Differenzialdiagnosen von Kolitiden

Neben chronisch-entzündlichen Darmerkrankungen sind die mikroskopische Kolitis (kollagene und lymphozytäre Kolitis), die NSAR-induzierte Kolitis und die Checkpoint-Inhibitor-induzierte Kolitis weitere Kolitis-Differenzialdiagnosen, die sich durch eindeutige histologische Befunde bzw. durch definierte ätiologische Auslöser auszeichnen. Wir geben einen Überblick über Pathogenese, diagnostisch wegweisende Kriterien und empfohlene Therapieansätze.

Kernaussagen

Mikroskopische Kolitis

• Das Leitsymptom der mikroskopischen Kolitis ist die wässrige, typischerweise nachts auftretende Diarrhö.

• Pathognomisch für die LC ist eine Infiltration der Mukosa mit > 20 IEL pro 100 Epithelzellen. Die CC ist durch ein > 10 µm messendes subepitheliales Kollagenband definiert.

• Die enterale Anwendung von Budesonid führt meist zu einer raschen klinischen und histologischen Remission. Es besteht allerdings ein erhebliches Rezidivrisiko nach Absetzen der Therapie.

NSAR-induzierte Kolitis/Enteropathie

• Bei ungeklärten Diarrhöen und (zurückliegendem) NSAR-Gebrauch sollte stets eine NSAR-induzierte Kolitis/Enteropathie differenzialdiagnostisch miteinbezogen werden.

• Schwerpunktmäßig ist neben distalen Dünndarm und Kolon die Ileozäkalregion miteinbezogen. Es können neben entzündeter Schleimhaut demarkierte Ulzerationen vorhanden sein.

• Residuelle narbige Stenosen sollten, sofern zugänglich, bevorzugt endoskopisch mittels TTS-Ballondilatation oder Nadelmesser interveniert werden.

CPI-induzierte Kolitis

• CPI-assoziierte Diarrhöen treten durchschnittlich bei 10 von 100 mit PD1- oder PD-L1-Inhibitoren behandelten Patienten auf. Die Prävalenz sowohl von Diarrhöen als auch Kolitis ist im Gefolge einer Therapie mit dem CTLA4-Inhibitor Ipilimumab höher.

• Für die Diagnosestellung sind zeitlicher Zusammenhang zu einer CPI-Therapie, Ausschluss einer infektiösen Genese und endoskopisch-bioptischer Befund entscheidend.

• Bei milden Verläufen (CTCAE Grad 1) ist die Pausierung der CPI-Therapie optional; bei schweren Verläufen (CTCAE Grad 3 und 4) sollte die CPI-Therapie dauerhaft beendet werden.

• Bei moderaten und schweren Verläufen (CTCAE Grad 2 – 4) ist eine systemische Kortikosteroidtherapie unumgänglich. In steroidrefraktären Fällen kann als „Rescue“-Maßnahme eine Biologikatherapie mit Infliximab oder Vedolizumab in Abhängigkeit von Alter, individuellem Infektrisiko und hämatologischen Begleiterkrankungen erfolgen.

Schlüsselwörter

Mikroskopische Kolitis; NSAR-induzierte Enteropathie; Checkpoint-Inhibitor-induzierte Kolitis

Publication History

Article published online:
21 June 2023

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