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Eigen cursus/ samenvatting vasculaire pathologie
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VASCULAIRE PATHOLOGIEINHOUDSTAFEL
INLEIDING ................................................................................................................................................ 8
1) Wat is homeostase ? ................................................................................................................... 8
2) Twee systemen ........................................................................................................................... 8
Het arteriële systeem .............................................................................................................. 9
Het veneuze systeem .............................................................................................................. 9
HOOFDSTUK 1 : Arteriële pathologie en TOS ....................................................................................... 10
1) Semiologie v/h arteriële stelsel ................................................................................................ 10
Anamnese ............................................................................................................................. 11
Klinisch onderzoek ................................................................................................................ 11
Pathofysiologie van artherosclerose..................................................................................... 12
Cardiovasculaire risicofactoren............................................................................................. 12
2) Stenoserend /occlusief arteriële ziekte .................................................................................... 12
Chronische arteriële insufficiëntie v/d OL ............................................................................ 12
Arteriële insufficiëntie v/d supra- aortische vaten en arterie carotis .................................. 15
Arteriële insufficiëntie viscerale vaten ................................................................................. 16
Renale bloedvaten ................................................................................................................ 16
De arteriën v/h BL ................................................................................................................. 16
3) Dilaterende arteriële ziekte ...................................................................................................... 17
Etiologie ................................................................................................................................ 18
Aneurysma aorta abdominalis .............................................................................................. 18
4) TOS = thoracic outlet syndrome .............................................................................................. 21
HOOFDSTUK 2 : symptomatisch perifeer arterieel vaatlijden .............................................................. 24
1) INLEIDING .................................................................................................................................. 24
2) GEZONDHEIDSPROBLEEM PAV ................................................................................................. 24
3) ANAMNESE................................................................................................................................ 26
4) Onderzoek ................................................................................................................................. 27
Functieonderzoek ................................................................................................................. 27
Differentiaaldiagnose ............................................................................................................ 30
Comorbiditeit ........................................................................................................................ 30
5) ANALAYSE.................................................................................................................................. 30
6) Behandeldoelen ........................................................................................................................ 31
7) Behandelplan ............................................................................................................................ 31
, Voorlichting ........................................................................................................................... 31
Verminderen v/d objectieve en subjectieve afname v/h inspanningsvermogen ................. 32
Verbeteren v/h looppatroon................................................................................................. 33
Optimaliseren van activiteiten en participatie ..................................................................... 33
Ondersteuning van cardiovasculair risicomanagement ....................................................... 33
Activeringsprogramma.......................................................................................................... 33
Eindevaluatie......................................................................................................................... 34
HOOFDSTUK 3 : ANATOMIE SCHEMA’S ................................................................................................ 35
1) Anatomie oppervlakkige lymfevaten bovenste lidmaat ........................................................... 35
2) Anatomie lymfeknopen v/d oksel & sleutelbeen ..................................................................... 35
3) Anatomie oppervlakkige lymfevaten borstklier........................................................................ 35
4) Implicatie bij de behandeling v/e oedeem door MLD na kanker operatie ............................... 36
5) Anatomie oppervlakkige lymfevaten v/d onderste ledematen ................................................ 36
6) Implicaties vo/d behandeling van secundaire oedeem via MLD na kanker operatie ............... 36
HOOFDSTUK 4 : HET LYMFESTELSEL ..................................................................................................... 37
1) Inleiding..................................................................................................................................... 37
Het lymfestelsel .................................................................................................................... 37
Lymfatische capillairen = de kleinste lymfevaten ................................................................. 37
(Pre)collectoren .................................................................................................................... 38
Lymfatische trunken ............................................................................................................. 38
Lymfeklieren.......................................................................................................................... 39
