Wien-Klassifikation des Morbus Crohn: hilfreich oder verzichtbar? Eine kritische Standortbestimmung

Zusammenfassung

In einer Übersicht werden historische Versuche, phänotypische Verlaufsformen des Morbus Crohn zu charakterisieren, dargestellt. Am Beispiel der Wien-Klassifikation des Morbus Crohn wird auf grundsätzliche Kritikpunkte bei klinischen Klassifikationen eingegangen, darüber hinaus werden Limitationen der Wien-Klassifikation im Detail diskutiert. Insbesondere wird dargestellt, dass das Kriterium „behaviour”, Krankheitsverhalten, ein schlecht geeignetes Klassifikationskriterium darstellt, da es sich im Verlauf der Krankheit erheblich ändern kann. Auf in der Wien-Klassifikation des Morbus Crohn nicht berücksichtigte, für den Krankheitsverlauf jedoch relevante Faktoren wie Einflüsse der frühen Kindheit, Einflüsse von Nikotinkonsum oder Einnahme von nicht-steroidalen Antirheumatika wird hingewiesen. Die Notwendigkeit des Klassifikationskriteriums „Alter” wird bezweifelt. Es wird bemängelt, dass sich aus der Wien-Klassifikation (bisher) keine Konsequenzen für die Therapie ergeben. Experimentelle Therapieansätze beim Morbus Crohn gehen von aktuellen genetischen und mikrobiologischen Konzepten aus und „passen” nicht in das der Wien-Klassifikation zugrunde liegende System. In wissenschaftstheoretischer Hinsicht wird die Notwendigkeit einer klinischen Phänotypisierung von Krankheiten unterstrichen und betont, dass nur über Subgruppenbildung, Charakterisierung von pathogenetischen Mechanismen und experimentellen Therapieversuchen letztlich eine Klärung der Krankheitsursache erreichbar ist. Wissenschaftlich wurden in den letzten 10 Jahren erhebliche Fortschritte gemacht, Kirsners „mysterious and multiplex” der chronisch-entzündlichen Darmerkrankungen zu klären. Als behandelnde Ärzte müssen wir auf das den Patienten ängstigende „menacing” einer chronischen Erkrankung fokussieren und nicht nur mit „Biologicals” eine Krankheit, sondern ganzheitlich einen kranken Patienten behandeln.

Abstract

A short review of phenotypic classification of Crohn’s disease is given. Pitfalls in a clinical system of disease classification into different phenotypes and limitations of the Vienna classification of Crohn’s disease are discussed. The concept of distinctive patterns of disease “behaviour” is criticized. The disease behaviour is not a persistent phenomenon and changes in the long-term follow-up significantly. Factors not addressed in the Vienna classification but, of course, influencing presentation and progression of Crohn’s disease such as influences of early childhood, smoking and use of non-steroidal anti-inflammatory drugs are mentioned. The need of the classification criterion “age” is questioned. It is criticized that the Vienna classification has (at least until now) no consequences for the management of Crohn’s disease. Experimental treatment approaches follow the current genetic or microbiological hypotheses and do not consider the Vienna classification system. In view of the philosophy of science the need of phenotypic classification into subgroups, clarification of mechanisms and experimentation with drug treatments in the elaboration of disease causation is stressed. In recent years much progress has been made in clarifying Kirsner’s “mysterious and multiplex” nature of inflammatory bowel disease. However, as physicians we have to focus on the “menace” of a chronic disease for the patient’s life and not only to treat the hole of the patient with “biologicals” but rather to treat the whole patient in a bio-psycho-social approach.

Schlüsselwörter

Morbus Crohn - Wien-Klassifikation - Pathogenese - Krankheitsverlauf

Key words

Crohn’s disease - Vienna classification - pathogenesis - disease progression

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