Gallensteine – Ursachen, Folgen und Therapieoptionen

Zusammenfassung

Gallensteine und deren Komplikationen sind eines der häufigsten gastroenterologischen zur Krankenhausaufnahme führenden Krankheitsbilder im europäischen Raum. Darunter sind Cholesterinsteine die am häufigsten gebildeten Steine – mit einigen wenigen Ausnahmen lässt sich hier ein direkter Bezug zum Lebensstil herstellen. Adipositas, Diabetes und wenig körperliche Aktivität sind nur einige der Faktoren. Diagnostischer Goldstandard zur Detektion ist der abdominelle Ultraschall; dies gilt in Bezug auf Steine in der Gallenblase wie auch im Gallengang. Die ERCP ist der Therapie von Gallengangsteinen vorenthalten und als Diagnostikum obsolet. Bei symptomatischen Gallenblasen – und Gallengangsteinen ist eine Cholezystektomie indiziert – unabhängig vom Alter. Diese sollte möglichst frühzeitig erfolgen, um Rezidivkoliken und weitere Komplikationen zu vermeiden. Bei Vorliegen einer Infektion, wie z. B. einer akuten Cholezystitis, sollte heutzutage eine Cholezystektomie innerhalb von 24h nach stationärer Aufnahme werden.

Abstract

Gallstones and their complications are one of most frequent gastroenterological diseases leading to hospital admission in Europe. Cholesterol stones are the most common; except of few patients there is a direct link to lifestyle. Obesity, diabetes and insufficient physical activity represent the major risk factors. Abdominal ultrasound is the gold standard for detection of gallstones. ERCP is indicated only in the therapeutic setting. In case of symptomatic gallbladder stones as well as bile duct stones, cholecystectomy is necessary. Higher age is no contraindication. To avoid further biliary colic episodes and / or additional complications, cholecystectomy should be performed as early as possible. In case of acute cholecystitis, cholecystectomy should be performed within 24 h after admission.

