Diagnostik und Therapie der chronischen nicht-infektiösen Diarrhö

Zusammenfassung

Die chronische, nicht-infektiöse Diarrhö kann durch eine Vielzahl gastrointestinaler Erkrankungen ausgelöst werden. Bereits bei der Anamnese ist auf begleitende Warnsymptome und spezifische Auslöser zu achten. Der fäkale Entzündungsmarker Calprotecin kann zwar bei der Differenzierung zwischen organischen und funktionellen Magen-Darmerkrankungen helfen, ist jedoch nicht spezifisch.

Zur symptomatischen Therapie der chronischen Diarrhö stehen u. a. gelbildende Ballaststoffe, Loperamid und Colestyramin zur Verfügung und auch die Gabe von Probiotika kann symptomlindernd wirken. Der zur Therapie einer akuten Diarrhö zugelassene Enkephalinase-Inhibitors Racecadotril kann für eine Langzeitanwendung bei chronischer Diarrhö bisher nur wenige Daten vorweisen. Mit dem Wirkstoff Eluxadolin, der durch Modulierung von Opioid-Rezeptoren im Darmnervensystem Bauchschmerzen und Durchfälle lindern kann, steht voraussichtlich demnächst eine neue therapeutische Option zur Verfügung. Weitere medikamentöse Ansätze beim Therapie-refraktären Reizdarmsyndrom mit Diarrhö umfassen 5-HT3-Rezeptor-Antagonisten, das Antibiotikum Rifaximin sowie niedrig dosierte trizyklische Antidepressiva. Spezifische Diäten wie die low-FODMAP-Diät können ebenfalls Beschwerden des RDS lindern.

Abstract

Chronic, non-infectious diarrhea can be caused by a variety of gastrointestinal diseases. In anamnesis, it is important to take accompanying warning symptoms and specific triggers into account. The fecal inflammatory marker calprotectin may help differentiating between organic and functional gastrointestinal disorders, but it is not specific. Among other options, gelling fibres, Loperamide and Cholestyramine as well as probiotics are available for the symptomatic treatment of chronic diarrhea. For long-term treatment of chronic diarrhea with the enkephalinase inhibitor racecadotril, which is approved for acute diarrhea, only limited data are available. Eluxadolin presents a new therapeutic option. It can alleviate abdominal pain and diarrhea by modulation of opioid receptors in the enteric nervous system. Additional approaches in intractable irritable bowel syndrome with diarrhea (IBS-D) include 5-HT3 receptor antagonists, the antibiotic Rifaximin as well as low-dose tricyclic antidepressants. Specific diets such as the low-FODMAP diet can also relieve symptoms in IBS.

Schlüsselwörter

chronische nichtinfektiöse Diarrhö - Calprotectin - Diarrhö-dominantes Reizdarmsyndrom - Low-FODMAP-Diät

Keywords

chronic non-infectious diarrhea - calprotectin - IBS with diarrhea - low-FODMAP diet

