Inhoudsopgave
De splanchnische circulatie..........................................................................................................................5
Doorbloeding..............................................................................................................................................5
Arterieel: aorta abdominalis..................................................................................................................5
Veneus................................................................................................................................................. 6
Leverhilus............................................................................................................................................. 6
Darmvilli................................................................................................................................................7
Regulatie van de splanchnische bloedflow.......................................................................................... 7
Fysiopathologie van vasculaire stoornissen...............................................................................................8
Darminfarct...........................................................................................................................................9
Segmentaire ischemie........................................................................................................................10
Angor abdominalis..............................................................................................................................10
Ischemische colitis..............................................................................................................................11
Fysiologie van de lever................................................................................................................................13
Functionele morfologie.............................................................................................................................13
Macroscopisch................................................................................................................................... 13
Microscopisch.....................................................................................................................................13
Metabole functie.......................................................................................................................................15
Koolhydraten...................................................................................................................................... 15
Eiwitten...............................................................................................................................................16
Lipiden................................................................................................................................................16
Detoxificatie functie.................................................................................................................................. 16
Cytochroom P450 enzymen............................................................................................................... 17
Bilirubine metabolisme....................................................................................................................... 17
Immunologische functie........................................................................................................................... 18
Galsecretie............................................................................................................................................... 18
Cholesterol metabolisme....................................................................................................................19
Synthese van galzouten..................................................................................................................... 19
Fysische eigenschappen van galzouten............................................................................................ 20
Hepatobiliaire transportsystemen.......................................................................................................21
Secretie van water en elektrolyten..................................................................................................... 22
Oefening...................................................................................................................................................23
Portale hypertensie......................................................................................................................................24
Hemodynamica........................................................................................................................................ 24
Weerstand (R).................................................................................................................................... 24
Portale inflow (Q)................................................................................................................................25
Gevolgen van portale hypertensie........................................................................................................... 26
Collateralen........................................................................................................................................ 26
Hypersplenisme..................................................................................................................................28
Ascites................................................................................................................................................28
Longen............................................................................................................................................... 31
Klinische aspecten en complicaties van portale hypertensie................................................................. 32
Fibrose en cirrose.................................................................................................................................... 32
HVPG-meting........................................................................................................................................... 32
1
,Oorzaken van portale hypertensie........................................................................................................... 32
Vena portaetrombose (prehepatisch)................................................................................................. 33
Syndroom van Budd-Chiari (posthepatisch).......................................................................................34
Sinusoïdaal obstructiesyndroom (intraheptisch, postsinusoïdaal)..................................................... 35
Complicaties van portale hypertensie...................................................................................................... 35
Gastro-oesofageale varices..................................................................................................................... 35
Slokdarmvarices.................................................................................................................................36
Maagvarices....................................................................................................................................... 36
Portale hypertensieve gastropathie....................................................................................................37
Bloedingen......................................................................................................................................... 37
Behandeling van acute bloeding........................................................................................................ 37
Preventie van bloeding.......................................................................................................................40
Ascites......................................................................................................................................................40
