Summary

Samenvatting "gastro-entero" - Abdomen 1 partim spijsverteringsorganen

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Course
Abdomen 1 partim spijsverteringsorganen

Institution
Universiteit Antwerpen (UA)

Samenvatting van de hoorcolleges over "Gastro-entero" gegeven door prof. De Schepper H. Onderdeel van het vak 'Abdomen 1 partim spijsverteringsorganen' gegeven in de 2e Bachelor Geneeskunde aan de UA. Samenvatting gebaseerd op slides én lesnotities.

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Uploaded on September 4, 2024
Number of pages 120
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Type Summary

slokdarmpathologie
achalasie
gerd
digestieve tractus
gastritis
ulcera
helicobacter pylori
dyspepsie
gastroparese
malabsorptie
coeliakie
salmonella
yersinia
campylobacter
ileus
pijnsensatie

Institution
Universiteit Antwerpen (UA)
Education
Geneeskunde
Course
Abdomen 1 partim spijsverteringsorganen

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Samenvatting - Anesthesie & Pijn

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1. Summary - Samenvatting "gastro-entero" - abdomen 1 partim spijsverteringsorganen
2. Summary - Samenvatting "hepato" - abdomen 1 partim spijsverteringsorganen
3. Summary - Samenvatting "histologie" - abdomen 1 partim spijsverteringsorganen
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Inhoudsopgave
Slokdarmpathologie.......................................................................................................................................6
Anatomie van de slokdarm.........................................................................................................................6
Fysiologie van de slikbeweging............................................................................................................6
Slokdarm motiliteitsstoornissen: orofaryngeale dysfagie........................................................................... 7
Hoge resolutie slokdarmmanometrie & impedantie..............................................................................7
Chicago classificatie.............................................................................................................................8
Achalasie....................................................................................................................................................8
Diagnostiek...........................................................................................................................................9
Behandeling....................................................................................................................................... 10
Distaal slokdarmspasme.......................................................................................................................... 11
Jackhammer slokdarm............................................................................................................................. 12
Aperistalsis: sclerodermie........................................................................................................................ 12
Ruminatie................................................................................................................................................. 12
Eosinofiele oesofagitis............................................................................................................................. 13
Gastro-oesofageale refluxziekte (GERD).................................................................................................13
Pathofysiologie................................................................................................................................... 13
Symptomen........................................................................................................................................ 15
Complicaties.......................................................................................................................................15
Diagnose............................................................................................................................................ 16
Behandeling....................................................................................................................................... 17
Slokdarmdivertikels.................................................................................................................................. 20
Zenker-divertikel.................................................................................................................................20
Types slokdarmdivertikels.................................................................................................................. 21

Regeling en organisatie van de digestieve tractus...................................................................................22
Functies van GI-tractus............................................................................................................................ 22
Controle en regulatie................................................................................................................................22
Hormonale regulatie.................................................................................................................................22
Endocriene mediatoren...................................................................................................................... 22
Paracriene mediatoren....................................................................................................................... 25
Neurocriene mediatoren.....................................................................................................................26
Overzicht digestieve hormonen..........................................................................................................26
Neuromusculair........................................................................................................................................ 26
Extrinsiek zenuwstelsel...................................................................................................................... 27
Enterisch zenuwstelsel.......................................................................................................................28
Glad spierweefsel van de GI-tractus.................................................................................................. 29
Immunologisch......................................................................................................................................... 30
Microbioom...............................................................................................................................................30
Enterotypes........................................................................................................................................ 31
Ontwikkeling en adaptatie van het microbioom..................................................................................31

Darm in beweging (motoriek)......................................................................................................................33
Dunne darm............................................................................................................................................. 33
Regeling............................................................................................................................................. 33
Contractiepatroon...............................................................................................................................33
Ziektebeelden.....................................................................................................................................34
1

, Dikke darm............................................................................................................................................... 34
Regeling............................................................................................................................................. 34
Anatomie............................................................................................................................................ 35
Motoriek..............................................................................................................................................35
Ziektebeelden.....................................................................................................................................36
Anorectum................................................................................................................................................37
Anorectale innervatie..........................................................................................................................37
Continentie......................................................................................................................................... 38
Defecatiecyclus.................................................................................................................................. 38
Technische evaluatie van colorectale motiliteit........................................................................................ 39
Anorectale manometrie...................................................................................................................... 39
MR defefcogram.................................................................................................................................40
Ziektebeeld: functionele constipatie................................................................................................... 40
Ziektebeeld: rectocoele (darmverzakking)......................................................................................... 42

