Akute Pankreatitis: eine „klinische“ Herangehensweise

Bei der akuten Pankreatitis handelt es sich um einen entzündlichen Prozess der Bauchspeicheldrüse, der zu lokalen und systemischen Komplikationen bis hin zum Organversagen führen kann. Die akute Pankreatitis ist eine der häufigsten nicht malignen Aufnahmediagnosen in der Gastroenterologie, wobei die schwere Form mit einer relevanten Letalität vergesellschaftet ist.

Kernaussagen

• Gallensteine und Alkoholkrankheit stellen die häufigsten Ursachen der akuten Pankreatitis dar.

• Anamnese, klinische Untersuchung sowie die transabdominelle Sonografie sind die Grundlagen der Diagnostik.

• In der Labordiagnostik spielen Lipase, Triglyzeride, Kalzium sowie Cholestase-Parameter eine wichtige Rolle.

• Das persistierende Organversagen (> 48 h) gilt als einer der stärksten Prädiktoren einer hohen Letalität.

• Eine kausale Therapie existiert nur für die biliäre Pankreatitis.

• Infizierte (peri-)pankreatische Nekrosen gehen mit einer erhöhten Mortalität einher.

• Die antibiotische und interventionelle Therapie sollte nicht verzögert werden.

• Eine schwere Pankreatitis hat eine relevante Letalität und erfordert eine enge Kooperation zwischen Intensivmedizinern, (interventionellen) Gastroenterologen und Chirurgen.

Schlüsselwörter

Cholezystolithiasis - Choledocholithiasis - Bauchspeicheldrüse - Gastroenterologie - Alkoholabusus