Oorzaken............................................................................................................................................40
Diagnose............................................................................................................................................ 41
Behandeling....................................................................................................................................... 42
Hepatische hydrothorax........................................................................................................................... 44
Spontane bacteriële peritonitis (SBP)...................................................................................................... 45
Secundaire bacteriële peritonitis........................................................................................................ 46
Dilutionele hyponatriëmie.........................................................................................................................46
Hepatorenaal syndroom (HRS)................................................................................................................46
Acute nierinsufficiëntie....................................................................................................................... 46
Hepatorenaal syndroom (HRS).......................................................................................................... 47
Hepatopulmonaal syndroom (HPS)......................................................................................................... 47
Portopulmonale hypertensie (PoPH)........................................................................................................48
Doel.......................................................................................................................................................... 48
Evaluatie leverstatus................................................................................................................................ 49
Gemeten waarden..............................................................................................................................49
Biochemische leverenzymtesten ( leverfunctietesten)............................................................................. 50
Parenchymateuze leverenzymen....................................................................................................... 50
Canaliculaire leverenzymen............................................................................................................... 51
Parenchymateus vs. cholestatisch leverlijden....................................................................................52
Prognostische leverfunctietest................................................................................................................. 52
Excretoire functie: bilirubine............................................................................................................... 53
Synthesefunctie: albumine................................................................................................................. 53
Synthesefunctie: stollingstesten......................................................................................................... 53
Synthesefunctie: cholinesterase.........................................................................................................54
Kwantitatieve levertesten......................................................................................................................... 54
Beeldvorming (macroscopisch)................................................................................................................54
Abdominale echografie.......................................................................................................................55
CT.......................................................................................................................................................55
voordelen............................................................................................................................................55
MRI.....................................................................................................................................................55
Elastometrie (microscopisch)................................................................................................................... 55
Leverbiopsie.............................................................................................................................................56
Percutane techniek.............................................................................................................................57
Transjugulaire techniek...................................................................................................................... 58
Oefening...................................................................................................................................................59
2
,Leverfalen & levercirrose............................................................................................................................ 60
Leverfalen................................................................................................................................................ 60
Stollingsstoornissen........................................................................................................................... 60
Endocrinologische afwijkingen........................................................................................................... 61
Hepatische encephalopathie (HE)......................................................................................................62
Levercirrose............................................................................................................................................. 65
Morfologische classificatie..................................................................................................................66
Klinisch verloop.................................................................................................................................. 67
Diagnose............................................................................................................................................ 68
Prognose............................................................................................................................................ 69
Opvolging van cirrose.........................................................................................................................70
Icterus & cholestase.................................................................................................................................... 71
Cholestase............................................................................................................................................... 71
Mechanismen..................................................................................................................................... 71
Diagnose............................................................................................................................................ 72
Behandeling (intrahepatische cholestase)......................................................................................... 73
Zwangerschapscholestase.................................................................................................................73
Icterus...................................................................................................................................................... 74
Diagnose............................................................................................................................................ 74
Prehepatische icterus.........................................................................................................................75
Intrahepatische icterus....................................................................................................................... 76
Posthepatische icterus (cholestatisch)............................................................................................... 77
