SPIJSVERTERING
INHOUDSOPGAVE
Inleiding (geen leerstof) ................................................................................................................................ 12
H1: Goedaardige aandoeningen slokdarm, maag en duodenum.................................................................... 14
1. Aandoeningen van de slokdarm .................................................................................................................... 14
1.1 Symptomen en diagnostiek van slokdarmaandoeningen ....................................................................... 14
Dysfagie .................................................................................................................................................... 14
Odynofagie ............................................................................................................................................... 15
Pyrosis en regurgitatie ............................................................................................................................. 15
Thoracale pijn ........................................................................................................................................... 15
Globusgevoel ............................................................................................................................................ 15
Secundair.................................................................................................................................................. 15
1.2 Technische onderzoeken bij slokdarmziekten ........................................................................................ 15
Endoscopie en biopsie.............................................................................................................................. 15
Manometrisch onderzoek ........................................................................................................................ 16
pH meting ................................................................................................................................................. 16
Radiologische onderzoeken ..................................................................................................................... 16
1.3 Gastro-oesofagale refluxziekte ............................................................................................................... 16
Presentatie ............................................................................................................................................... 17
Etiopathogenese ...................................................................................................................................... 17
Graden van reflux en refluxziekte ............................................................................................................ 17
Betekenis van de aanwezigheid van metaplastisch cilindercellig epitheel .............................................. 18
Diagnostische evaluatie bij een patiënt met refluxziekte ........................................................................ 18
Behandelingsmogelijkheden .................................................................................................................... 19
Praktisch therapieschema ........................................................................................................................ 20
1.4 Motorische stoornissen van de slokdarm (zz, geen details kennen) ...................................................... 21
Primaire motiliteitsstoornissen van de slokdarm..................................................................................... 21
Secundaire motoriekstoornissen van de slokdarm .................................................................................. 22
Eosinofiele esofagitis ................................................................................................................................ 22
Oesofagale ring of diafragma ................................................................................................................... 23
1.5 Candidiase van de slokdarm ................................................................................................................... 23
Virale oesofagitis ...................................................................................................................................... 24
1.6 Caustische esofagitis (niet in hb) ............................................................................................................ 24
1.7 Tumoren van de slokdarm (niet in hb) ................................................................................................... 24
Take home .................................................................................................................................................... 24
2. Aandoeningen van maag en duodenum ....................................................................................................... 24
2.1 Diagnose van een Helicobacter Pylori infectie ....................................................................................... 25
2.2 Behandeling van een HP infectie ............................................................................................................ 25
2.3 Maag- en duodenumulcus ...................................................................................................................... 25
Presentatie ............................................................................................................................................... 25
Definitie en lokalisatie .............................................................................................................................. 25
Pathogenese ............................................................................................................................................. 26
Diagnose ................................................................................................................................................... 27
Behandeling.............................................................................................................................................. 27
Verwikkelingen ......................................................................................................................................... 27
1
, 2.4 Syndroom van Zollinger-Ellison .............................................................................................................. 30
2.5 Acute diarreee ........................................................................................................................................ 31
2.6 Congenitale aandoeningen van maag en duodenum ............................................................................. 31
3. Inleiding tot de abdominale heelkunde ......................................................................................................... 31
Inleiding ........................................................................................................................................................ 31
3.1 Laparotomie ........................................................................................................................................... 32
3.2 Laparoscopie ........................................................................................................................................... 32
3.3 Minimaal invasieve technieken .............................................................................................................. 32
3.4 Viscerale anatomie ................................................................................................................................. 32
3.5 Basis voor de oncologische resectie van GI-tumoren ............................................................................ 33
3.6 Darmanastomose ................................................................................................................................... 33
Anastomoselek ......................................................................................................................................... 33
3.7 Stoma ...................................................................................................................................................... 33
3.8 Postoperatieve morbiditeit en mortaliteit ............................................................................................. 34
4. Morbide obesitas – metabole chirurgie ........................................................................................................ 34
Inleiding ........................................................................................................................................................ 34
4.1 Techniek van meest voorkomende procedures ..................................................................................... 35
Mason gastroplastie ................................................................................................................................. 35
Laparoscopische gastric banding.............................................................................................................. 35
Laparoscopische Roux-en-Y gastric bypass (RYGB) .................................................................................. 35
Sleeve gastrectomie ................................................................................................................................. 36
Nieuwe procedures .................................................................................................................................. 36
4.2 Indicaties................................................................................................................................................. 37
4.3 Complicaties ........................................................................................................................................... 38
