Monitoring und Therapie bei akuter Pankreatitis

Acute pancreatitis is a potentially life-threatening disorder with a rapid course of development; therefore, the time frame for diagnosis and treatment is narrow. Early diagnosis and therapy of severe necrotizing pancreatitis is of paramount importance with a mortality of 15–42?%. In contrast mild edematous pancreatitis has a fatal course in only 1?% of cases. Prediction of severity is impeded by a marked time dependency of the prognostic value of the different predictors; therefore, an exact determination of the onset of pain is highly relevant. At least three prognostic scenarios with different values for prognostic markers have to be taken into account. In the emergency room scenario, several simple parameters have a high prognostic value: increased blood glucose, increased hematocrit and increased blood urea nitrogen (BUN) have been demonstrated to be predictors with high sensitivity and high negative predictive value but low specificity and low positive predictive value. Furthermore, the relatively straightforward bedside index of severity in acute pancreatitis (BISAP) score has been validated to accurately predict prognosis. In the early re-evaluation scenario after 48 h the acute physiology and chronic health examination (APACHE) II score (cut-off 8 points) and the Ranson score (cut-off 3 points) provide high prognostic accuracy. For patients admitted to the intensive care unit (ICU admission scenario) specific markers of organ failure are available. The results of meta-analyses confirm a therapeutic effectiveness with limited effect size for the use of endoscopic retrograde cholangiography in severe biliary pancreatitis particularly in cases of cholangitis, for antibiotics (imipenem) in necrotizing pancreatitis and for early enteral feeding. An association of poor prognosis with increases in BUN and the hematocrit suggests the use of early goal-directed volume replacement which should be tailored to the clinical picture, echocardiography and/or modern hemodynamic parameters instead of central venous pressure which is unsuitable. Severe pain usually requires the use of opioid analgesia. Even when necrosis is present, conservative management (radiologically or endoscopically placed drainage) is appropriate. If these therapeutic approaches are not successful or cannot be managed technically, a surgical step-up should be considered.     

Therapie bei chronischer Pankreatitis

The therapy of chronic pancreatitis has recently changed in some major aspects. The therapy of acute episodes does not differ from the therapy of acute pancreatitis. Immediate and adequate fluid therapy is the backbone of the treatment of acute episodes. The general prophylactic administration of antibiotics in necrotizing pancreatitis does not seem to be useful; however, in cases of severe necrotizing pancreatitis administration of carbapenems may reduce the risk of pancreatic or peripancreatic infections. During acute episodes nutrition should be given enterally. Treatment of exocrine insufficiency includes supplementation of pancreatic enzymes. The presence of symptoms is an important decision-making point for pancreatic enzyme supplementation. The initial dosage is 20,000–40,000 lipase units per main meal and 10,000–20,000 for a snack. The dose can be doubled if symptoms do not improve. Therapy of pain follows the WHO guidelines. In some cases endoscopic therapy of pancreatic duct abnormalities can lead to pain relief. Surgical therapy is the best therapy for long-term pain relief. Infected necrosis or infected pseudocysts should initially be treated by conservative means. In cases of failure, endoscopic transgastric or transduodenal intervention should be given preference over an open surgical approach.     

Medikamentöse Therapie bei akuter und chronischer respiratorischer Insuffizienz

Zum Thema Die Diagnose der respiratorischen Insuffizienz orientiert sich an den arteriellen Blutgaswerten des Patienten. Abfall des pO₂ unter 55 mmHg und Anstieg des pCO₂über 48 mmHg gelten als Kriterien. Bei chronisch ateminsuffizienten Patienten ist es schwierig, akute Verschlechterungen zu diagnostizieren, da Hypoxie und Hyperkapnie über weite Bereiche toleriert werden. Klinische Parameter wie die Atemfrequenz/Minute, der Gebrauch der Atemhilfsmuskulatur und neu auftretende kardiale und neurologische Symptome helfen hier bei der Sicherung der Diagnose. Das respiratorische Versagen ist die dritth?ufigste Todesursache in Deutschland [1]. Verschiedene Lungen-, Bronchial- und Thoraxwanderkrankungen, aber auch extrapulmonale St?rungen (Tabelle 1) k?nnen dabei ein respiratorisches Versagen ausl?sen. Auch beim Bronchialkarzinom spielt die respiratorische Insuffizienz im fortgeschrittenen Krankheitsstadium eine entscheidende Rolle. Grunds?tzlich wird eine akute, durch medikament?se und Supportivma?nahmen reversible Form der Ateminsuffizienz von einer chronischen Verlaufsform unterschieden. Bei letzterer haben die therapeutischen Ma?nahmen palliativen Charakter und dienen der Linderung der Symptome des Patienten, in erster Linie also der Vermeidung von Dyspnoe- und Angstattacken.     

