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Klinische Vraagstukken Cluster C (zonder Zwangerschap)
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Samenvatting van E-learnings, ZSO's en colleges van Cluster C. Zonder Zwangerschap.
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Cluster CInhoudsopgave
Gastro-enterologie A ...................................................................................................................................... 4
Malabsorptie ...................................................................................................................................................... 4
Diarree ........................................................................................................................................................... 4
Malabsorptie.................................................................................................................................................. 5
Kliniek .......................................................................................................................................................... 10
Congenitale afwijkingen ................................................................................................................................... 11
Bovenbuik klachten........................................................................................................................................... 15
Functionele dyspepsie ................................................................................................................................. 15
Gastro-oesofageale reflux (-ziekte) ............................................................................................................. 15
..................................................................................................................................................................... 16
Gastritis ........................................................................................................................................................ 17
Ulcus ............................................................................................................................................................ 18
Passageproblemen....................................................................................................................................... 19
Bloedingen ........................................................................................................................................................ 20
Acute bloeding ............................................................................................................................................. 21
Farmacotherapie .............................................................................................................................................. 23
Pijnstilling..................................................................................................................................................... 23
Achtergrondinformatie - Pijn ....................................................................................................................... 23
Paracetamol ................................................................................................................................................. 25
NSAIDs ......................................................................................................................................................... 26
Opioïden ...................................................................................................................................................... 28
6-Step model................................................................................................................................................ 29
Gastro-enterologie B .................................................................................................................................... 31
Irritateble Bowel Disease (IBD) ......................................................................................................................... 31
Icterus ............................................................................................................................................................... 34
Inleiding ....................................................................................................................................................... 34
Galsteenlijden ................................................................................................................................................... 38
Galstenen .......................................................................................................................................................... 40
Acute cholecytitis .............................................................................................................................................. 41
- Ductus cysticus ................................................................................................................................... 42
- Ductus hepaticus communis .............................................................................................................. 42
- Lever ................................................................................................................................................... 42
Syndroom van Mirizzi .................................................................................................................................. 42
Galsteenileus ............................................................................................................................................... 42
Cholangitis ........................................................................................................................................................ 43
Acute billaire pancreatitis ................................................................................................................................. 44
Pancreatitis ....................................................................................................................................................... 46
Passagestoornissen .......................................................................................................................................... 48
Urogenitale problemen ................................................................................................................................ 50
Anticonceptie .................................................................................................................................................... 50
1
, De menstruatiecyclus........................................................................................................................................ 53
Seksualiteit ....................................................................................................................................................... 54
Vulvapathologie................................................................................................................................................ 58
SOA’s................................................................................................................................................................. 63
Urineweginfecties ............................................................................................................................................. 65
Moeizame mictie .............................................................................................................................................. 67
Zwangerschap .............................................................................................................................................. 69
Benigne urogynaecologie en proctologie ...................................................................................................... 70
Hevig menstrueel bloedverlies .......................................................................................................................... 70
Urine incontinentie ........................................................................................................................................... 73
Stress incontinentie ..................................................................................................................................... 73
Urge-incontinentie ....................................................................................................................................... 74
Verzakkingen .................................................................................................................................................... 75
Proctologische aandoeningen .......................................................................................................................... 78
Fistels en abcessen ...................................................................................................................................... 78
Hemorroïden ............................................................................................................................................... 79
Fissura ani .................................................................................................................................................... 79
Pruritus ani................................................................................................................................................... 80
Rectumprolaps ............................................................................................................................................. 81
Condylomata ................................................................................................................................................ 82
Anuscarcinoom ............................................................................................................................................ 83
Fistels en abcessen............................................................................................................................................ 84
Hemorrhoïden = aambeien ............................................................................................................................... 84
Fissura ani ......................................................................................................................................................... 85
Pruritus ani ....................................................................................................................................................... 87
Rectumprolaps .................................................................................................................................................. 88
Condylomata .................................................................................................................................................... 89
Anuscarcinoom ................................................................................................................................................. 90
Klinisch redeneren ....................................................................................................................................... 90
Speciële oncologie ........................................................................................................................................ 91
Gynaecologische maligniteiten ......................................................................................................................... 91
Cervicale pathologie .................................................................................................................................... 91
Ovariële pathologie...................................................................................................................................... 92
Uteriene pathologie ..................................................................................................................................... 92
Vulvapathologie ........................................................................................................................................... 94
MOLA-zwangerschap ................................................................................................................................... 94
Urologische maligniteiten ................................................................................................................................. 96
Blaascarcinoom ............................................................................................................................................ 96
Niercelcarcinoom ......................................................................................................................................... 97
Prostaatcarcinoom....................................................................................................................................... 98
Testiscarcinoom ........................................................................................................................................... 99
Maligniteit in de Tractus Digestivus ............................................................................................................... 102
Colorectaal carcinoom ............................................................................................................................... 102
Poliepen ..................................................................................................................................................... 104
Pancreascarcinoom.................................................................................................................................... 105
2
,Acute Buikpijn ............................................................................................................................................ 108
Algemeen ................................................................................................................................................... 108
Wat doe je bij acute pijn? .......................................................................................................................... 112
3
, Gastro-enterologie A
Malabsorptie
Diarree
Acute diarree bij kinderen komt zeer vaak voor en is wereldwijd een belangrijke oorzaak van
kindersterfte. De verwekkers betreffen vooral virussen, bacteriën en parasieten.
