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Samenvatting Spijsvertering (Laleman)
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Dit document bevat de leerstof van prof. Laleman voor het vak 'spijsvertering' van de 1e master. Het is gebaseerd op de slides van in de lessen.
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INHOUDDeel prof Laleman .................................................................................................................................................. 4
Hoofdstuk 1: acute leverziekten ............................................................................................................................. 4
Inleiding ............................................................................................................................................................... 4
Levertesten ......................................................................................................................................................... 5
Bilirubine ......................................................................................................................................................... 5
Aspartaat aminotransferase (AST) .................................................................................................................. 5
Alanine aminotransferase (ALT) ...................................................................................................................... 5
Lactaat dehydrogenase (LDH) ......................................................................................................................... 5
Alkalisch fosfatase (AF) ................................................................................................................................... 6
Gamma glutamyl transpeptidase (GGT) .......................................................................................................... 6
Protrombine tijd (PT, INR) ............................................................................................................................... 6
Albumine ......................................................................................................................................................... 6
Technische onderzoeken..................................................................................................................................... 6
Acute hepatitis .................................................................................................................................................... 8
Symptomen ..................................................................................................................................................... 8
Biochemische afwijkingen ............................................................................................................................... 8
Oorzaken ......................................................................................................................................................... 8
Hepatitis A (HAV) – infectieus viraal hepatotroop ...................................................................................... 9
Hepatitis B (HBV) – infectieus viraal hepatotroop .................................................................................... 10
Hepatitis D (delta) – infectieus viraal hepatotroop ................................................................................... 11
Hepatitis C (HCV) – infectieus viraal hepatotroop .................................................................................... 11
Hepatitis E (HEV) – infectieus viraal hepatotroop ..................................................................................... 12
Gele koorts virus – infectieus viraal niet-hepatotroop ............................................................................. 12
Brucellose – infectieus niet-viraal ............................................................................................................. 13
leptospirosis – infectieus niet-viraal ......................................................................................................... 13
Q-fever – infectieus niet-viraal.................................................................................................................. 13
DILI – toxisch ............................................................................................................................................. 14
Acuut leverfalen ............................................................................................................................................ 16
Hoofdstuk 2: chronische leverziekten ................................................................................................................... 17
Schade evalueren .............................................................................................................................................. 17
Symptomen ....................................................................................................................................................... 17
Oorzaken ....................................................................................................................................................... 18
Hepatitis B (HBV) – infectieus viraal .......................................................................................................... 18
Hepatitis D (delta) – infectieus viraal hepatotroop ................................................................................... 19
Hepatitis C (HCV) – infectieus viraal hepatotroop .................................................................................... 20
Inhoud 1
, Hepatitis E (HEV) – infectieus viraal hepatotroop ..................................................................................... 20
Chronische auto-immune hepatitis – inflammatoir .................................................................................. 21
Inleiding – cholestatisch ............................................................................................................................ 22
