Management des toxischen Megakolons

Zusammenfassung

Das toxische Megakolon ist eine seltene lebensbedrohliche Komplikation einer schwersten Kolitis, kenntlich an einer Aufweitung des Kolons > 6 cm bei fehlender Obstruktion und Vorhandensein einer „systemischen Toxizität“ (Hauptkriterien: Fieber, Tachykardie, Leukozytose, Anämie). Verschiedenste Auslöser sind bekannt, die wichtigsten sind die Colitis ulcerosa, die mittlerweile seltener bis zum toxischen Megakolon exazerbiert und zunehmend eine Clostridium-difficile-assoziierte Kolitis. Die Diagnose kann mit einfachen klinischen und laborchemischen Untersuchungen und der Röntgen-Übersichtsaufnahme des Abdomens gestellt werden. Die interdisziplinäre Abwägung einer adäquaten intensivmedizinischen konservativen Therapie vs. eines operativen Vorgehens (meist als subtotale Kolektomie mit endständigem Ileostoma) ist im Einzelfall hingegen sehr schwierig. Allgemeinmaßnahmen sind die Balance der Elektrolyte und des Volumens, potente Breitspektrumantibiotika unter Einschluss von Metronidazol und Lagerungsmaßnahmen sowie evtl. eine vorsichtige intermittierende Dekompression. Bei Colitis ulcerosa ist eine Immunsuppression mit Kortikoiden und bei gesicherten Fällen evtl. mit Calcineurininhibitoren einzuleiten, bei der pseudomembranösen Kolitis eine antibiotische Therapie mit Vancomycin oral sowie Metronidazol intravenös. Nach Möglichkeit ist eine Verlegung in ein erfahrenes Zentrum anzustreben.

Abstract

Toxic megacolon is a rare and life-threatening complication of severe colitis, defined as a dilatation of the colon > 6 cm in the absence of distal obstruction in combination with signs of systemic toxicity (major criteria: fever, tachycardia, leukocytosis, anaemia). Various triggers are known and the most common causes are underlying ulcerative colitis and Clostridium difficile. Diagnosis can easily be made by clinical examination, routine laboratory parameters and a plain X-ray of the abdomen. Much more difficult is to decide between non-surgical treatment including intensive care treatment or surgery (mostly subtotal colectomy with terminal ileostomy). Non-surgical therapy includes balancing of electrolytes and fluid volumes, broad-spectrum antibiotics including metronidazole, positioning of patients and probably careful intermittent decompression. In case of ulcerative colitis immunosuppression should be started with corticosteroids and potentially with calcineurin inhibitors. In pseudomembranous colitis vancomycin should be given orally and metronidazole should be given intravenously. As far as possible the patient should be treated in a centre with experience in the field.

Schlüsselwörter

chronisch entzündliche Darmerkrankung - Colitis ulcerosa - infektiöse Kolitis - CMV - pseudomembranöse Kolitis - Morbus Crohn

Key words

chronic inflammatory bowel disease - ulcerative colitis - infectous colitis - CMV - pseudomembranous colitis - Crohn’s disease

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