Ruhr-Universität Bochum PD Dr. med. F. Kutscha-Lissberg Dienstort: Bergmannsheil und Kinderklinik Buer GmbH Abteilung für Orthopädie und Unfallchirurgie Inzidenz und Ursachen einer sekundär sklerosierenden Cholangitis bei mehrfachverletzten Patienten Inaugural-Dissertation zur Erlangung des Doktorgrades der Medizin einer Hohen Medizinischen Fakultät der Ruhr-Universität Bochum vorgelegt von Nihat Erol aus Düsseldorf 2009
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Ruhr-Universität Bochum PD Dr. med. F. Kutscha-Lissberg ... · Während bei der primär sklerosierenden Cholangitis von einem autoimmunpathogenetischen oder idiopathischen Prozess
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Ruhr-Universität Bochum PD Dr. med. F. Kutscha-Lissberg
Dienstort: Bergmannsheil und Kinderklinik Buer GmbH Abteilung für Orthopädie und Unfallchirurgie
Inzidenz und Ursachen einer sekundär sklerosierenden Cholangitis bei mehrfachverletzten Patienten
Inaugural-Dissertation zur
Erlangung des Doktorgrades der Medizin einer
Hohen Medizinischen Fakultät der Ruhr-Universität Bochum
vorgelegt von Nihat Erol
aus Düsseldorf 2009
Dekan: Prof. Dr. med. K. Überla Referent: Priv.-Doz. Dr. med. F. Kutscha-Lissberg Koreferent: Priv.-Doz. Dr. med. T. Frangen Tag der Mündlichen Prüfung: 26.10.2010
Abstract Erol, Nihat Ercüment Problem: In Industriestaaten stellt das Polytrauma die Haupttodesursache in der Altersgruppe
bis 45 Jahren dar, wobei der Straßenverkehr ursächlich hierfür ist. Während früher ein
Großteil der Sterblichkeit durch die Frühletalität im Rahmen eines primären Organversagens
determiniert war, zeigen sich heute bei verminderter Frühletalität neben dem MOF und
MODS neue Krankheitsbilder die zu einer Spätletalität führen. Eines dieser wenig erforschten
Folgeerkrankungen ist die posttraumatische sekundär sklerosierenden Cholangitis (SSC),
welche als irreversibler und progredienter hepatischer Prozess imponiert.
Methode: In unserer prospektiv und monozentrisch geführten Studie wurden 225 Patienten
involviert, welche sich im Zeitraum vom November 2000 bis zum Juni 2004 in Behandlung
der Chirurgischen Abteilung der BG Kliniken Bergmannsheil Bochum befanden. Dabei
wurden Daten von schwerverletzten Patienten mit einem ISS > 16, einem Alter >16 Jahren
und einem Überleben >24 Stunden aus dem Schockraum sowie der Intensivstation erhoben
und ausgewertet.
Ergebnis: Die posttraumatische SSC trat bei 24,4% unserer Patienten auf. Betroffen waren
insbesondere Patienten, welche sekundär eingeliefert wurden. Dabei wiesen die SSC positiven
Patienten 4,35 verletzte Regionen im Schnitt mit einem besonders hohen Anteil an Thorax-
und Beckentraumata sowie einen hohen Weichteilverletzungsgrad auf. Auch hatten die SSC
positiven einen überdurchschnittlich hohen Anteil an MOF, welche mit hohen Letalitätsraten
einhergingen. Weiterhin war der Schockanteil im SSC positiven Kollektiv höher als im
negativen und verlief prolongiert.
Diskussion: Diese Traumakonstellation führte bei den betroffenen Patienten zu systemischen
und lokalen hepatischen Veränderungen, welche ab einem point of no return in einen
irreversiblen Leberschaden mündeten und das Bild der posttraumatischen SSC determinierten.
Während bei der primär sklerosierenden Cholangitis von einem autoimmunpathogenetischen
oder idiopathischen Prozess ausgegangen wird, stellt die posttraumatische sklerosierende
Cholangitis eine neue Variante der sekundären Cholangitiden, bei meist hepatisch
unbelasteten Patienten, dar.