Casussen........................................................................................................................................... 77
Pathofysiologie van galsecretie................................................................................................................. 79
Anatomie.................................................................................................................................................. 79
Fysiologie................................................................................................................................................. 79
Enterohepatische cyclus.................................................................................................................... 80
Galstenen.................................................................................................................................................81
Cholesterolstenen.............................................................................................................................. 82
Pigmentstenen................................................................................................................................... 83
Kliniek.................................................................................................................................................84
Diagnose en behandeling...................................................................................................................86
Alcohol en de lever...................................................................................................................................... 87
Alcoholprobleem in België & de wereld....................................................................................................87
Alcoholmetabolisme................................................................................................................................. 87
Microsomaal ethanol oxiderend systeem (MEOS)............................................................................. 88
Metabole gevolgen van het alcoholmetabolisme............................................................................... 88
Alcohol use disorder (AUD)......................................................................................................................89
Standaard alcoholgebruik...................................................................................................................89
Screening........................................................................................................................................... 90
Alcoholic liver disease (ALD)................................................................................................................... 90
Pathofysiologie van alcoholische leverbeschadiging......................................................................... 90
Kliniek: leverletsels.............................................................................................................................91
Risicofactoren.....................................................................................................................................92
3
, Diagnose............................................................................................................................................ 93
Screening........................................................................................................................................... 94
Preventie............................................................................................................................................ 94
Behandeling....................................................................................................................................... 94
Acute alcoholic hepatitis (AAH)................................................................................................................96
Behandeling....................................................................................................................................... 96
Patiënt met gestoorde levertesten............................................................................................................. 99
1. Anamnese............................................................................................................................................ 99
2. Fysisch onderzoek............................................................................................................................... 99
3. Laboratoriumonderzoek..................................................................................................................... 100
Asymptomatische stijging van transaminasen................................................................................. 100
Predominante verhoging van alkalisch fosfatase............................................................................. 100
4. Beeldvorming..................................................................................................................................... 101
4
,De splanchnische circulatie
Doorbloeding
Arterieel: aorta abdominalis
truncus coeliacus: thv niveau L1, juist onder diafragma
● a. gastrica sinistra: kleine curvatuur maag
○ connectie met oesophagus
● a. lienalis = a. splenica: milt
○ a. gastroepiploica sinistra: grote curvatuur maag, basis van
omentum majus
○ a. pancreaticoduodenalis dorsalis: pancreas
○ connectie met oesophagus
● a. hepatica communis
○ a. hepatica propria
■ a. cystica: galblaas
■ a. hepatica dextra (rechter leverlob), media & sinistra
○ a. gastrica dextra: kleine curvatuur maag
○ a. gastroduodenalis
■ a. pancreaticoduodenalis superior anterior en
posterior (tov pancreas, beiden posterieur van
duodenum)
■ a. gastroepiploica dextra: duodenum en pancreas
⇒ a. gastrica sinistra (rechtstreeks uit truncus coeliacus) en a. gastrica
dextra (uit a. hepatica communis) anastomeren in kleine curvatuur
a. mesenterica superior
● a. pancreaticoduodenalis inferior anterior en posterior (tov
pancreas)
○ anastomose met a. pancreaticoduodenialis superior uit truncus
coeliacus
● jejunale arteriën
● iliale arteriën
● a. iliocolica: terminale ileum, stukje colon, caecum en appendix
● a. colica dextra en media: colon en ileum
○ arcade van Riolan: verbinding tussen a. colica media (a.
mesenterica superior) en a. colica sinistra (a. mesenterica inferior)
⇒ doorbloeding van pancreas, duodenum en colon
(tot halverwege colon transversum)
a. mesenterica inferior
● a. colica sinistra
● marginale arteriën: colon
● aa. sigmoidea
● a. rectalis superior: rectum
⇒ doorbloeding van linker colon, sigmoïd en rectum
5
, rectum
● superior: a. mesenterica inferior → a. rectalis superior
● inferior: a. iliaca interna → a. rectales media en inferior (bilateraal)
Vaatanastomosen
buiten het maag-darmkanaal
● a. gastroepiploica sinistra (truncus coeliacus) met a. oesofagica
● a. rectalis superior (a. mesenterica inferior) en a. rectalis inferior (a. iliaca interna)
tussen de 3 grote vaatgebieden
● a. pancreaticoduodenalis superior (truncus coeliacus) met a. pancreaticoduodenalis inferior (a.
mesenterica superior)
● a. colica media (a. mesenterica superior) met a. colica sinistra (a. mesenterica inferior) = arcade
van Riolan
binnen de grote vaatgebieden
● truncus coeliacus
○ a. gastrica dextra en a. gastrica sinistra
○ a. gastroepiploica dextra en a. gastroepiploica sinistra
● a. mesenterica superior
○ aa. jejunales
○ aa. ilei
○ a. ileocolica en a. colica dextra en a. colica media
● a. mesenterica inferior
○ a. colica sinistra en aa. sigmoidea en a. rectalis superior
in de submucosa: verbinding tussen de vasa recta
Veneus
● dezelfde parallelle connecties tussen vaatgebieden als arterieel
● v. mesenterica: parallel achter de pancreas door naar de lever
○ komt samen met v. lienalis tot vena porta
⇒ geen vene parallel met a. mesenterica inferior
rectum
● v. iliaca → vena cava → rechter hart
● v. mesenterica → vena porta
Leverhilus
● a. hepatica communis (> truncus coeliacus)
● vena portae (> v. lienalis + v. mesenterica superior)
○ bloed van intestinale organen aanvoeren
● ductus hepaticus communis
○ gal afvoeren van lever naar duodenum
