Divertikelkrankheit – Klinisches Bild und Therapie

Zusammenfassung

Divertikulose, Divertikelkrankheit und Divertikulitis sind aktuell in den Fokus gerückt, weil es neue Erkenntnisse zu Diagnose, Risikofaktoren und Behandlung gibt, die jüngst zu einer gemeinsam von Gastroenterologen (DGVS) und Viszeralchirurgen (DGAV) verfassten deutschen Leitlinie geführt haben.

Entsprechend dieser Leitlinie ist die Diagnose Divertikulitis nur dann gesichert, wenn ein Schnittbildverfahren (Ultraschall [US] oder Computertomographie [CT]) den klinischen Verdacht (Validität des CRP > Leukozyten oder auch Fieber) durch Nachweis entzündlicher Veränderung am Divertikel bestätigt. Aus Gründen der Praktikabilität und entsprechend den Vorschriften des Strahlenschutzes sowie äquivalenter diagnostischer Treffsicherheit ist der US die Methode der 1. Wahl. Der US bietet eine bessere Auflösung und die Berücksichtigung der Schmerzlokalisation bei der Untersuchung. Die CT erkennt besser Abszesse in tiefen Abschnitten des Abdomens und in schwer einsehbaren Regionen des kleinen Beckens.

Klinik, Labor und Bildgebung ermöglichen die Abgrenzung zahlreicher Differentialdiagnosen und stellen auch die Grundlage einer neuen Klassifikation dar (Classification of Diverticular Disease, CDD), die alle Formen einer Divertikelkrankheit umfaßt, von der Divertikulose bis zur Divertikelblutung, einschließlich der verschiedenen Ausprägungen einer Divertikulitis. Diese Klassifikation, die bei jedem Patienten mit der Diagnose Divertikelkrankheit zur Verwendung kommen sollte, ist unabhängig von besonderen diagnostischen Vorlieben und sowohl bei konservativer wie auch operativer Therapie anwendbar.

Die Zahl reiterativer Episoden einer Divertikulitis stellt heute keine Indikation mehr für eine Operation dar; diese orientiert sich an der Schwere und / oder Komplikationen im Kontext mit Patienten-Faktoren (z. B. Leidensdruck). Aktuelle Daten lassen einen Verzicht auf Antibiotika unter definierten Umständen bei unkomplizierter Divertikulitis möglich erscheinen, wohingegen ihr Wert bei komplizierter Divertikulitis oder gefährdeten Patienten unstrittig ist. Spasmolytika und Flüssigkeitsersatz sind im Einzelfall erforderlich, während schädigende Medikamente (NSAR) vermieden werden sollten. Andere traditionelle Empfehlungen wie Nulldiät, Bettruhe und Laxantien entbehren der wissenschaftlichen Evidenz. Viele Überlegungen zur Primär- und Sekundärprävention beruhen auf epidemiologischen Erkenntnissen. Gedeckte Perforationen (CDD Typ 2a), rekurrierende Episoden einer unkomplizierten Divertikulitis und sogar einige Abszesse > 1 cm (CDD Typ 2 b) reagieren häufig erfolgreich auf eine medikamentöse Therapie. Eine sach- und zeitgerechte Indikationsstellung zur Operation bedarf daher einer präzisen Klassifikation und enger klinischer Kontrolle im Rahmen vertrauensvoller interdisziplinärer Zusammenarbeit von Gastroenterologen und Chirurgen.

Abstract

Diverticulosis, diverticular disease and diverticulitis have come into focus again because new aspects concerning diagnosis, risk factors and treatment arose only recently which prompted a new Guideline released by the DGVS and DGAV summarising the current evidence.

Along with the guideline’s essentials for medical practice a diagnosis of diverticulitis is considered unsatisfactory unless a cross-sectional imaging method (either ultrasonography [US] or computed tomography [CT] ) has proven that the clinical findings and inflammation (CRP considered superior to WBC and temperature) are due to diverticular inflammation. For reasons of practicability and considering relevant legislation for radiation exposure protection, US is the primary – and usually effectual – diagnostic method of choice as it is equipotent to CT. While US offers better resolution and enables precise imaging exactly at the location of pain as well as reiterative application, the latter implies advantages in the case of a deep abscess or diverticulitis in difficult locations (e. g. the small pelvis).

Clinical evidence and laboratory and imaging findings allow for distinguishing a large number of differential diagnoses and also form the basis of a new classification (classification of diverticular disease, CDD) which comprises all forms of diverticular disease, from diverticulosis to bleeding and to the different facettes of diverticulitis. This classification –which should be applied in any patient with the diagnosis of diverticular disease- is independent of specific diagnostic preferences and applicable both to conservative and operative treatment options.

While the number of recurrent episodes is no longer a significant indicator for surgery in diverticulitis, severity and / or complications determine treatment options along with the patients preferences. According to first data, conservative treatment may waive antibiotics under certain circumstances, however they are indispensible in complicated disease or patients bearing risk factors. Spasmoanalgetics and supportive fluid supply are individually necessary, and avoidance of potentially aggravating medications (e. g. NSAIDS) appears advisable, but many suggestions (nil by mouth, bed rest, laxatives) come along without an adaequate body of evidence. Similarly medical advice concerning prevention and secondary prophylaxis relies mainly on epidemiological plausibility. Because minor perforations (CDD type 2 a) as well as recurrent episodes of uncomplicated diverticulitis and even some abscesses > 1 cm (CDD type 2 b) respond favourably to medical treatment, the timely indication for surgery in these cases requires precise classification along with a close surveillance in trustful cooperation between the gastroenterologist and the surgeon.

Schlüsselwörter

Divertikelkrankheit - Divertikulitis - Darmsonografie

Keywords

diverticular disease - diverticulitis - intestinal ultrasonography

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