Diagnostik und Therapie von Gallenwegserkrankungen

Die Endosonografie (EUS) und die Magnetresonanz-Cholangiopankreatikografie (MRCP) haben die endoskopisch retrograde Cholangiopankreatikografie (ERCP) als rein diagnostisches Untersuchungsverfahren weitestgehend abgelöst. Ziel dieses Artikels ist es, vor diesem Hintergrund einen aktualisierten Überblick über die endoskopische Therapie häufiger benigner und maligner Gallenwegserkrankungen zu geben.

Kernaussagen

• Für die Diagnostik von Gallenwegserkrankungen liefert die diagnostische Endosonografie (EUS) wegen ihrer konkurrenzlosen Ortsauflösung und Detailgenauigkeit wichtige Informationen; auch im Bereich der therapeutischen Endosonografie haben sich innerhalb der letzten Jahre viele neue Anwendungsmöglichkeiten etabliert.

• Bei der Indikationsstellung zu Diagnostik und Therapie müssen die Leitlinien im Zusammenhang mit dem klinischen Kontext des jeweiligen Patienten individuell interpretiert werden.

• Die endoskopisch retrograde Cholangiopankreatikografie (ERCP) – als Untersuchungsverfahren weitestgehend abgelöst von EUS und Magnetresonanz-Cholangiopankreatikografie (MRCP) – hat sich zu einem spezialisierten, therapeutischen Eingriff entwickelt, der häufig erst sekundär nach Sicherung der Diagnose durch Komplementärdiagnostik durchgeführt wird.

• Im Falle des Nachweises einer Choledocholithiasis besteht die allgemeine Empfehlung zur Konkrementextraktion mittels ERCP.

• Der Goldstandard in der Therapie der akuten Cholezystitis ist die laparoskopische Cholezystektomie, alternativ die Drainage der Gallenblase mittels interventioneller Verfahren (perkutane, EUS-geführte und transpapilläre Drainage).

• Die endoskopische Resektion ist als das bevorzugte Verfahren für Papillenadenome etabliert.

• Bei maligner Cholestase hat sich die EUS-Gallengangdrainage als konkurrierendes Verfahren zur ERCP und PTCD (perkutane transhepatische Cholangiografie) etabliert.

• Die Frage nach dem Vorgehen bei benigner Gallengangstenose im Rahmen chronischer Pankreatitiden ist noch offen.

• Der positive Effekt der photodynamischen Therapie (PDT) bei malignen Gallengangstenosen ist belegt, während die Ergebnisse für die Radiofrequenzablation (RFA) noch uneinheitlich sind.

Schlüsselwörter

Gallengangstenose - Cholezystitis - Choledocholithiasis - Endoskopie

Publication History

Article published online:
21 June 2023

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