SPIJSVERTERING: PROF. DR. TOPAL
TABLE OF CONTENTS
1. Goedaardige aandoeningen van de galblaas en galwegen (hb p. 453-462) ................................ 3
1.1 Anatomie en fysiologie .........................................................................................................3
1.2 Cholecystolithiasis ..............................................................................................................4
1.3 Complicaties van cholecystolithiasis ...................................................................................8
1.3.1 chronische calculeuze cholecystitis ............................................................................9
1.3.2 hydrops van de galblaas ..............................................................................................9
1.3.3 acute cholecystitis .................................................................................................... 10
1.3.4 flegmone cholecystitis .............................................................................................. 12
1.3.5 choledocholithiasis .................................................................................................. 12
1.3.6 acute cholangitis ...................................................................................................... 14
1.3.7 acute biliaire pancreatitis .......................................................................................... 15
1.3.8 pancreatische pseudocyste ...................................................................................... 16
1.3.9 mirizzi-syndroom ...................................................................................................... 16
1.3.10 galsteen-ileus ........................................................................................................... 17
1.3.11 galblaaskanker ......................................................................................................... 18
1.4 Biliaire dyskinesie ............................................................................................................. 18
1.5 Take home messages ........................................................................................................ 19
2. hepatobiliaire tumoren (hb p. 515-523) .................................................................................21
2.1 inleiding ............................................................................................................................ 21
2.2 pathologie en type tumoren ............................................................................................... 21
2.2.1 hepatocellulair carcinoom (HCC) .............................................................................. 22
2.2.2 cholangiocarcinoom (CCA) ....................................................................................... 25
2.2.3 galblaascarcinoom (GBC) ......................................................................................... 29
2.2.4 goedaardige levertumoren......................................................................................... 31
2.2.5 goedaardige tumoren van de galwegen en galblaas ..................................................... 33
2.2.6 secundaire leverkanker ............................................................................................. 33
3. tumoren slokdarm, maag, duodenum (hb p. 199-209) ............................................................35
3.1 slokdarmtumoren ............................................................................................................. 35
3.1.1 inleiding ................................................................................................................... 35
3.1.2 pathologie en type tumoren ....................................................................................... 35
3.1.3 goedaardige slokdarmtumoren .................................................................................. 40
3.2 maagtumoren ................................................................................................................... 40
3.2.1 inleiding ................................................................................................................... 40
1
, 3.2.2 maagadenocarcinoom .............................................................................................. 41
3.2.3 gastro-intestinale stromale tumor .............................................................................. 47
3.2.4 MALT-lymfoom ......................................................................................................... 48
3.2.5 goedaardige maagtumoren........................................................................................ 49
3.3 doudenumtumoren ........................................................................................................... 50
3.3.1 inleiding ................................................................................................................... 50
3.3.2 kwaadaardige duodenumtumoren ............................................................................. 51
3.3.3 goedaardige duodenumtumoren ............................................................................... 52
4. pancreastumoren en NET (hb p. 523-531) ..............................................................................54
4.1 pancreastumoren ............................................................................................................. 54
4.1.1 inleiding ................................................................................................................... 54
4.1.2 types pancreastumoren ............................................................................................ 54
