Gastrointestinale Motilitätsstörungen bei Intensivpatienten

Disturbances of gastrointestinal motility are a frequent problem in critically ill patients. The entire gastrointestinal tract can be afflicted and the clinical course of intensive care patients can be substantially complicated. Most commonly there are delays in gastric emptying, diarrhea and constipation. A variety of causes have to be taken into account. In addition to changes in the autonomic nerve system status (particularly elevated sympathetic tonus), drugs (e.g. catecholamines, opiates, sedatives and anticholinergics), electrolyte and glucose metabolism disorders and inflammation mediators also play an important role. For treatment a variety of motility effective drugs are available which require a differentiated use due to their different times of administration and mechanisms of action.     

Gastrointestinale Motilitätsstörungen in der Intensivmedizin

Gastrointestinal (GI) motility disorders in critically ill patients are a common clinical problem. These disorders can be the consequence of the underlying disease or result from the medical or interventional intensive care treatment. Despite increasing knowledge of the underlying physiology and pathophysiology of the motility disorders, there is a lack in therapeutic alternatives (prokinetics), which can be used and are approved under these conditions. Swallowing disorders, gastroesophageal reflux and gastroparesis due to various underlying causes comprise the most import clinically relevant disorders in the upper GI tract, with dysphagia, nausea, and vomiting being the leading symptoms. Constipation with delayed passage, paralysis, or ileus, on the one hand, as well as diarrhea due to various causes, on the other hand, are the most important clinical disorders in the lower GI tract. Intestinal pseudo-obstruction is a special form of paralytic ileus with an acute or chronic form occurring in various diseases and post-operative conditions. Improvement in the general intensive care management of critically ill patients can dramatically reduce the incidence of gastrointestinal motility disorders. Reduction of stress and pain, cautious use of medications with inhibitory effects on gastrointestinal motility (e.g., opioids, catecholamines), balancing electrolytes and fluid losses, early mobilization, physical therapy, and early enteral feeding can reduce the overall incidence. Besides cholinomimetics, only a few prokinetic substances (domperidone, metclopramide, erythromycin, cholecystokinin (CCK) agonists) are approved and available for treatment in the upper GI tract. In the lower GI tract, decompression and the use of laxatives are most commonly used for treatment; however, newer substances (lubiprostone, prucalopride) are on the horizon.     

Chronische Motilitätsstörungen des oberen Gastrointestinaltrakts im Alter

Primary motility disorders of the upper gastrointestinal (GI) tract result from an impairment of the motor function of the esophagus, stomach, and duodenum by malfunction of the enteric nervous system or degeneration of the gastrointestinal muscle layer. Other forms of upper GI motility disorders occur secondary to underlying systemic diseases. The exact pathophysiology of the disturbances within the enteric nervous system of the upper GI tract is not yet clearly understood. For motility disorders resulting from systemic diseases the lack of knowledge with respect to the underlying pathomechanism is even greater. The term functional dyspepsia summarizes some symptoms of the upper abdomen, suggesting a disorder of upper GI motility or perception; however, this link to disturbed physiology has never been convincingly demonstrated. This overview describes therapeutic options for motility disorders of the upper GI tract regarding medicinal, endoscopic and surgical targets. The efficacy of medicinal therapy of upper GI motility disorders is low due to the lack of understanding of the pathophysiology. Therefore, endoscopic and other interventional therapies have to be applied also in the elderly patient group. The restrictions for metoclopramide published by the European Medicines Agency (EMA) in July 2013 have limited the armentarium of medicinal therapy of chronic motility disorders of the upper GI tract.     

St?rungen der gastrointestinalen Motilit?t

Inhibition of gastrointestinal motility is a major problem in critically ill patients. Impaired gastrointestinal motility leads to a multitude of subsequent complications in critically ill patients, with intolerance of enteral feeding as one of great importance. The pharmacological treatment of impaired gastrointestinal motility is difficult to handle, because the underlying mechanisms are complex and not fully understood and the number of pharmacological treatment options available is limited. A standardized concept for the use of prokinetic agents in the treatment of impaired gastrointestinal motility in critically ill patients involves the early use of baseline therapeutic options followed by goal-directed therapy. The early use of enemas and of laxatives which promote water secretion and prevent excessive water absorption, such as bisacodyl or sodium picosulfate, is highly recommended. The first line medication in patients with impaired gastric emptying is erythromycin given intravenously. Patients suffering from gastroparesis and impaired intestinal motility may benefit from erythromycin followed hours later by the combination of metoclopramide plus neostigmine.     