6
De splanchnische circulatie..........................................................................................................................5
Doorbloeding..............................................................................................................................................5
Arterieel: aorta abdominalis..................................................................................................................5
Veneus................................................................................................................................................. 6
Leverhilus............................................................................................................................................. 6
Darmvilli................................................................................................................................................7
Regulatie van de splanchnische bloedflow.......................................................................................... 7
Fysiopathologie van vasculaire stoornissen...............................................................................................8
Darminfarct...........................................................................................................................................9
Segmentaire ischemie........................................................................................................................10
Angor abdominalis..............................................................................................................................10
Ischemische colitis..............................................................................................................................11
Fysiologie van de lever................................................................................................................................13
Functionele morfologie.............................................................................................................................13
Macroscopisch................................................................................................................................... 13
Microscopisch.....................................................................................................................................13
Metabole functie.......................................................................................................................................15
Koolhydraten...................................................................................................................................... 15
Eiwitten...............................................................................................................................................16
Lipiden................................................................................................................................................16
Detoxificatie functie.................................................................................................................................. 16
Cytochroom P450 enzymen............................................................................................................... 17
Bilirubine metabolisme....................................................................................................................... 17
Immunologische functie........................................................................................................................... 18
Galsecretie............................................................................................................................................... 18
Cholesterol metabolisme....................................................................................................................19
Synthese van galzouten..................................................................................................................... 19
Fysische eigenschappen van galzouten............................................................................................ 20
Hepatobiliaire transportsystemen.......................................................................................................21
Secretie van water en elektrolyten..................................................................................................... 22
Oefening...................................................................................................................................................23
Portale hypertensie......................................................................................................................................24
Hemodynamica........................................................................................................................................ 24
Weerstand (R).................................................................................................................................... 24
Portale inflow (Q)................................................................................................................................25
Gevolgen van portale hypertensie........................................................................................................... 26
Collateralen........................................................................................................................................ 26
Hypersplenisme..................................................................................................................................28
Ascites................................................................................................................................................28
Longen............................................................................................................................................... 31
Klinische aspecten en complicaties van portale hypertensie................................................................. 32
Fibrose en cirrose.................................................................................................................................... 32
HVPG-meting........................................................................................................................................... 32
1
,Oorzaken van portale hypertensie........................................................................................................... 32
Vena portaetrombose (prehepatisch)................................................................................................. 33
Syndroom van Budd-Chiari (posthepatisch).......................................................................................34
Sinusoïdaal obstructiesyndroom (intraheptisch, postsinusoïdaal)..................................................... 35
Complicaties van portale hypertensie...................................................................................................... 35
Gastro-oesofageale varices..................................................................................................................... 35
Slokdarmvarices.................................................................................................................................36
Maagvarices....................................................................................................................................... 36
Portale hypertensieve gastropathie....................................................................................................37
Bloedingen......................................................................................................................................... 37
Behandeling van acute bloeding........................................................................................................ 37
Preventie van bloeding.......................................................................................................................40
Ascites......................................................................................................................................................40
