50 Jahre Fortschritt in Pathophysiologie, Diagnostik und Behandlung der chronischen Pankreatitis

Zusammenfassung

Die Zeitschrift für Gastroenterologie feiert im Jahr 2013 ihr 50-jähriges Bestehen. In diesem halben Jahrhundert haben Originalarbeiten, Übersichten und Leitlinien zur akuten Pankreatitis, zur chronischen Pankreatitis und zum Pankreaskarzinom kontinuierlich eine prominente Rolle in den Seiten der ZfG eingenommen. Schon in der Erstausgabe der Zeitschrift veröffentlichten Haemmerli und Hefti die Züricher Erfahrungen zum natürlichen Verlauf der chronischen Pankreatitis, ergänzt um eine detaillierte Darstellung des Standes der Wissenschaft im Jahr 1963. Fünfzig Jahre später ist die aktuelle Leitlinie der DGVS zur chronischen Pankreatitis in den Seiten der ZfG erschienen und erlaubt eine Zusammenfassung der Fortschritte über diesen Zeitraum. Damals wurde die chronische Pankreatitis als sehr seltene Erkrankung betrachtet (10-fach seltener als z. B. die akute Pankreatitis oder das Pankreaskarzinom), was wenig mit der tatsächlichen Prävalenz und viel mit den noch wenig empfindlichen diagnostischen Möglichkeiten, insbesondere in der Bildgebung zu tun hatte. Während die pathogenetischen Ursachen der chronischen Pankreatitis, einschließlich einer möglichen erblichen Genese, 1963 bereits weitgehend bekannt waren, hat sich das Verständnis ihrer zellulären Grundlagen rasant weiterentwickelt. Die größten Fortschritte in der Diagnostik wurden durch die Entwicklung bildgebender Verfahren wie Sonografie und Endosonografie, ERCP, CT und MRCP ermöglicht. Auch in der Therapie haben sich nicht nur die pharmakotherapeutischen Ansätze verändert (Verlassen der Sekretionshemmung als Therapieprinzip), sondern v. a. die Alternativen die endoskopisch-interventionellen und die chirurgische Therapie sind neu entstanden.

Abstract

The German Journal of Gastroenterology celebrates its fifties anniversary in 2013. Over half a century original studies, reviews and guidelines covering the topics of acute and chronic pancreatitis as well as pancreatic cancer have assumed a prominent role on its pages. Already in the first edition of the Journal Haemmerli and Hefti have summarized the Zurich experience with chronic pancreatitis and provided a detailed state-of-the-art review for the year 1963. 50 years later the current guidelines of the German Society of Digestive and Metabolic Diseases (DGVS) have been published in the same Journal and allow to summarize the scientific progress over this period. Back then chronic pancreatitis was regarded as a rare disorder (tenfold less common than e. g. acute pancreatitis or pancreatic cancer). This misconception had little to do with actual prevalence but with highly insensitive diagnostic tests, particularly in the area of diagnostic imaging. While pathogenetic factors for chronic pancreatitis, including a possible genetic disposition, were largely known in 1963, our understanding of their cellular mechanisms has very much improved. The greatest progress in diagnostic options was achieved by the introduction of novel imaging techniques such as ultrasound and endoscopic ultrasound, ERCP, CT and MRCP. In terms of therapy the notion that a blockage of pancreatitic secretion is an effective pharmacological option has been abandoned and endoscopic intervention and surgical treatment have been newly developed as alternatives.

Schlüsselwörter

Chronische Pankreatitis - Schmerztherapie der chronischen Pankreatitis - Enzymsupplementierung bei exokriner Insuffizienz - endoskopische Therapie der chronischen Pankreatitis - hereditäre Pankreatitis

Key words

chronic pancreatitis - pain management in chronic pancreatitis - enzyme replacement for exocrine failure - endoscopic therapy for chronic pancreatitis - hereditary pancreatitis

