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Therapie der schweren akuten Pankreatitis

Treatment of severe acute pancreatitis

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Zusammenfassung

Bei einer Inzidenz von jährlich 30–45 pro 100.000 Einwohner ist die akute Pankreatitis (AP) in Deutschland in mehr als zwei Drittel der Fälle biliärer oder alkoholischer Genese. Daneben kann die AP iatrogen, metabolisch, genetisch oder durch einen Tumor verursacht sein. Die Diagnose stützt sich auf das Vorhandensein des typischen epigastrischen Schmerzes mit Ausstrahlung in den Rücken und die mindestens 3‑fache Erhöhung von Lipase oder Amylase im Serum. Bei schmalem „therapeutischem Fenster“ ist die frühzeitige Risikobewertung essenziell, um bei schwerer AP (Mortalität bis 42 %) rechtzeitig intensiv überwachen und therapieren zu können. Ungünstige Prognosefaktoren sind Erhöhung von Harnstoff, Hämatokrit und Blutzucker im Serum. Daneben werden verschiedene Scores eingesetzt. Zur Schweregradeinteilung im Verlauf wird die Atlanta-Klassifikation herangezogen. Die Entfernung eines impaktierten Gallensteins bei biliärer AP mittels endoskopischer retrograder Cholangiographie (ERC) ist die einzige kausale Therapie. Die ERC ist auch bei Zeichen der Cholangitis sowie bei schwerer biliärer AP indiziert. Schmerztherapie und Flüssigkeitssubstitution sind die wichtigsten symptomatischen Maßnahmen. Um extravasale Flüssigkeitsverluste auszugleichen, sollte in der Frühphase der AP eine Volumenzufuhr mit Kristalloiden erfolgen. Im Intensivsetting steht neben der Echokardiographie ein erweitertes hämodynamisches Monitoring zur zielgerichteten Volumentherapie zur Verfügung. Eine antibiotische Prophylaxe ist bei schwerer AP möglicherweise vorteilhaft. Die Ernährung sollte möglichst frühzeitig enteral erfolgen. Eine chirurgische Intervention ist Komplikationen (Blutung, abdominelles Kompartmentsyndrom) und anderweitig nicht erreichbaren infizierten Nekrosen vorbehalten.

Abstract

In Germany, acute pancreatitis (AP) has an incidence of 30–45 cases per 100,000 person–years. More than two of three 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. Early prognosis is crucial to optimize therapy in patients with severe AP with a mortality of up to 42%. Elevation of blood urea nitrogen, hematocrit or blood glucose are early predictors of poor outcome. Furthermore, various scores can be used for risk assessment. Finally, the Atlanta classification can be used to classify the long-term severity of AP. Endoscopic retrograde cholangiography (ERC) with removal of the incarcerated gallstone should be performed in case of cholangitis and/or severe biliary AP. ERC is the only causal therapy in AP. Pain management and fluid resuscitation are the most important symptomatic measures. Early goal-directed fluid resuscitation using colloids might mitigate severe courses of AP. In the critical care setting, therapy should be guided by echocardiography and advanced hemodynamic monitoring. Antibiotic prophylaxis is likely advantageous in patients with severe AP. Furthermore, enteral nutrition should be provided as early as feasible. If these approaches are not possible or in case of complications (e.g., intra-abdominal compartment syndrome or bleeding), surgery is recommended (“step-up” approach).

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Literatur

  1. Huber W, Algul H (2019) Treatment of acute necrotizing pancreatitis. Internist 60:226–234. https://doi.org/10.1007/s00108-019-0558-y

    Article  Google Scholar 

  2. Forsmark CE, Vege SS, Wilcox CM (2017) Acute Pancreatitis. N Engl J Med 376:598–599. https://doi.org/10.1056/NEJMc1616177

    Article  PubMed  Google Scholar 

  3. Phillip V et al (2011) Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany. Clin Gastroenterol Hepatol 9:995–1000.e3. https://doi.org/10.1016/j.cgh.2011.06.016

    Article  PubMed  Google Scholar 

  4. Huber W, Phillip V, Schmid R, Schneider J (2017) Acute pancreatitis: what is new? Dtsch Med Wochenschr 142:525–529. https://doi.org/10.1055/s-0042-100233

    Article  PubMed  Google Scholar 

  5. Dellinger EP et al (2012) Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg 256:875–880. https://doi.org/10.1097/SLA.0b013e318256f778

    Article  PubMed  Google Scholar 

  6. Banks PA et al (2013) Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 62:102–111. https://doi.org/10.1136/gutjnl-2012-302779

    Article  PubMed  Google Scholar 

  7. Wu BU et al (2011) Blood urea nitrogen in the early assessment of acute pancreatitis: an international validation study. Arch Intern Med 171:669–676. https://doi.org/10.1001/archinternmed.2011.126

    Article  PubMed  Google Scholar 

  8. Wu BU et al (2008) The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 57:1698–1703. https://doi.org/10.1136/gut.2008.152702