Primaire biliaire cholangitis (PBC) – cholestatisch .................................................................................... 22
Primaire scleroserende cholangitis (PSC) – cholestatisch ......................................................................... 23
Hemochromatose – metabool .................................................................................................................. 24
Ziekte van Wilson – metabool ................................................................................................................... 25
Alfa-1-antitrypsine deficiëntie (A1AT) – metabool ................................................................................... 26
Metabolic dysfunction associated steatotic liver disease (MASLD) – steatotic liver disease (SLD) .......... 27
Alcohol associated steatotic liver disease (ALD) – steatotic liver disease (SLD) ....................................... 28
Alcoholische steatohepatitis (ASH) – steatotic liver disease (SLD) ........................................................... 30
Metabolic dysfunction and alcohol intake (combinatie: MetALD) – steatotic liver disease (SLD) ............ 31
Specific aetiology SLD – steatotic liver disease (SLD) ................................................................................ 31
Cryptogene SLD – steatotic liver disease (SLD) ......................................................................................... 31
Hoofdstuk 3: cirrose en complicaties .................................................................................................................... 32
Cirrose ............................................................................................................................................................... 32
Oorzaken ....................................................................................................................................................... 32
Symptomen ................................................................................................................................................... 33
Technische onderzoeken............................................................................................................................... 33
Behandeling .................................................................................................................................................. 33
Complicaties door portale hypertensie ............................................................................................................. 34
Gastro-oesofagale varices bloeding .............................................................................................................. 34
Congestieve gastropathie – gastrisch antrale vasculaire ectasie (GAVE) ...................................................... 36
Ascites ........................................................................................................................................................... 36
Hepatorenaal syndroom ............................................................................................................................... 38
Hepatopulmonaal syndroom ........................................................................................................................ 38
Portopulmonaire hypertensie ....................................................................................................................... 39
Complicaties door leverinsufficiëntie................................................................................................................ 39
Hepatische encefalopathie............................................................................................................................ 39
Acuut op chronisch leverfalen (ACLF) ............................................................................................................... 41
Hoofdstuk 4: benigne aandoeningen van de pancreas ......................................................................................... 42
Anatomie pancreas ........................................................................................................................................... 42
Fysiologie pancreas ........................................................................................................................................... 42
Evaluatie pancreasschade en -functie ............................................................................................................... 43
Benigne aandoeningen van pancreas ............................................................................................................... 43
Congenitale pancreas pathologie .................................................................................................................. 43
Pancreas divisum....................................................................................................................................... 43
Inhoud 2
, Pancreas annulare ..................................................................................................................................... 44
Acute pancreatitis ......................................................................................................................................... 44
Chronische pancreatitis................................................................................................................................. 47
Hoofdstuk 5: vasculaire aandoeningen van de lever ............................................................................................ 50
Vasculaire anatomie van de lever ..................................................................................................................... 50
Vasculaire aandoeningen van de lever ............................................................................................................. 50
Vena porta trombose .................................................................................................................................... 50
Syndroom van Budd-Chiari (BCS) .................................................................................................................. 51