Oorzaken............................................................................................................................................40
Diagnose............................................................................................................................................ 41
Behandeling....................................................................................................................................... 42
Hepatische hydrothorax........................................................................................................................... 44
Spontane bacteriële peritonitis (SBP)...................................................................................................... 45
Secundaire bacteriële peritonitis........................................................................................................ 46
Dilutionele hyponatriëmie.........................................................................................................................46
Hepatorenaal syndroom (HRS)................................................................................................................46
Acute nierinsufficiëntie....................................................................................................................... 46
Hepatorenaal syndroom (HRS).......................................................................................................... 47
Hepatopulmonaal syndroom (HPS)......................................................................................................... 47
Portopulmonale hypertensie (PoPH)........................................................................................................48
Doel.......................................................................................................................................................... 48
Evaluatie leverstatus................................................................................................................................ 49
Gemeten waarden..............................................................................................................................49
Biochemische leverenzymtesten ( leverfunctietesten)............................................................................. 50
Parenchymateuze leverenzymen....................................................................................................... 50
Canaliculaire leverenzymen............................................................................................................... 51
Parenchymateus vs. cholestatisch leverlijden....................................................................................52
Prognostische leverfunctietest................................................................................................................. 52
Excretoire functie: bilirubine............................................................................................................... 53
Synthesefunctie: albumine................................................................................................................. 53
Synthesefunctie: stollingstesten......................................................................................................... 53
Synthesefunctie: cholinesterase.........................................................................................................54
Kwantitatieve levertesten......................................................................................................................... 54
Beeldvorming (macroscopisch)................................................................................................................54
Abdominale echografie.......................................................................................................................55
CT.......................................................................................................................................................55
voordelen............................................................................................................................................55
MRI.....................................................................................................................................................55
Elastometrie (microscopisch)................................................................................................................... 55
Leverbiopsie.............................................................................................................................................56
Percutane techniek.............................................................................................................................57
Transjugulaire techniek...................................................................................................................... 58
Oefening...................................................................................................................................................59
2
,Leverfalen & levercirrose............................................................................................................................ 60
Leverfalen................................................................................................................................................ 60
Stollingsstoornissen........................................................................................................................... 60
Endocrinologische afwijkingen........................................................................................................... 61
Hepatische encephalopathie (HE)......................................................................................................62
Levercirrose............................................................................................................................................. 65
Morfologische classificatie..................................................................................................................66
Klinisch verloop.................................................................................................................................. 67
Diagnose............................................................................................................................................ 68
Prognose............................................................................................................................................ 69
Opvolging van cirrose.........................................................................................................................70
Icterus & cholestase.................................................................................................................................... 71
Cholestase............................................................................................................................................... 71
Mechanismen..................................................................................................................................... 71
Diagnose............................................................................................................................................ 72
Behandeling (intrahepatische cholestase)......................................................................................... 73
Zwangerschapscholestase.................................................................................................................73
Icterus...................................................................................................................................................... 74
Diagnose............................................................................................................................................ 74
Prehepatische icterus.........................................................................................................................75
Intrahepatische icterus....................................................................................................................... 76
Posthepatische icterus (cholestatisch)............................................................................................... 77