Het functioneren van de maag....................................................................................................................43
Fysiologie................................................................................................................................................. 43
Anatomische regio’s........................................................................................................................... 43
Gastrische motiliteit............................................................................................................................ 43
Slow wave activiteit van maag en duodenum.................................................................................... 44
Regulatie van maagmotoriek..............................................................................................................45
Maagzuursecretie...............................................................................................................................45
Fases van maagzuursecretie............................................................................................................. 46
Gastritis.................................................................................................................................................... 47
Acute gastritis.....................................................................................................................................47
Chronische gastritis............................................................................................................................48
Speciale vormen.................................................................................................................................49
Peptische ulcus........................................................................................................................................ 49
Pathofysiologie: klassieke theorie...................................................................................................... 49
Pathofysiologie: Helicobacter pylori theorie....................................................................................... 51
Symptomen........................................................................................................................................ 52
Complicaties.......................................................................................................................................52
Diagnose............................................................................................................................................ 52
Behandeling....................................................................................................................................... 53
Helicobacter pylori....................................................................................................................................53
Ziektebeelden.....................................................................................................................................54
Diagnose............................................................................................................................................ 54
Behandeling....................................................................................................................................... 55
Hoge gastro-intestinale bloeding (GIB).................................................................................................... 55
Hemodynamica.................................................................................................................................. 55
Non-PTH UGIB...................................................................................................................................56
Behandeling....................................................................................................................................... 56
Dyspepsie................................................................................................................................................ 56
Pathofysiologie................................................................................................................................... 57
Diagnose............................................................................................................................................ 57
Functionele dyspepsie........................................................................................................................58
Behandeling....................................................................................................................................... 59
Gastroparese........................................................................................................................................... 59
2

, Diagnose............................................................................................................................................ 60
Behandeling....................................................................................................................................... 60

Digestie & absorptie.................................................................................................................................... 61
Functies van het digestief systeem.......................................................................................................... 61
Dunne darm epitheel.......................................................................................................................... 61
Secretie en absorptie............................................................................................................................... 62
Mucosaal transport.............................................................................................................................62
Transcellulair transport....................................................................................................................... 62
Natriumreabsorptie.............................................................................................................................63
Chloor secretie................................................................................................................................... 63
HCO3- secretie...................................................................................................................................63
Digestie.................................................................................................................................................... 63
Vertering thv maag............................................................................................................................. 64
Vertering thv darm.............................................................................................................................. 64
Vetvertering........................................................................................................................................ 65
Koolhydraatvertering.......................................................................................................................... 65
Eiwitvertering......................................................................................................................................66
Mineralen............................................................................................................................................67
Vitaminen........................................................................................................................................... 67

Malabsorptie................................................................................................................................................. 69
Malabsorptie.............................................................................................................................................69
Disaccharide malabsorptie (koolhydraten)......................................................................................... 69
Malabsorptie van vetten..................................................................................................................... 71
Malabsorptie van eiwitten...................................................................................................................71
Coeliakie.................................................................................................................................................. 71
Pathogenese...................................................................................................................................... 72
Symptomen........................................................................................................................................ 72
Complicaties.......................................................................................................................................73
Diagnose............................................................................................................................................ 73
Behandeling....................................................................................................................................... 74
Short Bowel Syndrome............................................................................................................................ 74
Symptomen en behandeling...............................................................................................................75

Diarree...........................................................................................................................................................76
Diarree..................................................................................................................................................... 76
Pathofysiologie.........................................................................................................................................76
Subtypes............................................................................................................................................ 77
Acute diarree............................................................................................................................................80
Acute infectieuze diarree....................................................................................................................80
Antibiotica-geïnduceerde acute diarree..............................................................................................80
Chronische diarree...................................................................................................................................81
Chronische vetdiarree........................................................................................................................ 81
Chronische waterige diarree.............................................................................................................. 82

Infectieuze diarree........................................................................................................................................84
Algemene principes..................................................................................................................................84
3