Sinusoïdaal obstructie syndroom (SOS) ........................................................................................................ 52
Ziekte van Rendu-Osler-Weber (hereditaire hemorragische teleangiëctasie – HHT) ................................... 52
Porto-sinusoïdaal vasculaire stoornis (PSVD) ................................................................................................ 53
Hoofdstuk 6: zwangerschap en leverziekte .......................................................................................................... 54
Leverproblemen in de zwangerschap ............................................................................................................... 54
Hyperemesis gravidarum .............................................................................................................................. 54
Intrahepatic cholestasis of pregnancy (ICP) .................................................................................................. 55
HELLP syndroom............................................................................................................................................ 55
Acute fatty liver of pregnancy ....................................................................................................................... 56
Hoofdstuk 7: icterus .............................................................................................................................................. 57
Vormen en oorzaken van icterus ...................................................................................................................... 57
Stappenplan diagnose ....................................................................................................................................... 57
Inhoud 3
,DEEL PROF LALEMAN
HOOFDSTUK 1: ACUTE LEVERZIEKTEN
INLEIDING
Opbouw van de lever
- Lever < 4 lobben
o Lobus quadratus
o Lobus caudatus
o Lobus dextra
o Lobus sinistra
o Anterior: ligamentum falciforme -> ligamentum teres
- Lever < 8 segmenten → belangrijk voor chirurgie (segmentectomie)
Biliaire anatomie
- Gal: 600 ml/dag
- Intrahepatische galcanaliculi -> d hepaticus -> d choledochus (+ d cysticus uitmonden) -> duodenum
thv papil van Vater
Functies van de lever
1. Synthese
• Eiwitten
• Lokaal binden
• Lokaal enzymatisch
• Exportproteïnen (albumine, stollingseiwitten, glyco- en lipoproteïnen)
• Koolhydraten
• Glucose laatste voeding (1-2u)
• Glycogeen reserve (4-12u)
• Ketonen via vetzuuroxidatie (3-4u)
• Gluconeogenese (aanmaak glucose uit AZ)
• Cholesterol en triglyceriden
• Galzuren en hormonen
2. Afbraak
• Xenobiotica en toxines
• Ureum cyclus (NH3)
• Bilirubine
• Glycogenolyse (glycogeen afgebroken tot glucose)
• => wateroplosbaar maken en excreteren via gal, stoelgang
3. Stockeren
• Glycogeen (100 g)
• Vitamine A, D, E, K, B12
• Ijzer (ferritine)
• Koper
4. Immunologisch
• Aangeboren (innate) en verworven (adaptive) immuniteit
• Tolerantie
• Cytokineproductie en regulatie
Deel prof Laleman 4
,Functie van gal
- Emulgeren vetten tot micellen
- Hulp bij absorptie van vetoplosbare vitamines (A, D, E, K)
- Excretie van afvalstoffen (bilirubine)
- Bufferen maagzuur (alkalische pH 7,5-8)
- Bacteriostatisch/bactericide werking (IgA)
LEVERTESTEN
Geen functie testen
- Synthese functie: PT, albumine
- Excretie functie: totaal bilirubine, ammoniak
- Hepatocellulaire necrose: AST, ALT, LDH
- Cholestase: alkalisch fosfatase (AF), GGT
Nooit op zichzelf interpreteren, wel in gebruik van klinische context
Aanvullen met anamnese en KO
BILIRUBINE
RBC -> Hb -> globine + heem -> bilirubine (ongeconjugeerd, binden aan albumine) -> bilirubine (geconjugeerd,
in lever) -> urine, faeces
Problemen
- Hemolyse (afbraak RBC tot Hb)
- Competitie met binding albumine
- Conjugatiestoornis of leverceldysfunctie (geen °geconjugeerd bilirubine)
- Galwegobstructie (problemen afvoer)
ASPARTAAT AMINOTRANSFERASE (AST)
- Productie AST in hart, spieren, lever (lager thv: hersenen, RBC, pancreas, nieren)
- Lektest: weefselschade -> vrijkomen AST (bloed)
o Myocardinfarct, rhabdomyolyse, spierdystrofie, hemolyse
o Hepatitis, ischemie, hepatotoxiciteit
Niet per se leverprobleem!
ALANINE AMINOTRANSFERASE (ALT)
- Productie ALT in lever (lager thv: hart, spieren, nieren)
- Lektest: weefselschade -> vrijkomen ALT (in bloed)
o Myocardinfarct, rhabdomyolyse, spierdystrofie, hemolyse
o Hepatitis, ischemie, hepatotoxiciteit, galwegobstructie
Meer leverspecifiek dan AST
LACTAAT DEHYDROGENASE (LDH)
- Productie LDH in hart, spieren, lever, hersenen, RBC, nieren
- Lektest: weefselschade -> vrijkomen LDH (in bloed)
o Vnl context ischemie
Niet leverspecifiek!
Hoofdstuk 1: acute leverziekten 5
, ALKALISCH FOSFATASE (AF)
- Productie AF in lever, botten, placenta
- Indien op zichzelf gestegen (geïsoleerd) → bot, placenta nakijken (bv zwangerschap)
- Indien gestegen + GGT → cholestase
o Intra- of extrahepatisch
o Compressie, obstructie, infiltratie
o Zien na 24 u
GAMMA GLUTAMYL TRANSPEPTIDASE (GGT)
- Productie GGT in lever (lager thv: hart, nieren, darmen)
- Indien gestegen + AF → cholestase
- GGT/AF > 2,5 → suggestief voor EtOH
- Kan ook stijgen bij: anticonceptiepil, steatose
PROTROMBINE TIJD (PT, INR)
- Productie stollingsfactoren in lever
- Merker voor acute leverziekten!
- Kan ook dalen bij: hypovitaminose K, anticoagulantia, hemofilie, DIC
Beste lever ‘functie’ test!
ALBUMINE
- Productie albumine in lever (hepatocyten -> 10 g/dag)
- Merker voor chronische leverziekten!
- Kan ook dalen bij: malnutritie, nefrotisch syndroom, protein-losing enteropathy
Functies
- Oncotische druk
- Oplosbaarheid, transport, metabolisme
- Anti-oxidant
- Immunomodulatie
- Endotheliale stabilisatie
- Hemostatische effecten
- Capillaire permeabiliteit
TECHNISCHE ONDERZOEKEN
Echo abdomen CT abdomen
- Geen RX stralen (+) - Morfologie (+)
- Vlot beschikbaar (+) - Vascularisatie (+)
- Goedkoop (+) - 3 fasen (+)
- Snel (+) - Snel (+)
- Operator-dependent (-) - RX stralen (-)
- Redelijk duur (-)
- Contrast -> allergie (-)
Hoofdstuk 1: acute leverziekten 6
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