Prognose und Monitoring bei akuter Pankreatitis

Acute pancraetitis is a potentially life-threatening disorder with increasing incidence. Early diagnosis and therapy of severe/necrotizing pancreatitis with a mortality of 15–42% is of paramount importance. By contrast, mild/edematous pancreatitis has a mortality below 1%. Prediction of severity as well as prognosis are further impeded by a marked time dependency of the prognostic value of the different predictors. Therefore, exact determination of the onset of symptoms (pain) is highly relevant. Depending on the time that the symptoms started, at least three prognostic scenarios with different values of prognostic markers have to be taken into account. Regarding the first presentation/emergency room scenario, several “simple” parameters have high prognostic value: early presentation (within <24 h after the onset of symptoms), increased blood glucose, increased hematocrit, and increased blood urea nitrogen (BUN) have been demonstrated to be predictors with high sensitivity and high negative predictive value, but low specificity and low positive predictive value. Patients fulfilling at least one of these criteria should be transferred to the ICU, although not all of these patients will develop severe/necrotizing pancreatitis. After 48 h (early re-evaluation scenario), the APACHE-II score (cut-off >8), the Ranson score (cut-off >3 points), and a serum CRP level >15 mg/dl have appropriate prognostic accuracy. For the subgroup of patients admitted to an ICU (ICU admission scenario), a specific score has been introduced with arterial pH, age, mean arterial pressure (MAP), and BUN being the most important predictors for mortality. Retrospective analyses at the end of the ICU stay demonstrated an association of mortality with the requirement of renal replacement therapy and minimum levels of serum protein, calcium, and arterial bicarbonate.     

Rechtsherzversagen bei chronischer pulmonaler Hypertonie und akuter Lungenembolie

Right-sided heart failure is a severe and often life-threatening complication of chronic pulmonary hypertension. The detection of trigger factors that induce right heart failure in previously stable patients is important to initiate a causal therapeutic strategy. Pulmonary embolism (PE) is a frequent cause of acute right heart failure and therapeutic strategies for PE are well documented in the current guidelines. Treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) is surgical pulmonary endarterectomy (PEA) and patients with possible CTEPH should be referred to an experienced PEA surgeon without delay. Intensive care management for overt right heart failure is complex and includes the use of pulmonary vasodilators, individual adjustment of diuretic or volume therapy, augmentation of myocardial contractility and left ventricular afterload. Therapeutic regimens aim at optimized filling of the right ventricle, improvement of myocardial perfusion by avoiding tachycardia, elevating systemic pressure and reducing right ventricular afterload. Early communication with a specialized center for pulmonary hypertension is recommended.     

Ern?hrung bei akuter und chronischer Nierenersatztherapie

Infektionsneigung, allgemeine Morbidit?t und Mortalit?t bei akuter und chronischer Niereninsuffizienz werden wesentlich durch den Ern?hrungszustand der Patienten beeinflu?t. Die Malnutrition bei chronischer Niereninsuffizienz h?ngt haupts?chlich mit dem gest?rten Stoffwechsel zusammen und wird vom Verlust von Nahrungsstoffen ins Dialysat mitbestimmt. Natürlich spielen auch andere Faktoren eine Rolle, wozu auch die Hospitalisierung und eine depressive Grundstimmung dieser Patienten z?hlen. Bemerkenswert ist die Isolierung eines Toxins, das bei Nierengesunden mit dem Urin ausgeschieden wird, bei H?modialysepatienten aber offenbar kumuliert und tierexperimentell zu einer Hemmung der Eiwei?- und Kohlenhydrataufnahme führt.     

