Mesenteriale Durchblutungsstörungen: Diagnostik und Therapie

Zusammenfassung

Die mesenteriale Ischämie wird durch eine akute arterielle Embolie oder Thrombose, eine Mesenterialvenenthrombose und die non-okklusive mesenteriale Durchblutungsstörung hervorgerufen. Das initiale Bild ist das eines akuten Abdomens; die Patienten sind in den meisten Fällen über 70 Jahre alt. Zu den Risikofaktoren zählen kardiale Erkrankungen, Aneurysmata der Aorta und der Viszeralarterien, eine arterielle Verschlusskrankheit, Kompressionen durch Tumoren und verschiedene andere Erkrankungen die eine Herabsetzung des Blutvolumens und der Flußgeschwindigkeit im Versorgungsgebiet der Arteria mesenterica superior zur Folge haben. Der Goldstandard in der Diagnostik ist die CT-Angiographie mit 3D-Rekonstruktion. Die Therapie erfolgt angepasst an die jeweils zugrunde liegende Pathologie. Eine signifikant erhöhte Letalität von über 95 % ist mit einem Intervall zwischen Einsetzen der akuten abdominellen Schmerzen von mehr als 12 Stunden sowie mit der non-okklusiven Durchblutungsstörung assoziiert ist, bleibt die Zeit bis zur Therapie der überlebensentscheidende Faktor. Aufgrund des Alters und der Begleiterkrankungen der Patienten ist bei Fehlen von Peritonitis und Darmnekrosen eine interventionelle Therapie einer Laparotomie in der zeitlichen Abfolge vorzuziehen.

Abstract

Acute mesenteric ischemia is secondary to acute embolic disease or thrombosis of the superior mesenteric artery. Further pathologies that manifest themselves with the same clinical presentation are thrombosis of the superior mesenteric vein and non-occlusive disease. The patients are admitted to the emergency room with an acute abdomen. Most patients are more than 70 years old. Known risk factors for mesenteric ischemia are cardiac diseases as atrial fibrillation, aneurysms of the aorta and the visceral arteries, occlusive arterial diseases, tumorigenic compression of the vessel and several diseases that result in a reduction of the flow and intravascular volume in the superior mesenteric artery. The golden standard in the diagnosis of acute mesenteric ischemia is CT-angiography of the abdominal vessels with 3 D reconstruction. The therapy is different and dependent from the underlying pathology. A statistically significantly elevated mortality of more than 95 % is associated with a delay of surgical or interventional therapy of more than 12 hours after the initial symptoms and non-occlusive mesenteric ischemia. Because of the advanced age of the patients and the co-morbidities a non-surgical interventional re-canalisation of the superior mesenteric vessels is recommended. A laparotomy is necessary in all patients with peritonitis and/or bowel necrosis or perforation.

Schlüsselwörter

mesenteriale Ischämie - akutes Abdomen - arterielle Thrombose - Mesenterialvenenthrombose - nicht-okklusive Durchblutungsstörung

Keywords

acute mesenteric ischemia - arterial thrombosis - thrombosis of superior mesenteric vein - non-occlusive disease

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