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Intensivmedizin up2date 2005; 1(4): 353-364
DOI: 10.1055/s-2005-870478
Operative Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Schwere akute Pankreatitis

Jens  Werner, Werner  Hartwig, Markus  W.  Büchler
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Publication History

Publication Date:
29 November 2005 (online)

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Kernaussagen

Bisher existiert kein zuverlässiger Prädiktor für einen schweren Krankheitsverlauf bei akuter Pankreatitis. Deshalb sollten alle Patienten mit einer akuten Pankreatitis engmaschig überwacht werden.

Patienten, bei denen im CT mehr als 50 % des Pankreasparenchyms nekrotisch sind und bei denen CRP und Procalcitonin erhöht sind, sollten aufgrund des erhöhten Risikos einer schweren Pankreatitis und septischer Komplikationen intensivmedizinisch überwacht werden.

Bei Patienten mit biliärer Pankreatitis und eingeklemmten Gallensteinen, biliärer Sepsis oder obstrukivem Ikterus ist eine ERCP und Sphinkterotomie indiziert.

Bei Patienten mit nekrotisierender Pankreatitis und septischem Krankheitsbild sollte eine Feinnadelaspiration zur Unterscheidung von sterilen und infizierten Nekrosen durchgeführt werden.

Die symptomatische Basistherapie besteht aus einer ausreichenden Volumensubstitution, die einen positiven Effekt auf die Pankreasperfusion und Oxygenierung hat.

Bei nekrotisierender Pankreatitis führt eine Antibiotikaprophylaxe zur Reduktion von septischen Komplikationen.

Die Reduktion der Mortalität in der frühen Krankheitsphase ist vor allem auf die Verbesserung der intensivmedizinischen Überwachung und Therapie zurückzuführen.

Die chirurgische Therapie ist bei septischen Patienten mit infizierten Nekrosen indiziert. Bei sterilen Nekrosen ist eine operative Therapie nur in Ausnahmefällen erforderlich.

Das operative Therapieverfahren der Wahl ist die offene Nekrosektomie und die anschließende geschlossene Lavage der Bursa omentalis und des Retroperitoneums.

