Nichtoperative Therapie des Gallensteinleidens

Zusammenfassung

Gallensteine sind in der Bevölkerung häufig anzutreffen. Im Alter von 75 Jahren haben 20 % der Männer und 35 % der Frauen Gallensteine. Aufgrund der Klinik unterscheidet man asymptomatische Gallensteine von symptomatischen Gallensteinleiden. Asymptomatische Gallenblasensteine bedürfen weder einer medikamentösen noch einer interventionellen bzw. operativen Therapie. Träger von asymptomatischen Gallensteinen haben jährlich in 1 - 2 % mit späteren Komplikationen zu rechnen. Bei symptomatischen Gallenblasensteine stellt die laparoskopische Cholezystektomie die primäre Behandlungsoption dar. Bei klinischem Verdacht ist die präoperative Sicherung von Gallengangssteinen anzustreben. Bei positivem Steinnachweis im Gallengang empfiehlt sich präoperativ - im Sinne eines „therapeutischen Splittings” - die Sanierung der Gallenwege mit endoskopischen Techniken durchzuführen. Die medikamentöse Therapie von Gallensteinen ist bestimmten Patienten vorbehalten aber spielt als alleinige Therapie nur in seltenen Fällen noch eine Rolle. Die ESWL hat sich für die Behandlung von Gallenblasensteinen nicht durchsetzen können, da eine hohe Rate an Steinrezidiven auftritt. Der wesentliche Stellenwert der ESWL ist die Behandlung von komplizierten, endoskopisch nicht extrahierbaren Gallengangssteinen. Bei alten Patienten mit Gallengangs- und Gallenblasensteinen sowie einem hohen Operationsrisiko ist ein alleiniges endoskopisches Vorgehen möglich, dabei ist aber in 15 % der Fälle mit späteren Komplikationen zu rechnen, die eine Cholezystektomie notwendig machen.

Abstract

Gallstones are highly prevalent in the general population. By the age of 75 years approximately 20 percent of men and 35 percent of women suffer from gallstone disease. Based on clinical manifestations we distinguish asymptomatic gallstones and symptomatic gallstone disease. Patients with asymptomatic gallstones develop serious symptoms or complications in 1 to 2 percent per year, therefore they do not need any therapy. The treatment of choice for symptomatic cholecystolithiasis is laparoscopic cholecystectomy. Preoperative Endoscopic Retrograde Cholangiography with stone extraction is recommended in cases with common bile duct stones. Oral bile acid dissolution with ursodeoxycholic acid is reserved to special patient groups. Extracorporeal shock wave lithotripsy (ESWL) is an important method for treatment of difficult common bile duct stones, not removable by endoscopic techniques. For treament of cholecystolithiasis ESWL plays no role. For patients with gallstones in the common bile duct and gallbladder in situ who are older or of high risk for surgery the endoscopic treatment (papillotomy and stone extraction) is the method of choice. The need for cholecystectomy in these patients is approximately 15 percent within 5 years, with a high rate of emergency procedures.

Schlüsselwörter

Cholelithiasis - Lithotripsie - Endoskopie - Gallensäuren - ESWL

Key words

Cholelithiasis - lithocholic acid - endoscopy - ESWL - Endoscopy

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