Korte termijn complicaties ....................................................................................................................... 38
Lange termijn complicaties ...................................................................................................................... 39
4.4 Follow-up na bariatrische chirurgie ........................................................................................................ 40
4.5 Conclusies en toekomstperspectieven ................................................................................................... 40
H2: Goedaardige aandoeningen dunne darm, colon en rectum ..................................................................... 41
Studiedoelstellingen .......................................................................................................................................... 41
1. Ziekten gekenmerkt door malabsorptie ........................................................................................................ 41
1.1 Wat is malabsorptie? .............................................................................................................................. 41
1.2 Klinisch relevante malabsorptie ............................................................................................................. 41
Presentatie ............................................................................................................................................... 41
Malabsorptie van vetten .......................................................................................................................... 41
Malabsorptie van koolhydraten ............................................................................................................... 43
Malabsorptie van proteïnen..................................................................................................................... 43
Bijzondere klinische symptomen van malabsorptie................................................................................. 43
2. Coeliakie ........................................................................................................................................................ 44
Presentatie ................................................................................................................................................... 44
2.1 Definitie .................................................................................................................................................. 44
2.2 Etiologie en pathogenese ....................................................................................................................... 44
Diagnose (histopathologie) ...................................................................................................................... 44
Verwikkelingen ......................................................................................................................................... 45
Behandeling.............................................................................................................................................. 45
3. Bacteriële overgroei in de dunne darm ......................................................................................................... 45
Presentatie ................................................................................................................................................... 45
3.1 Oorzaken................................................................................................................................................. 45
3.2 Mechanismen ......................................................................................................................................... 46
3.3 Diagnose ................................................................................................................................................. 46
2
, 3.4 Behandeling ............................................................................................................................................ 46
4. Congenitale aandoeningen van de dunne darm ........................................................................................... 46
5. Pathologie van de appendix .......................................................................................................................... 46
5.1 Anatomie ................................................................................................................................................ 46
5.2 Acute appendicitis .................................................................................................................................. 46
Diagnose ................................................................................................................................................... 47
Behandeling.............................................................................................................................................. 47
Valkuilen en moeilijkheden ...................................................................................................................... 48
Pathologie ................................................................................................................................................ 48
6. Inflammatoire darmaandoeningen ............................................................................................................... 48
Presentatie ................................................................................................................................................... 49
6.1 Samenvatting .......................................................................................................................................... 49
6.2 Wat zijn inflammatoire darmziekten? .................................................................................................... 49
6.3 Incidentie ................................................................................................................................................ 49
6.4 Geografische verspreiding ...................................................................................................................... 49
6.5 Erfelijkheid .............................................................................................................................................. 50
6.6 Risicofactoren ......................................................................................................................................... 50
6.7 Immunologie ........................................................................................................................................... 50
6.8 Bacteriën................................................................................................................................................. 50
6.9 Pathologie ............................................................................................................................................... 50
6.10 Extra-intestinale manifestaties ............................................................................................................. 51
6.11 Classificaties van IBD ............................................................................................................................ 51
De Montreal-classificatie van de ziekte van Crohn .................................................................................. 51
De Montreal-classificatie van colitis ulcerosa .......................................................................................... 52
Diagnose ....................................................................................................................................................... 52
Labo .......................................................................................................................................................... 52
Differentiaaldiagnose ............................................................................................................................... 52
Behandeling .................................................................................................................................................. 53
Medische behandeling en doelstellingen van de behandeling ................................................................ 53
Complicaties ............................................................................................................................................. 56
7. Chirurgische aspecten van inflammatoire darmziekten ................................................................................ 57
7.1 De ziekte van Crohn ................................................................................................................................ 57
7.2 Stenoserende ziekte ............................................................................................................................... 57
Presentatie ............................................................................................................................................... 57
Inleiding .................................................................................................................................................... 57
Diagnose ................................................................................................................................................... 57
Chirurgische behandeling ......................................................................................................................... 58
7.3 Fistulerende ziekte ................................................................................................................................. 58
Presentatie ............................................................................................................................................... 58
Inleiding .................................................................................................................................................... 59
