Viszeralchirurgie 2007; 42(6): 359-365
DOI: 10.1055/s-2007-981387
Originalarbeit

© Georg Thieme Verlag Stuttgart · New York

Chronisch-entzündliche Darmerkrankungen - Konservative und postoperative Therapie

Inflammatory Bowel Disease - Medical and Post-Surgical TherapyG. Rogler1
  • 1Klinik für Gastroenterologie und Hepatologie, Department für Innere Medizin, Universitäts-Spital Zürich
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
20. Dezember 2007 (online)

Einleitung

Die konservative Therapie der chronisch-entzündlichen Darmerkrankungen ist, obwohl in den letzten Jahren wichtige Fortschritte im Verständnis der Pathophysiologie und Ätiologie gemacht werden konnten, weitgehend symptomatisch orientiert. Der Verlauf und die Ausdehnung von Morbus Crohn und Colitis ulcerosa sind sehr variabel, was eine differenzierte Therapie erfordert, die sich an individuellen Gegebenheiten orientiert. Nach wie vor ist ein wesentlicher Bestandteil der Behandlung von Patienten mit chronisch-entzündlichen Darmerkrankungen die medikamentöse Therapie. Sie wird zur Remissionsinduktion bei akuten Erkrankungsschüben, bei chronisch-aktiver Erkrankung, sowie zur Remissionserhaltung eingesetzt. Beim Versagen der medikamentösen Therapie oder beim Auftreten von Komplikationen sind operative Maßnahmen indiziert. Häufig werden diese sehr spät eingesetzt, obwohl sich die operativen Verfahren in den letzten Jahren vielfach verbessert haben. Im folgenden werden die konservativen Therapieoptionen bei chronisch-entzündlichen Darmerkrankungen zunächst für den Morbus Crohn und dann für die Colitis ulcerosa dargestellt.