Schlüsselwörter

Gallensteine - akute Cholezystitis - Choledocholithiasis

Keywords

Gallstones - bile duct stones - acute cholecystitis

• Literatur

• 1 Farthing M, Roberts SE, Samuel DG et al. Survey of digestive health across Europe: Final report. Part 1: The burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe. United European Gastroenterol J 2014; 2: 539-543
• 2 Lammert F, Acalovschi M, Ercolani G et al. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65: 146-181
• 3 Stender S, Nordestgaard BG, Tybjaerg-Hansen A. Elevated body mass index as a causal risk factor for symptomatic gallstone disease: a Mendelian randomization study. Hepatology 2013; 58: 2133-2141
• 4 Neoptolemos JP, Hofmann AF, Moossa AR. Chemical treatment of stones in the biliary tree. Br J Surg 1986; 73: 515-524
• 5 Banim PJ, Luben RN, Wareham NJ et al. Physical activity reduces the risk of symptomatic gallstones: a prospective cohort study. Eur J Gastroenterol Hepatol 2010; 22: 983-988
• 6 Leitzmann MF, Giovannucci EL, Rimm EB et al. The relation of physical activity to risk for symptomatic gallstone disease in men. Ann Intern Med 1998; 128: 417-425
• 7 Tsunoda K, Shirai Y, Hatakeyama K. Prevalence of cholesterol gallstones positively correlates with per capita daily calorie intake. Hepatogastroenterology 2004; 51: 1271-1274
• 8 Tsai CJ, Leitzmann MF, Willett WC. Fruit and vegetable consumption and risk of cholecystectomy in women. Am J Med 2006; 119: 760-767
• 9 Lammert F, Gurusamy K, Ko CW et al. Gallstones. Nat Rev Dis Primers 2016; 2: 16024
• 10 Sanabria A, Dominguez LC, Valdivieso E et al. Antibiotic prophylaxis for patients undergoing elective laparoscopic cholecystectomy. Cochrane Database Syst Rev 2010; 12: CD005265
• 11 Jüngst C, Kullak-Ublick GA, Jungst D. Gallstone disease: Microlithiasis and sludge. Best Pract Res Clin Gastroenterol 2006; 20: 1053-1062
• 12 Thorboll J, Vilmann P, Jacobsen B et al. Endoscopic ultrasonography in detection of cholelithiasis in patients with biliary pain and negative transabdominal ultrasonography. Scand J Gastroenterol 2004; 39: 267-269
• 13 Ros E, Navarro S, Bru C et al. Occult microlithiasis in ‘idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991; 101: 1701-1709
• 14 Kiewiet JJ, Leeuwenburgh MM, Bipat S et al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 2012; 264: 708-720
• 15 Bennett GL, Rusinek H, Lisi V et al. CT findings in acute gangrenous cholecystitis. AJR Am J Roentgenol 2002; 178: 275-281
• 16 Attili AF, De Santis A, Capri R et al. The natural history of gallstones: the GREPCO experience. Hepatology 1995; 21: 655-660
• 17 Friedman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J Clin Epidemiol 1989; 42: 127-136
• 18 Ransohof DF, Gracie WA. Treatment of gallstones. Ann Intern Med 1993; 119: 606-619
• 19 Ashur H, Siegal B, Oland Y et al. Calcified ballbladder (porcelain gallbladder). Arch Surg 1978; 113: 594-596
• 20 Stephen AE, Berger DL. Carcinoma in the porcelain gallbladder: a relationship revisited. Surgery 2001; 129: 699-703
• 21 Okamoto M, Okamoto H, Kitahara F et al. Ultrasonographic evidence of association of polyps and stones with gallbladder cancer. Am J Gastroenterol 1999; 94: 446-450
• 22 Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg 1993; 165: 399-404
• 23 Besselin MG, Venneman NG, Go PM et al. Is complicated gallstone disease preceded by biliary colic?. J Gastrointest Surg 2009; 13: 312-317
• 24 Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis?. JAMA 2003; 289: 80-86
• 25 Ralls PW, Colletti PM, Lapin SA et al. Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs. Radiology 1985; 155: 767-771
• 26 Bedirli A, Sakrak O, Sözüer EM et al. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology 2001; 48: 1275-1278
• 27 Wilson RG, Macintyre IM, Nixon SJ et al. Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis. BMJ 1992; 305: 394-396
• 28 Gurusamy KS, Koti R, Fusai G et al. Early versus delayed laparoscopic cholecystectomy for uncomplicated biliary colic. Cochrane Database Syst Rev 2013; 6: CD007196
• 29 McAlister VC, Davenport E, Renouf E. Cholecystectomy deferral in patients with endoscopic sphincterotomy. Cochrane Database Syst Rev 2007; 4: CD006233
• 30 Lill S, Rantala A, Vahlberg T et al. Elective laparoscopic cholecystectomy: the effect of age on conversions, complications and long-term results. Dig Surg 2011; 28: 205-209
• 31 Kim HO, Yun JW, Shin JH et al. Outcome of laparoscopic cholecystectomy is not influenced by chronological age in the elderly. World J Gastroenterol 2009; 15: 722-726
• 32 Kuy S, Sosa JA, Roman SA. Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans. Am J Surg 2011; 201: 789-796
• 33 Kuwabara K, Matsuda S, Fushimi K et al. Relationships of age, cholecystectomy approach and timing with the surgical and functional outcomes of elderly patients with cholecystitis. Int J Surg 2011; 9: 392-399
• 34 Anciaux ML, Pelletier G, Attali P et al. Prospective study of clinical and biochemical features of symptomatic choledocholithiasis. Dig Dis Sci 1986; 31: 449-453
• 35 Onken JE, Brazer SR, Eisen GM et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996; 91: 762-767
• 36 Patwardhan RV, Smith OJ, Farmelant MH. Serum transaminase levels and cholescintigraphic abnormalities in acute biliary tract obstruction. Arch Intern Med 1987; 147: 1249-1253
• 37 Abboud PA, Malet PF, Berlin JA et al. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996; 44: 450-455
• 38 Hunt DR. Common bile duct stones in non-dilated bile ducts?. An ultrasound study. Australas Radiol 1996; 40: 221-222
• 39 Rickes S, Treiber G, Mönkemüller K et al. Impact of the operator’s experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: a prospective comparison using endoscopic retrograde cholangiography as the gold standard. Scand J Gastroenterol 2006; 41: 838-843
• 40 Baron TH, Harewood GC. Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized, controlled trials. Am J Gastroenterol 2004; 99: 1455-1460
• 41 Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones. Cochrane Database Syst Rev 2006; 18: CD004890
• 42 De Lédinghen V, Lecesne R, Raymond JM et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography?. A prospective controlled study. Gastrointest Endosc 1999; 49: 26-31
• 43 Kondo S, Isayama H, Akahane M et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur J Radiol 2005; 54: 271-275
• 44 Reinders JS, Goud A, Timmer R et al. Early laparoscopic cholecystectomy improves outcomes after endoscopic sphincterotomy for choledochocystolithiasis. Gastroenterology 2010; 138: 2315-2320
• 45 Da Costa DW, Bouwense SA, Schepers NJ et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015; 386: 1261-1268
• 46 Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Gastroenterol Hepatol 2012; 36: 122-129
• 47 Shiffman ML, Kaplan GD, Brinkman-Kaplan V et al. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program. Ann Intern Med. 1995; 122: 899-905
• 48 Stokes CS, Gluud LL, Casper M et al. Ursodeoxycholic acid and diets higher in fat prevent gallbladder stones during weight loss: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol 2014; 12: 1090-1100
• 49 Gutt CN, Encke J, Köninger J et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial. Ann Surg. 2013; 258: 385-393