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DOI: 10.1055/s-0033-1335808
S2k-Leitlinie Chronische Obstipation: Definition, Pathophysiologie, Diagnostik und Therapie
Gemeinsame Leitlinie der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM) und der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS)1 – AWMF-Registriernummer: 021/019Publikationsverlauf
Publikationsdatum:
09. Juli 2013 (online)
![](https://www.thieme-connect.de/media/zfg/201307/lookinside/thumbnails/10.1055-s-0033-1335808-1.jpg)
Einleitung und Methodik
E-1 Hintergrund
Chronische Obstipationsbeschwerden zählen mit einer Prävalenz von 5 – 15 % zu den häufigen Gesundheitsstörungen in Deutschland, wobei die Prävalenz mit dem Alter zunimmt und Frauen deutlich häufiger betroffen sind als Männer [1] [2].
Die zugrunde liegenden Pathomechanismen sind komplex, uneinheitlich und nur z. T. aufgeklärt. Die verfügbare Evidenz hat aber die traditionelle Auffassung widerlegt, dass es sich lediglich um eine banale Befindlichkeitsstörung ohne Krankheitswert handele, welche überdies durch falsche Lebensgewohnheiten selbst verschuldet und daher auch leicht zu korrigieren sei. So wurde überzeugend belegt, dass die Betroffenen dabei unter einer Vielzahl von belästigenden Symptomen leiden und sie dadurch in ihrer Lebensqualität – z. T. deutlich – beeinträchtigt sind [3] [4].
Dessen ungeachtet wird die chronische Obstipation nur unzureichend als ein für die Patienten oft relevantes Gesundheitsproblem akzeptiert. Dies wird auch dadurch deutlich, dass etablierte und effektive medikamentöse Therapieansätze, deren regelmäßige Einnahme für schwerer Betroffene meist unverzichtbar ist, lediglich unter der undefinierten Etikettierung „Laxans“ in die Sparte der nicht verschreibungsfähigen Selbstmedikation verbannt und quasi allein in die Hände der Apotheker übergeben worden sind. Selbst neueren, innovativen und daher noch verschreibungspflichtigen Medikamenten wird allein aufgrund der Indikation „Obstipation“ ihre allgemeine Erstattungsfähigkeit genommen.
Tatsächlich mag diese Auffassung für milde, meist transiente Obstipationsbeschwerden, wie sie auch viele Gesunde im Rahmen von Änderungen ihrer Lebensumstände (z. B. Reisen, fremdländische Kost o. Ä.) erleben, angemessen sein. Demgegenüber untermauern sowohl wissenschaftliche Evidenz wie auch medizinische Realität, dass es sich bei der chronischen Obstipation in der Mehrzahl der Fälle um eine persistierende, nicht selten mit hohem Leidensdruck einhergehende Erkrankung handelt. Dabei kann der Symptomkomplex der Obstipation ganz unterschiedliche Ursachen haben, welche von unerwünschten Arzneimittelwirkungen über Stoffwechselstörungen im Sinne von sekundären Obstipationsformen bis hin zu Erkrankungen des enterischen Nerven- und Muskelsystems (im Sinne primärer Obstipationsformen) reichen können.
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E-2 Ziele der Leitlinie
Ziel der vorliegenden interdisziplinären S2k-Leitlinie war es, den aktuellen Kenntnisstand zu Definition, Pathophysiologie, Diagnostik und Therapie der chronischen Obstipation bei Erwachsenen auf Basis der wissenschaftlichen Evidenz zusammenzufassen, im Experten-Konsens zu bewerten und daraus praxisrelevante Empfehlungen abzuleiten.
Hierzu seien einige erläuternde Vorbemerkungen vorausgeschickt:
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Diese Leitlinie soll auch der allgemeinen Aufklärung darüber dienen, dass die chronische Obstipation eine Erkrankung ist, die grundsätzlich ein gewisses Maß an diagnostischer Abklärung sowie in der Mehrzahl der Fälle einer dauerhaften medikamentösen Therapie zugeführt werden muss. Ganz bewusst setzen die Leitlinienautoren sich daher auch dafür ein, den undefinierten und oft als negativ empfundenen Begriff des „Laxans“ zu verlassen. Vielmehr sollte der einer Erkrankung angemessene Begriff der medikamentösen Therapie bevorzugt werden. Die bisher als „Laxanzien“ bekannten Behandlungsformen werden in dieser Leitlinie daher als konventionelle medikamentöse Therapieansätze bezeichnet in historischer, aber bewusst nicht in formaler Abgrenzung zu den modernen Arzneimittel-Entwicklungen zur Obstipationsbehandlung.
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Die erläuterten Therapiekonzepte beschränken sich dabei im Wesentlichen auf die primären Formen der chronischen Obstipation, da für die sekundären Obstipationsformen eine umfassende Darlegung der therapeutischen Optionen aller möglichen Grundkrankheiten/-störungen den Rahmen einer evidenzbasierten Leitlinie übersteigen würde.