• Literatur

• 1 Haemmerli UP, Hefti ML. Chronische Pankreatitis. Zeitschrift für Gastroenterologie 1963; 1: 27-35
• 2 Hoffmeister A, Mayerle J, Beglinger C et al. S3-Consensus guidelines on definition, etiology, diagnosis and medical, endoscopic and surgical management of chronic pancreatitis German Society of Digestive and Metabolic Diseases (DGVS). Z Gastroenterol 2012; 50: 1176-1224
• 3 Peery AF, Dellon ES, Lund J et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143: 1179-1187 e1171-e1173
• 4 Siegmund E, Lohr JM, Schuff-Werner P. The diagnostic validity of non-invasive pancreatic function tests – a meta-analysis. Z Gastroenterol 2004; 42: 1117-1128
• 5 Gress TM, Muller-Pillasch F, Lerch MM et al. Balance of expression of genes coding for extracellular matrix proteins and extracellular matrix degrading proteases in chronic pancreatitis. Z Gastroenterol 1994; 32: 221-225
• 6 Maisonneuve P, Lowenfels AB, Mullhaupt B et al. Cigarette smoking accelerates progression of alcoholic chronic pancreatitis. Gut 2005; 54: 510-514
• 7 Ellis I, Lerch MM, Whitcomb DC. Genetic testing for hereditary pancreatitis: guidelines for indications, counselling, consent and privacy issues. Pancreatology 2001; 1: 405-415
• 8 Keim V, Bauer N, Teich N et al. Clinical characterization of patients with hereditary pancreatitis and mutations in the cationic trypsinogen gene. The American journal of medicine 2001; 111: 622-626
• 9 Weiss FU, Simon P, Bogdanova N et al. Complete cystic fibrosis transmembrane conductance regulator gene sequencing in patients with idiopathic chronic pancreatitis and controls. Gut 2005; 54: 1456-1460
• 10 Nitsche C, Maertin S, Scheiber J et al. Drug-induced pancreatitis. Current gastroenterology reports 2012; 14: 131-138
• 11 Yoshida K, Toki F, Takeuchi T et al. Chronic pancreatitis caused by an autoimmune abnormality. Proposal of the concept of autoimmune pancreatitis. Digestive diseases and sciences 1995; 40: 1561-1568
• 12 Hart PA, Kamisawa T, Brugge WR et al. Long-term outcomes of autoimmune pancreatitis: a multicentre, international analysis. Gut 2012; epub ahead of print
• 13 Shimosegawa T, Chari ST, Frulloni L et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 2011; 40: 352-358
• 14 Pickartz T, Mayerle J, Lerch MM. Autoimmune pancreatitis. Nature clinical practice Gastroenterology & hepatology 2007; 4: 314-323
• 15 Hernandez CA, Lerch MM. Sphincter stenosis and gallstone migration through the biliary tract. Lancet 1993; 341: 1371-1373
• 16 Halangk W, Kruger B, Ruthenburger M et al. Trypsin activity is not involved in premature, intrapancreatic trypsinogen activation. American journal of physiology Gastrointestinal and liver physiology 2002; 282: G367-G374
• 17 Hirano T, Saluja A, Ramarao P et al. Apical secretion of lysosomal enzymes in rabbit pancreas occurs via a secretagogue regulated pathway and is increased after pancreatic duct obstruction. The Journal of clinical investigation 1991; 87: 865-869
• 18 Mayerle J, Schnekenburger J, Kruger B et al. Extracellular cleavage of E-cadherin by leukocyte elastase during acute experimental pancreatitis in rats. Gastroenterology 2005; 129: 1251-1267
• 19 Sendler M, Dummer A, Weiss FU et al. Tumour necrosis factor alpha secretion induces protease activation and acinar cell necrosis in acute experimental pancreatitis in mice. Gut 2013; 62: 430-439
• 20 Axon AT. Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. Cambridge classification. Radiologic clinics of North America 1989; 27: 39-50
• 21 Catalano MF, Sahai A, Levy M et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointestinal endoscopy 2009; 69: 1251-1261
• 22 Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut 2005; 54 (Suppl. 06) vi1-vi28
• 23 DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme ouputs and malabsorption in severe pancreatic insufficiency. The New England journal of medicine 1973; 288: 813-815
• 24 Kahl S, Zimmermann S, Genz I et al. Risk factors for failure of endoscopic stenting of biliary strictures in chronic pancreatitis: a prospective follow-up study. The American journal of gastroenterology 2003; 98: 2448-2453
• 25 Dite P, Ruzicka M, Zboril V et al. A prospective, randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis. Endoscopy 2003; 35: 553-558
• 26 Cahen DL, Gouma DJ, Laramee P et al. Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis. Gastroenterology 2011; 141: 1690-1695
• 27 Bradley EL, Clements JL Jr, Gonzalez AC. The natural history of pancreatic pseudocysts: a unified concept of management. American journal of surgery 1979; 137: 135-141
• 28 Gouyon B, Levy P, Ruszniewski P et al. Predictive factors in the outcome of pseudocysts complicating alcoholic chronic pancreatitis. Gut 1997; 41: 821-825
• 29 Lerch MM, Stier A, Wahnschaffe U et al. Pancreatic pseudocysts: observation, endoscopic drainage, or resection?. Deutsches Ärzteblatt international 2009; 106: 614-621