4.2 Neuro-endocriene tumoren ............................................................................................... 63
4.2.1 inleiding ................................................................................................................... 63
4.2.2 pathologie ................................................................................................................ 63
4.2.3 differentiatie en gradering pNETs ............................................................................... 63
4.2.4 klinische presentatie pNETs ...................................................................................... 64
2
,1. GOEDAARDIGE AANDOENINGEN VAN DE GALBLAAS EN GALWEGEN (HB P. 453-
462)
1.1 ANATOMIE EN FYSIOLOGIE
Fysiologie
• 1 L gal/d geproduceerd door hepatocyten in de lever
o Kan variëren afh v voeding, toestand v lever
o Continue proces v productie
o Essentieel voor spijsvertering + vetopname
• Gal
> water, galzouten, bilirubine, cholesterol en andere stoffen
o Geel groene vloeistof
o Galzouten → emulsificatie + vertering v vetten
▪ Na vertering vet + vit ADEK: opname in ileum
→ via vena porta terug naar lever
=> enterohepatische cyclus
o Bilirubine → pigmentatie gal
o Water → geëxtraheerd uit gal om gal te concentreren: effectievere vetvertering
• Galblaas
o Opslag + concentratie v gal
o Retroperitoneale ligging
• Extrahepatische galwegen
o d. hepaticus communis
o d. choledochus
▪ deels intra-pancreatisch
▪ vervoegt d. pancreaticus in ampulla v Vater
→ drainage in duodenum door Sfincter v Oddi
• Galafvoer:
→ hepatocyten
→ galcanaliculi
→ grote galgangen (d. hepaticus communis)
→ galblaas (d. cystica) of dunne darm (d. choledochus)
• Bloedvoorziening
o A. hepatica dextra: d. hepaticus communis, d. choledochus
o A. cystica: galblaas
> a. hepatica dextra
! kan anatomische variaties
o Veneuze afloop galblaas
→ geen specifieke v. cystica, maar gebeurt door kleine venen die zich in de lever in het
portaalsystemen draineren
3
, • Ligging
→ Rechterhypochonder: belangrijk voor DD
o Colon (flexura hepatica)
o Nieren
o Pancreaskop
o Duodenum
1.2 CHOLECYSTOLITHIASIS
Cholecystolithiasis
= galstenen in de galblaas
→ ontstaat in galblaas en kan verwikkelingen veroorzaken
Prevalentie
• 15% Eu & USA populatie heeft galstenen
• Hoe ouder, hoe meer kans
• V>M
→ vnl V boven 50 j: 25% prevalentie
Pathofysiologie
Disbalans v stoffen waaruit gal bestaat
→ ophoping v harde steenvormige deeltjes
→ vorming v sludge of galstenen in galblaas
Drievoudig mechanisme
• Lever scheidt meer cholesterol af dan opgelost kan w
→ cholesterol vormt kristallen oiv galzouten
=> cholesterolstenen
> 70-95 % cholesterol
→ meest freq
! niets te maken met serum cholesterol
• Onvoldoende lediging galblaas
→ stagnatie gal
=> steenvorming
• Meer productie bilirubine door lever door bepaalde aandoening
=> pigmentstenen
> calciumbilirubinaat (donkere kleur)
→ bv. bij pt met chronische hemodialyse
=> onafh v mechanisme hebben ze vergelijkbare klinische presentatie + behandeling
4
TABLE OF CONTENTS
1. Goedaardige aandoeningen van de galblaas en galwegen (hb p. 453-462) ................................ 3
1.1 Anatomie en fysiologie .........................................................................................................3
1.2 Cholecystolithiasis ..............................................................................................................4
1.3 Complicaties van cholecystolithiasis ...................................................................................8
1.3.1 chronische calculeuze cholecystitis ............................................................................9
1.3.2 hydrops van de galblaas ..............................................................................................9
1.3.3 acute cholecystitis .................................................................................................... 10
1.3.4 flegmone cholecystitis .............................................................................................. 12
1.3.5 choledocholithiasis .................................................................................................. 12
1.3.6 acute cholangitis ...................................................................................................... 14
1.3.7 acute biliaire pancreatitis .......................................................................................... 15
1.3.8 pancreatische pseudocyste ...................................................................................... 16
1.3.9 mirizzi-syndroom ...................................................................................................... 16
1.3.10 galsteen-ileus ........................................................................................................... 17
1.3.11 galblaaskanker ......................................................................................................... 18
1.4 Biliaire dyskinesie ............................................................................................................. 18
1.5 Take home messages ........................................................................................................ 19
2. hepatobiliaire tumoren (hb p. 515-523) .................................................................................21
2.1 inleiding ............................................................................................................................ 21
2.2 pathologie en type tumoren ............................................................................................... 21
2.2.1 hepatocellulair carcinoom (HCC) .............................................................................. 22
2.2.2 cholangiocarcinoom (CCA) ....................................................................................... 25