Het lymfesysteem ................................................................................................................. 39
2) Het interstitium ......................................................................................................................... 40
Actieve weefselmassa(ATM)/ extracellulaire masse(ECM) .................................................. 40
Proteïnen en mineralen ........................................................................................................ 40
Interstitium bevat ................................................................................................................. 40
Structuur interstitium ........................................................................................................... 40
Fysiologie .............................................................................................................................. 43
3) Oedeem..................................................................................................................................... 45
Inleiding................................................................................................................................. 45
Intracellulaire oedemen door : ............................................................................................. 45
Extra cellulaire oedeem ........................................................................................................ 45
Behandeling lymfoedeem ..................................................................................................... 49
Risicofactoren op lymfeoedeem ........................................................................................... 49
HOOFDSTUK 5 :Behandeling oedeem via complex physical therapy ................................................... 50
1) Inleiding..................................................................................................................................... 50
, 2) Huidverzorging is super belangrijk ............................................................................................ 50
3) Manuele lymfedrainage ............................................................................................................ 50
Vodder methode ................................................................................................................... 51
Casley-smith methode .......................................................................................................... 51
Földi methode ....................................................................................................................... 51
Leduc methode (VUB-ULB) ................................................................................................... 51
Technieken ............................................................................................................................ 52
4) compressie therapie ................................................................................................................. 52
Intermitterende pneumatische compressie ......................................................................... 52
Compressie therapie (in)elastische meerlagige benadering ................................................ 53
5) Lymfetaping via kinesiotape ..................................................................................................... 54
6) Gezonde levenstijl ..................................................................................................................... 54
Oefeningen, beweging en elevatie ....................................................................................... 54
7) Belgische wetgeving behandeling van (lymf)oedeem .............................................................. 55
HOOFDSTUK 6 : manueel lymfedrainage: evidence ............................................................................. 58
1) Diagnostiek................................................................................................................................ 58
2) Back to basics ............................................................................................................................ 58
Starling evenwicht : krachten – proteïnen............................................................................ 58
Vulling en lediging ................................................................................................................. 59
Samentrekkingen en stroming .............................................................................................. 59
Bijkomende routes ................................................................................................................ 59
Autonoom zenuwstelsel ....................................................................................................... 60
3) Beyond the basics ..................................................................................................................... 60
4) Nieuwe opportuniteiten ........................................................................................................... 60
Rol van de patiënt i/d lymfoedeemzorg ............................................................................... 60
Internationaal : state of the art = consensusdocument ISL .................................................. 61
Microchirurgie verwijzing voor lymfeoedeem ...................................................................... 61
5) ISL CONSENSUS DOCUMENT..................................................................................................... 61
Diagnose & behandeling ....................................................................................................... 61
HOOFDSTUK 7: KANKER IN BEWEGING ................................................................................................ 66
1) Inleiding..................................................................................................................................... 66
2) Revalidatie................................................................................................................................. 67
Fysieke revalidatie................................................................................................................. 67
3) Richtlijnen & literatuur : oefentherapie oncologie ................................................................... 68
Geschiedenis ......................................................................................................................... 68
Kanker framework ................................................................................................................ 68
, Preventie ............................................................................................................................... 68
Nadelige neveneffecten ........................................................................................................ 69
Cardiorespiratoire fitness CVRC ............................................................................................ 69