    Article  CAS  PubMed  Google Scholar 

  9. Whitcomb DC (2006) Clinical practice. Acute pancreatitis. N Engl J Med 354:2142–2150. https://doi.org/10.1056/NEJMcp054958

    Article  PubMed  Google Scholar 

  10. Whitcomb DC (2013) Genetic risk factors for pancreatic disorders. Gastroenterology 144:1292–1302. https://doi.org/10.1053/j.gastro.2013.01.069

    Article  CAS  PubMed  Google Scholar 

  11. Frossard JL, Steer ML, Pastor CM (2008) Acute pancreatitis. Lancet 371:143–152. https://doi.org/10.1016/S0140-6736(08)60107-5

    Article  PubMed  Google Scholar 

  12. Lankisch PG et al (2001) Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol 96:2081–2085. https://doi.org/10.1111/j.1572-0241.2001.03966.x

    Article  CAS  PubMed  Google Scholar 

  13. Wu BU, Johannes RS, Conwell DL, Banks PA (2009) Early hemoconcentration predicts increased mortality only among transferred patients with acute pancreatitis. Pancreatology 9:639–643. https://doi.org/10.1159/000181175

    Article  PubMed  Google Scholar 

  14. Rosas JM et al (2007) Intra-abdominal pressure as a marker of severity in acute pancreatitis. Surgery 141:173–178. https://doi.org/10.1016/j.surg.2006.04.016

    Article  PubMed  Google Scholar 

  15. Lankisch PG, Weber-Dany B, Hebel K, Maisonneuve P, Lowenfels AB (2009) The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clin Gastroenterol Hepatol 7:702–705. https://doi.org/10.1016/j.cgh.2009.02.020 (quiz 607)

    Article  PubMed  Google Scholar 

  16. Ranson JH et al (1974) Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 139:69–81

    CAS  PubMed  Google Scholar 

  17. Cho YS et al (2013) Usefulness of the bedside index for severity in acute pancreatitis in the early prediction of severity and mortality in acute pancreatitis. Pancreas 42:483–487. https://doi.org/10.1097/MPA.0b013e318267c879

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  19. Lankisch PG 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 

  20. 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. https://doi.org/10.1097/01.CCM.0000269031.13283.C8

    Article  PubMed  Google Scholar 

  21. 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. https://doi.org/10.1097/01.CCM.0000288112.02538.78 (author reply 2671–2672)

    Article  PubMed  Google Scholar 

  22. Zeitler H, Balta Z, Klein B, Strassburg CP (2015) Extracorporeal treatment in severe hypertriglyceridemia-induced pancreatitis. Ther Apher Dial 19:405–410. https://doi.org/10.1111/1744-9987.12286

    Article  PubMed  Google Scholar 

  23. Huber W, Malbrain ML (2013) Goal-directed fluid resuscitation in acute pancreatitis: shedding light on the penumbra by dynamic markers of preload? Intensive Care Med 39:784–786. https://doi.org/10.1007/s00134-012-2783-x

    Article  PubMed  Google Scholar 

  24. Wu BU, Johannes RS, Sun X, Conwell DL, Banks PA (2009) Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology 137:129–135. https://doi.org/10.1053/j.gastro.2009.03.056

    Article  CAS  PubMed  Google Scholar 

  25. Brown A, Baillargeon JD, Hughes MD, Banks PA (2002) Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis? Pancreatology 2:104–107. https://doi.org/10.1159/000055899

    Article  CAS  PubMed  Google Scholar 

  26. Mao EQ et al (2009) Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J 122:169–173

    PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  28. Gardner TB et al (2009) Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 9:770–776. https://doi.org/10.1159/000210022

    Article  PubMed  Google Scholar 

  29. Warndorf MG et al (2011) Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 9:705–709. https://doi.org/10.1016/j.cgh.2011.03.032

    Article  PubMed  PubMed Central  Google Scholar 

  30. Buxbaum JL et al (2017) Early aggressive hydration hastens clinical improvement in mild acute pancreatitis. Am J Gastroenterol 112:797–803. https://doi.org/10.1038/ajg.2017.40

    Article  PubMed  Google Scholar 

  31. Wang MD et al (2013) Early goal-directed fluid therapy with fresh frozen plasma reduces severe acute pancreatitis mortality in the intensive care unit. Chin Med J 126:1987–1988

    PubMed  Google Scholar 

  32. Wu BU et al (2011) Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 9:710–717.e1. https://doi.org/10.1016/j.cgh.2011.04.026

    Article  PubMed  Google Scholar 

  33. Buxbaum J et al (2014) Aggressive hydration with lactated Ringer’s solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 12:303–307.e1. https://doi.org/10.1016/j.cgh.2013.07.026

    Article  CAS  PubMed  Google Scholar 

  34. Sun Y et al (2015) The effects of fluid resuscitation according to PiCCO on the early stage of severe acute pancreatitis. Pancreatology. https://doi.org/10.1016/j.pan.2015.06.006

