Akute Pankreatitis

Severe pancreatitis is characterized by organ failure or sepsis and is present in approximately 20% of patients. The severity of the disease is difficult to judge at onset. Mild disease is present in patients with normal urea, hematocrit and blood glucose. Patients should be treated in an intensive care unit. Enteral nutrition is now obligatory. The role of prophylactic antibiotics in necrotizing pancreatitis is unclear. High dose analgesics may be used, including opioids. The treatment of infected necrosis should be performed not earlier than 3 weeks when the necrosis has become demarcated. The primary interventional procedure is superior to a surgical approach. Nevertheless, this disease has a mortality of approximately 15%.     

Akute Pankreatitis

While interstitial acute pancreatitis usually takes a benign course, necrotizing acute pancreatitis takes a severe course, mainly because of severe local and systemic complications. After a quick diagnosis it is necessary to rapidly assess a degree of severity of the disease and thus the prognosis. The clinical picture and the result of imaging procedures do not always correspond. The management basically includes to treat pain as well as to administer fluid, electrolyte, protein and calories. In addition, systemic treatment of complications such as shock or respiratory and renal insufficiency—if occurring—is necessary. In case of pancreatic necrosis, prophylactic administration of pancreas-penetrable antibiotics is recommended to avoid infection. In the severely ill with infected pancreatic necrosis, surgery is the treatment of choice. In approximately 10% of all patients with alcohol-induced pancreatitis, there is a gradual transition to chronic pancreatitis.     

Akute Pankreatitis

Acute pancreatitis is a potentially fatal disease. It can be diagnosed based on present history, the patient’s clinical appearance, and, typically, laboratory and radiological findings. Each patient must be admitted to the hospital because the disease course cannot be determined at the initial presentation. Increasing severity demands an increasingly individualized therapy, but the most important interventions are rapid fluid resuscitation and analgesic therapy with opioids. Pancreatitis-specific therapeutic agents have failed to prove any advantages so far. The roles of antibiotic therapy and nutritional support have been carefully reassessed over the last years. Surgery and endoscopic interventions could be necessary and beneficial for well-selected patients. In this review, we summarize the clinically relevant issues in acute pancreatitis.     

Akute Pankreatitis

The timely diagnosis of acute pancreatitis is important for developing a therapeutic strategy. Differential diagnosis, clarification of the etiology, evaluation of severity and determination of a prognosis are crucial for the course of the disease. Due to the lack of specific therapy, modern therapeutic options aim to optimize the conservative treatment by exploiting ITU care. These benefit especially from the experience of new insights in sepsis and ventilation treatment. The major aims are to stabilize the course and postpone possible complications, such as infection of the necrosis, in the late phase of the disease. Sterile necrosis can be treated medically, but surgery for infected necrosis is still usual. However, timing of the intervention is under discussion, and there is evidence that medical treatment only may be as beneficial as surgery. Percutaneous or minimally invasive strategies in case of infected necrosis are under evaluation. In general, with the use of a careful, modern therapeutic approach, mortality in severe necrotizing pancreatitis has decreased to 15–25%.     

Akute nekrotisierende Pankreatitis

Zum Thema Die akute Pankreatitis manifestiert sich klinisch mit pl?tzlich auftretenden, meist gürtelf?rmig in den Rücken ausstrahlenden Oberbauchschmerzen, begleitet von übelkeit, Erbrechen, Meteorismus, Darmparese und Fieber. Gallenwegserkrankungen und Alkoholismus sind die Hauptursachen der akuten Pankreatitis. Die h?ufige Form der ?demat?s-interstitiellen Pankreatitis (ca. 80%) hat eine Letalit?t von 0–2%, die seltenere Form der h?morrhagisch-nekrotisierenden Pankreatitis (ca. 20%) eine Letalit?t von 20–30%. Die wichtigsten diagnostischen Parameter für die letztgenannte Form sind das C-reaktives Protein (CRP>120 mg/l), die Laktatdehydrogenase (LDH>280–300 mU/l) und das i.v. kontrastmittelverst?rkte Computertomogramm. Die akute nekrotisierende Pankreatitis ist in jedem Fall als lebensbedrohliche Erkrankung einzustufen. Die vorliegende Arbeit gibt eine übersicht über den derzeitigen wissenschaftlich fundierten Standard der Behandlung der akuten Pankreatitis.     

Chronische Pankreatitis

Die chronische Pankreatitis ist durch eine schubweise oder kontinuierliche Zerst?rung des Pankreasgewebes gekennzeichnet. Nach einer subklinischen Phase unterschiedlicher Dauer kommt es meist zu rezidivierenden akuten Schüben und zur exokrinen und endokrinen Pankreas-Insuffizienz.     