Spier/ lichaamscompositie .................................................................................................... 69
Levenskwaliteit ..................................................................................................................... 69
Pharmacokinetics .................................................................................................................. 69
Patiëntenfiche ....................................................................................................................... 70
Prescriptie oefeningen ...................................................................................................... 70
HOOFDSTUK 8: BORSTKANKER ............................................................................................................. 71
1) Anatomie................................................................................................................................... 71
Anatomie van de borst:......................................................................................................... 71
Anatomie van de Axilla: ........................................................................................................ 71
Vereenvoudigde anatomie: .................................................................................................. 71
2) Histologie van de borst: ............................................................................................................ 71
3) Goedaardige borstaandoeningen: ............................................................................................ 71
Mannen: ................................................................................................................................ 71
Symptomen: .......................................................................................................................... 71
Benigne-maligne ratio: .......................................................................................................... 72
4) Goedaardige borstaandoeningen: ............................................................................................ 72
Mastitis: ................................................................................................................................ 72
Goedaardig fibroadenoom:................................................................................................... 73
Borstcyste: ............................................................................................................................ 73
Vetnecrose: ........................................................................................................................... 74
5) Borstkanker: .............................................................................................................................. 74
Risicofactoren: ...................................................................................................................... 74
Lichamelijk onderzoek: ......................................................................................................... 74
Alarmsymptomen: ................................................................................................................ 75
Uitsluiten/bevestigen kwaadaardigheid via onderzoek: ...................................................... 75
Borstdensiteit:....................................................................................................................... 75
Onderzoek: volgende stap : .................................................................................................. 76
6) Tumorbiologie ........................................................................................................................... 76
Borstkanker ........................................................................................................................... 76
In situ versus invasief ............................................................................................................ 76
Histologische type: ................................................................................................................ 77
Differentiatiegraad:............................................................................................................... 77
Ki67 proliferatie-index: ......................................................................................................... 77
, Oestrogeenreceptoren & progesteronreceptoren: .............................................................. 77
HER2 amplificatie: .................................................................................................................. 77
Moleculaire typering ............................................................................................................. 78
GEP: Gen Expressie Profiel .................................................................................................... 78
Moleculaire typering: fenotypische benadering van genotype ........................................ 78
7) Diagnose → oppuntstelling ...................................................................................................... 78
Correcte stadiëring = heel belangrijk .................................................................................... 78
8) Heelkundige behandeling: ........................................................................................................ 79
9) Borstkankerheelkunde .............................................................................................................. 79
Belangrijke zaken om te weten over kankerdiagnose & behandeling: ................................ 79
Mammaire heelkunde:.......................................................................................................... 79
Eenvoudige mastectomie: .................................................................................................... 80
Skinsparing mastectomie: ..................................................................................................... 80
Nipplesparing mastectomie: ................................................................................................. 80
Borstsparende heelkunde ..................................................................................................... 80
10) Oncoplastische heelkunde .................................................................................................... 81
Mammoplastie ...................................................................................................................... 81
Round-block: ......................................................................................................................... 81
Axillaire uitruiming ................................................................................................................ 81
Sentinelprocedure................................................................................................................. 82
11) Lymfeklieraanpak .................................................................................................................. 82