Diagnostik und Bedeutung psychischer St?rungen bei k?rperlich kranken geriatrischen Patienten

125 nacheinander in einer medizinisch-geriatrischen Abteilung aufgenommene Patienten sollten mit einem naturalistischen Design im Hinblick auf psychische St?rungen diagnostiziert werden. Auf der Basis der klinischen Untersuchung sowie der Werte in der Mini-Mental-State-Examination (2) wurden 51 Kranke als nicht untersuchbar eingesch?tzt. Die übrigen 74 Patienten wurden klinisch und mit Screening-Skalen (Geriatric Depression Scale (11); Angst- und Depressionsskala der Hospital Anxiety and Depression-Scale (4)) auf psychische St?rungen untersucht. Bei entsprechendem Verdacht wurden ein Interview durch einen gerontopsychosomatisch erfahrenen Psychotherapeuten durchgeführt und erg?nzende Informationen von ?rzten und Pflegepersonal eingeholt. Dementielle Entwicklungen wurden ggf. durch neuropsychologische Testungen nachgewiesen oder ausgeschlossen. Bei 41 Patienten wurden psychische St?rungen von Krankheitswert (meist Anpassungsst?rungen oder Depression) gefunden, bei über der H?lfte davon war die St?rung relevant für die Gesamtbehandlung in der Klinik. Die eingesetzten Screening-Instrumente erwiesen sich als zuverl?ssig, so da? sie für den weiteren Einsatz empfohlen werden k?nnen. Offen bleibt aber, wie die nach diesem Resultat bei jedem 5. bis 6. Patienten erforderliche Therapie der psychischen St?rung im Setting einer medizinisch-geriatrischen Abteilung gew?hrleistet werden kann.     

Schlafst?rungen und schlafbezogene Atmungsst?rungen

Gesunder Schlaf verläuft in mehreren Zyklen pro Nacht mit Leicht-, Tief- und Traumschlaf und dient der körperlichen sowie geistigen Erholung und somit der Leistungsfähigkeit im Wachzustand. Störungen des normalen Schlafs manifestieren sich meist als Ein- und Durchschlafstörungen und/oder sie verursachen eine vermehrte Tagesschläfrigkeit. Etwa 10% der Erwachsenen leiden an ausgeprägten Schlafstörungen, eine ähnlich hohe Zahl berichtet ausgeprägte Tagesschläfrigkeit. Schlafstörungen verursachen hohe volkswirtschaftliche Kosten durch das gesteigerte Unfallrisiko, durch Folgeerkrankungen und Arbeitsausfall. Viele der 88 schlafmedizinischen Diagnosen können anhand der Anamnese hinreichend sicher diagnostiziert und behandelt werden. Patienten mit stark vermehrter Tagesschläfrigkeit werden im Schlaflabor untersucht und therapiert, da ursächlich häufig schlafbezogene Atmungsstörungen vorliegen.Störungen des Schlafs oder der Atmung im Schlaf können mit gutem Erfolg behandelt werden. Die Therapie beinhaltet Verhaltensmaßnahmen und eine differenzierte medikamentöse Therapie bis hin zur mechanischen Beatmung bei schlafbezogenen Atmungsstörungen.     

Diagnostik und Therapie gastrointestinaler Funktionsstörungen bei Diabetes mellitus

Gastrointestinal functional disturbances frequently cause abdominal symptoms in patients with diabetes mellitus and have been shown to impair the quality of life. Autonomic neuropathy is an important pathomechanism but other disturbances affecting the enteric nervous system, interstitial cells of Cajal (ICC), smooth muscle cells, release of insulin and other regulatory peptide hormones and glucose homeostasis also contribute to the pathogenesis. Diagnostic procedures should start with exclusion of infectious and structural diseases by laboratory investigations, endoscopy, abdominal sonography and/or radiological methods. If the diagnosis remains unclear individual parameters decide whether a therapeutic trial can be started or whether functional diagnostic procedures are needed for further clarification. Optimization of blood glucose control is generally of importance but frequently difficult to achieve due to interactions between gastrointestinal dysfunction and blood glucose control. Apart from this, symptom-oriented therapy is usually performed as established for patients without diabetes. Moreover, diabetes-associated functional disturbances, particularly those affecting the proximal gastrointestinal tract, may cause few symptoms but may still impair blood glucose and therefore need therapy. In this article the diabetes-associated diseases dysphagia, reflux disease, gastropathy, exocrine pancreatic insufficiency, gallbladder dysfunction, diarrhea, constipation and stool incontinence are discussed with respect to the diagnostic procedures and therapy     

Leitliniengerechte Diagnostik von Dyslipid?mien

Cardiovascular diseases are the main cause of mortality for patients with advanced age. Changes in lipid metabolism are common and play an important role as key risk factors. This article explains an approach in the diagnosticis of dyslipidemia according to the current guidelines. First, the overall risk evaluation of cardiovascular mortality based on the current chart has to be evaluated. Depending on these results an individual LDL-C goal should be defined. The article also includes other relevant cardiovascular risk factors which were not included in the established risk charts. Furthermore, the main innovative biomarkers are discussed in their possible applications and diagnostic value.     