Publication History

Article published online:
11 March 2022

• Literatur

• 1 Peery AF, Crockett SD, Murphy CC. et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: Update 2018. Gastroenterology 2019; 156: 254-272.e11 DOI: 10.1053/j.gastro.2018.08.063. (PMID: 30315778)
• 2 Oskarsson V, Hosseini S, Discacciati A. et al. Rising incidence of acute pancreatitis in Sweden: national estimates and trends between 1990 and 2013. United European Gastroenterol J 2020; 8: 472-480 DOI: 10.1177/2050640620913737. (PMID: 32213040)
• 3 Schepers NJ, Bakker OJ, Besselink MG. et al. Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis. Gut 2019; 68: 1044-1051 DOI: 10.1136/gutjnl-2017-314657. (PMID: 29950344)
• 4 Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr JM, Schneider A, Lynen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis. Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). AWMF Registernummer 021–003. Im Internet (Stand: 01.01.2022): https://www.awmf.org/uploads/tx_szleitlinien/021–003l_S3_Pankreatitis_2021–09.pdf
• 5 Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet 2015; 386: 85-96 DOI: 10.1016/S0140-6736(14)60649-8. (PMID: 25616312)
• 6 Innere Medizin. Herold G. Köln: Dr. Gerd Herold; 2020
• 7 Venneman NG, Buskens E, Besselink MG. et al. Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?. Am J Gastroenterol 2005; 100: 2540-2550 DOI: 10.1111/j.1572-0241.2005.00317.x. (PMID: 16279912)
• 8 Aycock RD, Westafer LM, Boxen JL. et al. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med 2018; 71: 44-53.e4 DOI: 10.1016/j.annemergmed.2017.06.041. (PMID: 28811122)
• 9 Wilhelm-Leen E, Montez-Rath ME, Chertow G. Estimating the risk of radiocontrast-associated nephropathy. J Am Soc Nephrol 2017; 28: 653-659 DOI: 10.1681/ASN.2016010021. (PMID: 27688297)
• 10 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111 DOI: 10.1136/gutjnl-2012-302779. (PMID: 23100216)
• 11 Sternby H, Bolado F, Canaval-Zuleta HJ. et al. Determinants of severity in acute pancreatitis: a nation-wide multicenter prospective cohort study. Ann Surg 2019; 270: 348-355 DOI: 10.1097/SLA.0000000000002766. (PMID: 29672416)
• 12 Lytras D, Manes K, Triantopoulou C. et al. Persistent early organ failure: defining the high-risk group of patients with severe acute pancreatitis?. Pancreas 2008; 36: 249-254 DOI: 10.1097/MPA.0b013e31815acb2c. (PMID: 18362837)
• 13 Jin Z, Xu L, Wang X. et al. Risk factors for worsening of acute pancreatitis in patients admitted with mild acute pancreatitis. Med Sci Monit 2017; 23: 1026-1032 DOI: 10.12659/msm.900383. (PMID: 28238002)
• 14 Kumar A, Chari ST, Vege SS. Can the time course of systemic inflammatory response syndrome score predict future organ failure in acute pancreatitis?. Pancreas 2014; 43: 1101-1105 DOI: 10.1097/MPA.0000000000000170. (PMID: 25036912)
• 15 Koutroumpakis E, Wu BU, Bakker OJ. et al. Admission hematocrit and rise in blood urea nitrogen at 24 h outperform other laboratory markers in predicting persistent organ failure and pancreatic necrosis in acute pancreatitis: a post hoc analysis of three large prospective databases. Am J Gastroenterol 2015; 110: 1707-1716 DOI: 10.1038/ajg.2016.271. (PMID: 27481437)
• 16 Mikolasevic I, Milic S, Orlic L. et al. Metabolic syndrome and acute pancreatitis. Eur J Intern Med 2016; 32: 79-83 DOI: 10.1016/j.ejim.2016.04.004. (PMID: 27157403)
• 17 Natu A, Stevens T, Kang L. et al. Visceral adiposity predicts severity of acute pancreatitis. Pancreas 2017; 46: 776-781 DOI: 10.1097/MPA.0000000000000845. (PMID: 28609366)
• 18 Mounzer R, Langmead CJ, Wu BU. et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology 2012; 142: 1476-1482 DOI: 10.1053/j.gastro.2012.03.005. (PMID: 22425589)
• 19 Lankisch PG, Weber-Dany B, Hebel K. et al. The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clin Gastroenterol Hepatol 2009; 7: 702-705
• 20 Haas SA, Lange T, Saugel B. et al. Severe hyperlactatemia, lactate clearance and mortality in unselected critical ill patients. Intensive Care Med 2016; 42: 202-210 DOI: 10.1007/s00134-015-4127-0. (PMID: 26556617)
• 21 Kirkpatrick AW, Roberts DJ, De Waele J. et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39: 1190-1206 DOI: 10.1007/s00134-013-2906-z. (PMID: 23673399)
• 22 Yamashita T, Horibe M, Sanui M. et al. Large volume fluid resuscitation for severe acute pancreatitis is associated with reduced mortality: a multicenter retrospective study. J Clin Gastroenterol 2019; 53: 385-391 DOI: 10.1097/MCG.0000000000001046. (PMID: 29688917)
• 23 Wu BU, Hwang JQ, Gardner TH. et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9: 710-717.e1 DOI: 10.1016/j.cgh.2011.04.026. (PMID: 21645639)