12) Chemotherapie ..................................................................................................................... 83
Beslissing tot chemotherapie................................................................................................ 83
Neoadjuvante chemotherapie (NAC):................................................................................... 83
Nabehandeling chemotherapie ............................................................................................ 83
Nahbehandeling : (anti)hormonale....................................................................................... 83
13) Reconstructie na borstamputatie ......................................................................................... 85
Borstrecontructie .................................................................................................................. 85
Tepelreconstructie ................................................................................................................ 86
Reconstructive ...................................................................................................................... 86
14) Reconstructie-oncologische behandeling ............................................................................. 86
HOOFDSTUK 9: LITTEKENTHERAPIE ...................................................................................................... 87
1) Rol kinesitherapie ..................................................................................................................... 87
2) De huid ...................................................................................................................................... 87
3) Wondgenezing .......................................................................................................................... 87
Haemostatische processen (enkele seconden) .................................................................... 87
, Inflammatiefase (3-7 dagen) ................................................................................................. 87
Proliferatiefase : overlapping inflammatiefase ( 2-3 weken) ............................................... 88
Hermodelleringsfase (3weken – 2 jaar) ................................................................................ 88
4) Pathologische wondheling ........................................................................................................ 88
5) Invloed op wondheling en littekenvorming .............................................................................. 88
6) Classificatie van littekens volgens uiterlijke kenmerken .......................................................... 88
contractiele littekens ............................................................................................................ 88
Atrofische littekens ............................................................................................................... 88
Uitgerekte littekens .............................................................................................................. 89
Hypertrofisch litteken ........................................................................................................... 89
Keloide littekens.................................................................................................................... 89
7) Behandeling littekens door kinesitherapeuten ........................................................................ 89
Manuele technieken ............................................................................................................. 89
Vacuummassage ................................................................................................................... 90
Shock-wave therapie............................................................................................................. 90
Taping.................................................................................................................................... 90
Hydratatie en siliconen sheeds ............................................................................................. 91
Mechanptransductie ............................................................................................................. 91
8) Behandelplan ............................................................................................................................ 91
9) Scar assessment scales.............................................................................................................. 91
PSOAS littekenschaal ............................................................................................................ 92
10) CASUS : behandeling ............................................................................................................. 92
HOOFDSTUK 10: LIPOEDEEM ................................................................................................................ 93
1) Inleiding..................................................................................................................................... 93
2) Klinische revalidatie .................................................................................................................. 93
3) Epidemiologie ........................................................................................................................... 93
4) Etiologie .................................................................................................................................... 93
5) Pathofysiologie.......................................................................................................................... 93
6) Verloop lipoedeem ................................................................................................................... 94
7) Lipolymfoedeem ....................................................................................................................... 94
8) Diagnose.................................................................................................................................... 94
Anamnese ............................................................................................................................. 95
Inspectie ................................................................................................................................ 95
Palpatie ................................................................................................................................. 95
Klinisch onderzoek ................................................................................................................ 95
ICF MODEL ............................................................................................................................ 95
, Diagnose................................................................................................................................ 96
Differentiaal diagnose ........................................................................................................... 96
9) Behandeling .............................................................................................................................. 97