Literatur

  • 1 Lofberg R. Review article: medical treatment of mild to moderately active Crohn's disease.  Aliment Pharmacol Ther. 2003;  17 Suppl 2 18-22
  • 2 Bergman R, Parkes M. Systematic review: the use of mesalazine in inflammatory bowel disease.  Aliment Pharmacol Ther. 2006;  23 841-855
  • 3 Hanauer S B. Review article: aminosalicylates in inflammatory bowel disease.  Aliment Pharmacol Ther. 2004;  20 Suppl 4 60-65
  • 4 Hanauer S B, Stromberg U. Oral Pentasa in the treatment of active Crohn's disease: A meta-analysis of double-blind, placebo-controlled trials.  Clin Gastroenterol Hepatol. 2004;  2 379-388
  • 5 Greenberg G R, Feagan B G, Martin F, Sutherland L R, Thomson A B, Williams C N, Nilsson L G, Persson T. Oral budesonide for active Crohn's disease. Canadian Inflammatory Bowel Disease Study Group.  N Engl J Med. 1994;  331 836-841
  • 6 Otley A, Steinhart A H. Budesonide for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2005: CD000296
  • 7 Sandborn W J, Lofberg R, Feagan B G, Hanauer S B, Campieri M, Greenberg G R. Budesonide for maintenance of remission in patients with Crohn's disease in medically induced remission: a predetermined pooled analysis of four randomized, double-blind, placebo-controlled trials.  Am J Gastroenterol. 2005;  100 1780-1787
  • 8 Mantzaris G J, Petraki K, Sfakianakis M, Archavlis E, Christidou A, Chadio-Iordanides H, Triadaphyllou G. Budesonide versus mesalamine for maintaining remission in patients refusing other immunomodulators for steroid-dependent Crohn's disease.  Clin Gastroenterol Hepatol. 2003;  1 122-128
  • 9 Rutgeerts P. Budesonide led to a greater remission rate and fewer severe adverse events than did mesalamine in Crohn's disease.  Gut. 1999;  45 13-14
  • 10 Lennard-Jones J E. Medical treatment of Crohn's disease.  Can J Surg. 1974;  17 402-404
  • 11 Jones J H, Lennard-Jones J E. Corticosteroids and corticotrophin in the treatment of Crohn's disease.  Gut. 1966;  7 181-187
  • 12 Domenech E. Inflammatory bowel disease: current therapeutic options.  Digestion. 2006;  73 Suppl 1 67-76
  • 13 Rutgeerts P J. Review article: the limitations of corticosteroid therapy in Crohn's disease.  Aliment Pharmacol Ther. 2001;  15 1515-1525
  • 14 Scribano M, Prantera C. Review article: medical treatment of moderate to severe Crohn's disease.  Aliment Pharmacol Ther. 2003;  17 Suppl 2 23-30
  • 15 Van Assche G, Vermeire S, Rutgeerts P. Medical treatment of inflammatory bowel diseases.  Curr Opin Gastroenterol. 2005;  21 443-447
  • 16 Siegel C A, Sands B E. Review article: practical management of inflammatory bowel disease patients taking immunomodulators.  Aliment Pharmacol Ther. 2005;  22 1-16
  • 17 Fraser A G, Orchard T R, Jewell D P. The efficacy of azathioprine for the treatment of inflammatory bowel disease: a 30 year review.  Gut. 2002;  50 485-489
  • 18 Rutgeerts P, Van Assche G, Vermeire S. Review article: Infliximab therapy for inflammatory bowel disease - seven years on.  Aliment Pharmacol Ther. 2006;  23 451-463
  • 19 Richter J A, Bickston S J. Infliximab use in luminal Crohn's disease.  Gastroenterol Clin North Am. 2006;  35 775-793
  • 20 Akobeng A K, Zachos M. Tumor necrosis factor-alpha antibody for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2004: CD003574
  • 21 Hanauer S B, Sandborn W J, Rutgeerts P, Fedorak R N, Lukas M, MacIntosh D, Panaccione R, Wolf D, Pollack P. Human anti-tumor necrosis factor monoclonal antibody (adalimumab) in Crohn's disease: the CLASSIC-I trial.  Gastroenterology. 2006;  130 323-333 ,  quiz 591
  • 22 Sisson G, Harris A. Certolizumab pegol (CDP870) for treatment of Crohn's disease.  Gastroenterology. 2006;  130 285-286 ,  author reply 286
  • 23 Cosnes J, Nion-Larmurier I, Beaugerie L, Afchain P, Tiret E, Gendre J P. Impact of the increasing use of immunosuppressants in Crohn's disease on the need for intestinal surgery.  Gut. 2005;  54 237-241
  • 24 Kamm M A. Review article: chronic active disease and maintaining remission in Crohn's disease.  Aliment Pharmacol Ther. 2004;  20 Suppl 4 102-105
  • 25 Ludwig D, Stange E F. German Imurek Study Group . Efficacy of azathioprine in the treatment of chronic active Crohn's disease: prospective one-year follow-up study.  Z Gastroenterol. 1999;  37 1085-1091