Preoperatieve beeldvorming.................................................................................................................... 59
Chirurgische behandeling ......................................................................................................................... 59
Postoperatieve therapie........................................................................................................................... 59
7.4 Anale Crohn ............................................................................................................................................ 60
7.5 Colitis ulcerosa ........................................................................................................................................ 60
Presentatie ............................................................................................................................................... 60
Indicaties voor heelkunde ........................................................................................................................ 60
Type heelkunde ........................................................................................................................................ 61
Ileostoma.................................................................................................................................................. 62
8. Verwikkelingen van radio-enteritis en radiorectitis ...................................................................................... 62
Presentatie ................................................................................................................................................... 62
8.1 Oorzaken en voorkomen ........................................................................................................................ 62
3
, 8.2 Pathologie ............................................................................................................................................... 62
8.3 Lokalisatie ............................................................................................................................................... 63
8.4 Differentieeldiagnose ............................................................................................................................. 63
8.5 Behandeling ............................................................................................................................................ 63
9. Invaginatie .................................................................................................................................................... 63
Presentatie ................................................................................................................................................... 63
9.1 Pathologie ............................................................................................................................................... 63
9.2 Klinische tekens ...................................................................................................................................... 63
9.3 Diagnose ................................................................................................................................................. 63
9.4 Verwikkelingen ....................................................................................................................................... 64
9.5 Behandeling ............................................................................................................................................ 64
9.6 Prognose ................................................................................................................................................. 64
10. Volvulus ....................................................................................................................................................... 64
Presentatie ................................................................................................................................................... 64
10.1 Pathologie ............................................................................................................................................. 64
10.2 Diagnose ............................................................................................................................................... 65
10.3 Evolutie ................................................................................................................................................. 65
10.4 Behandeling .......................................................................................................................................... 65
11. Diverticulose en diverticulitis ...................................................................................................................... 65
Definitie ........................................................................................................................................................ 65
11.1 Epidemiologie ....................................................................................................................................... 65
11.2 Pathogenese ......................................................................................................................................... 65
11.3 Acute diverticulitis ................................................................................................................................ 66
Presentatie ............................................................................................................................................... 66
Diagnose ................................................................................................................................................... 66
Behandeling.............................................................................................................................................. 66
11.4 recidiverende diverticulitis ................................................................................................................... 66
11.5 Sigmoidfistels ........................................................................................................................................ 67
11.6 Diverticumaire bloeding ....................................................................................................................... 67
11.7 Heelkunde voor diverticulitis en verwikkelingen .................................................................................. 67
Electieve sigmoidresectie ......................................................................................................................... 67
Heelkunde voor Hinchey 3 (purulente peritonitis)................................................................................... 67
Heelkunde voor Hinchey 4 (fecale peritonitis) ......................................................................................... 68
11.8 Speciale gevallen .................................................................................................................................. 68
12. Endometriose .............................................................................................................................................. 68
Presentatie ................................................................................................................................................... 68
Definitie ........................................................................................................................................................ 68
12.1 Epidemiologie ....................................................................................................................................... 69
12.2 Pathogenese ......................................................................................................................................... 69
12.3 Pathologie ............................................................................................................................................. 69
12.4 Diagnose ............................................................................................................................................... 69
12.5 Transvaginale echografie ................................................................................................................. 70
12.6 RX colon (bariumenema) .................................................................................................................. 70
12.7 MR .................................................................................................................................................... 70
Exploratieve laparoscopie ........................................................................................................................ 70
12.8 Behandeling .......................................................................................................................................... 70
Algemene principes .................................................................................................................................. 70
Dunne darm en appendix ......................................................................................................................... 71
Prognose .................................................................................................................................................. 71
13. Vasculaire insufficiëntie van de darm ......................................................................................................... 71
13.1 Bemerkingen vooraf ............................................................................................................................. 71
13.2 Angor abdominalis ................................................................................................................................ 71