• Literatur

• 1 Laux G, Kühlein T, Gutscher A et al. Versorgungsforschung in der Hausarztpraxis – Ergebnisse aus dem CONTENT-Projekt 2006–2009. München: Springer Medizin, Urban und Vogel GmbH; 2010
• 2 Wilking H, Spitznagel H, Werber D et al. Acute gastrointestinal illness in adults in Germany: a population-based telephone survey. Epidemiol Infect 2013; 141: 2365-2375
• 3 Layer P, Rosien U, Thiel S et al. Gallensäureverlustsyndrom. In: Praktische Gastroenterologie. P. Layer, U. Rosien (Hrsg.) 2011. Urban & Fischer Verlag; München: 157-158
• 4 Lankisch PG, Mahlke R, Lübbers H et al. Leitsymptom Diarrhö. Dtsch Arztebl 2006; 103: A261-A269
• 5 Stotzer PO, Abrahamsson H, Bajor A et al. Are the definitions for chronic diarrhoea adequate? Evaluation of two different definitions in patients with chronic diarrhoea. United European Gastroenterol J 2015; 3: 381-386
• 6 Felber J, Aust D, Baas S et al. [Results of a S2k-Consensus Conference of the German Society of Gastroenterolgy, Digestive- and Metabolic Diseases (DGVS) in conjunction with the German Coeliac Society (DZG) regarding coeliac disease, wheat allergy and wheat sensitivity]. Z Gastroenterol 2014; 52: 711-743
• 7 Abraham BP, Kane S. Fecal markers: calprotectin and lactoferrin. Gastroenterol Clin North Am 2012; 41: 483-495
• 8 Schoepfer AM, Trummler M, Seeholzer P et al. Discriminating IBD from IBS: comparison of the test performance of fecal markers, blood leukocytes, CRP, and IBD antibodies. Inflamm Bowel Dis 2008; 14: 32-39
• 9 Vermeire S, Van Assche G, Rutgeerts P. Laboratory markers in IBD: useful, magic, or unnecessary toys?. Gut 2006; 55: 426-431
• 10 Roseth AG, Fagerhol MK, Aadland E et al. Assessment of the neutrophil dominating protein calprotectin in feces. A methodologic study. Scand J Gastroenterol 1992; 27: 793-798
• 11 von Roon AC, Karamountzos L, Purkayastha S et al. Diagnostic precision of fecal calprotectin for inflammatory bowel disease and colorectal malignancy. Am J Gastroenterol 2007; 102: 803-813
• 12 Fischer B, Hoh S, Wehler M et al. Faecal elastase-1: lyophilization of stool samples prevents false low results in diarrhoea. Scand J Gastroenterol 2001; 36: 771-774
• 13 Hoffmeister A, Mayerle J, Beglinger C et al. [S3-Consensus guidelines on definition, etiology, diagnosis and medical, endoscopic and surgical management of chronic pancreatitis German Society of Digestive and Metabolic Diseases (DGVS)]. Z Gastroenterol 2012; 50: 1176-1224
• 14 Barnert J. Dünndarmfunktionstests. In: Klinische Gastroenterologie – Das Buch für Fort- und Weiterbildung. H. Messmann (Hrsg.) 2011. Georg Thieme Verlag KG; Stuttgart: 61
• 15 Layer P, Andresen V, Pehl C et al. [Irritable bowel syndrome: German consensus guidelines on definition, pathophysiology and management]. Z Gastroenterol 2011; 49: 237-293
• 16 Romagnuolo J, Schiller D, Bailey RJ. Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation. Am J Gastroenterol 2002; 97: 1113-1126
• 17 Posserud I, Stotzer PO, Bjornsson ES et al. Small intestinal bacterial overgrowth in patients with irritable bowel syndrome. Gut 2007; 56: 802-808
• 18 Corazza GR, Menozzi MG, Strocchi A et al. The diagnosis of small bowel bacterial overgrowth. Reliability of jejunal culture and inadequacy of breath hydrogen testing. Gastroenterology 1990; 98: 302-309
• 19 Golger D, Scheubel R. Pankreasfunktionstests. In: Klinische Gastroenterologie – Das Buch für Fort- und Weiterbildung, H. Messmann, Editor 2011. Georg Thieme Verlag KG; Stuttgart: 57
• 20 Keim V, Klar E, Poll M et al. Postoperative care following pancreatic surgery: surveillance and treatment. Dtsch Arztebl Int 2009; 106: 789-794
• 21 Eberlin M, Muck T, Michel MC. A comprehensive review of the pharmacodynamics, pharmacokinetics, and clinical effects of the neutral endopeptidase inhibitor racecadotril. Front Pharmacol 2012; 3: 93
• 22 Brenner DM, Moeller MJ, Chey WD et al. The utility of probiotics in the treatment of irritable bowel syndrome: a systematic review. Am J Gastroenterol 2009; 104: 1033-1049
• 23 McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J Gastroenterol 2008; 14: 2650-2661
• 24 Wedlake L, A’Hern R, Russell D et al. Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 2009; 30: 707-717
• 25 Lee KJ. Pharmacologic Agents for Chronic Diarrhea. Intest Res 2015; 13: 306-312
• 26 Trinkley KE, Nahata MC. Treatment of irritable bowel syndrome. J Clin Pharm Ther 2011; 36: 275-82
• 27 Shepherd SJ, Halmos E, Glance S. The role of FODMAPs in irritable bowel syndrome. Curr Opin Clin Nutr Metab Care 2014; 17: 605-609
• 28 Shepherd SJ, Lomer MC, Gibson PR. Short-chain carbohydrates and functional gastrointestinal disorders. Am J Gastroenterol 2013; 108: 707-717
• 29 Ford AC, Talley NJ, Schoenfeld PS et al. Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis. Gut 2009; 58: 367-378
• 30 Rahimi R, Nikfar S, Rezaie A et al. Efficacy of tricyclic antidepressants in irritable bowel syndrome: a meta-analysis. World J Gastroenterol 2009; 15: 1548-1553
• 31 Gorard DA, Libby GW, Farthing MJ. Effect of a tricyclic antidepressant on small intestinal motility in health and diarrhea-predominant irritable bowel syndrome. Dig Dis Sci 1995; 40: 86-95
• 32 Kane JS, Ford AC. Rifaximin for the treatment of diarrhea-predominant irritable bowel syndrome. Expert Rev Gastroenterol Hepatol 2016; 10: 431-442
• 33 Thompson JR. Is irritable bowel syndrome an infectious disease?. World J Gastroenterol 2016; 22: 1331-1334
• 34 Sharara AI, Aoun E, Abdul-Baki H et al. A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence. Am J Gastroenterol 2006; 101: 326-333
• 35 Pimentel M, Park S, Mirocha J et al. The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial. Ann Intern Med 2006; 145: 557-563
• 36 Rivkin A, Rybalov S. Update on the Management of Diarrhea-Predominant Irritable Bowel Syndrome: Focus on Rifaximin and Eluxadoline. Pharmacotherapy 2016; 36: 300-316
• 37 Andresen V, Montori VM, Keller J et al. Effects of 5-hydroxytryptamine (serotonin) type 3 antagonists on symptom relief and constipation in nonconstipated irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol 2008; 6: 545-555
• 38 Chiba T, Yamamoto K, Sato S et al. Long-term efficacy and safety of ramosetron in the treatment of diarrhea-predominant irritable bowel syndrome. Clin Exp Gastroenterol 2013; 6: 123-128
• 39 Fukudo S, Kinoshita Y, Okumura T et al. Ramosetron Reduces Symptoms of Irritable Bowel Syndrome With Diarrhea and Improves Quality of Life in Women. Gastroenterology 2016; 150: 358-366e8
• 40 Nee J, Zakari M, Lembo AJ. Novel Therapies in IBS-D Treatment. Curr Treat Options Gastroenterol 2015; 13: 432-440
• 41 Garsed K, Chernova J, Hastings M et al. A randomised trial of ondansetron for the treatment of irritable bowel syndrome with diarrhoea. Gut 2014; 63: 1617-1625
• 42 Keller J, Layer P Rosien. Bakterielle Fehlbesiedlung. In Praktische Gastroenterologie. P. Layer, U. Rosien (Hrsg.) 2011. Urban & Fischer Verlag; München: 164-165