  • 26 Lemann M, Mary J Y, Colombel J F, Duclos B, Soule J C, Lerebours E, Modigliani R, Bouhnik Y. A randomized, double-blind, controlled withdrawal trial in Crohn's disease patients in long-term remission on azathioprine.  Gastroenterology. 2005;  128 1812-1818
  • 27 Gonvers J J, Juillerat P, Mottet C, Felley C, Burnand B, Vader J P, Michetti P, Froehlich F. Maintenance of remission in Crohn's disease.  Digestion. 2005;  71 41-48
  • 28 Vilien M, Dahlerup J F, Munck L K, Norregaard P, Gronbaek K, Fallingborg J. Randomized controlled azathioprine withdrawal after more than two years treatment in Crohn's disease: increased relapse rate the following year.  Aliment Pharmacol Ther. 2004;  19 1147-1152
  • 29 Schedel J, Godde A, Schutz E, Bongartz T A, Lang B, Scholmerich J, Muller-Ladner U. Impact of thiopurine methyltransferase activity and 6-thioguanine nucleotide concentrations in patients with chronic inflammatory diseases.  Ann N Y Acad Sci. 2006;  1069 477-491
  • 30 Colombel J F, Ferrari N, Debuysere H, Marteau P, Gendre J P, Bonaz B, Soule J C, Modigliani R, Touze Y, Catala P, Libersa C, Broly F. Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy.  Gastroenterology. 2000;  118 1025-1030
  • 31 Travis S P, Stange E F, Lemann M, Oresland T, Chowers Y, Forbes A, D'Haens G, Kitis G, Cortot A, Prantera C, Marteau P, Colombel J F, Gionchetti P, Bouhnik Y, Tiret E, Kroesen J, Starlinger M, Mortensen N J. European evidence based consensus on the diagnosis and management of Crohn's disease: current management.  Gut. 2006;  55 Suppl 1 16-35
  • 32 Feagan B G. Methotrexate treatment for Crohn's disease.  Inflamm Bowel Dis. 1998;  4 120-121
  • 33 Feagan B G, Rochon J, Fedorak R N, Irvine E J, Wild G, Sutherland L, Steinhart A H, Greenberg G R, Gillies R, Hopkins M. et al . Methotrexate for the treatment of Crohn's disease.  N Engl J Med. 1995;  332 292-297
  • 34 Feagan B G. Maintenance therapy for inflammatory bowel disease.  Am J Gastroenterol. 2003;  98 S6-S17
  • 35 Rutgeerts P J. Review article: efficacy of infliximab in Crohn's disease - induction and maintenance of remission.  Aliment Pharmacol Ther. 1999;  13 Suppl 4 9-15 ,  discussion 38
  • 36 Kevans D, Keegan D, Mulcahy H E, O'Donoghue D P. Infliximab therapy in Crohn's disease: a pragmatic approach?.  Aliment Pharmacol Ther. 2006;  24 351-359
  • 37 Rutgeerts P, Diamond R H, Bala M, Olson A, Lichtenstein G R, Bao W, Patel K, Wolf D C, Safdi M, Colombel J F, Lashner B, Hanauer S B. Scheduled maintenance treatment with infliximab is superior to episodic treatment for the healing of mucosal ulceration associated with Crohn's disease.  Gastrointest Endosc. 2006;  63 433-442 ,  quiz 464
  • 38 Schreiber S, Sandborn W J. CLASSIC-I study the efficacy of adalimumab.  Gastroenterology. 2006;  130 1929-1930
  • 39 Sandborn W J, Hanauer S, Loftus Jr E V, Tremaine W J, Kane S, Cohen R, Hanson K, Johnson T, Schmitt D, Jeche R. An open-label study of the human anti-TNF monoclonal antibody adalimumab in subjects with prior loss of response or intolerance to infliximab for Crohn's disease.  Am J Gastroenterol. 2004;  99 1984-1989
  • 40 Schreiber S, Rutgeerts P, Fedorak R N, Khaliq-Kareemi M, Kamm M A, Boivin M, Bernstein C N, Staun M, Thomsen O O, Innes A. A randomized, placebo-controlled trial of certolizumab pegol (CDP870) for treatment of Crohn's disease.  Gastroenterology. 2005;  129 807-818
  • 41 Akobeng A K, Gardener E. Oral 5-aminosalicylic acid for maintenance of medically-induced remission in Crohn's Disease. Cochrane Database Syst Rev 2005: CD003715
  • 42 Pearson D C, May G R, Fick G, Sutherland L R. Azathioprine for maintaining remission of Crohn's disease. Cochrane Database Syst Rev 2000: CD000067
  • 43 Rolfe V E, Fortun P J, Hawkey C J, Bath-Hextall F. Probiotics for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2006: CD004826
  • 44 Brookes M J, Green J R. Maintenance of remission in Crohn's disease: current and emerging therapeutic options.  Drugs. 2004;  64 1069-1089
  • 45 Froehlich F, Juillerat P, Felley C, Mottet C, Vader J P, Burnand B, Michetti P, Gonvers J J. Treatment of postoperative Crohn's disease.  Digestion. 2005;  71 49-53