4
INHOUDSOPGAVE
Inleiding (geen leerstof) ................................................................................................................................ 12
H1: Goedaardige aandoeningen slokdarm, maag en duodenum.................................................................... 14
1. Aandoeningen van de slokdarm .................................................................................................................... 14
1.1 Symptomen en diagnostiek van slokdarmaandoeningen ....................................................................... 14
Dysfagie .................................................................................................................................................... 14
Odynofagie ............................................................................................................................................... 15
Pyrosis en regurgitatie ............................................................................................................................. 15
Thoracale pijn ........................................................................................................................................... 15
Globusgevoel ............................................................................................................................................ 15
Secundair.................................................................................................................................................. 15
1.2 Technische onderzoeken bij slokdarmziekten ........................................................................................ 15
Endoscopie en biopsie.............................................................................................................................. 15
Manometrisch onderzoek ........................................................................................................................ 16
pH meting ................................................................................................................................................. 16
Radiologische onderzoeken ..................................................................................................................... 16
1.3 Gastro-oesofagale refluxziekte ............................................................................................................... 16
Presentatie ............................................................................................................................................... 17
Etiopathogenese ...................................................................................................................................... 17
Graden van reflux en refluxziekte ............................................................................................................ 17
Betekenis van de aanwezigheid van metaplastisch cilindercellig epitheel .............................................. 18
Diagnostische evaluatie bij een patiënt met refluxziekte ........................................................................ 18
Behandelingsmogelijkheden .................................................................................................................... 19
Praktisch therapieschema ........................................................................................................................ 20
1.4 Motorische stoornissen van de slokdarm (zz, geen details kennen) ...................................................... 21
Primaire motiliteitsstoornissen van de slokdarm..................................................................................... 21
Secundaire motoriekstoornissen van de slokdarm .................................................................................. 22
Eosinofiele esofagitis ................................................................................................................................ 22
Oesofagale ring of diafragma ................................................................................................................... 23
1.5 Candidiase van de slokdarm ................................................................................................................... 23
Virale oesofagitis ...................................................................................................................................... 24
1.6 Caustische esofagitis (niet in hb) ............................................................................................................ 24
1.7 Tumoren van de slokdarm (niet in hb) ................................................................................................... 24
Take home .................................................................................................................................................... 24
2. Aandoeningen van maag en duodenum ....................................................................................................... 24
2.1 Diagnose van een Helicobacter Pylori infectie ....................................................................................... 25
2.2 Behandeling van een HP infectie ............................................................................................................ 25
2.3 Maag- en duodenumulcus ...................................................................................................................... 25
Presentatie ............................................................................................................................................... 25
Definitie en lokalisatie .............................................................................................................................. 25
Pathogenese ............................................................................................................................................. 26
Diagnose ................................................................................................................................................... 27
Behandeling.............................................................................................................................................. 27
Verwikkelingen ......................................................................................................................................... 27
1
, 2.4 Syndroom van Zollinger-Ellison .............................................................................................................. 30
2.5 Acute diarreee ........................................................................................................................................ 31
2.6 Congenitale aandoeningen van maag en duodenum ............................................................................. 31
3. Inleiding tot de abdominale heelkunde ......................................................................................................... 31
Inleiding ........................................................................................................................................................ 31
3.1 Laparotomie ........................................................................................................................................... 32
3.2 Laparoscopie ........................................................................................................................................... 32
3.3 Minimaal invasieve technieken .............................................................................................................. 32
3.4 Viscerale anatomie ................................................................................................................................. 32
3.5 Basis voor de oncologische resectie van GI-tumoren ............................................................................ 33
3.6 Darmanastomose ................................................................................................................................... 33
Anastomoselek ......................................................................................................................................... 33
3.7 Stoma ...................................................................................................................................................... 33
3.8 Postoperatieve morbiditeit en mortaliteit ............................................................................................. 34
4. Morbide obesitas – metabole chirurgie ........................................................................................................ 34
Inleiding ........................................................................................................................................................ 34
4.1 Techniek van meest voorkomende procedures ..................................................................................... 35
Mason gastroplastie ................................................................................................................................. 35
Laparoscopische gastric banding.............................................................................................................. 35
Laparoscopische Roux-en-Y gastric bypass (RYGB) .................................................................................. 35
Sleeve gastrectomie ................................................................................................................................. 36
Nieuwe procedures .................................................................................................................................. 36
4.2 Indicaties................................................................................................................................................. 37
4.3 Complicaties ........................................................................................................................................... 38