, Verdediging tegen darminfecties........................................................................................................ 84
Patronen van infectieuze diarree........................................................................................................84
Behandeling van bacteriële darminfecties..........................................................................................85
Voedselinfectie: toxine-gemedieerd................................................................................................... 85
Klinische syndromen bij infectieuze diarree....................................................................................... 85
Bacteriële oorzaken van diarree.............................................................................................................. 86
Salmonella..........................................................................................................................................86
Campylobacter (jejuni)....................................................................................................................... 86
Yersinia...............................................................................................................................................87
Escherichia coli.................................................................................................................................. 87
Staphylococcus aureus...................................................................................................................... 88
Shigella (bacillaire dysenterie)........................................................................................................... 88
Listeria monocytogenes..................................................................................................................... 88
Mycobacterium tuberculosis...............................................................................................................88
Antibiotica geïnduceerde diarree........................................................................................................89
Virale oorzaken van diarree..................................................................................................................... 89
Parasitaire oorzaken van diarree............................................................................................................. 89
Protozoa............................................................................................................................................. 90
Helminthen (wormen)......................................................................................................................... 90
SOA..........................................................................................................................................................91
Chlamydia trachomatis.......................................................................................................................92
Lymfogranuloma venereum................................................................................................................92
Neisseria gonorrhoeae....................................................................................................................... 92
Herpes simplex...................................................................................................................................92
Syfilis.................................................................................................................................................. 93
Condylomata accuminata...................................................................................................................93

Ileus en obstructie....................................................................................................................................... 94
Paralytische ileus..................................................................................................................................... 94
Mechanische ileus/obstructie................................................................................................................... 95
Hernia.................................................................................................................................................96
Behandeling....................................................................................................................................... 96
Ogilvie syndroom..................................................................................................................................... 98
Colonobstructie........................................................................................................................................ 98

Fysiologie en pathofysiologie van de pancreas....................................................................................... 99
Anatomie en structuur.............................................................................................................................. 99
Innervatie............................................................................................................................................99
Opbouw van de pancreas................................................................................................................ 100
Fysiologie............................................................................................................................................... 100
Pancreassecretie..............................................................................................................................100
Pancreasenzymen............................................................................................................................103
Samenvattende figuur...................................................................................................................... 104
Pathofysiologie: acute pancreatitis.........................................................................................................104
Pathofysiologie................................................................................................................................. 104
Systemische manifestaties...............................................................................................................105
Verdedigingsmechanismen.............................................................................................................. 105
Pathofysiologie: Chronische pancreatitis............................................................................................... 106
4

, Pathofysiologie................................................................................................................................. 106
Oorzaken van pijn............................................................................................................................ 107

Abdominale pijn......................................................................................................................................... 108
Abdominale pijn......................................................................................................................................108
Viscerale pijn.......................................................................................................................................... 108
Afferente neuronen...........................................................................................................................108
Supraspinale banen (ruggenmerg)...................................................................................................109
Limbisch systeem (visceral or emotional brain)............................................................................... 109
Viscerale vs. somatische pijnprikkels..................................................................................................... 110
Viscerale pijn.....................................................................................................................................111
Somatische pijn................................................................................................................................ 112
Pijnsensatie............................................................................................................................................ 112
Perifere sensitisatie.......................................................................................................................... 113
Centrale sensitisatie (spinaal).......................................................................................................... 113
Falende descenderende inhibitie......................................................................................................114
Hypersensitiviteit.............................................................................................................................. 114
Kliniek van abdominale pijn.............................................................................................................. 114
Prikkelbare darmsyndroom.....................................................................................................................115

Nucleaire geneeskunde............................................................................................................................. 117
Isotopen in de gastro-enterologie........................................................................................................... 117
Maagontledigingsonderzoeken (vast en vloeistof)........................................................................... 117
Gastro-oefsofageale refluxmeting.................................................................................................... 118
Mechel scintigrafie............................................................................................................................118
Opsporen van gastro-intestinale bloedingen.................................................................................... 118
Hepatobiliaire scintigrafie = cholescintigrafie......................................................................................... 119
Leverfunctie bepalen........................................................................................................................ 120
Positron emissie tomografie (FDG) bij gastro-intestinale kanker........................................................... 120
Colorectale kanker........................................................................................................................... 120
Oesofageale kanker......................................................................................................................... 121
Gastrische kanker............................................................................................................................ 121
Pancreatische kanker = adenocarcinoom........................................................................................ 121
Somatostatine-receptor scintigrafie........................................................................................................121
Neuro-endocriene tumoren (NET)....................................................................................................122