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Innerhalb der primären Obstipationsformen stellt das obstipationsprädominante Reizdarmsyndrom einen Sonderfall und dabei eine der wichtigsten Untergruppen dar. Die vorliegenden Empfehlungen richten sich jedoch primär auf die Behandlung der Obstipationssymptome und haben in diesem Rahmen in aller Regel auch für die Obstipation beim Reizdarmsyndrom Gültigkeit. Für umfassendere Informationen und Therapieempfehlungen zum polysymptomatischen Reizdarmsyndrom wird jedoch an dieser Stelle auf die kürzlich publizierte umfassende S3-Leitlinie zum Reizdarmsyndrom [5] verwiesen.
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Methodik
Hinweis: Eine ausführliche Beschreibung der Methodik sowie die detaillierten Angaben zu potenziellen Interessenkonflikten der Leitlinienautoren sind dem separat veröffentlichten Methodik-Report der Leitlinie zu entnehmen (Preiss und Andresen, AWMF).
M-1 Versorgungsbereich und Zielgruppen
Die Empfehlungen gelten insbesondere für die ambulante medizinische Versorgung und richten sich an das gesamte Spektrum der an der Diagnostik und Therapie beteiligten Berufsgruppen (Allgemeinmediziner, Internisten, Gastroenterologen, Proktologen, Chirurgen, Psychologen, Psychosomatiker) ebenso wie an Betroffene.
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M-2 Zusammensetzung der Leitliniengruppe: Beteiligung von Interessengruppen
Die Deutsche Gesellschaft für Neurogastroenterologie und Motilität (DGNM) und die Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS) beauftragten Viola Andresen und Christian Pehl mit der Koordination der Leitlinie. Diese legten die Eckpunkte des Konsentierungsverfahrens fest, luden andere Fachgesellschaften ein und wählten die Mitglieder der Arbeitsgruppen aus ([Tab. M-1]). Die Auswahl der AG-Mitglieder erfolgte dabei primär nach fachlicher Expertise. Es wurde Wert darauf gelegt, aus jeder Berufsgruppe, für die die Leitlinie gelten soll, mindestens einen Vertreter miteinzubeziehen. Alle beteiligten Fachgesellschaften hatten dabei die Möglichkeit, mindestens ein AG-Mitglied zu benennen. Auch eine Patientenvertreterin war beteiligt.
Inhaltsverzeichnis |
|
Einleitung und Methodik |
651 |
E-1 Hintergrund |
651 |
E-2 Ziele der Leitlinie |
652 |
M-1 Versorgungsbereich und Zielgruppen |
652 |
M-2 Zusammensetzung der Leitliniengruppe: Beteiligung von Interessengruppen |
652 |
M-3 Beteiligte Gruppierungen und Fachgesellschaften |
653 |
M-4 Durchführung |
653 |
a) Recherche, Auswahl und Bewertung wissenschaftlicher Belege (Evidenzbasierung) |
653 |
b) Formulierung der Empfehlungen und strukturierte Konsensfindung |
653 |
Kapitel 1: Definition und Epidemiologie (AG 1) |
654 |
Kapitel 2: Ätiologie und Pathophysiologie (AG 2) |
655 |
Kapitel 3: Diagnostik (AG 3) |
657 |
Kapitel 4: Therapie A: Allgemeine Empfehlungen zum Therapie-Management (AG 4) |
658 |
Kapitel 5: Therapie B: Konventionelle medikamentöse Therapie (konventionelle „Laxanzien“) (AG 5) |
660 |
Kapitel 6: Therapie C: Neue medikamentöse Therapieansätze (AG 6) |
662 |
Kapitel 7: Therapie D: Chirurgische Therapie (AG 7) |
663 |
Kapitel 8: Therapie E: Biofeedback (AG 8) |
665 |
Kapitel 9: Therapie F: Probiotika (AG 9) |
666 |
Kapitel 10: Therapie G: Komplementäre und alternativmedizinische Methoden (CAM) (AG 9) |
666 |
Literatur |
667 |
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M-3 Beteiligte Gruppierungen und Fachgesellschaften
Federführung und Koordination
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Deutsche Gesellschaft für Neurogastroenterologie und Motilität (DGNM)
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Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS)
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Mitarbeit
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Deutsche Gesellschaft für Innere Medizin (DGIM)
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Chirurgische Arbeitsgemeinschaft für Coloproktologie (CACP) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV)
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Deutsche Gesellschaft für Koloproktologie (DGK)
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Deutsche Reizdarmselbsthilfe e. V. (Patientenorganisation)
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#
M-4 Durchführung
a) Recherche, Auswahl und Bewertung wissenschaftlicher Belege (Evidenzbasierung)
Die DGNM hat 2011 gemeinsam mit der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS) die S3-Leitlinie Reizdarmsyndrom herausgegeben [5]. Die im Rahmen der dort durchgeführten systematischen Literatursuche diente als Basis für diese Leitlinie. Die Literatur zur Obstipation sollte weitgehend durch die verwendete Suchstrategie abgedeckt sein. Die im Kapitel obstipationsbetontes Reizdarmsyndrom ausgewählte Literatur wurde ergänzt durch weitere und neuere Arbeiten, die den Arbeitsgruppenmitgliedern bekannt waren oder individuell neu recherchiert wurden. Eine erneute systematische Literatursuche erfolgte jedoch nicht.
