Therapie der akuten schweren Colitis ulcerosa im Krankenhaus – Ein Update

Die Therapie der Colitis ulcerosa erfolgt heutzutage in den meisten Fällen ambulant. Trotzdem ist bei schwersten Schüben mit systemischen Begleitsymptomen eine stationäre Therapie erforderlich. In diesem Fall ist ein intensiver interdisziplinärer Austausch zwischen Chirurgen und Internisten erforderlich, um eine konservative Therapie gegenüber einer Operation (Kolektomie) abzuwägen. Bei stationärer Aufnahme werden in der Regel, neben einer empirischen Antibiose als Primärtherapie, intravenöse Steroide eingesetzt. Sprechen diese nicht schnell genug an (nach 3–5 Tagen), sollte auf eine Zweitlinientherapie mit einem Calcineurininhibitor oder einem TNFα-Antagonisten eskaliert werden. Ob ein Calcineurininhibitor oder ein TNFα-Antagonist in der Zweitlinie bevorzugt zum Einsatz kommt, muss im Einzelfall unter Beachtung der Vor- und Nachteile sowie der persönlichen Erfahrungen mit den Substanzen abgewogen werden. Die Indikation für einen sequenziellen Einsatz dieser Substanzen in Drittlinie ist in der Regel nicht indiziert und sollte nur sehr zurückhaltend gestellt werden. Eine Kolektomie sollte insbesondere dann erwogen werden, wenn die Erstlinientherapie mit Steroiden nicht erfolgreich ist, wenn die Zweitlinientherapie versagt oder wenn Komplikationen auftreten. Der überwiegende Teil der Patienten (> 70 %) zeigt bei einer konservativen Therapie ein Ansprechen, sodass eine Proktokolektomie und Pouchanlage im gebesserten Allgemeinzustand im Intervall erfolgen oder sogar langfristig vermieden werden kann.

The therapy for ulcerative colitis is today mostly on an outpatient basis. Even so inpatient care is needed for the most severe episodes with accompanying systemic symptoms. In such cases an intensive interdisciplinary exchange between surgeons and internists is required in order to decide between conservative therapy and surgical therapy (colectomy). On admission to hospital as a rule besides an empirical antibiotic therapy intravenous steroids are administered as primary treatment. If this does not take effect sufficiently rapidly (after 3–5 days), a second-line therapy with a calcineurin inhibitor or a TNFα-antagonist is applied. Whether administration of a calcineurin inhibitor or a TNFα-antagonist is preferred as second line must be assessed on a case-to-case basis under consideration of their advantages and disadvantages as well as personal experience with the respective substances. An indication for the sequential adminsitration of these substances as a third line is generally not given and should only be undertaken after careful consideration. A colectomy should e taken into consideration especially when the first-line therapy with steroids was not successful, when the second-line therapy has failed or when complications arise. The Majority of the patients (> 70 %) respond to conservative therapy so that a proctocolectomy and pouch construction can be delayed for an interval until the general condition has improved or even be avoided completely.

Key words

Chronic inflammatory bowel disease - ulcerative colitis - toxic megacolon - proctocolectomy - pouch - calcineurin inhibitors - biologicals

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