Die Gastroparese des kritisch kranken Patienten – ein unterschätztes Problem?

Zusammenfassung

Das Outcome kritisch kranker Patienten kann durch Störungen der intestinalen Motilität – wie z. B. einer Gastroparese – deutlich verschlechtert werden. Nicht nur der erschwerte Kostaufbau und die unzureichende Nahrungsaufnahme, sondern auch Komplikationen wie die stille Aspiration von Mageninhalt mit möglichen nachfolgenden pulmonalen und systemischen Infekten bis hin zu Sepsis und Multiorganversagen wären hier zu nennen. Die Diagnosestellung der Gastroparese ist erschwert durch die unspezifischen und diffusen Symptome, aber auch durch das teilweise erst in Entwicklung befindliche Problembewusstsein der behandelnden Ärzte. Nach der Diagnose kann die Einteilung beim kritisch kranken Patienten nach der Dauer der Gastroparese in eine permanente oder eine passagere Form erfolgen. Im Falle einer permanenten Form erfolgt dann je nach Schweregrad der Magenentleerungsstörung eine Einteilung in 3 Schweregrade. Therapeutisch steht neben einer Änderung der Ernähungsgewohnheiten bzw. des Nahrungsangebots im Krankenhaus, eine Therapie mit prokinetisch und antiemetisch wirksamen Substanzen im Vordergrund. Extubierten Patienten sollten gerade beim Kostaufbau 4–6 kleine Mahlzeiten angeboten werden. Da die Entleerung von Flüssigkeiten länger erhalten bleibt, sollten diese Mahlzeiten eher flüssig als fest, fett und faserarm sein. Bei intubierten Patienten gibt es kaum Literaturempfehlungen, auf die man zurückgreifen kann, generell wird aber ein Beginn mit kleineren Mengen und ein langsameres Steigern der Menge empfohlen.

Abstract

Intestinal motility disturbances – like gastroparesis – worsen the outcome of critically ill patients. Inadequate and delayed feeding as well as micro aspiration, pneumonia and systemic infections up to sepsis and multiple organ failure have to be mentioned. Especially in milder cases and in the beginning symptoms are unspecific and diffuse. On the other hand the awareness of physicians has not been raised sufficiently; both problems are responsible for a lower number of patients diagnosed than affected. Especially in critically ill patients it is reasonable to distinguish between a temporary and a permanent gastroparesis. In patients with permanent gastroparesis we distinguish between three grades of severity. The most important therapeutic option is to adapt enteral nutrition according to the delay in gastric emptying. Four to six fluid-dominated, low fat and low fiber meals should be preferred in patients who eat by themselves, in intubated patients enteral nutrition should be started with lower rates, and increased more slowly. Prokinetic and antiemetic drugs complete the therapeutic options we have in critically ill patients.

Schlüsselwörter

Gastroparese - Akkommodationsstörung - Gastrointestinaltrakt - Migrating Motor Complex - digestive Motilität

Key words

gastroparesis - disturbances of accommodation - gastrointestinal tract - migrating motor complex - digestive motility

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