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b) Formulierung der Empfehlungen und strukturierte Konsensfindung
Die Konsentierung der Empfehlungen erfolgte in 3 Phasen ([Tab. M-2]). Über eine von den Arbeitsgruppen erstellte erste Version wurde von der gesamten Konsensgruppe per E-Mail abgestimmt. Die Ergebnisse der Abstimmung und obligatorische Kommentare wurden an die Arbeitsgruppen zurückgespiegelt. Eine zweite Version wurde im Rahmen einer 2-tägigen Konsensuskonferenz diskutiert und bearbeitet. Einige Statements und Empfehlungen, für die kein ausreichender Konsens in der Plenarsitzung erreicht werden konnte, wurden erneut überarbeitet. In dieser Phase wurde erneut von der Konsensusgruppe per E-Mail abgestimmt. Persistierender Dissens oder Minderheitenmeinungen sind in den Kommentaren diskutiert. Die Konsensstärken sind in [Tab. M-3 ]dargestellt.
AG 1 |
Definition und Epidemiologie |
Prof. Dr. P. Enck, Tübingen (DGNM) |
AG 2 |
Ätiologie und Pathophysiologie |
M. Schemann, München |
AG 3 |
Diagnostik |
T. Frieling, Krefeld |
AG 4 |
Therapie A: Allgemeine Empfehlungen zum Therapie-Management |
C. Pehl, Vilsbiburg (DGNM, DGVS) |
AG 5 |
Therapie B: Konventionelle medikamentöse Therapie (konventionelle „Laxanzien“) |
A. Madisch, Hannover |
AG 6 |
Therapie C: Neue medikamentöse Therapieansätze |
V. Andresen, Hamburg (DGNM, DGVS, DGIM) |
AG 7 |
Therapie D: Chirurgische Therapie |
M. Kasparek, München |
AG 8 |
Therapie E: Biofeedback |
H. Mönnikes, Berlin |
AG 9 |
Therapie F: Probiotika |
H. Krammer, Mannheim (DGK) |
Patientenvertreter |
P. Ilgenstein, Burgdorf (Deutsche Reizdarmselbsthilfe e. V.) |
|
methodische Beratung |
J. C. Preiß, Berlin |
|
inhaltliche Beratung |
A. Herold, Mannheim (CACP-DGAV) |
|
Koordination |
V. Andresen, Hamburg (DGNM, DGVS, DGIM) |
|
redaktionelle Unterstützung |
D. Menge, Hamburg |
1 Beratung: J. Langhorst, Essen.
Da die Obstipation zwar mit einer deutlichen Lebensqualitätseinbuße verbunden sein kann, jedoch üblicherweise keine erhöhte Mortalität hat, sind Nutzen und Risiken besonders vorsichtig abzuwägen. In den Kapiteln zur medikamentösen Therapie sind potenzielle unerwünschte Arzneimittelwirkungen jeweils gemeinsam mit der erwarteten Wirkung diskutiert. Bei allen Statements, die eine Handlungs-Empfehlung darstellen, ist die Stärke der Empfehlung anhand der Formulierung sowie anhand der Kennzeichnung durch ein Pfeilsymbol ersichtlich. Die Formulierungen und Bedeutung der Empfehlungsstärken sind in [Tab. M-4] dargelegt. In allen Kommentaren wurden die Empfehlungen mit der jeweils zugrunde liegenden Literatur verknüpft. Evidenz- oder Empfehlungsgrade wurden in dieser S2k-Leitlinie nicht vergeben.
Die Leitlinie wurde unmittelbar von der Deutschen Gesellschaft für Neurogastroenterologie und Motilität finanziert. Eine inhaltliche Beeinflussung erfolgte dabei nicht. Alle Mitglieder der Konsensusgruppe mussten potenzielle Interessenkonflikte entsprechend der AWMF-Vorgaben offenlegen. Die jeweiligen Ausführungen der einzelnen Leitlinienmitglieder sind in einer Übersichtstabelle unter Punkt 9 des Methodikreports zusammengefasst. Nach Einschätzung der Koordinatoren ergab sich dabei kein Interessenkonflikt, der die Empfehlungen der Leitlinie hätte relevant verzerren können.
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1 In Zusammenarbeit mit Deutsche Gesellschaft für Innere Medizin (DGIM), Chirurgische Arbeitsgemeinschaft für Coloproktologie (CACP) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Deutsche Gesellschaft für Koloproktologie (DGK), Deutsche Reizdarmselbsthilfe e. V. (Patientenorganisation)
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