Casussen........................................................................................................................................... 77
Pathofysiologie van galsecretie................................................................................................................. 79
Anatomie.................................................................................................................................................. 79
Fysiologie................................................................................................................................................. 79
Enterohepatische cyclus.................................................................................................................... 80
Galstenen.................................................................................................................................................81
Cholesterolstenen.............................................................................................................................. 82
Pigmentstenen................................................................................................................................... 83
Kliniek.................................................................................................................................................84
Diagnose en behandeling...................................................................................................................86
Alcohol en de lever...................................................................................................................................... 87
Alcoholprobleem in België & de wereld....................................................................................................87
Alcoholmetabolisme................................................................................................................................. 87
Microsomaal ethanol oxiderend systeem (MEOS)............................................................................. 88
Metabole gevolgen van het alcoholmetabolisme............................................................................... 88
Alcohol use disorder (AUD)......................................................................................................................89
Standaard alcoholgebruik...................................................................................................................89
Screening........................................................................................................................................... 90
Alcoholic liver disease (ALD)................................................................................................................... 90
Pathofysiologie van alcoholische leverbeschadiging......................................................................... 90
Kliniek: leverletsels.............................................................................................................................91
Risicofactoren.....................................................................................................................................92
3
, Diagnose............................................................................................................................................ 93
Screening........................................................................................................................................... 94
Preventie............................................................................................................................................ 94
Behandeling....................................................................................................................................... 94
Acute alcoholic hepatitis (AAH)................................................................................................................96
Behandeling....................................................................................................................................... 96
Patiënt met gestoorde levertesten............................................................................................................. 99
1. Anamnese............................................................................................................................................ 99
2. Fysisch onderzoek............................................................................................................................... 99
3. Laboratoriumonderzoek..................................................................................................................... 100
Asymptomatische stijging van transaminasen................................................................................. 100
Predominante verhoging van alkalisch fosfatase............................................................................. 100
4. Beeldvorming..................................................................................................................................... 101
4
,De splanchnische circulatie
Doorbloeding
Arterieel: aorta abdominalis
truncus coeliacus: thv niveau L1, juist onder diafragma
● a. gastrica sinistra: kleine curvatuur maag
○ connectie met oesophagus
● a. lienalis = a. splenica: milt
○ a. gastroepiploica sinistra: grote curvatuur maag, basis van
omentum majus
○ a. pancreaticoduodenalis dorsalis: pancreas
○ connectie met oesophagus
● a. hepatica communis
○ a. hepatica propria
■ a. cystica: galblaas
■ a. hepatica dextra (rechter leverlob), media & sinistra
○ a. gastrica dextra: kleine curvatuur maag
○ a. gastroduodenalis
■ a. pancreaticoduodenalis superior anterior en
posterior (tov pancreas, beiden posterieur van
duodenum)
■ a. gastroepiploica dextra: duodenum en pancreas
⇒ a. gastrica sinistra (rechtstreeks uit truncus coeliacus) en a. gastrica
dextra (uit a. hepatica communis) anastomeren in kleine curvatuur
a. mesenterica superior
● a. pancreaticoduodenalis inferior anterior en posterior (tov
pancreas)
○ anastomose met a. pancreaticoduodenialis superior uit truncus
coeliacus
● jejunale arteriën
● iliale arteriën
● a. iliocolica: terminale ileum, stukje colon, caecum en appendix
● a. colica dextra en media: colon en ileum
○ arcade van Riolan: verbinding tussen a. colica media (a.
mesenterica superior) en a. colica sinistra (a. mesenterica inferior)
⇒ doorbloeding van pancreas, duodenum en colon
(tot halverwege colon transversum)
a. mesenterica inferior
● a. colica sinistra
● marginale arteriën: colon
● aa. sigmoidea
● a. rectalis superior: rectum
⇒ doorbloeding van linker colon, sigmoïd en rectum
5
, rectum
● superior: a. mesenterica inferior → a. rectalis superior
● inferior: a. iliaca interna → a. rectales media en inferior (bilateraal)
Vaatanastomosen
buiten het maag-darmkanaal
● a. gastroepiploica sinistra (truncus coeliacus) met a. oesofagica
● a. rectalis superior (a. mesenterica inferior) en a. rectalis inferior (a. iliaca interna)
tussen de 3 grote vaatgebieden
● a. pancreaticoduodenalis superior (truncus coeliacus) met a. pancreaticoduodenalis inferior (a.
mesenterica superior)
● a. colica media (a. mesenterica superior) met a. colica sinistra (a. mesenterica inferior) = arcade
van Riolan
binnen de grote vaatgebieden
● truncus coeliacus
○ a. gastrica dextra en a. gastrica sinistra
○ a. gastroepiploica dextra en a. gastroepiploica sinistra
● a. mesenterica superior
○ aa. jejunales
○ aa. ilei
○ a. ileocolica en a. colica dextra en a. colica media
● a. mesenterica inferior
○ a. colica sinistra en aa. sigmoidea en a. rectalis superior
in de submucosa: verbinding tussen de vasa recta
Veneus
● dezelfde parallelle connecties tussen vaatgebieden als arterieel
● v. mesenterica: parallel achter de pancreas door naar de lever
○ komt samen met v. lienalis tot vena porta
⇒ geen vene parallel met a. mesenterica inferior
rectum
● v. iliaca → vena cava → rechter hart
● v. mesenterica → vena porta
Leverhilus
● a. hepatica communis (> truncus coeliacus)
● vena portae (> v. lienalis + v. mesenterica superior)
○ bloed van intestinale organen aanvoeren
● ductus hepaticus communis
○ gal afvoeren van lever naar duodenum
6
