Behandlung chronisch entzündlicher Darmerkrankungen in der Intensivmedizin

Zusammenfassung

Die chronisch entzündlichen Darmerkrankungen Morbus Crohn und Colitis ulcerosa können insbesondere bei schweren Verläufen oder Komplikationen der immunsuppressiven Therapie eine intensivmedizinische Behandlung erforderlich machen. Klinisch präsentieren diese Patienten häufig schwere blutige Diarrhöen, die eine umfassende differentialdiagnostische Abklärung zum Ausschluss anderer Ursachen wie infektiöse Colitiden, pseudomembranöse Colitis oder intestinale Ischämie, benötigen. Typische Medikamente, die sowohl in der Remissionserhaltung als auch beim akuten Schub eingesetzt werden, sind Steroide, Immunsuppressiva wie Azathioprin, 6-Mercaptopurin, Methotrexat oder Ciclosporin, sowie die Biologicals Infliximab und Adalimumab, die gegen TNF-alpha gerichtet sind. Unter der immunsuppressiven Therapie können potentiell lebensbedrohliche Infektionen und die Reaktivierung latenter Infekte (Tuberkulose, CMV) auftreten. Fisteln, Abszesse, Perforationen, aber auch intestinale Obstruktionen sind typische Komplikationen des Morbus Crohn, während bei der Colitis ulcerosa der akute Schub und das Perforations- und Blutungs-gefährdete toxische Megacolon klinisch im Vordergrund stehen. Neben der Behandlung der Grunderkrankung sind beim kritisch kranken Crohn/Colitis-Patienten die empirische antibiotische Therapie bei infektiösen Komplikationen, die umgehende perkutane Abszessdrainage zur Kontrolle eines septischen Fokus, die Entlastung beim toxischen Megacolon sowie die frühzeitige chirurgische Mitbeurteilung wichtige Grundpfeiler der erfolgreichen Therapie.

Abstract

In patients with inflammatory bowel disease (IBD) complications of both IBD and immunosuppressive therapy may be life-threatening conditions requiring intensive care therapy. These patients oftentimes present themselves with severe bloody diarrhoea, and infectious colitis, pseudomembranous colitis or intestinal ischemia must be included in the differential diagnosis. Steroids, immunosuppressants such as azathioprine, 6-mercaptopurine, methotraxate or ciclosporine, as well as biologicals, which act as TNF-alpha antagonists, are commonly used for maintenance therapy and treatment of acute exacerbations of IBD. Due to immunosuppressive therapy potentially life-threatening infections and reactivations of latent infections like tuberculosis or cytomegalovirus (CMV) can occur. Fistulas, abscesses, perforations and intestinal obstructions are typical complications of Crohn's disease in the intensive care setting, whereas clinical presentation in ulcerative colitis is characterised by its acute exacerbation and the toxic dilatation of the colon, potentially resulting in toxic megacolon with high risk of perforation or severe bleeding. Most important for an effective therapy in the critically ill patient with inflammatory bowel disease are the control of the underlying disease, the empiric antibiotic therapy in case of infectious complications, transcutaneous drainage of abscesses, bowel decompression in toxic megacolon and the early interdisciplinary assessment of the abdomen.

Schlüsselwörter

Morbus Crohn - Colitis ulcerosa - toxisches Megakolon - akuter Schub

Keywords

Crohn‘s disease - ulcerative colitis - toxic megacolon - acute exacerbation

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