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Klinisches Management der akuten Pankreatitis

Clinical management of acute pancreatitis

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Zusammenfassung

Die akute Pankreatitis (AP) hat eine Inzidenz von jährlich 30–45 pro 100.000 Einwohner. In Deutschland sind mehr als 2 Drittel der Fälle biliärer oder alkoholischer Genese. Seltener ist die AP iatrogen, metabolisch, genetisch oder maligne verursacht. Die Diagnosestellung erfolgt bei Vorhandensein des typischen epigastrischen Schmerzes mit Ausstrahlung in den Rücken und einer dreifachen Enzymerhöhung (Lipase oder Amylase) im Serum. Nur selten muss zur Diagnosestellung ein bildgebendes Verfahren hinzugezogen werden. Eine frühe Risikoerfassung ist wichtig, um Patienten mit schwerer AP (Mortalität bis über 40 %) rechtzeitig intensiv zu überwachen. Prognostisch ungünstig sind eine Erhöhung von Harnstoff-/Blutharnstoff-Stickstoff (BUN) im Serum, Hämatokrit und Blutzucker. Daneben werden verschiedene Scores zur Einschätzung des Krankheitsverlaufs eingesetzt. Die Atlanta-Klassifikation dient der Schweregradeinteilung. Die einzig kausale Therapie ist die Entfernung eines impaktierten Gallensteines bei der biliären AP mittels endoskopischer retrograder Cholangiographie. Unter den symptomatischen Maßnahmen stehen die Schmerztherapie und die Flüssigkeitssubstitution im Vordergrund. Zur Analgesie werden überwiegend Opiate eingesetzt. Die Periduralanästhesie ist auf Intensivpatienten beschränkt. In der Frühphase der AP sollte eine kristalloide Volumenzufuhr durchgeführt werden. Zur Steuerung steht neben der Echokardiographie ein erweitertes hämodynamisches Monitoring zur Verfügung. Die Ernährung sollte frühzeitig enteral erfolgen. Auch bei Nachweis von Verhalten und Nekrosen in der Bildgebung wurde das primär chirurgische Vorgehen zugunsten eines interventionellen „step-up“ verlassen. Die Chirurgie bleibt eine Therapieoption bei Komplikationen sowie bei anderweitig nicht erreichbaren infizierten Nekrosen.

Abstract

The incidence of acute pancreatitis (AP) is 30–45 cases per 100,000 person–years. In Germany, more than two-thirds of cases are caused by gallstones or alcohol. Iatrogenic, metabolic or malignant etiologies are markedly less frequent. Diagnosis is established based on the typical epigastric pain radiating to the back and a three-fold increase in serum lipase or amylase. In case of doubt, sonographic or radiological findings support the diagnosis. Early risk assessment is crucial to optimize therapy in patients with severe AP which carries a mortality of up to 40%. Early predictors of outcome are blood urea nitrogen (BUN), hematocrit or blood glucose. Various scores are used for risk assessment. The severity of AP on long-term-course is classified according to the Atlanta classification. Endoscopic retrograde cholangiography (ERC) with removal of the incarcerated gallstone is the only causal therapy. Symptomatic measures include pain therapy and fluid substitution. Opioids are required in most cases. Peridural anesthesia is restricted to critical care patients. Early appropriate fluid resuscitation is considered to mitigate severe courses of AP. Enteral nutrition should be provided as early as feasible. Fluid collection and necrosis should be treated by less invasive techniques such as endoscopic or percutaneous drainage and video-assisted percutaneous retroperitoneal debridement. Only if these approaches fail, or in case of complications such as intra-abdominal compartment or bleeding, is surgery recommended (“step-up” approach).

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  1. Intensivstation R3a, Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Deutschland

    W. Huber, J. Schneider, H. Algül & V. Phillip

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W. Huber ist Mitglied des Advisory Board von Pulsion Medical Systems SE, Feldkirchen. V. Phillip hat einen Beratervertrag mit der Firma Nordmark. J. Schneider und H. Algül haben keinen Interessenkonflikt.

Für diesen Beitrag wurden vom Autor keine Studien an Menschen oder Tieren durchgeführt. Für die im Beitrag zitierten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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M. Fried, Zürich

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Huber, W., Schneider, J., Algül, H. et al. Klinisches Management der akuten Pankreatitis. Gastroenterologe 13, 412–424 (2018). https://doi.org/10.1007/s11377-018-0302-5

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