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Diagnostik bei Cholelithiasis

Diagnosis of cholelithiasis

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Zusammenfassung

Hintergrund

In der westlichen Welt finden sich bei bis zu 20 % der Patienten Gallensteine in Form einer Cholezysto- und oder Choledocholithiasis. Die klinische Symptomatik reicht von asymptomatischen Gallensteinen bis zur akuten biliären Kolik oder Komplikationen wie der Cholezystitis, Cholangitis oder der biliären Pankreatitis.

Diagnostik

Die klinische Symptomatik besteht aus akuten rechtsseitigen Oberbauchschmerzen mit Ausstrahlung in die rechte Schulter oder den Rücken, im Fall einer Cholangitis oder Cholezystitis begleitet von Fieber und erhöhten Infektionsparametern. Laborchemisch sind in der Frühphase meist die Transaminasen deutlich erhöht, gefolgt von einem langsamen Anstieg der Cholestaseparameter. Die biliäre Pankreatitis geht mit über 3‑fach erhöhten Pankreasenzymen einher.

Die Bildgebung der 1. Wahl ist die transabdominelle Sonographie. Der Nachweis von Gallenblasensteinen, Zeichen der Cholezystitis oder einer Erweiterung des Ductus hepaticus communis als indirektes Zeichen einer Choledocholithiasis gelingt hier mit einer hohen Sensitivität. Die 2. Stufe der bildgebenden Diagnostik – insbesondere bei fehlendem Steinnachweis und hohem oder mittelgradigem klinischem Verdacht – umfassen die Endosonographie und die Magnetresonanzcholangiopankreatikographie (MRCP). Die Computertomographie kommt bei akutem Abdomen und zur Komplikationsdiagnostik (Abszess, Perforation, nekrotisierende Pankreatitis) zur Anwendung.

Zusammenfassung

Bei symptomatischen Gallensteinen ist die Anamnese, klinische Untersuchung und Laborchemie in Kombination mit der transabdominellen Sonographie meist wegweisend. Die Endosonographie und MRCP kommen insbesondere zum Ausschluss präpapillärer Konkremente bei intermediärem Risiko zur Anwendung.

Abstract

Background

In western countries, gallstones occurring as cholecysto- and/or choledocholithiasis are found in up to 20% of patients. The clinical presentation ranges from asymptomatic patients to acute biliary colic or infectious complications, e. g., cholecystitis/cholangitis, or biliary pancreatitis.

Diagnostics

Typical symptoms are episodic pain attacks in the upper abdominal quadrant radiating into the right shoulder or back. In case of cholangitis or cholecystitis, fever and elevated infectious parameters are frequently present. Transaminases are significantly elevated in the early phase followed by a more continuous rise of bilirubin. In case of biliary pancreatitis, pancreatic enzymes are elevated at least threefold. Abdominal ultrasound represents the first-line imaging method. Gallbladder stones, a dilated common bile duct (CBD) as an indirect sign of choledocholithiasis or a cholecystitis can be diagnosed with high sensitivity. The second phase of imaging—especially in case of absent stone detection and a high or intermediate clinical probability—includes endoscopic ultrasound or magnetic resonance cholangiopancreatography (MRCP). Early computed tomography scans are used to diagnose complications (abscess, perforation, necrotizing pancreatitis) in severe cases of acute abdominal pain.

Conclusions

Symptomatic gallstones are usually diagnosed based on clinical symptoms and laboratory values in combination with transabdominal ultrasound. In case of missing stone detection and intermediate probability for CBD stones, endoscopic ultrasound or MCRP are the imaging methods of choice.

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  1. Sektion Endoskopie, Gastroenterologie, Endokrinologie und Stoffwechsel, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland

    U. Denzer

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F. Lammert, Homburg

A. Meining, Ulm

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Denzer, U. Diagnostik bei Cholelithiasis. Gastroenterologe 13, 23–29 (2018). https://doi.org/10.1007/s11377-017-0217-6

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