    Article  PubMed  Google Scholar 

  35. Mole DJ, Hall A, McKeown D, Garden OJ, Parks RW (2011) Detailed fluid resuscitation profiles in patients with severe acute pancreatitis. HPB (Oxford) 13:51–58. https://doi.org/10.1111/j.1477-2574.2010.00241.x

    Article  Google Scholar 

  36. Wall I et al (2011) Decreased mortality in acute pancreatitis related to early aggressive hydration. Pancreas 40:547–550. https://doi.org/10.1097/MPA.0b013e318215368d

    Article  PubMed  Google Scholar 

  37. De Waele JJ et al (2015) Intra-abdominal hypertension and abdominal compartment syndrome in pancreatitis, paediatrics, and trauma. Anaesthesiol Intensive Ther 47:219–227. https://doi.org/10.5603/AIT.a2015.0027

    Article  PubMed  Google Scholar 

  38. Huber 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. https://doi.org/10.1097/CCM.0b013e3181809928

    Article  PubMed  Google Scholar 

  39. Trepte CJ et al (2013) The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis. Intensive Care Med 39:717–726. https://doi.org/10.1007/s00134-012-2775-x

    Article  PubMed  Google Scholar 

  40. Mair S et al (2016) Applicability of stroke volume variation in patients of a general intensive care unit: a longitudinal observational study. J Clin Monit Comput. https://doi.org/10.1007/s10877-016-9951-4

    Article  PubMed  Google Scholar 

  41. Huber W, Kemnitz V, Phillip V, Schmid RM, Faltlhauser A (2015) Outcome prediction, fluid resuscitation, pain management, and antibiotic prophylaxis in severe acute pancreatitis. Intensive Care Med 41:2034–2035. https://doi.org/10.1007/s00134-015-4022-8

    Article  PubMed  Google Scholar 

  42. https://clinicaltrials.gov/ct2/show/NCT00894907. Zugegriffen: 27.01.2020

  43. Siriwardena AK 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. https://doi.org/10.1136/gut.2006.115873

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Jakobs R, Adamek MU, von Bubnoff AC, Riemann JF (2000) Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study. Scand J Gastroenterol 35:1319–1323

    Article  CAS  PubMed  Google Scholar 

  45. Bernhardt A, Kortgen A, Niesel H, Goertz A (2002) Using epidural anesthesia in patients with acute pancreatitis—prospective study of 121 patients. Anaesthesiol Reanim 27:16–22

    CAS  PubMed  Google Scholar 

  46. Yokoe M et al (2015) Japanese guidelines for the management of acute pancreatitis: Japanese guidelines 2015. J Hepatobiliary Pancreat Sci 22:405–432. https://doi.org/10.1002/jhbp.259

    Article  PubMed  Google Scholar 

  47. Working Group IAP/APA Acute Pancreatitis Guidelines (2013) IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 13:e1–15. https://doi.org/10.1016/j.pan.2013.07.063

    Article  Google Scholar 

  48. Tenner S, Baillie J, DeWitt J, Vege SS (2013) American college of gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 108:1400–1415; 1416. https://doi.org/10.1038/ajg.2013.218

    Article  CAS  PubMed  Google Scholar 

  49. Luiten EJ, Hop WC, Lange JF, Bruining HA (1995) Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 222:57–65

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Ukai T et al (2015) Early prophylactic antibiotics administration for acute necrotizing pancreatitis: a meta-analysis of randomized controlled trials. J Hepatobiliary Pancreat Sci 22:316–321. https://doi.org/10.1002/jhbp.221

    Article  PubMed  Google Scholar 

  51. Heinrich S, Schafer M, Rousson V, Clavien PA (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154–168. https://doi.org/10.1097/01.sla.0000197334.58374.70

    Article  PubMed  PubMed Central  Google Scholar 

  52. Forsmark CE, Swaroop Vege S, Wilcox CM (2016) Acute pancreatitis. N Engl J Med 375:1972–1981. https://doi.org/10.1056/NEJMra1505202

    Article  CAS  PubMed  Google Scholar 

  53. Besselink MG (2011) The “step-up approach” to infected necrotizing pancreatitis: delay, drain, debride. Dig Liver Dis 43:421–422. https://doi.org/10.1016/j.dld.2011.04.001

    Article  PubMed  Google Scholar 

  54. van Brunschot S et al (2018) Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 391:51–58. https://doi.org/10.1016/S0140-6736(17)32404-2

    Article  PubMed  Google Scholar 

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

    W. Huber, J. Schneider & R. M. Schmid

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  1. W. Huber
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Correspondence to W. Huber.

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W. Huber, J. Schneider und R.M. Schmid geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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A. Koch, Aachen

A. Canbay, Bochum

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Huber, W., Schneider, J. & Schmid, R.M. Therapie der schweren akuten Pankreatitis. Gastroenterologe 15, 41–52 (2020). https://doi.org/10.1007/s11377-020-00422-1

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