Ook chronische diarree is een frequent optredende klacht bij kinderen als gevolg van:
- infectieuze gastro-enteritis / parasitaire darminfectie,
- voedingsfouten (sorbitol, fructose, overmaat/tekort aan vezels)
- malabsorptie (coeliakie, lactose intolerantie, voedselallergie, korte darmsyndroom)
- chronisch inflammatoire darmziekte
We spreken van chronische diarree wanneer diarree langer dan 14 tot 28 dagen duurt, de
ontlasting moet dan dunner dan normaal zijn, meer volume (>200 ml/24 uur) en frequenter
(>3x per dag).
Het grootste gedeelte van de darminhoud wordt in de dunne darm opgenomen, een kleiner
gedeelte in de dikke darm. Naast de orale voedsel en vochtinname van 1 tot 2 liter per dag,
is er bij een volwassene zo’n 7 liter vochtproductie per dag in de vorm van speeksel,
maagsap, gal, alvleeskliersap en darmsap. Hiervan absorbeert de dunne darm 6 tot 7 liter, de
dikke darm absorbeert de resterende 1 tot 2 liter.
De consistentie van de ontlasting wordt grotendeels bepaald door het fecale watergehalte.
Dit is bij jonge kinderen circa 5-10 ml/kg lichaamsgewicht/dag en bij oudere kinderen en
volwassenen totaal circa 100-200 ml per dag. Neemt het fecale watergehalte meer dan
normaal toe dan ervaart men dat als diarree. Hierbij is er een afname van de consistentie en
meestal ook een toename van de frequentie van de ontlasting. Men zou de klacht diarree
kunnen omschrijven als het optreden van dunne ontlasting met een frequentie van meer dan
driemaal per dag. Deze omschrijving levert echter bij jonge kinderen meteen al problemen
op omdat gezonde borst gevoede zuigelingen ook frequent dunne ontlasting kunnen
hebben. Hetzelfde geldt voor gezonde peuters die meer dan driemaal daags ongebonden
ontlasting kunnen hebben zonder dat er sprake is van pathologie. Diarree omschrijven als
ontlasting die dunner is dan normaal heeft ook weer nadelen omdat dit mede individueel
bepaald is en daarom als definitie lastig is voor epidemiologisch en klinisch onderzoek.
Waterdunne diarree betekent dat de wateropname of –uitscheiding in de darm niet kan
worden opgevangen cq. gecompenseerd. Water kan alleen over de darm worden
getransporteerd samen met partikels zoals elektrolyten. Transport van voedingsstoffen met
elektrolyten over de darmwand kan ook water mee transporteren.
Onderscheid in diarree kan op meerdere wijzen worden gemaakt. Zo is er een indeling van
acute en chronische diarree, osmotische en secretoire diarree, en kan diarree worden
gekenmerkt door flink eiwit- en/of bloedverlies. Acute diarree is meestal waterdun en kan
overgaan in chronische diarree. Jonge kinderen met acute waterdunne diarree lopen meer
kans op uitdroging dan grotere kinderen en volwassenen. Chronische diarree wordt
gedefinieerd als diarree die langer dan twee weken duurt. Bij chronische diarree kan de
patiënt in een slechte voedingstoestand raken, jonge kinderen vertonen dan een zgn. ‘failure
to thrive’. Bij zowel acute als chronische diarree wijst bloedbijmenging op beschadiging van
het darmslijmvlies. Bij verhoogde uitscheiding van water en elektrolyten spreken we van
secretoire diarree. Bij verminderde opname van water, elektrolyten en voedingsstoffen
spreken we van osmotische diarree.
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