Diagnostik und Therapie des ?sophaguskarzinoms

The prognosis for patients with advanced esophageal cancer is poor. Proper risk assessment and knowledge of tumor biology may facilitate early diagnosis of adenocarcinomas and squamous cell cancer of the esophagus. New endoscopic techniques are available (e.g., (virtual) chromoendoscopy, autofluorescence, and endomicroscopy) for the early detection of cancer. Endoscopic therapy with complete resection of mucosal cancers offers long-term survival. En bloc resection combined with the removal of locoregional lymph nodes is the surgical option of choice for locally advanced cancer. In this respect, minimally invasive surgery offers the patient numerous advantages. Multimodal therapy results in better outcome for defined cancer stages and includes surgery, chemotherapy and chemoradiation. Multimodal treatment should always be individualized and requires cooperation of all subspecialties (tumor board conference). New chemotherapeutic strategies may offer improved survival but may also include new side effects. Patients with inoperable esophageal cancer also benefit from multimodal treatment.     

Behandlungsmanual zur Psychotherapie von akuten und posttraumatischen Belastungsst?rungen nach ICD-Mehrfachschocks

In view of the inceasing number of implanted defibrillators in all industrial nations, the number of people who have suffered so-called multiple shocks (electrical storm, ES) also increases. Common complaints are severe and continuously recurrent massive anxiety, panic attacks, fear of death, helplessness and hopelessness, depression, nervosity and irritability as well as reclusive and uncontrollable avoidance behaviour, intrusions, nightmares, flashbacks, sleeplessness and the inability to show feelings and limitation of future perspectives. Because people with an ICD are often physically (very) ill and after multiple ICD shocks are additionally very insecure, it would seem logical if the inpatient treatment would be carried out in an institution which has close connections and is also spatially close to a cardiology department. The basis of the diagnostics is the clinical anamnesis and a systematic exploration of the trauma situation and the resulting complaints. As an additional diagnostic element psychological test procedures should be implemented to determine the core symptomatic (anxiety, depression, trauma symptoms). Psychological test procedures should be included in the diagnostics so that at the end of treatment it is obvious even to the patient which alterations have occurred. The core element of inpatient treatment is daily intensive psychotherapy and includes deep psychologically well-founded psychotherapy and behavioral therapeutic-oriented anxiety therapy as well as cognitive restructuring and elements of eye movement desensitization and reprocessing (EMDR). A follow-up examination within 4 months of the multiple shocks episode is recommended because symptoms of posttraumatic stress disorder often occur after a long latent time period.     

Schlafbezogene Atmungsst?rungen und Vorhofflimmern

Sleep-disordered breathing is one of the most common sleep disorders. Especially obstructive sleep apnea (OSA) is an independent cardiovascular risk factor. Clinical studies have proven a significant association between OSA and atrial fibrillation, the most common cardiac arrhythmia. Currently, there is no proven evidence for causality. Untreated OSA seems to be a risk factor for failure of rhythm control strategy in atrial fibrillation. The recurrence rate after cardioversion is higher in case of additional untreated OSA. Continuous positive airway pressure (CPAP) therapy in OSA patients could reduce relapse rate. However, there is a lack of randomized controlled clinical trials with defined end points on this topic. A specific sleep medicine interview as well as sleep studies with portable monitoring and cardiorespiratory polysomnography are recommended when sleep-disordered breathing is suspected. Procedures for the management of patients with atrial fibrillation are given.     

Endokrine St?rungen und Verdauungstrakt

The endocrine system has a central and integrative role in maintaining whole body homeostasis in humans. Therefore, endocrine disorders consequently affect other organs, such as the digestive system. Gastrointestinal symptoms, such as swallowing disorders, abdominal pain, diarrhea or obstipation are common clinical problems in the general practice. Besides primary gastroenterological causes, such as achalasia, gastrointestinal malignancies or chronic inflammatory bowel disease, endocrine disorders have to be ruled out when searching for the correct diagnosis. Hyperparathyroidism or endocrine pancreatic tumors, for example, can be the cause for fulminant diarrhea. The correlation of endocrine and gastroenterological diseases can also be found in the associations of papillary thyroid carcinoma with familial adenomatous polyposis (FAP), multiple endocrine neoplasia with Hirschsprung??s disease and Hashimoto??s thyroiditis with celiac disease and chronic atrophic gastritis. Knowledge of these associations seems not only clinically important for establishing a correct diagnosis but also has consequences in the follow-up of patients, for example the diagnosis of medullary thyroid malignancy may precede the diagnosis of FAP and vice versa.