Antibiotische Therapie bei Cholezystitis, Cholangitis und Pankreatitis

Teil 1 Die Cholezystitis und Cholangitis stellen eine h?ufige Komplikation der Cholezystolithiasis dar, die mit einer hohen Morbidit?t und auch Mortalit?t behaftet ist. Die Behandlung besteht aus einer Kombination von antibiotischer Therapie und chirurgischer oder endoskopischer Intervention. Je nach Schweregrad sollte die antibiotische Therapie in Form einer Monotherapie oder Kombinationstherapie durchgeführt werden. Teil 2 Die akute nekrotisierende Pankreatitis ist wegen der Gefahr einer bakteriellen Infektion des nekrotisierten Pankreasgewebes mit nachfolgendem septischen Multiorganversagen ein sehr ernstzunehmendes Krankheitsbild, welches mit einer hohen Letalit?t von bis zu 40% einhergeht. Bei infizierten Pankreasnekrosen geh?rt die antibiotische Therapie heute zu den Standardtherapieverfahren, Uneinigkeit herrscht jedoch über den Stellenwert der antibiotischen Therapie bei alleinigem Nachweis einer Pankreasnekrose.     

Interventionelle Therapieverfahren bei akuter nekrotisierender Pankreatitis

The clinical course of acute pancreatitis is variable. Severe pancreatitis is observed in up to 20% of cases and is associated with high mortality rates of up to 40%. The most serious complication is the infection of the (peri-)pancreatic necroses. The therapeutic goal is debridement of the infected material. Whereas surgical methods still represent the gold standard, minimally invasive interventional approaches are gaining importance. This article reviews the different interventional procedures, particularly percutaneous, CT-guided drainage and necrosectomy. Furthermore, an overview of published studies about interventional therapy in patients with acute necrotizing pancreatitis is given.     

Indikation und Auswahl der Dialyseverfahren bei akuter und chronischer Niereninsuffizienz einschlie?lich kontinuierlicher Verfahren

Zum Thema Diese Arbeit, allen anderen Arbeiten dieses Hefts vorangestellt, gibt zunächst einen Überblick über die derzeit in Deutschland gebräuchlichen Dialyseverfahren. Das bei weitem am häufigsten angewandte Verfahren ist die Hämodialyse (ca. 82%), weitere Verfahren sind die Hämodiafiltration (ca. 9%), die Hämofiltration (ca. 1%) und die Peritonealdialyse (ca. 7%). Innerhalb dieser Verfahren gibt es weitere differenzierte Methoden der Nierenersatzbehandlung. Sodann werden die Indikationen zur Dialyse und deren Prognose behandelt. Sobald die renale Entgiftungsfunktion nicht mehr ausreicht, um die harnpflichtigen Substanzen zu eliminieren, und Störungen im Wasser-, Elektrolyt- und Säure-Basen-Haushalt anders nicht mehr zu therapieren sind, ist die Dialyse indiziert. Als grenzwertige Laborparameter gelten dafür: ·*Harnstoff >200 mg/dl, ·*Kreatinin >10 mg/dl, ·*Kalium >7 mmol/l, ·*Bikarbonat <15 mmol/l. Die Zahlen sprechen für sich: Anfang 1999 dürften in Deutschland (geschätzt) gut 70.000 Patienten auf Dialyseverfahren angewiesen sein, ca. 15.000 stehen zusätzlich in der Transplantationsnachsorge. In den letzten Jahrzehnten hat sich die Nephrologie als ausgewiesene Subdisziplin etabliert, und das entsprechende Krankengut ist in Bezug auf die nephrologische Betreuung den Allgemein-Internisten weitgehend entzogen. Bei den zahlreichen nicht nephrologischen Fragestellungen bei Dialysepatienten bedarf es der ärztlichen Zusammenarbeit mit Allgemein-Internisten, anderen internistischen Subdisziplinen und der hausärztlichen Koordination auch mit anderen Fachdisziplinen. So wendet sich diese Übersichtsarbeit nicht nur an Nephrologen, sondern auch an die große Zahl von Nichtspezialisten, um die Kenntnisse zu vermitteln, die für die Betreuung von Dialysepatienten erforderlich sind.     