Korte termijn complicaties ....................................................................................................................... 38
Lange termijn complicaties ...................................................................................................................... 39
4.4 Follow-up na bariatrische chirurgie ........................................................................................................ 40
4.5 Conclusies en toekomstperspectieven ................................................................................................... 40
H2: Goedaardige aandoeningen dunne darm, colon en rectum ..................................................................... 41
Studiedoelstellingen .......................................................................................................................................... 41
1. Ziekten gekenmerkt door malabsorptie ........................................................................................................ 41
1.1 Wat is malabsorptie? .............................................................................................................................. 41
1.2 Klinisch relevante malabsorptie ............................................................................................................. 41
Presentatie ............................................................................................................................................... 41
Malabsorptie van vetten .......................................................................................................................... 41
Malabsorptie van koolhydraten ............................................................................................................... 43
Malabsorptie van proteïnen..................................................................................................................... 43
Bijzondere klinische symptomen van malabsorptie................................................................................. 43
2. Coeliakie ........................................................................................................................................................ 44
Presentatie ................................................................................................................................................... 44
2.1 Definitie .................................................................................................................................................. 44
2.2 Etiologie en pathogenese ....................................................................................................................... 44
Diagnose (histopathologie) ...................................................................................................................... 44
Verwikkelingen ......................................................................................................................................... 45
Behandeling.............................................................................................................................................. 45
3. Bacteriële overgroei in de dunne darm ......................................................................................................... 45
Presentatie ................................................................................................................................................... 45
3.1 Oorzaken................................................................................................................................................. 45
3.2 Mechanismen ......................................................................................................................................... 46
3.3 Diagnose ................................................................................................................................................. 46
2
, 3.4 Behandeling ............................................................................................................................................ 46
4. Congenitale aandoeningen van de dunne darm ........................................................................................... 46
5. Pathologie van de appendix .......................................................................................................................... 46
5.1 Anatomie ................................................................................................................................................ 46
5.2 Acute appendicitis .................................................................................................................................. 46
Diagnose ................................................................................................................................................... 47
Behandeling.............................................................................................................................................. 47
Valkuilen en moeilijkheden ...................................................................................................................... 48
Pathologie ................................................................................................................................................ 48
6. Inflammatoire darmaandoeningen ............................................................................................................... 48
Presentatie ................................................................................................................................................... 49
6.1 Samenvatting .......................................................................................................................................... 49
6.2 Wat zijn inflammatoire darmziekten? .................................................................................................... 49
6.3 Incidentie ................................................................................................................................................ 49
6.4 Geografische verspreiding ...................................................................................................................... 49
6.5 Erfelijkheid .............................................................................................................................................. 50
6.6 Risicofactoren ......................................................................................................................................... 50
6.7 Immunologie ........................................................................................................................................... 50
6.8 Bacteriën................................................................................................................................................. 50
6.9 Pathologie ............................................................................................................................................... 50
6.10 Extra-intestinale manifestaties ............................................................................................................. 51
6.11 Classificaties van IBD ............................................................................................................................ 51
De Montreal-classificatie van de ziekte van Crohn .................................................................................. 51
De Montreal-classificatie van colitis ulcerosa .......................................................................................... 52
Diagnose ....................................................................................................................................................... 52
Labo .......................................................................................................................................................... 52
Differentiaaldiagnose ............................................................................................................................... 52
Behandeling .................................................................................................................................................. 53
Medische behandeling en doelstellingen van de behandeling ................................................................ 53
Complicaties ............................................................................................................................................. 56
7. Chirurgische aspecten van inflammatoire darmziekten ................................................................................ 57
7.1 De ziekte van Crohn ................................................................................................................................ 57
7.2 Stenoserende ziekte ............................................................................................................................... 57
Presentatie ............................................................................................................................................... 57
Inleiding .................................................................................................................................................... 57
Diagnose ................................................................................................................................................... 57
Chirurgische behandeling ......................................................................................................................... 58
7.3 Fistulerende ziekte ................................................................................................................................. 58
Presentatie ............................................................................................................................................... 58
Inleiding .................................................................................................................................................... 59
