Aktualisierte S3-Leitlinie – „Diagnostik und Therapie des Morbus Crohn“ 2014^[1]

Einführung

Der Morbus Crohn (ICD-10: K50) ist neben der Colitis ulcerosa (ICD-10: K51) die wichtigste chronisch-entzündliche Darmerkrankung. Für den M. Crohn wurde in Deutschland zuletzt eine Inzidenz bis 6,6 pro 100 000 Einwohner berichtet [1]. Die Prävalenz dürfte bei 100 – 200 pro 100 000 Einwohner liegen [2] [3]. Die höchste altersspezfische Inzidenz liegt im dritten Lebensjahrzehnt, das mediane Erkrankungsalter bei 33 Jahren [4]. Somit beginnt für die meisten Patienten mit M. Crohn ihre Erkrankung während der Berufsausbildung und dauert während ihres gesamten beruflichen Lebens an. Daraus folgt, dass durch die Erkrankung nicht nur direkte Kosten (Medikamente, Arztbesuche, Operationen, Krankenhausaufenthalte etc.), sondern auch umfangreiche indirekte Kosten (Rente, Arbeitsausfälle etc.) entstehen. Es ist davon auszugehen, dass bei Patienten mit M. Crohn fast zwei Drittel (64 %) der Gesamtkosten den indirekten Kosten zuzuordnen sind [5]. An direkten medizinischen Kosten wurden dabei zuletzt zwischen 3500 und 6000 € pro Jahr für einen Patienten mit M. Crohn errechnet. Insgesamt entfielen 69 % der direkten Kosten allein auf Arzneimittelkosten [5] [6]. Hochgerechnet werden allein in Deutschland 2 – 3 Milliarden Euro pro Jahr für die Versorgung von Patienten mit M. Crohn aufgewandt.

Eine besondere Untergruppe von Patienten mit M. Crohn sind Kinder und Jugendliche. 19 % aller an M. Crohn Erkrankten sind unter 20 Jahre alt, vereinzelt beginnt die Erkrankung im Säuglingsalter [4]. Das Symptommuster unterscheidet sich bei Kindern von dem erwachsener Patienten. Die Behandlung von Kindern und Jugendlichen vor und während der Pubertät bis zum Abschluss des Wachstums sollte durch den in der Gastroenterologie spezialisierten Facharzt für Kinder- und Jugendmedizin erfolgen. Der klinische Verlauf, das Befallsmuster und das Ausmaß an extraintestinalen Manifestationen sind zudem sehr variabel. Daraus ergibt sich die Notwendigkeit einer komplexen Diagnostik und einer abgestuften Therapie in der klinischen Praxis.

Die jetzt überarbeitete Leitlinie basiert wesentlich auf der Leitlinie der DGVS aus dem Jahr 2008 sowie der Leitlinie der European Crohn’s and Colitis Organization (ECCO) von 2010 und der Colitis-ulcerosa-Leitlinie der DGVS von 2011 [7] [8] [9] [10] [11].

Einige Teilgebiete aus der Diagnostik und Therapie der chronisch-entzündlichen Darmerkrankungen (CED) wurden 2011 ausführlich in der Colitis-ulcerosa-Leitlinie dargestellt und wurden daher hier nicht mehr aufgearbeitet. Daher wird in den Abschnitten zur Karzinomüberwachung, der Psychosomatik und der Komplementär- und Alternativmedizin teilweise auf die Empfehlungen der Colitis-ulcerosa-Leitlinie verwiesen. Die Empfehlungen zu Schwangerschaft und Stillen, zur Schmerztherapie und zu extraintestinalen Manifestationen und Komplikationen wurden hingegen in dieser Leitlinie ausführlich überarbeitet und sollen daher in der nächsten Colitis-ulcerosa-Leitlinie übernommen werden.

Die methodischen Grundlagen für den organisatorischen Ablauf des Konsensusprozesses war das AWMF-Regelwerk Leitlinien, das Deutsche Leitlinien-Bewertungsinstrument (DELBI) und die Levels of Evidence and Grades of Recommendation vom März 2009 des Oxford-Centre for Evidence Based Medicine [12] [13] [14]. Durch den im Folgenden beschriebenen organisatorischen Ablauf und die dargestellte Methodik zur Ableitung von Empfehlungen erfüllt die Leitlinie die Kriterien einer evidenzbasierten Konsensusleitlinie (Stufe 3).

¹ Erstellt unter Federführung der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) unter Beteiligung von Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Deutsche Gesellschaft für Chirurgie (DGCh), Deutsche Gesellschaft für Innere Medizin (DGIM), Deutsche Gesellschaft für Koloproktologie (DGK), Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung (DCCV), Gesellschaft für Pädiatrische Gastroenterologie und Ernährung (GPGE), Kompetenznetz chronisch entzündliche Darmerkrankungen.

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