Literatur

  • 1 Beger H G, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis - a prospective clinical study.  Gastroenterology. 1986;  91 433-441
    PubMedGoogle Scholar
  • 2 Lankisch P, Pflichthofer D, Lehnick D. No strict correlation between necrosis and organ failure in acute pancreatitis.  Pancreas. 2000;  20 319-322
    CrossrefPubMedGoogle Scholar
  • 3 Klar E, Werner J. New pathophysiological findings in acute pancreatitis.  Chirurg. 2000;  71 253-264
    PubMedGoogle Scholar
  • 4 Rünzi M, Layer P, Büchler M. The therapy of acute pancreatitis. General guidelines. Workng group of the society for scientific-medical specialities.  Z Gastroenterol. 2000;  38 571-581
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Uhl W, Warshaw A, Imrie C. et al . IAP Guidelines for the surgical management of acute pancreatitis.  Pancreatology. 2002;  2 565-573
    CrossrefPubMedGoogle Scholar
  • 6 Büchler M W, Gloor B, Müller C A. et al . Acute necrotizing pancreatitis: treatment strategy according to the status of infection.  Ann Surg. 2000;  232 619-626
    CrossrefPubMedGoogle Scholar
  • 7 Werner J, Feuerbach S, Uhl W, Büchler M. Management of acute pancreatitis: from surgery to interventional intensive care.  Gut. 2005;  54 426-436
    CrossrefPubMedGoogle Scholar
  • 8 Guidelines UK . UK guidelines for the management of acute pncreatitis.  Gut. 2005;  54 Suppl 3: iii 1-9
    PubMedGoogle Scholar
  • 9 Bradley E L 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992.  Arch Surg. 1993;  128 586-590
    PubMedGoogle Scholar
  • 10 Lankisch P G. Epidemiology of acute pancreatitis. In: Büchler MW, Uhl W, Friess H, Malfertheiner P, eds Acute Pancreatitis: Novel Concepts in Biology and Therapy. Berlin, Vienna; Blackwell Science Inc 1999: 145-153
    Google Scholar
  • 11 Steer L M. Etiology and pathophysiology of acute pancreatitis. In: Go VLW, ed The pancreas: Biology, Pathobiology and Disease. New York; Raven Press 1993: 581-591
    Google Scholar
  • 12 Werner J, Uhl W, Büchler M. Surgical treatment of acute pancreatitis.  Curr Treatm Opt Gastroenterol. 2003;  6 359-368
    PubMedGoogle Scholar
  • 13 Sigurdson G. Acute pancreatitis: therapeutic options in multiple organ failure. In: Büchler MW, Uhl W, Friess H, Malfertheiner P, eds Acute pancreatitis: novel concepts in biology and therapy. Oxford; Blackwell Science Ltd 1999: 395-410
    Google Scholar
  • 14 Isenmann R, Rau B, Beger H. Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis.  Br J Surg. 1999;  86 1020-1024
    CrossrefPubMedGoogle Scholar
  • 15 Heath D, Alexander D, Wilson C. et al . Which complications of acute pancreatitis are most lethal? A prospective multicenter clinical study of 719 episodes.  Gut. 1995;  36 478
    PubMedGoogle Scholar
  • 16 Gullo A, Berlot G. Ingredients of organ dysfunction or failure.  World J Surg. 1996;  20 430-436
    CrossrefPubMedGoogle Scholar
  • 17 Neoptolemos J P, Raraty M, Finch M, Sutton R. Acute pancreatitis: the substantial human and financial cases.  Gut. 1998;  42 886-891
    PubMedGoogle Scholar
  • 18 Werner J, Hartwig W, Uhl W. et al . Acute pancreatitis: Are there useful markers for monitoring disease progression?.  Pancreatology. 2003;  3 115-127
    CrossrefPubMedGoogle Scholar
  • 19 Larvin M, McMahon M. APACHE II score for assessment and monitoring of cute pancreatitis.  Lancet. 1989;  22 201-205
    PubMedGoogle Scholar
  • 20 Corfield A P, Cooper M J, Williamson R CN. Prediction of severity in acute pancreatitis. a prospective comparison of three prognostic indices.  Lancet. 1985;  24 403-407
    PubMedGoogle Scholar
  • 21 Uhl W, Roggo A, Kirschstein T. et al . Influence of contrast-enhanced computed tomography on course and outcome in patients with acute pancreatitis.  Pancreas. 2002;  24 191-197
    CrossrefPubMedGoogle Scholar