• 24 Iqbal U, Anwar H, Scribani M. Ringer’s lactate versus normal saline in acute pancreatitis: A systematic review and meta-analysis. J Dig Dis 2018; 19: 335-341 DOI: 10.1111/1751-2980.12606. (PMID: 29732686)
• 25 Wang MD, Ji Y, Xu J. et al. Early goal-directed fluid therapy with fresh frozen plasma reduces severe acute pancreatitis mortality in the intensive care unit. Chin Med J (Engl) 2013; 126: 1987-1988 (PMID: 23673124)
• 26 Meng W, Yuan J, Zhang C. et al. Parenteral analgesics for pain relief in acute pancreatitis: a systematic review. Pancreatology 2013; 13: 201-206 DOI: 10.1016/j.pan.2013.02.003. (PMID: 23719588)
• 27 Jabaudon M, Belhadj-Tahar N, Rimmele T. et al. Thoracic epidural analgesia and mortality in acute pancreatitis: a multicenter propensity analysis. Crit Care Med 2018; 46: e198-e205 DOI: 10.1097/CCM.0000000000002874. (PMID: 29194144)
• 28 Kahl S, Zimmermann S, Pross M. et al. Procaine hydrochloride fails to relieve pain in patients with acute pancreatitis. Digestion 2004; 69: 5-9 DOI: 10.1159/000076541. (PMID: 14755147)
• 29 Baltatzis M, Mason JM, Chandrabalan V. et al. Antibiotic use in acute pancreatitis: An audit of current practice in a tertiary centre. Pancreatology 2016; 16: 946-951 DOI: 10.1016/j.pan.2016.08.012. (PMID: 27613614)
• 30 Howes R, Zuidema GD, Cameron JL. Evaluation of prophylactic antibiotics in acute pancreatitis. J Surg Res 1975; 18: 197-200 DOI: 10.1016/0022-4804(75)90016-5. (PMID: 1094193)
• 31 Finch WT, Sawyers JL, Schenker S. A prospective study to determine the efficacy of antibiotics in acute pancreatitis. Ann Surg 1976; 183: 667-671 DOI: 10.1097/00000658-197606000-00008. (PMID: 788655)
• 32 Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg 1998; 2: 496-503 DOI: 10.1016/s1091-255x(98)80048-6. (PMID: 10457308)
• 33 Ukai T, Shikata S, Inoue M. et al. Early prophylactic antibiotics administration for acute necrotizing pancreatitis: a meta-analysis of randomized controlled trials. J Hepatobiliary Pancreat Sci 2015; 22: 316-321 DOI: 10.1002/jhbp.221. (PMID: 25678060)
• 34 Luiten EJ, Hop WC, Lange JF. et al. Differential prognosis of gram-negative versus gram-positive infected and sterile pancreatic necrosis: results of a randomized trial in patients with severe acute pancreatitis treated with adjuvant selective decontamination. Clin Infect Dis 1997; 25: 811-816 DOI: 10.1086/515545. (PMID: 9356793)
• 35 Ding N, Sun YH, Wen LM. et al. Assessment of prophylactic antibiotics administration for acute pancreatitis: a meta-analysis of randomized controlled trials. Chin Med J (Engl) 2020; 133: 212-220 DOI: 10.1097/CM9.0000000000000603. (PMID: 31929369)
• 36 Bakker OJ, van Brunschot S, Farre A. et al. Timing of enteral nutrition in acute pancreatitis: meta-analysis of individuals using a single-arm of randomised trials. Pancreatology 2014; 14: 340-346 DOI: 10.1016/j.pan.2014.07.008. (PMID: 25128270)
• 37 Bakker OJ, van Brunschot S, van Santvoort HC. et al. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med 2014; 371: 1983-1993 DOI: 10.1056/NEJMoa1404393. (PMID: 25409371)
• 38 Li JY, Yu T, Chen GC. et al. Enteral nutrition within 48 hours of admission improves clinical outcomes of acute pancreatitis by reducing complications: a meta-analysis. PLoS One 2013; 8: e64926 DOI: 10.1371/journal.pone.0064926. (PMID: 23762266)
• 39 Wereszczynska-Siemiatkowska U, Swidnicka-Siergiejko A, Siemiatkowski A. et al. Early enteral nutrition is superior to delayed enteral nutrition for the prevention of infected necrosis and mortality in acute pancreatitis. Pancreas 2013; 42: 640-646 DOI: 10.1097/MPA.0b013e318271bb61. (PMID: 23508012)
• 40 Sun JK, Mu XW, Li WQ. et al. Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. World J Gastroenterol 2013; 19: 917-922 DOI: 10.3748/wjg.v19.i6.917. (PMID: 23431120)
• 41 Singh N, Sharma B, Sharma M. et al. Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial. Pancreas 2012; 41: 153-159 DOI: 10.1097/MPA.0b013e318221c4a8. (PMID: 21775915)
• 42 Stimac D, Poropat G, Hauser G. et al. Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: a randomized clinical trial. Pancreatology 2016; 16: 523-528 DOI: 10.1016/j.pan.2016.04.003. (PMID: 27107634)
• 43 Phillip V, Huber W, Hagemes F. et al. Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany. Clin Gastroenterol Hepatol 2011; 9: 995-1000.e3
• 44 Tenner S, Dubner H, Steinberg W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis. Am J Gastroenterol 1994; 89: 1863-1866 (PMID: 7942684)
• 45 Ammori BJ, Boreham B, Lewis P. et al. The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging. Pancreas 2003; 26: e32-e35 DOI: 10.1097/00006676-200303000-00023. (PMID: 12604925)
