Cholangitis und biliäre Pankreatitis) bedeutet ein relevantes Morbiditäts- und ggf. auch Mortalitätsrisiko für die werdende Mutter und den Fötus und stellt die Behandler (Gastroenterologen, Gynäkologen, Viszeralchirurgen) immer wieder vor schwierige diagnostische und therapeutische Entscheidungen. Die supportive medikamentöse Therapie der symptomatischen Cholelithiasis unterscheidet sich nicht wesentlich von der bei Nichtschwangeren. Risikokategorien der Food and Drug Administration (FDA) zum Medikamenteneinsatz und die umfangreiche Online-Datenbank Embryotox erweisen sich hierbei als sehr hilfreich, die supportive Therapie effektiv umzusetzen. Zusätzlich wird bei symptomatischer Cholelithiasis zunehmend ein frühzeitiges chirurgisches Vorgehen, vorzugsweise im 2. Trimenon, empfohlen. Diese Kursänderung beruht vor allem auf dem Wissen um eine hohe Rezidiv- und Progressrate der symptomatischen Cholelithiasis bei rein konservativem Vorgehen und dem gegenüber einer chirurgischen Therapie assoziierten höheren Risiko für Frühgeburtlichkeit und der Notwendigkeit zur vorzeitigen Geburtseinleitung.
Abstract
There is a high incidence of gallstones (up to 12%) and sludge (up to 30%) in pregnant women due to the lithogenic effect of increasing estrogen and progesterone levels throughout pregnancy. Symptomatic gallstone-related disease, which is believed to occur in 1–3% of affected women, is associated with a relevant risk for morbidity and consequently mortality concerning the expectant mothers and their fetuses requiring challenging diagnostic and therapeutic decisions from the involved physicians (gastroenterologists, obstetricians, surgeons). Supportive drug therapy for symptomatic gallstone disease does not substantially differ from that initiated in non-pregnant patients. Risk categories of the Food and Drug Administration (FDA) for drug therapy in pregnancy as well as the online platform embryotox.de represent valuable tools for choosing the appropriate medication. Current studies demonstrate a high relapse and progression rate of symptomatic cholelithiasis managed conservatively. In addition, some studies showed a higher rate of preterm deliveries and induction of labor associated with conservative treatment compared to surgical therapy. Therefore there is a growing consensus favouring an early laparoscopic cholecystectomy for symptomatic gallstone disease, preferably within the second trimester.
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S. Bremer und B. Terjung geben an, dass kein Interessenkonflikt besteht.
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F. Lammert, Homburg
A. Meining, Ulm
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Bremer, S., Terjung, B. Gallenkoliken. Gastroenterologe 13, 36–44 (2018). https://doi.org/10.1007/s11377-018-0228-y
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DOI: https://doi.org/10.1007/s11377-018-0228-y