Conservatieve behandeling................................................................................................... 97
Chirurgische ingreep ............................................................................................................. 98
Opvolging .............................................................................................................................. 98
HOOFDSTUK 11 : SPORTGYNAECOLOGIE .............................................................................................. 99
1) Lymphatic Mapping Sentinel Node: radio-colloïd methode ..................................................... 99
2) Lichamelijke activiteit en lymfoedeem van de onderste ledematen bij overlevenden van
baarmoederkanker ........................................................................................................................... 99
3) Risico’s van axillaire operatie .................................................................................................. 100
4) Axillary web syndrome (AWS) or cording ............................................................................... 101
5) Lymfeoedeem checklist guidelines ......................................................................................... 102
6) Risicofactoren vo/h ontwikkelen van bovenarm lymfeoedeem na borstkanker behandeling
103
7) NICE guidelines........................................................................................................................ 104
8) Waarom fysieke activiteit ....................................................................................................... 104
9) Primaire preventie .................................................................................................................. 105
10) Tijdens de behandeling ....................................................................................................... 107
11) Na de behandeling .............................................................................................................. 109
12) Hoe motiveren? .................................................................................................................. 111
,INLEIDING
1) Wat is homeostase ?
=fysiologisch proces, waarbij organismen het inwendig milieu van biochemische en
biofysische processen in evenwicht houden, ondanks veranderingen i/d omgeving waarin
het organisme zich bevindt.
Door homeostase kan een organisme de functie van elk individueel orgaan aanpassen,
waardoor aan de integrale behoefte van het lichaam wordt voldaan.
2) Twee systemen
• Vasculair systeem en lymfesysteem ➔ zijn met elkaar verbonden
• Groot verschil tss deze twee systemen :
o Vasculair = gesloten systeem dus continue circulatie
o Lymfesysteem= geen continue circulatie; open systeem
• Het cardiovasculair systeem
• Lymfesysteem is belangrijk bij capillair netwerk
,Het arteriële systeem
• Circulatie : Aorta ➔ arteriën ➔ arteriolen ➔ metarteriolen (= spierlaag; contractie
mogelijk)➔ pre-capillaire sfincter ➔ capillairen ( = geen spiercellen i/d wand dus geen
contractie mogelijk) ➔ microvasculair bed
• Na sfincter ➔ innervatie / activatie mogelijk door para- en sympatische zenuwstelsel ➔
zw zorgt voor contractie
• Metarteriole + precapillaire sfincter = hebben spierlaag ➔ vasomotoriek
• Flow en druk v/h bloed voor en na sfincter verschillend (verschillend tss metarteriolen
en capillairen, want de ene spierlaag en de andere niet )
• Doel arterieel systeem ➔ Uitwisseling bloed-weefsel
• Postcapillaire venulen : uitwisselingsfuctie
a) Arteriolen bevatten verschillende lagen
• Tunica intima = binnenste vaatwand
o Vlotte doorstroming v/h vat
o Bevat endotheel cellen en lamina basalis
• Tunica media = middelste vaatwand
o 2 gladde spiervezels lagen + collagene en elastische vezels
• Tunica adventitia = buitenkant v/d vaatwand
o Bindweefsel verbinding
b) Capillairen
• Endotheelcellen + lamina basalis + collageen
• Wandcellen : golgi complex, mitochondriën + microfilamenten +
transportblaasjes
• Microfilamenten : contractiliteit ( actinemoleculen helix)
• Diffusie ( dunne wand, oppervlakte, stroomsnelheid) via kleine poriën
• Intercellulaire spleten
• Transcytosis (= blaasjestransport)
Het veneuze systeem
• 60% bloed
• 3 lagen : tunica media zeer dun, en adventitia laag is dikker
• Transport en sturing kan door vershcillen,de mechanisme
o Veneuze unidirectionele kleppen
o Arteriele pulsaties
o Spierpomp/ respiratoir
o Skeletspierpomp
▪ samendrukken ( kuit en voetpomp) om veneuze circulatie te bevorderen
respiratoire pomp thv thorax
o RESPIRATOIRE POMP
▪ Wnr inademing thoracale ruimte vergroot en dus druk
neemt af ➔ compressie thv abdomen ➔ dit druk op aorta
▪ Ruitme kleiner = druk groter en bloed gepompt richting
het hart
o Restdruk v/h hart
o Arterio-veneuze anastomosen = directe verbinding mogelijk
tss arteriële en veneuze systeem ➔ VIA anastomosen lumen
afsluiten of heel veel bloed pompen naar capillair netwerk
, HOOFDSTUK 1 : Arteriële pathologie en TOS
1) Semiologie v/h arteriële stelsel
• Arterieel lijden: stenoserende – dilaterende vorm
o Dilaterende vorm : arteriën die zich uitzetten bv aneurysma
o Stenoserende vorm : slagader vernauwd of verstopt geraakt altijd door arteriosclerose (=
slagader verkalking)
• Atheroscleroserende stenoserende ziekte in 4 territoria :
o Supra aortische bloedvaten ➔ bloedvaten die uitmonden
v/d aortaboog
▪ Gevormd door de aorta ascedens en aorta descedens
▪ 4 zijtakkken:
• RECHTS : Truncus brachiocephalicus splitsen tot
arterie subclavia & arterie carotis communis rechts
• LINKS : arterie communis links & arteria subclavia
• Eerste zijtak arterie subclavia is arteria vertebralis en
samenkomen tot arteria basilaris ( deze arterie gaat
naar hersenstam & cerebelum van bloed voorzien)
o Arteries v/d onderste ledematen
▪ Komt v/d aorta abominalis ➔ Infrarenale aorta
abdominalis die zich splits i/e linker & rechter arteria iliaca
communis ➔ die zich verder splits i/e arteria interna &
externa
▪ Arteria iliaca externa onder de lies regio (= onder ligament
introgrenale) ➔ het wordt arteria femoralis communis en
splits in arteria femoralis profunda & superficialis ➔ vanaf
knie wordt het arteria poplita
• Arteria poplitea splits in twee takken : arteria tibialis
anterior & truncus fibularis ( die zich verder splits in
tibialis posterior en arteria fibularis)
▪ Arteria iliaca interna
o Digestieve en nier arteriën
▪ Ontstaat uit de aorta abdominaris
▪ Net onder het ligamentum arcuatum de truncus ceoliacus die
zich splits in arteria gastrica sinistra (= maag, pancreas &
dunne darm) , arteria hepatica communis (= lever) en arteria
splenica (= milt)
▪ Belangrijke zijtak : arteria mesenterica superior die een groot
gedeelte v/d colon en gans de dunne darm gaat bloed geven
▪ Andere zijtak : rechter en linker arteria renalis ➔ nieren van
bloed voorzien
▪ Andere zijtak : arteria mesenteruca inferior die andere deel
colon & rectum van bloed voorzien
o Kransslagaders ➔ coronaire slagaders
• Stenoserende ziekte kunnen acuut of chronisch zijn
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