Die intestinale Blutung bei portaler Hypertension bei Leberzirrhose

Zusammenfassung

Die Prophylaxe und Behandlung der oberen intestinalen Blutung bei portaler Hypertension hat drei Ziele: Prophylaxe der ersten Blutung, Therapie der aktiven Blutung und Prophylaxe der Rezidivblutung. Hierfür steht eine ganze Reihe von Techniken zur Verfügung. Die Gabe eines nicht selektiven Betablockers ist bei großen Ösophagusvarizen nach wie vor die Therapie der Wahl zur Verhinderung der ersten Blutung. Alternativ kann jedoch auch ligiert werden. Die akute Blutung sollte endoskopisch (Ligatur) versorgt werden bei gleichzeitiger pharmakologischer und antibiotischer Therapie. Zur Rezidivblutungsprophylaxe muss individuell vorgegangen werden. Junge Patienten im Stadium Child A können nach wie vor durch eine offene Shuntoperation versorgt werden. Patienten mit schwer mobilisierbarem Aszites und einem Bilirubin unter 3 mg/dl sind gute Kandidaten für den Einsatz eines TIPS zur Prophylaxe der Rezidivblutung. Primär wird in Deutschland jedoch bei den meisten Patienten mit einer Ligaturbehandlung begonnen, die - zumindest nach der derzeitigen Studienlage - einer pharmakologischen Therapie nicht überlegen ist, vor allem, wenn diese unter einer hämodynamischen Kontrolle (Lebervenenverschlussdruck) vorgenommen wird. Blutungen aus extraösophagealen Quellen (hypertensive Gastropathie, Fundusvarizen) sollten individuell behandelt werden. Hier kommen die Injektionstherapie, der TIPS und auch die medikamentöse portaldrucksenkende Therapie zum Einsatz.

Abstract

There are three major goals in the prophylaxis and treatment of upper gastrointestinal bleeding in portal hypertensive patients: prophylaxis of the first bleeding episode, therapy of active bleeding and prophylaxis of recurrent bleeding. Several therapeutic options are available: non-selective beta-blockers are the treatment of choice in the primary prophylaxis of the first bleeding episode in patients with large esophageal varices. Alternatively, endoscopic band ligation therapy is an option. Acute bleeding varices should be treated by ligation pharmacological and antibiotic therapy. Prophylaxis of recurrent bleeding is patient-dependent: shunt surgery is an option in young patients in a good medical condition (Child-Pugh class A). In patients with refractory ascites and a bilirubin below 3 mg/dl, TIPS is a good option together with recurrent bleeding. At the moment, there are no trials showing that endoscopic ligation therapy is superior to prevent pharmacological therapy. Nevertheless, the first-line treatment in most patients in Germany is endoscopic band ligation. Bleeding from ectopic varices and bleeding from hypertensive gastropathy should be treated individually either by endoscopy, TIPS or drug therapy.

Schlüsselwörter

Obere Gastrointestinale Blutung - portale Hypertension - Ösophagusvarizen - Fundusvarizen - ektope Varizen - endoskopische Therapie - TIPS

Key words

Upper gastrointestinal bleeding - portal hypertension - esophageal varices - gastric varices - ectopic varices - endoscopic therapy - TIPS

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