  • 22 Balthazar E, Robinson D, Megibow A, Ranson J. Acute pancreatitis: value of CT in establishing prognosis.  Radiology. 1990;  174 331-336
    CrossrefPubMedGoogle Scholar
  • 23 Kemppainen E, Sainio V, Haapiainen R. et al . Early localization of necrosis by contrast-enhanced computed tomography can predict outcome in severe acute pancreatitis.  Br J Surg. 1996;  83 924-929
    PubMedGoogle Scholar
  • 24 Tenner S, Sica G, Hughes M. et al . Relationship of necrosis to organ failure in severe acute pancreatitis.  Gastroenterology. 1997;  113 899-903
    CrossrefPubMedGoogle Scholar
  • 25 Ranson J, Rifkind K, Roses D. et al . Prognostic signs and the role of operative management in acute pancreatitis.  Surg Gynecol Obstet. 1974;  139 69-81
    PubMedGoogle Scholar
  • 26 Wilson C, Heath D I, Imrie C W. Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems.  Br J Surg. 1990;  77 1260-1264
    CrossrefPubMedGoogle Scholar
  • 27 Toh S, Phillips S, Johnson C. A prospective audit against management of acute pncreatitis in the south of England.  Gut. 2000;  46 239-243
    CrossrefPubMedGoogle Scholar
  • 28 Wilson C, Heads A, Shenkin A, Imrie C W. C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis [see comments].  Br J Surg. 1989;  76 177-181
    PubMedGoogle Scholar
  • 29 Büchler M W, Malfertheiner P, Schoetensack C. et al . Sensitivity of antiproteases, complement factors and C-reactive protein in detecting pancreatic necrosis: results of a prospective clinical trial study.  Int J Pancreatol. 1986;  1 227-235
    PubMedGoogle Scholar
  • 30 Banks P, Gerzof S, Langevin R. et al . CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome.  Int J Pancreatol. 1995;  18 265-270
    PubMedGoogle Scholar
  • 31 Rau B, Pralle U, Mayer J, Beger H. Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.  Br J Surg. 1998;  85 179-184
    CrossrefPubMedGoogle Scholar
  • 32 Levin D, Bret P. Percutaneous fine-needle aspiration biopsy of the pancreas resulting in death.  Gastrointest Radiol. 1991;  16 67-69
    CrossrefPubMedGoogle Scholar
  • 33 Isenmann R, Buchler M, Uhl W. et al . Pancreatic necrosis: an early finding in severe acute pancreatitis.  Pancreas. 1993;  8 358-361
    PubMedGoogle Scholar
  • 34 Gastroenterology: B So. United Kingdom guidelines for the management of acute pancreatitis.  Gut. 1998;  42 S1-S13
    PubMedGoogle Scholar
  • 35 Dervenis C, Johnson C D, Bassi C. et al . Diagnosis, objective assessment of severity, and management of acute pancreatitis.  Int J Pancreatol. 1999;  25 195-200
    PubMedGoogle Scholar
  • 36 Uhl W, Warshaw A, Imrie C. et al . IAP guidelines for the surgical management of acute pancreatitis.  Pancreatology. 2002;  2 565-573
    CrossrefPubMedGoogle Scholar
  • 37 Pitchumoni C, Agarwal N, Jain N. Systemic complications of acute pancreatitis.  Am J Gastroenterol. 1988;  83 597-604
    PubMedGoogle Scholar
  • 38 Buter A, Imrie C, Carter C. et al . Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis.  Br J Surg. 2002;  89 298-302
    CrossrefPubMedGoogle Scholar
  • 39 Werner J, Klar E. Effective treatment regimens in the management of acute pancreatitis.  Chir Gastroenterol. 1999;  15 328-333
    PubMedGoogle Scholar
  • 40 Karanjia N D, Widdison A L, Lutrin F J, Reber H A. Dopamine in models of alcoholic acute pancreatitis.  Gut. 1994;  35(4) 547-551
    PubMedGoogle Scholar
  • 41 Klar E, Rattner D W, Compton C. et al . Adverse effect of therapeutic vasoconstrictors in experimental acute pancreatitis [see comments].  Ann Surg. 1991;  214(2) 168-174
    PubMedGoogle Scholar
  • 42 Tenner S, Banks P. Acute pancreatitis: nonsurgical management.  World J Surg. 1997;  21 143-148
    CrossrefPubMedGoogle Scholar
  • 43 Brown A, Baillargeon J, Hughes M, Banks P. Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis?.  Pancreatology. 2002;  2 104-107
    CrossrefPubMedGoogle Scholar