  • 46 Frieri G, Pimpo M T, Andreoli A, Annese V, Comberlato M, Corrao G, Palumbo G, Sturniolo G C, Tonelli F, Caprilli R. Gruppo Italiano per lo Studio del Colon e del Retto . Prevention of post-operative recurrence of Crohn's disease requires adequate mucosal concentration of mesalazine.  Aliment Pharmacol Ther. 1999;  13 577-582
  • 47 Biddle W L, Miner Jr  P B. Long-term use of mesalamine enemas to induce remission in ulcerative colitis.  Gastroenterology. 1990;  99 113-118
  • 48 Safdi M, DeMicco M, Sninsky C, Banks P, Wruble L, Deren J, Koval G, Nichols T, Targan S, Fleishman C, Wiita B. A double-blind comparison of oral versus rectal mesalamine versus combination therapy in the treatment of distal ulcerative colitis.  Am J Gastroenterol. 1997;  92 1867-1871
  • 49 Cohen R D, Woseth D M, Thisted R A, Hanauer S B. A meta-analysis and overview of the literature on treatment options for left-sided ulcerative colitis and ulcerative proctitis.  Am J Gastroenterol. 2000;  95 1263-1276
  • 50 Marshall J K, Irvine E J. Rectal corticosteroids versus alternative treatments in ulcerative colitis: a meta-analysis.  Gut. 1997;  40 775-781
  • 51 Regueiro M, Loftus Jr  E V, Steinhart A H, Cohen R D. Medical management of left-sided ulcerative colitis and ulcerative proctitis: critical evaluation of therapeutic trials.  Inflamm Bowel Dis. 2006;  12 979-994
  • 52 Campieri M, Gionchetti P, Belluzzi A, Brignola C, Tabanelli G M, Miglioli M, Barbara L. 5-Aminosalicylic acid as enemas or suppositories in distal ulcerative colitis?.  J Clin Gastroenterol. 1988;  10 406-409
  • 53 Ardizzone S, Doldo P, Ranzi T, Sturniolo G C, Giglio L A, Annese V, D'Arienzo A, Gaia E, Gullini S, Riegler G, Valentini M, Massa P, Del Piano M, Rossini F, Guidetti C S, Pera A, Greinwald R, Bianchi Porro G. The SAF-3 study group . Mesalazine foam (Salofalk foam) in the treatment of active distal ulcerative colitis. A comparative trial vs Salofalk enema.  Ital J Gastroenterol Hepatol. 1999;  31 677-684
  • 54 Truelove S C, Witts L J. Cortisone in ulcerative colitis; final report on a therapeutic trial.  Br Med J. 1955;  2 1041-1048
  • 55 Mulder C J, Fockens P, Meijer J W, van der Heide H, Wiltink E H, Tytgat G N. Beclomethasone dipropionate (3 mg) versus 5-aminosalicylic acid (2 g) versus the combination of both (3 mg / 2 g) as retention enemas in active ulcerative proctitis.  Eur J Gastroenterol Hepatol. 1996;  8 549-553
  • 56 Sutherland L, Macdonald J K. Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis. Cochrane Database Syst Rev 2006: CD000543
  • 57 Kjeldsen J. Treatment of ulcerative colitis with high doses of oral prednisolone. The rate of remission, the need for surgery, and the effect of prolonging the treatment.  Scand J Gastroenterol. 1993;  28 821-826
  • 58 Travis S P, Farrant J M, Ricketts C, Nolan D J, Mortensen N M, Kettlewell M G, Jewell D P. Predicting outcome in severe ulcerative colitis.  Gut. 1996;  38 905-910
  • 59 Turner D, Walsh C M, Steinhart A H, Griffiths A M. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression.  Clin Gastroenterol Hepatol. 2007;  5 103-110
  • 60 Caprilli R, Viscido A, Latella G. Current management of severe ulcerative colitis.  Nat Clin Pract Gastroenterol Hepatol. 2007;  4 92-101
  • 61 Dickinson R J, Ashton M G, Axon A T, Smith R C, Yeung C K, Hill G L. Controlled trial of intravenous hyperalimentation and total bowel rest as an adjunct to the routine therapy of acute colitis.  Gastroenterology. 1980;  79 1199-1204
  • 62 Seo M, Okada M, Yao T, Furukawa H, Matake H. The role of total parenteral nutrition in the management of patients with acute attacks of inflammatory bowel disease.  J Clin Gastroenterol. 1999;  29 270-275
  • 63 Van Assche G, D'Haens G, Noman M, Vermeire S, Hiele M, Asnong K, Arts J, D'Hoore A, Penninckx F, Rutgeerts P. Randomized, double-blind comparison of 4 mg / kg versus 2 mg / kg intravenous cyclosporine in severe ulcerative colitis.  Gastroenterology. 2003;  125 1025-1031
  • 64 Lichtiger S, Present D H, Kornbluth A, Gelernt I, Bauer J, Galler G, Michelassi F, Hanauer S. Cyclosporine in severe ulcerative colitis refractory to steroid therapy.  N Engl J Med. 1994;  330 1841-1845
  • 65 Shibolet O, Regushevskaya E, Brezis M, Soares-Weiser K. Cyclosporine A for induction of remission in severe ulcerative colitis. Cochrane Database Syst Rev 2005: CD004277
