Abklärung und Therapie von Refluxbeschwerden

Zusammenfassung

Traditionell und in der aktuellen deutschen Leitlinie wird zur Abklärung von Refluxbeschwerden eine Endoskopie des oberen Verdauungstraktes empfohlen, in der täglichen Routine und in anderen Ländern wird aber häufig einem symptomadaptierten Vorgehen der Vorzug gegeben. Sowohl eine endoskopiebasierte Managementstrategie als auch ein symptomgesteuertes Konzept ist an Prämissen gebunden. Die eingehende Prüfung dieser Prämissen zeigt, dass weder die eine noch die andere Strategie uneingeschränkt empfohlen werden kann. Das bevorzugte Vorgehen richtet sich nach der jeweiligen klinischen Ausgangssituation, die neben den Beschwerden so genannte Alarmsymptome, Risikofaktoren für das Adenokarzinom in der Speiseröhre bzw. dessen Vorstufen, demografische Faktoren wie Alter und Geschlecht, Patientenwunsch und bei primär nicht indizierter Endoskopie das Ansprechen auf eine Therapie mit einem Protonenpumpeninhibitor berücksichtigt. Die Mehrzahl der Patienten mit eindeutigen Refluxbeschwerden kann nach sorgfältiger Prüfung der individuellen Ausgangssituation ohne Endoskopie risikoarm und ökonomisch behandelt werden.

Abstract

The current guidelines of the German Society for Digestive Diseases (DGVS) endoscopy recommends for patients representing with reflux symptoms. In daily routine as well as in Guidelines from other countries and international guidelines, however, a symptom-based strategy for the management of patients with reflux disease is favoured. Since either strategies is dependent on specific clinical findings, neither can be recommended. The preference for one or the other strategy depends on the prevalence of so-called alarm symptoms, risk factors for a reflux carcinoma or Barrett’s metaplasia, demographic factors, e. g., age and gender, patient’s wish and initial response to empirical therapy with proton pump inhibitors (PPI). However, most patients with characteristic reflux symptoms without any alarm symptoms and/or other risk factors can be safely managed with a symptom-based strategy in acute and long-term care.

Barrett-Ösophagus - NERD - GERD - ERD - PPI - Rolle der Endoskopie

Barrett’s oesophagus - NERD - GERD - ERD - PPI - role of endoscopy

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1 Sodbrennen, definiert als ein brennendes, vom Epigastrium hinter dem Brustbein aufsteigendes Gefühl; Säureregurgitation, definiert als ein Rückfluss von sauer schmeckendem Magensaft bis in den Mundbereich.

2 PPI-Standarddosis (1-0-0) für 4 Wochen, 2× PPI-Standarddosis für 4 Wochen (1-0-1).

3 Barrett-Ösophagus: endoskopisch sichtbare Rötung der Schleimhaut des distalen Ösophagus mit histologischem Nachweis einer spezialisierten intestinalen Metaplasie.

4 Refluxkrankheit, definiert als typische Refluxsymptome mit Beeinträchtigung der Lebensqualität und Ansprechen auf PPI und/oder endoskopisch eindeutigem Nachweis einer Refluxösophagitis.

5 Dysphagie, unbeabsichtigter Gewichtsverlust (> 10 % des Körpergewichts), Blutungszeichen.

6 Endoskopie bei allen Patienten mit Refluxbeschwerden.

7 Standarddosis eines PPI für mindestens 4 Wochen.

8 Unter Einschluss von Biopsien aus makroskopisch verdächtigen Läsionen und Quadrantenbiopsien gemäß DGVS-Leitlinie bei Nachweis von roter Schleimhaut im distalen Ösophagus.

9 Tägliche oder nahezu tägliche Einnahme eines PPI.