  • 44 Gloor B, Müller C, Worni M. et al . Late mortality in patients with severe acute pancreatitis.  Br J Surg. 2001;  88 975-979
    CrossrefPubMedGoogle Scholar
  • 45 Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J.  Gastrointest Surg. 1998;  2 496-503
    CrossrefPubMedGoogle Scholar
  • 46 Sharma V K, Howden C W. Prophylactic antibiotic sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis.  Pancreas. 2001;  22 28-31
    CrossrefPubMedGoogle Scholar
  • 47 Isenmann R, Runzi M, Kron M. et al . Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.  Gastroenterology. 2004;  126 997-1004
    CrossrefPubMedGoogle Scholar
  • 48 Villatoro E, Larvin M, Bassi C. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.  The Cochrane Database of Systematic Reviews. 2005;  4 CD002941
    PubMedGoogle Scholar
  • 49 Buchler M, Malfertheiner P, Friess H. et al . Human pancreatic tissue concentration of bactericidal antibiotics.  Gastroenterology. 1992;  103 1902-1908
    PubMedGoogle Scholar
  • 50 Sitzmann J V, Steinborn P A, Zinner M J, Cameron J L. Total parenteral nutrition and alternate energy substrates in treatment of severe acute pancreatitis.  Surg Gynecol Obstet. 1989;  168 311-317
    PubMedGoogle Scholar
  • 51 Kalfarentzos F, Kehagias J, Mead N. et al . Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.  Br J Surg. 1997;  84 1665-1669
    CrossrefPubMedGoogle Scholar
  • 52 Fan S T, Lai E C, Mok F P. et al . Early treatment of acute biliary pancreatitis by endoscopic papillotomy.  N Engl J Med. 1993;  328 282-232
    CrossrefPubMedGoogle Scholar
  • 53 Fölsch U R, Nitsche R, Ludtke R. et al . Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis.  N Engl J Med. 1997;  336 237-242
    Google Scholar
  • 54 Neoptolemos J P, Carr-Locke D L, London N J. et al . Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones.  Lancet. 1988;  2 979-983
    Google Scholar
  • 55 Widdison A L, Karanjia N D. Pancreatic infection complicating acute pancreatitis.  Br J Surg. 1993;  80 148-154
    PubMedGoogle Scholar
  • 56 Sarr M G, Nagorney D M, Mucha P Jr. et al . Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains.  Br J Surg. 1991;  78 576-581
    CrossrefPubMedGoogle Scholar
  • 57 Tsiotos G G, Luque-de Leon E, Sarr M G. Long-term outcome of necrotizing pancreatitis treated by necrosectomy.  Br J Surg. 1998;  85 1650-1653
    CrossrefPubMedGoogle Scholar
  • 58 Fernandez-del Castillo C, Rattner D W, Makary M A. et al . Debridement and closed packing for the treatment of necrotizing pancreatitis.  Ann Surg. 1998;  228(5) 676-684
    CrossrefPubMedGoogle Scholar
  • 59 Bradley E L 3rd. Operative management of acute pancreatitis: ventral open packing.  Hepatogastroenterology. 1991;  38 134-138
    PubMedGoogle Scholar
  • 60 Bradley A, Allen K. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.  Am J Surg. 1991;  161 19-24
    CrossrefPubMedGoogle Scholar
  • 61 Beger H G, Buchler M, Bittner R. et al . Necrosectomy and postoperative local lavage in necrotizing pancreatitis.  Br J Surg. 1988;  75 207-212
    CrossrefPubMedGoogle Scholar
  • 62 Bradley E L 3rd. Management of infected pancreatic necrosis by open drainage.  Ann Surg. 1987;  206(4) 542-550
    CrossrefPubMedGoogle Scholar
  • 63 Bradley E L 3rd. A fifteen year experience with open drainage for infected pancreatic necrosis.  Surg Gynecol Obstet. 1993;  177 215-222
    PubMedGoogle Scholar
  • 64 Carter C, McKay C J, Imrie C. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pacreatic necrosis: an initial experience.  Ann Surg. 2000;  232 175-180
    CrossrefPubMedGoogle Scholar

PD Dr. Jens Werner

Abteilung für Allgemeine und Viszerale Chirurgie, INF 110

Chirurgische Universitätsklinik Heidelberg · 69120 Heidelberg

Phone: 0 62 21/5 63 96 92

Fax: 0 62 21/56 54 50

Email: Jens_Werner@med.uni-heidelberg.de

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