5

,Slokdarmpathologie
Anatomie van de slokdarm
● bovenste slodarmsfinter (UES): dwarsgestreept spierweefsel
● slokdarm: onverhoornd meerlagig plaveiselepitheel
○ proximaal ⅓: dwarsgestreept spierweefsel
○ transitiezone
○ distaal ⅓: glad spierweefsel
● onderste slokdarmsfincter (LES): glad spierweefsel

functie: transport van de voedselbolus (niet absorptie en secretie)

Fysiologie van de slikbeweging
● proximaal: dwarsgestreept spierweefsel
○ rechtstreekse innervatie door n. vagus
○ somatomotorische zenuwen maken direct synaps met het dwarsgestreept spierweefsel
● distaal: glad spierweefsel
○ intrinsieke innervatie door enterisch zenuwstelsel
○ modulatie door n. vagus
○ viscerale motorische zenuwen maken geen directe synaps met gladde spiercellen, maar met
neuronen tussen de spierlagen

1. orofaryngeale fase: voedselbolus naar de orofarynx brengen door tongbewegingen
● malen en mengen met speeksel (amylasen)
● afferente impulsen via craniale zenuwen V, IX, X naar het slikcentrum in het verlengde merg
○ bevelen vertrekken vanuit het verlengde merg om de slikbeweging verder af te
werken
● bolus beweegt naar posterieure farynx, wat de slikreflex induceert
○ farynxconstrictie
○ afsluiten van larynx (doorgang naar luchtwegen) door epiglottis
○ palatum elevatie sluit de mondholte en nasofarynx af
○ tonische UES relaxeren
○ inhibitie van spraak en ademhaling

⇒ drukopbouw die enkel weg kan naar de slokdarm

2. slokdarmfase: transport door peristaltiek
● primaire peristaltiek = peristaltische contractie, uitgelokt door de slikbeweging
○ slokdarmperistaltiek die voorafgegaan wordt door een orofaryngeale fase
● secundaire peristaltiek = peristaltiek, zonder er een slikbeweging aan vooraf gaat

6

, ○ wanneer maaginhoud in de slokdarm komt of het slokdarmlumen opgerekt wordt
(wanneer de slokdarm niet volledig geledigd is door primaire peristaltiek)
○ onwillekeurig en niet aangevoeld
○ functie: anti-reflux mechanisme
● tertiaire peristaltiek = onafhankelijk van slikbeweging, maar gedragen zich niet peristaltisch

⇒ UES open voor voedselbolus → UES sluit → peristaltische slokdarmcontractie naar de maag → LES
open voor voedselbolus → LES sluit

3. receptieve relaxatie van de maag
● oraal segment: relaxatie samen met LES, voor accommodatie van de voedselbolus
● na passage van de voedselbolus keert de tonus terug naar de uitgangswaarde

⇒ grote volumes in de maag opnemen, zonder dat de intragastrische druk stijgt (falen: dyspepsie)

Anti-reflux mechanismen (barrièrefunctie)
● LES + diafragmapijler: slokdarm en maag scheiden
● secundaire slokdarmperistaltiek
○ functie: zuur/maaginhoud bij reflux terug inslikken
● speekselsecretie (HCO3-)
● mucosabarrière: meerlagig plaveiselepitheel
○ bescherming tegen fysieke passage (van onverteerd voedsel) en
chemische passage

Slokdarm motiliteitsstoornissen: orofaryngeale dysfagie
= doorslikstoornissen

orofaryngeale dysfagie: stoornis van het slikmechanisme
● oorzaken
○ gebrekkige aandrijvingskracht
○ obstructie in de flow: door compressie of incompetente relaxatie van UES
● vaak bij neurologische en musculaire aandoeningen, waarbij bezenuwing van slikspieren niet werkt
○ hersenen: cerebrovasculaire aandoeningen, multiple sclerose, ziekte van Parkinson
○ neurologische aandoeningen: ALS, CVA, poliomyelitis
○ spieraandoeningen: dermatomyositis
○ neuromusculaire aandoeningen: myasthenia gravis
● risico: aspiratie → pneumonie

oesophagale dysfagie: gevoel dat voedsel blokkeert, nadat het is doorgeslikt

Hoge resolutie slokdarmmanometrie & impedantie
→ motoriek van de slokdarm meten

manometrie
1. katheter met druksensoren via neus naar slokdarm/maag
2. patiënt laten slikken (primaire peristaltiek): contractie plant zich voort naar distaal, waarna LES
relaxeert

7

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