• 46 Mayer AD, McMahon MJ. Biochemical identification of patients with gallstones associated with acute pancreatitis on the day of admission to hospital. Ann Surg 1985; 201: 68-75 (PMID: 2578276)
• 47 Kiriyama S, Kozaka K, Takada T. et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25: 17-30 DOI: 10.1002/jhbp.512. (PMID: 29032610)
• 48 Alper E, Unsal B, Buyrac Z. et al. Role of radial endosonography in the diagnosis of acute cholangitis. Dig Dis Sci 2011; 56: 2191-2196 DOI: 10.1007/s10620-010-1552-3. (PMID: 21221785)
• 49 Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012; (05) CD009779 DOI: 10.1002/14651858.CD009779.pub2. (PMID: 22592743)
• 50 van Geenen EJ, van Santvoort HC, Besselink MG. et al. Lack of consensus on the role of endoscopic retrograde cholangiography in acute biliary pancreatitis in published meta-analyses and guidelines: a systematic review. Pancreas 2013; 42: 774-780 DOI: 10.1097/MPA.0b013e318287d208. (PMID: 23774699)
• 51 Besselink MG, van Minnen LP, van Erpecum KJ. et al. Beneficial effects of ERCP and papillotomy in predicted severe biliary pancreatitis. Hepatogastroenterology 2005; 52: 37-39 (PMID: 15782989)
• 52 Burstow MJ, Yunus RM, Hossain MB. et al. Meta-analysis of early endoscopic retrograde cholangiopancreatography (ERCP) +/- endoscopic sphincterotomy (ES) versus conservative management for gallstone pancreatitis (GSP). Surg Laparosc Endosc Percutan Tech 2015; 25: 185-203 DOI: 10.1097/SLE.0000000000000142. (PMID: 25799261)
• 53 Sharma VK, Howden CW. Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis. Am J Gastroenterol 1999; 94: 3211-3214 DOI: 10.1111/j.1572-0241.1999.01520.x. (PMID: 10566716)
• 54 van Baal MC, Besselink MG, Bakker OJ. et al. Timing of cholecystectomy after mild biliary pancreatitis: a systematic review. Ann Surg 2012; 255: 860-866 DOI: 10.1097/SLA.0b013e3182507646. (PMID: 22470079)
• 55 Aboulian A, Chan T, Yaghoubian A. et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg 2010; 251: 615-619 DOI: 10.1097/SLA.0b013e3181c38f1f. (PMID: 20101174)
• 56 da Costa DW, Bouwense SA, Schepers NJ. et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015; 386: 1261-1268 DOI: 10.1016/S0140-6736(15)00274-3. (PMID: 26460661)
• 57 Werge M, Novovic S, Schmidt PN. et al. Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis. Pancreatology 2016; 16: 698-707 DOI: 10.1016/j.pan.2016.07.004. (PMID: 27449605)
• 58 Kochhar R, Ahammed SK, Chakrabarti A. et al. Prevalence and outcome of fungal infection in patients with severe acute pancreatitis. J Gastroenterol Hepatol 2009; 24: 743-747 DOI: 10.1111/j.1440-1746.2008.05712.x. (PMID: 19220667)
• 59 Besselink MG, van Santvoort HC, Boermeester MA. et al. Timing and impact of infections in acute pancreatitis. Br J Surg 2009; 96: 267-273 DOI: 10.1002/bjs.6447. (PMID: 19125434)
• 60 Isenmann R, Rünzi M, Kron M. et al. Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology 2004; 126: 997-1004 DOI: 10.1053/j.gastro.2003.12.050. (PMID: 15057739)
• 61 Dellinger EP, Tellado JM, Soto NE. et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg 2007; 245: 674-683 DOI: 10.1097/01.sla.0000250414.09255.84. (PMID: 17457158)
• 62 García-Barrasa A, Borobia FG, Pallares R. et al. A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis. J Gastrointest Surg 2009; 13: 768-774 DOI: 10.1007/s11605-008-0773-7. (PMID: 19082671)
• 63 Sarathi Patra P, Das K, Bhattacharyya A. et al. Natural resolution or intervention for fluid collections in acute severe pancreatitis. Br J Surg 2014; 101: 1721-1728 DOI: 10.1002/bjs.9666. (PMID: 25329330)
• 64 Rau BM, Bothe A, Kron M. et al. Role of early multisystem organ failure as major risk factor for pancreatic infections and death in severe acute pancreatitis. Clin Gastroenterol Hepatol 2006; 4: 1053-1061 DOI: 10.1016/j.cgh.2006.05.030. (PMID: 16843734)
• 65 Ji L, Wang G, Li L. et al. Risk factors for the need of surgical necrosectomy after percutaneous catheter drainage in the management of infection secondary to necrotizing pancreatitis. Pancreas 2018; 47: 436-443 DOI: 10.1097/MPA.0000000000001031. (PMID: 29517639)
• 66 Besselink MG, Verwer TJ, Schoenmaeckers EJ. et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007; 142: 1194-1201 DOI: 10.1001/archsurg.142.12.1194. (PMID: 18086987)
• 67 Rana SS, Bhasin DK, Rao C. et al. Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome. Pancreatology 2013; 13: 486-490 DOI: 10.1016/j.pan.2013.07.284. (PMID: 24075512)
• 68 Peng T, Peng X, Huang M. et al. Serum calcium as an indicator of persistent organ failure in acute pancreatitis. Am J Emerg Med 2017; 35: 978-982 DOI: 10.1016/j.ajem.2017.06.056. (PMID: 28751040)