In großer Dankbarkeit meiner
Mutter
1
Inhaltsverzeichnis 1. Einleitung 5 1.1. Todesursachen 5 1.2. Polytrauma, MOF und MODS 5 1.3 SIRS, Sepsis, septischer Schock 6 1.3.1. Sepsis 6 1.4. Primärer und sekundärer Tod beim Polytrauma 7 1.5. Die sekundär sklerosierende Cholangitis (SSC) 8 1.5.1. Morphologie und Klinik 8 1.5.2. Ätiologie der sklerosierenden Cholangitiden 9 2. Fragestellung 10 3. Material und Methode 11 3.1. Studienkonzept 11 3.2. Studienkriterien 12 3.2.1. Einschlusskriterien 12 3.2.2. Ausschlusskriterien 12 3.3. Klinische Untersuchungen und diagnostische Methoden 12 3.3.1. Leitliniendiagnostik 12 3.3.2. Schockraummanagement 13 3.4. Apparative Methoden 13 3.4.1. Bildgebung 13 3.4.2. Beatmung 14 3.4.3. ERCP 14 3.5. Klinische Beurteilungsparameter 15 3.5.1. Kreislaufparameter 15 3.5.2. Sauerstoffsättigung 15 3.5.3. Schockindex 15 3.5.4. Leberparameter 16 3.6. Erfassung der Verletzungsschwere 16 3.6.1. Injury Severity Score (ISS) und LD50 17 3.7. Dokumentation 18 3.7.1. Definition der Vorerkrankungen 18 3.7.2. Datenerhebung und Datenverarbeitung 19 4. Ergebnisse 21 4.1. Allgemeine Betrachtung 21 4.2. Geschlecht 21 4.3. Alter 22 4.4. Unfallursachen 23 4.5. Transportart 24 4.6. Verletzungsschwere 25 4.7. Differenzierung der Körperregionen nach Patienten 27
Tabelle 6: Traumadifferenzierung nach Anzahl der Patienten bezogen auf das Gesamtkollektiv (225), gesamte SSC positive (55) und gesamte SSC negative Kollektiv (170) sowie verletzte Regionen im Schnitt
Gesamttraumata 938 239 599
Gesamtkollektiv 225 55 170
Verletzte Regionen
im Schnitt
4,17 4,35 3,52
4.7.1. Anzahl SHT
129 Patienten hatten (57,3%) eine Traumatisierung des Kraniums erlitten, wovon 124 (96,1%)
eine Verletzung des Neurokraniums im Form einer Schädel-Hirn Traumatisierung und 5
(3,9%) eine Verletzung des Viszerokraniums aufwiesen. Bei den Schädel-Hirn-Traumata
(SHT) erlitten 76 Patienten (58,9%) ein erstgradiges SHT, wobei 20,9% (27 Patienten) ein
SHT II° und 16,3% (21 Patienten) ein SHT III° aufwiesen. 5 Patienten (3,1%) erlitten eine
unkomplizierte Mittelgesichtsfraktur. Bei 27 Patienten SSC positiven Patienten (16%) wurde
ein Schädel-Hirn-Traumata (SHT) festgestellt: Hiervon hatte 19 ein SHT I° (70,4%), 4
Patienten (14,8%) ein SHT II° und 3 (11,1%) eine drittgradige Schädel-Hirn Traumatisierung.
Bei einem (3,7%) konnte eine Mittelgesichtsfraktur diagnostiziert werden. 102 (60%) SSC
negativen Patienten hatten eine Traumatisierung des Kraniums erlitten, wovon 98 (96,1%)
eine Verletzung des Neurokraniums im Form einer Schädel-Hirn Traumatisierung und 4
(3,9%) eine Verletzung des Viszerokraniums aufwiesen. Bei den Schädel-Hirn-Traumata
(SHT) erlitten 57 Patienten (55,9%) ein erstgradiges SHT, wobei 22,5 % (23 Patienten) ein
SHT II° und 17,6% (18 Patienten) ein SHT III° aufwiesen. 4 Patienten (3,9%) erlitten eine
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7. Danksagung Herrn Priv.-Doz. Dr. med. Kutscha-Lissberg danke ich herzlich für die Überlassung dieses
Dissertationsthemas, seiner hilfreichen Kritik sowie für die gute und freundliche Betreuung.
8. Lebenslauf
Persönliche Daten: Vor- und Zuname: Nihat Ercüment Erol Geburtstag: 26.08.1980 Geburtsort: Düsseldorf Wohnort: 45134 Essen, Trappenbergstr. 16 Telefon: 0231/9773967 oder 0163/8783413 E-Mail: [email protected] Familienstand: ledig Studium/Weiterbildung: seit 07/2010 Wissenschaftlicher Assistenzarzt an der Chirurgischen Universitätsklinik Bochum-Langendreer, Abteilung für Unfallchirurgie , Knappschaftskrankenhaus - Universitätsklinik der Ruhr Universität Bochum - 04/2007- 05/2010 Wissenschaftlicher Assistenzarzt an der Klinik und Poliklinik für Orthopädie der Universität Duisburg-Essen, Universitätsklinikum Essen 01/2007-03/2007 Assistenzarzt im Zentrum für Orthopädie und Unfallchirurgie am St. Anna Hospital Herne 28.11.2006: Erteilung der ärztlichen Approbation WS 2005 – 17.9.2006: Dritter klinischer Studienabschnitt in den Berufs- genossenschaftlichen Kliniken Bergmannsheil Bochum, Klinikum der Ruhr Universität Bochum (Ablegen der dritten ärztlichen Prüfung 08.11.06) 1.Tertial: Unfallchirurgie (17.10.05 – 05.02.06) 2.Tertial: Chirurgie (06.02.06 – 28.05.06) 3.Tertial: Innere Medizin (29.05.06 – 17.09.06) WS 2003 – SS 2005: Studium der praktischen klinischen Humanmedizin an
der Ruhr Universität Bochum (Ablegen der zweiten ärztlichen Prüfung am 01.09.2005)
WS 2002 – SS 2003: Studium der theoretischen klinischen Humanmedizin an
der Ruhr-Universität-Bochum (Ablegen der ersten ärztlichen Prüfung am 28.08.2003)
WS 2000 – SS 2002: Studium der vorklinischen Humanmedizin an der Ruhr-Universität-Bochum (Ablegen der vorärztlichen Prüfung am 05.09.2002) Schulbildung: 1991 - 2000 Gymnasium an der Schweizer Allee in Dortmund Aplerbeck. Abschluss: Allgemeine Hochschulreife 1987 - 1991 Aplerbecker Mark Grundschule in Dortmund Aplerbeck. Abschluss: Gymnasialeignung