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Gastroenterologie up2date 2013; 09(02): 81-93
DOI: 10.1055/s-0032-1326444
Ösophagus/Magen/Duodenum
© Georg Thieme Verlag KG Stuttgart · New York

Prophylaxe und Therapie der Varizenblutung

Ulrike W. Denzer
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Publication History

Publication Date:
14 June 2013 (online)

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Kernaussagen

Endoskopisches Screening

  • Im Rahmen der Erstdiagnose einer Leberzirrhose sollte eine Indexgastroskopie zum Varizenscreening durchgeführt werden.

  • Die weiteren Screeningintervalle richten sich nach dem Schweregrad der Varizen und der Leberfunktion der Patienten.

Primärprophylaxe

  • In der Primärprophylaxe von Ösophagusvarizenblutungen sind nichtselektive Betablocker die Therapie der Wahl.

  • Bei bestehenden Risikofaktoren (Child-Pugh-Stadium B – C, Red Spots, Red Wale Signs) oder Unverträglichkeit für Betablocker kann alternativ die endoskopische Varizenligatur zum Einsatz kommen.

Akute Varizenblutung

  • Die Therapie der akuten Ösophagusvarizenblutung besteht aus Pharmakotherapie (Terlipressin) plus endoskopischer Therapie (1. Wahl: Ligaturtherapie; alternativ: Sklerotherapie mit n-Butyl-2-cyanoacrylat).

  • Als Interimslösung kann bei Versagen der endoskopischen Therapie ein selbstexpandierender Notfallblutungsstent eingebracht werden.

  • Als prophylaktische Medikation haben sich Antibiotika zur Reduktion der infektionsbedingten Mortalität und Laktulose zur Reduktion der hepatischen Enzephalopathie etabliert.

  • Bei Versagen der endoskopischen Therapie ist bei geeigneten Patienten als definitive Therapie die Anlage eines TIPS zu erwägen.

Sekundärprophylaxe

  • In der Sekundärprophylaxe von Ösophagusvarizen ist die Kombination NSBB plus Ligaturtherapie der Standard.

  • Nach der ersten Ligaturtherapie sollten bis zur kompletten Eradikation der Varizen PPI verabreicht werden.

Portal-hypertensive Gastropathie und GAVE

  • Aufgrund der unterschiedlichen Therapie der Blutung sind portal-hypertensive Gastropathie und GAVE streng zu unterscheiden.

  • Bei der portal-hypertensiven Gastropathie kommen NSBB und/oder TIPS zum Einsatz, bei GAVE endoskopisch-thermische Verfahren (z. B. APC) oder Bandligatur.

 

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