Diagnostik und Therapie der chronischen Pankreatitis

Chronic pancreatitis is characterized by recurrent or persisting pain. As the exocrine pancreatic insufficiency occurs early in the progression of the disease, the endocrine function may persist intact. Imaging procedures and pancreatic function tests are used to make a diagnosis. Therapy consists of pain reduction, which might require endoscopic or surgical intervention. Treatment of exocrine and endocrine pancreatic insufficiency is based on diet and substitution of pancreatic enzymes, minerals and vitamins, as well as insulin.     

Diagnostik und Therapie der akuten Pankreatitis

Acute pancreatitis is a potentially life-threatening illness, with a short time frame for diagnosis and treatment. A number of recent experimental and clinical multicentre trials as well as meta-analyses have provided more far-reaching recommendations compared to previous guidelines. To answer 12 key questions, we performed a review of recent literature and current guidelines. Diagnosis can be made on the basis of history, physical examination and serum lipase alone. Cholestatic parameters and upper abdominal ultrasound enable verification of biliary etiology. Poor prognostic indicators include elevated blood sugar, BUN and hematocrit. The latter suggests early, adequate volume replacement, which should be tailored to the clinical picture, echocardiography and/or modern hemodynamic parameters. In addition to opiate analgesia, meta-analyses support the use of endoscopic retrograde cholangiography in pancreatitis of biliary origin, antibiotics in necrotizing pancreatitis and early enteral feeding. Even where necrosis is present, conservative management (radiologically or endoscopically placed drains) is appropriate.     

Diagnostik und Therapie der chronischen Pankreatitis

Chronic pancreatitis (CP) is characterized by progressive, chronic inflammation of the pancreas, resulting in loss of exocrine and endocrine function and chronic abdominal pain. In most cases, CP is induced by long-term alcoholism. The second most frequent diagnosis is idiopathic CP, in the absence of known causes of CP. However, the identification of genetic and immunological causes continuously reduces the number of cases classified as idiopathic pancreatitis. Common symptoms of CP comprise abdominal pain radiating to the back, diarrhea, steatorrhea and the development of diabetes. The diagnosis is mainly based on clinical features, typical morphological findings such as pancreatic calcifications, duct stenoses and dilatations, as well as pathologic pancreatic function tests. Treatment of CP includes watch and wait strategies in asymptomatic patients, symptomatic treatment of the clinical features such as pain, exocrine and endocrine insufficiency, as well as interventional or surgical therapy of complications such as pseudocysts, pancreatic duct stenosis, stones or biliary obstruction.     

Diagnostik und Therapie der chronischen Pankreatitis

Chronic pancreatitis is defined as a recurrent inflammation of the pancreas that leads to loss of exocrine and endocrine pancreatic function. Its most common cause is alcohol abuse. Hereditary pancreatitis is a form of pancreatitis that mostly has an autosomal dominant mode of inheritance and is characterised by a phenotypic penetrance of up to 80%. Patients with hereditary pancreatitis have a markedly elevated lifetime risk of developing pancreatic cancer. As there is still no causal treatment, therapy focuses on pain control and replacement therapy for endocrine and exocrine pancreatic insufficiency. In 30–60% of patients disease-associated complications such as persistent pain, strictures of the common bile duct or pancreatic duct stones develop, which may require either interventional or surgical treatment.     

Diagnostik und Therapie der akuten Pankreatitis

In acute pancreatitis the evaluation of severity is as important as the diagnosis. If there is evidence for severe pancreatitis, an immediate intensive care of all organ systems is needed, to avoid complications. Besides clinical signs, serum CRP is the most valuable parameter to define severity. According to present knowledge, a CT-scan is only needed in sepsis or multiorgan failure. Non-invasive ventilation should be started early in case of hypoxia. Up to now, no general benefit was detected for antibiotic prophylaxis or enteral nutrition. No consensus exists whether and when endoscopic interventions are superior to surgery in the treatment of infected necrosis.