  • 66 Domenech E, Garcia-Planella E, Bernal I, Rosinach M, Cabre E, Fluvia L, Boix J, Gassull M A. Azathioprine without oral ciclosporin in the long-term maintenance of remission induced by intravenous ciclosporin in severe, steroid-refractory ulcerative colitis.  Aliment Pharmacol Ther. 2002;  16 2061-2065
  • 67 Fernandez-Banares F, Bertran X, Esteve-Comas M, Cabre E, Menacho M, Humbert P, Planas R, Gassull M A. Azathioprine is useful in maintaining long-term remission induced by intravenous cyclosporine in steroid-refractory severe ulcerative colitis.  Am J Gastroenterol. 1996;  91 2498-2499
  • 68 Regueiro M, Curtis J, Plevy S. Infliximab for hospitalized patients with severe ulcerative colitis.  J Clin Gastroenterol. 2006;  40 476-481
  • 69 Jarnerot G. Infliximab or cyclosporine for severe ulcerative colitis.  Gastroenterology. 2006;  130 286 ,  author reply 287
  • 70 Jarnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlen P, Granno C, Vilien M, Strom M, Danielsson A, Verbaan H, Hellstrom P M, Magnuson A, Curman B. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study.  Gastroenterology. 2005;  128 1805-1811
  • 71 Hanauer S B. Infliximab or cyclosporine for severe ulcerative colitis.  Gastroenterology. 2005;  129 1358-1359 ,  author reply 1359
  • 72 Timmer A, McDonald J, Macdonald J. Azathioprine and 6-mercaptopurine for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev 2007: CD000478
  • 73 Ginsburg P M, Dassopoulos T. Steroid dependent ulcerative colitis: azathioprine use is finally “evidence-based”.  Inflamm Bowel Dis. 2006;  12 921-922
  • 74 Ardizzone S, Maconi G, Russo A, Imbesi V, Colombo E, Bianchi Porro G. Randomised controlled trial of azathioprine and 5-aminosalicylic acid for treatment of steroid dependent ulcerative colitis.  Gut. 2006;  55 47-53
  • 75 Lawson M M, Thomas A G, Akobeng A K. Tumour necrosis factor alpha blocking agents for induction of remission in ulcerative colitis. Cochrane Database Syst Rev 2006; 3: CD005112
  • 76 Sutherland L, Macdonald J K. Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev 2006: CD000544
  • 77 Orchard T, Probert C S, Keshav S. Review article: maintenance therapy in patients with ulcerative colitis.  Aliment Pharmacol Ther. 2006;  24 Suppl 1 17-22
  • 78 Marshall J K, Irvine E J. Putting rectal 5-aminosalicylic acid in its place: the role in distal ulcerative colitis.  Am J Gastroenterol. 2000;  95 1628-1636
  • 79 Kane S, Huo D, Aikens J, Hanauer S. Medication nonadherence and the outcomes of patients with quiescent ulcerative colitis.  Am J Med. 2003;  114 39-43
  • 80 Kane S V, Cohen R D, Aikens J E, Hanauer S B. Prevalence of nonadherence with maintenance mesalamine in quiescent ulcerative colitis.  Am J Gastroenterol. 2001;  96 2929-2933
  • 81 d'Albasio G, Pacini F, Camarri E, Messori A, Trallori G, Bonanomi A G, Bardazzi G, Milla M, Ferrero S, Biagini M, Quaranta S, Amorosi A. Combined therapy with 5-aminosalicylic acid tablets and enemas for maintaining remission in ulcerative colitis: a randomized double-blind study.  Am J Gastroenterol. 1997;  92 1143-1147
  • 82 Sartor R B. Probiotic therapy of intestinal inflammation and infections.  Curr Opin Gastroenterol. 2005;  21 44-50
  • 83 Kruis W, Fric P, Pokrotnieks J, Lukas M, Fixa B, Kascak M, Kamm M A, Weismueller J, Beglinger C, Stolte M, Wolff C, Schulze J. Maintaining remission of ulcerative colitis with the probiotic Escherichia coli Nissle 1917 is as effective as with standard mesalazine.  Gut. 2004;  53 1617-1623
  • 84 Rembacken B J, Snelling A M, Hawkey P M, Chalmers D M, Axon A T. Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial.  Lancet. 1999;  354 635-639
  • 85 Sohi S, Cohen R D. Management of refractory ulcerative colitis.  Curr Treat Options Gastroenterol. 2006;  9 234-245
  • 86 Katz S. Update in medical therapy of ulcerative colitis: newer concepts and therapies.  J Clin Gastroenterol. 2005;  39 557-569

Prof. Dr. med. Dr. phil. G. Rogler

Klinik für Gastroenterologie und Hepatologie · Department für Innere Medizin · Universitäts-Spital Zürich · Zürcher Zentrum für Integrative Humanphysiologie (ZIHP) · Universität Zürich

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