Kernaussagen
Bisher existiert kein zuverlässiger Prädiktor für einen schweren Krankheitsverlauf bei akuter Pankreatitis. Deshalb sollten alle Patienten mit einer akuten Pankreatitis engmaschig überwacht werden.
Patienten, bei denen im CT mehr als 50 % des Pankreasparenchyms nekrotisch sind und bei denen CRP und Procalcitonin erhöht sind, sollten aufgrund des erhöhten Risikos einer schweren Pankreatitis und septischer Komplikationen intensivmedizinisch überwacht werden.
Bei Patienten mit biliärer Pankreatitis und eingeklemmten Gallensteinen, biliärer Sepsis oder obstrukivem Ikterus ist eine ERCP und Sphinkterotomie indiziert.
Bei Patienten mit nekrotisierender Pankreatitis und septischem Krankheitsbild sollte eine Feinnadelaspiration zur Unterscheidung von sterilen und infizierten Nekrosen durchgeführt werden.
Die symptomatische Basistherapie besteht aus einer ausreichenden Volumensubstitution, die einen positiven Effekt auf die Pankreasperfusion und Oxygenierung hat.
Bei nekrotisierender Pankreatitis führt eine Antibiotikaprophylaxe zur Reduktion von septischen Komplikationen.
Die Reduktion der Mortalität in der frühen Krankheitsphase ist vor allem auf die Verbesserung der intensivmedizinischen Überwachung und Therapie zurückzuführen.
Die chirurgische Therapie ist bei septischen Patienten mit infizierten Nekrosen indiziert. Bei sterilen Nekrosen ist eine operative Therapie nur in Ausnahmefällen erforderlich.
Das operative Therapieverfahren der Wahl ist die offene Nekrosektomie und die anschließende geschlossene Lavage der Bursa omentalis und des Retroperitoneums.
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PD Dr. Jens Werner
Abteilung für Allgemeine und Viszerale Chirurgie, INF 110
Chirurgische Universitätsklinik Heidelberg · 69120 Heidelberg
Telefon: 0 62 21/5 63 96 92
Fax: 0 62 21/56 54 50
eMail: Jens_Werner@med.uni-heidelberg.de
