Das akute (chirurgische) Abdomen – Epidemiologie, Diagnostik und allgemeine Prinzipien des Managements

Zusammenfassung

Hintergrund: In dieser Übersicht wird zu Epidemiologie, Diagnostik und allgemeinen Prinzipien des chirurgischen Managements bei Patienten mit akutem Abdomen Stellung genommen. Definition und Epidemiologie: Häufigste Ursache des akuten Bauchschmerzes ist der unspezifische Bauchschmerz, dessen Prävalenz in der Literatur mit 24 – 44,3 %, bezogen auf das jeweilige Gesamtkrankengut, angegeben wird, gefolgt von der akuten Appendizitis (15,9 – 28,1 %), dem akuten Gallensteinleiden (2,9 – 9,7 %) sowie Darmverschluss und Divertikulitis bei älteren Patienten. Speziell bei Kindern macht die akute Appendizitis ca. ⅔ aller Operationsindikationen bei akutem Abdomen aus. Diagnostik: Vorrangig ist die klinische Untersuchung, die mit einer Sonografie zu verbinden ist. Aus Gründen der Strahlenbelastung des Patienten und der Kosten sollte die CT sorgfältig indiziert werden, der in dieser Arbeit vorgestellte Ablaufpfad beschränkt die CT auf weniger als die Hälfte der Patienten mit akutem Bauchschmerz. Die explorative Laparoskopie ist erst indiziert, wenn nach bildgebender Diagnostik die Ursache des akuten Bauchschmerzes weiterhin unklar ist. Bei der Indikation ist zu berücksichtigen, dass bei Verdacht auf nicht spezifischen Bauchschmerz eine abwartende Haltung (klinische Beobachtung des Patienten für 24 – 48 h) immer noch Standard ist. Management: Der Stellenwert des laparoskopischen Zugangs zum akuten Abdomen ist beim Ileus nicht unumstritten, obwohl speziell beim Bridenileus hervorragende Ergebnisse berichtet wurden. Bei Patienten auf der Intensivstation mit unklarem Abdomen, Verdacht auf Sepsis abdomineller Genese, bei Verdacht auf Cholezystitis, Mesenterialischämie oder bei refraktärer Laktatazidose (speziell nach herzchirurgischen Eingriffen) wird die Bedside-Laparoskopie angeraten. Generell ist eine frühzeitige Analgesie bei Patienten mit akutem Abdomen angezeigt, da verschiedene Studien zeigen konnten, dass sich damit der Patientenkomfort erhöht, ohne die Sicherheit der Diagnostik wesentlich zu beeinträchtigen. Doch ist die Beeinflussung der diagnostischen Genauigkeit von der Dosierung, der Art der Schmerzmittelapplikation und der Grundkrankheit abhängig, sodass eine frühe Analgesie angemessen gehandhabt werden soll. Dies zeigen Umfragen bei Pädiatern und Chirurgen, die belegen, dass nicht mehr als 50 % der Chirurgen und Pädiater das Konzept der Frühanalgesie auch tatsächlich in der Routine regelmäßig umsetzen.

Abstract

Aim: This review comments on epidemiology, diagnosis and general principles of surgical management in patients with acute abdomen. Definition and Epidemiology: The most common cause of acute abdominal pain is non-specific abdominal pain (24 – 44.3 % of the study populations), followed by acute appendicitis (15.9 – 28.1 %), acute biliary disease (2.9 – 9.7 %) and bowel obstruction or diverticulitits in elderly patients. Acute appendicitis represents the cause of surgical intervention in two-thirds of the children with acute abdomen. Diagnosis: A standardised physical examination combined with ultrasonography (US) represents the initial investigation in patients with acute abdominal pain. Due to the risk associated with radiation and due to the costs, a selective use of CT imaging is recommended. The work-flow given in this paper restricts the use of CT imaging to less than 50 % of patients with acute abdominal pain. Diagnostic laparoscopy should be considered in patients without a specific diagnosis after appropriate imaging and as an alternative to active clinical observation which is the current practice in patients with non-specific abdominal pain. Management: Acute small bowel obstruction has previously been considered as a relative contraindication for laparoscopic management, but it has been shown in the meantime that laparoscopic treatment is an elegant tool for the management of simple band small bowel obstruction. Bedside diagnostic laparoscopy is recommended in intensive care unit (ICU) patients with acute abdomen or sepsis of unknown origin, in suspicion of acute cholecystitis, diffuse gut hypoperfusion and mesenteric ischaemia or in refractory lactic acidosis, especially after cardiac surgery. Early administration of analgesia to patients with acute abdominal pain in the emergency department will reduce the patient’s discomfort without impairing clinically important diagnostic accuracy and is recommended on the basis of some prospective randomised trials. However, the impact on diagnostic accuracy depends on dosage, kind of application and cause of acute abdominal pain. A practice of judicious provision of analgesia therefore appears safe. There are significant differences between the knowledge of the current literature and the routine practice of providing analgesia as a survey has shown demonstrating that less than 50 % of paediatric emergency physicians and paediatric surgeons are usually willing to provide analgesia before definitive diagnosis.

Schlüsselwörter

akutes Abdomen - akuter Bauchschmerz - Diagnostik - Management - Workflow

Key words

acute abdomen - acute abdominal pain - diagnostics - management - work-flow

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