Preoperatieve beeldvorming.................................................................................................................... 59
Chirurgische behandeling ......................................................................................................................... 59
Postoperatieve therapie........................................................................................................................... 59
7.4 Anale Crohn ............................................................................................................................................ 60
7.5 Colitis ulcerosa ........................................................................................................................................ 60
Presentatie ............................................................................................................................................... 60
Indicaties voor heelkunde ........................................................................................................................ 60
Type heelkunde ........................................................................................................................................ 61
Ileostoma.................................................................................................................................................. 62
8. Verwikkelingen van radio-enteritis en radiorectitis ...................................................................................... 62
Presentatie ................................................................................................................................................... 62
8.1 Oorzaken en voorkomen ........................................................................................................................ 62
3
, 8.2 Pathologie ............................................................................................................................................... 62
8.3 Lokalisatie ............................................................................................................................................... 63
8.4 Differentieeldiagnose ............................................................................................................................. 63
8.5 Behandeling ............................................................................................................................................ 63
9. Invaginatie .................................................................................................................................................... 63
Presentatie ................................................................................................................................................... 63
9.1 Pathologie ............................................................................................................................................... 63
9.2 Klinische tekens ...................................................................................................................................... 63
9.3 Diagnose ................................................................................................................................................. 63
9.4 Verwikkelingen ....................................................................................................................................... 64
9.5 Behandeling ............................................................................................................................................ 64
9.6 Prognose ................................................................................................................................................. 64
10. Volvulus ....................................................................................................................................................... 64
Presentatie ................................................................................................................................................... 64
10.1 Pathologie ............................................................................................................................................. 64
10.2 Diagnose ............................................................................................................................................... 65
10.3 Evolutie ................................................................................................................................................. 65
10.4 Behandeling .......................................................................................................................................... 65
11. Diverticulose en diverticulitis ...................................................................................................................... 65
Definitie ........................................................................................................................................................ 65
11.1 Epidemiologie ....................................................................................................................................... 65
11.2 Pathogenese ......................................................................................................................................... 65
11.3 Acute diverticulitis ................................................................................................................................ 66
Presentatie ............................................................................................................................................... 66
Diagnose ................................................................................................................................................... 66
Behandeling.............................................................................................................................................. 66
11.4 recidiverende diverticulitis ................................................................................................................... 66
11.5 Sigmoidfistels ........................................................................................................................................ 67
11.6 Diverticumaire bloeding ....................................................................................................................... 67
11.7 Heelkunde voor diverticulitis en verwikkelingen .................................................................................. 67
Electieve sigmoidresectie ......................................................................................................................... 67
Heelkunde voor Hinchey 3 (purulente peritonitis)................................................................................... 67
Heelkunde voor Hinchey 4 (fecale peritonitis) ......................................................................................... 68
11.8 Speciale gevallen .................................................................................................................................. 68
12. Endometriose .............................................................................................................................................. 68
Presentatie ................................................................................................................................................... 68
Definitie ........................................................................................................................................................ 68
12.1 Epidemiologie ....................................................................................................................................... 69
12.2 Pathogenese ......................................................................................................................................... 69
12.3 Pathologie ............................................................................................................................................. 69
12.4 Diagnose ............................................................................................................................................... 69
12.5 Transvaginale echografie ................................................................................................................. 70
12.6 RX colon (bariumenema) .................................................................................................................. 70
12.7 MR .................................................................................................................................................... 70
Exploratieve laparoscopie ........................................................................................................................ 70
12.8 Behandeling .......................................................................................................................................... 70
Algemene principes .................................................................................................................................. 70
Dunne darm en appendix ......................................................................................................................... 71
Prognose .................................................................................................................................................. 71
13. Vasculaire insufficiëntie van de darm ......................................................................................................... 71
13.1 Bemerkingen vooraf ............................................................................................................................. 71
13.2 Angor abdominalis ................................................................................................................................ 71
4