Chronische Pankreatitis

The identification of a specific mutation in the human cationic trypsinogen gene in large kindreds with hereditary pancreatitis was the key to understand the genetic background of chronic pancreatitis. Rapidly, other variants within the same gene were identified-even in small families with a minority of patients. Later, mutations of the most important intrapancreatic trypsin inhibitor SPINK1 were found with high prevalence in patients with idiopathic, tropical and alcoholic chronic pancreatitis. We summarize interesting genetic and biochemical findings, point to clinical features and review recommendations for genetic analysis, follow-up and cancer prevention.     

Chronische Pankreatitis

Recurrent inflammation of the pancreas can lead to chronic pancreatitis. Progressive weight loss, periodic abdominal pain and steatorrhoea describe characteristic symptoms. While diagnosis of end-stage chronic pancreatitis requires a detailed medical history and a transabdominal ultrasound examination, detection of early onset chronic pancreatitis is far more difficult. Therapy comprises tailored pain medication, enzyme supplementation, blood sugar control and dietetic treatment. The development of complications associated with chronic pancreatitis requires regular monitoring of these patients. Management of these complications might necessitate comprehensive endoscopic as well as surgical procedures.     

Autoimmune Pankreatitis

Autoimmune pancreatitis has been established as a special entity of pancreatitis. It is an enigmatic disease since it is adding an autoimmune etiology to the existing causes of pancreatitis. Morphological hallmarks of the disease are narrowing of the pancreatic duct system and the bile duct by periductal lymphoplasmocytic inflammation. This results in many cases in obstructive jaundice due to a mass-forming lesion in the pancreatic head mimicking pancreatic ductal adenocarcinoma. Therefore, patients will frequently undergo surgery. Histopathologically, the disease can be diagnosed by IgG4-positive plasma cells. Serologically, patients may present with elevated serum IgG and IgG4 levels. Other autoantibodies are also described. Association with other autoimmune manifestations in a wide range of organs is frequent. Autoimmune pancreatitis will respond to steroid treatment, which is of specific importance because pancreatic cancer is one of its clinical differential diagnoses. It is important to positively diagnose autoimmune pancreatitis, especially if the bile ducts are affected, since cholangitis may be or become a prominent problem before or after surgery.     

Akute Alkoholintoxikation

Despite an increasing rate of emergency admissions with acute alcohol intoxication, specific data concerning clinical risk estimation are scarce. We performed a retrospective analysis of all 857 patients admitted to the University Medical Center Mannheim with acute alcohol intoxication between 2003 and 2007. Most patients were men (76%), the mean age was 45.1 years, mean blood alcohol concentration was 2.5 ‰. The majority of patients (74%) were discharged directly from the emergency department. The present data indicate a low clinical risk of alcohol intoxication and suggest that outpatient treatment is sufficient in the majority of cases. Nevertheless, a standardized diagnostic and therapeutic approach is essential in view of rare complications. Clinical monitoring should include repeated physical and especially neurological examination, toxicological blood tests, and radiological diagnostics. Discharge is possible provided that patients are awake, not disorientated and mobile. If necessary, patients should be encouraged to enter a withdrawal treatment program.     

Akute Niereninsuffizienz

Acute renal failure is increasingly found in critically ill patients as part of the multiple organ dysfunction syndrome. Intermittent hemodialysis and continuous renal replacement therapy are standard extracorporeal replacement therapies. Continuous therapies are thought to be especially useful in cardiovascularly instable patients in the intensive care unit. Recently, slow, extended daily dialysis was introduced as a hybrid method, combining the advantages of intermittent and continuous renal replacement therapy. While controlled studies have uniformly shown that a high dose of such replacement therapy increases survival, studies have failed to support a definitive advantage for any method in terms of patient survival. Therefore, the choice of renal replacement therapy should be based on personal experience, the available resources/infrastructure as well as the needs of the individual patient.     

Akute Tracheobronchitis

Zusammenfassung Atemwegsinfektionen stellen einen der häufigsten Gründe für Arztbesuche dar, wobei vor allem im ambulanten Bereich die akute Tracheobronchitis im Vordergrund steht. Atemwegsviren sind die wichtigsten Erreger, gefolgt von typischen und atypischen Bakterien. In den meisten Fällen ist die Erkrankung selbstlimitierend, nur selten kommt es zu Komplikationen wie Pneumonie und chronischer Bronchitis. Nichtsdestotrotz werden in den meisten Fällen mehrere Medikamente verschrieben. Ziel dieses Beitrags ist es, die unterschiedlichen Behandlungsoptionen darzustellen und ihren Nutzen kritisch zu hinterfragen.

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Akute Herzinsuffizienz

Ohne Zusammenfassung