Aktueller Stand der Sonografie in der Gastroenterologie - Darm und oberer Gastrointestinaltrakt - Teil 1

Zusammenfassung

Die Sonografie hat sich in der Diagnostik von Erkrankungen des Gastrointestinaltraktes (GIT) einen zunehmend wichtigeren Platz erobert. Sie beurteilt nicht nur Lumen, sondern auch Wand (inklusive deren Schichtung) und die Umgebung von Magen und Darm. Darüber hinaus sind funktionelle Abläufe (Peristaltik, Durchblutung) darzustellen und geben insbesondere wertvolle Hinweise zur Passage und Vaskularisation. Mit der hochauflösenden (Kompressions-)Sonografie verfügt der Gastroenterologe über ein ideales komplementäres Verfahren zur Endoskopie. Der Einsatz erfolgt unter anderem in der Notfalldiagnostik bei Fragestellungen wie akuter Appendizitis und Peridivertikulitis. Hier ist die Sonografie die Methode der ersten Wahl und erreicht eine hohe Treffsicherheit. Dies gilt in gleicher Weise für den Ileus, der deutlich früher als mit der herkömmlichen Abdomenübersichtsaufnahme (Röntgen) zu diagnostizieren ist. Wesentliches kann die Sonografie zur Klärung der Genese beitragen (z. B. Invagination und Intussuszeption). Das Erkennen einer Perforation ist stärker von der Untersucherkompetenz abhängig. Die Vorteile liegen insbesondere in der Erkennung der häufigeren gedeckten Perforation und in der Klärung der Genese (z. B. Ulkus). Weniger geläufig, aber umso wichtiger, ist der Einsatz bei der einheimischen Sprue, bei der nicht nur das floride Krankheitsbild, sondern auch deren Komplikationen erkannt werden können. Fortgeschrittene Tumoren des Gastrointestinaltraktes sind gut darstellbar, jedoch in den frühen Stadien der Sonografie nicht sicher zugängig und ein exaktes T-Staging ist mit der „perkutanen” Sonografie nicht möglich. Dies liegt nicht zuletzt daran, dass einzelne Darmabschnitte (z. B. Rektum) nicht komplett darstellbar sind. Ein Tumorausschluss bzw. eine Früherkennung ist sonografisch somit nicht möglich. Bei den Darmerkrankungen werden durch die Sonografie, ergänzend zum klinischen und endoskopischen Aspekt, wichtige zusätzliche Informationen geliefert. Die Sonografie ist in der Differenzialdiagnose und Verlaufskontrolle von Bedeutung und „erspart” oft belastendere endoskopische Eingriffe. In der Erkennung der Komplikationen (Fistel, Abszess, Stenose) ist der Ultraschall anderen Bildgebungen zumindest gleichwertig. Dem Umfang der Thematik geschuldet, bleibt es einer nachfolgenden Übersicht vorbehalten, den aktuellen Stand der Sonografie bei chronisch entzündlichen Darmerkrankungen (CED), seltenen Darmentzündungen (u. a. bakterielle, pseudomembranöse, neutropene Kolitis, Darmtuberkulose), ischämischen Darmkrankheiten sowie bei Erkrankungen des oberen Gastrointestinaltraktes (Magen) darzustellen.

Abstract

Ultrasonography has become widely accepted as a diagnostic tool for gastrointestinal diseases. It not only assesses the lumen but more importantly also the wall and the surrounding structures of the stomach and bowel. Furthermore, functional processes (peristalsis, blood flow) can be visualised and provide important information for passage and perfusion. Modern high resolution (compressive) sonography represents an ideal complementary method besides endoscopy for the gastroenterologist. It is used in emergency diagnosis in cases of acute appendicitis and peridiverticulitis. Here sonography is the method of first choice achieving a high sensitivity. The same applies to ileus, which can be diagnosed significantly earlier by sonography than with conventional X-ray methods. Meanwhile sonography can contribute considerable information to clarify pathogenesis (e. g., invagination, intususception). The detection of a perforation depends strongly on the competence of the examiner. The main advantage is the detection of a covered perforation and the genesis (e. g., ulcer). Ultrasound is less commonly considered in celiac sprue but important complementary information can be obtained. Advanced tumours of the gastrointestinal tract can easily be visualised, although early stages can hardly be detected by means of sonography. An accurate T-staging of tumours is not possible with transabdominal sonography, not least because some parts of the bowel (colon and rectum) cannot always and completely be seen. Exclusion of tumour or early detection is not possible by ultrasound. In intestinal diseases additional information besides clinical and endoscopic aspects can be achieved by ultrasound. Sonography is important for differential diagnosis and follow-up and spares the patient from more incriminatory endoscopic operations. Ultrasound is equal to other imaging methods in detecting complications (fistulas, abscess, stenosis). Due to the complexity of the topic the following review will concentrate on giving an idea of the present status of sonography in chronic inflammatory bowel disease, some less frequent intestinal infections (bacterial, pseudomembranous, neutropenic colitis, intestinal tuberculosis), the ischaemic bowel diseases as well as diseases of the upper gastrointestinal tract.

Schlüsselwörter

Darmsonografie - Ileus - Perforation - Appendizitis - Peridivertikulitis

Key words

transabdominal sonography - ileus - perforation - appendicitis - peridivertikulitis

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