2.2.3 galblaascarcinoom (GBC) ......................................................................................... 29
2.2.4 goedaardige levertumoren......................................................................................... 31
2.2.5 goedaardige tumoren van de galwegen en galblaas ..................................................... 33
2.2.6 secundaire leverkanker ............................................................................................. 33
3. tumoren slokdarm, maag, duodenum (hb p. 199-209) ............................................................35
3.1 slokdarmtumoren ............................................................................................................. 35
3.1.1 inleiding ................................................................................................................... 35
3.1.2 pathologie en type tumoren ....................................................................................... 35
3.1.3 goedaardige slokdarmtumoren .................................................................................. 40
3.2 maagtumoren ................................................................................................................... 40
3.2.1 inleiding ................................................................................................................... 40
1
, 3.2.2 maagadenocarcinoom .............................................................................................. 41
3.2.3 gastro-intestinale stromale tumor .............................................................................. 47
3.2.4 MALT-lymfoom ......................................................................................................... 48
3.2.5 goedaardige maagtumoren........................................................................................ 49
3.3 doudenumtumoren ........................................................................................................... 50
3.3.1 inleiding ................................................................................................................... 50
3.3.2 kwaadaardige duodenumtumoren ............................................................................. 51
3.3.3 goedaardige duodenumtumoren ............................................................................... 52
4. pancreastumoren en NET (hb p. 523-531) ..............................................................................54
4.1 pancreastumoren ............................................................................................................. 54
4.1.1 inleiding ................................................................................................................... 54
4.1.2 types pancreastumoren ............................................................................................ 54
4.2 Neuro-endocriene tumoren ............................................................................................... 63
4.2.1 inleiding ................................................................................................................... 63
4.2.2 pathologie ................................................................................................................ 63
4.2.3 differentiatie en gradering pNETs ............................................................................... 63
4.2.4 klinische presentatie pNETs ...................................................................................... 64
2
,1. GOEDAARDIGE AANDOENINGEN VAN DE GALBLAAS EN GALWEGEN (HB P. 453-
462)
1.1 ANATOMIE EN FYSIOLOGIE
Fysiologie
• 1 L gal/d geproduceerd door hepatocyten in de lever
o Kan variëren afh v voeding, toestand v lever
o Continue proces v productie
o Essentieel voor spijsvertering + vetopname
• Gal
> water, galzouten, bilirubine, cholesterol en andere stoffen
o Geel groene vloeistof
o Galzouten → emulsificatie + vertering v vetten
▪ Na vertering vet + vit ADEK: opname in ileum
→ via vena porta terug naar lever
=> enterohepatische cyclus
o Bilirubine → pigmentatie gal
o Water → geëxtraheerd uit gal om gal te concentreren: effectievere vetvertering
• Galblaas
o Opslag + concentratie v gal
o Retroperitoneale ligging
• Extrahepatische galwegen
o d. hepaticus communis
o d. choledochus
▪ deels intra-pancreatisch
▪ vervoegt d. pancreaticus in ampulla v Vater
→ drainage in duodenum door Sfincter v Oddi
• Galafvoer:
→ hepatocyten
→ galcanaliculi
→ grote galgangen (d. hepaticus communis)
→ galblaas (d. cystica) of dunne darm (d. choledochus)
• Bloedvoorziening
o A. hepatica dextra: d. hepaticus communis, d. choledochus
o A. cystica: galblaas
> a. hepatica dextra
! kan anatomische variaties
o Veneuze afloop galblaas
→ geen specifieke v. cystica, maar gebeurt door kleine venen die zich in de lever in het
portaalsystemen draineren
3
, • Ligging
→ Rechterhypochonder: belangrijk voor DD
o Colon (flexura hepatica)
o Nieren
o Pancreaskop
o Duodenum
1.2 CHOLECYSTOLITHIASIS
Cholecystolithiasis
= galstenen in de galblaas
→ ontstaat in galblaas en kan verwikkelingen veroorzaken
Prevalentie
• 15% Eu & USA populatie heeft galstenen
• Hoe ouder, hoe meer kans
• V>M
→ vnl V boven 50 j: 25% prevalentie
Pathofysiologie
Disbalans v stoffen waaruit gal bestaat
→ ophoping v harde steenvormige deeltjes
→ vorming v sludge of galstenen in galblaas
Drievoudig mechanisme
• Lever scheidt meer cholesterol af dan opgelost kan w
→ cholesterol vormt kristallen oiv galzouten
=> cholesterolstenen
> 70-95 % cholesterol
→ meest freq
! niets te maken met serum cholesterol
• Onvoldoende lediging galblaas
→ stagnatie gal
=> steenvorming
• Meer productie bilirubine door lever door bepaalde aandoening
=> pigmentstenen
> calciumbilirubinaat (donkere kleur)
→ bv. bij pt met chronische hemodialyse
=> onafh v mechanisme hebben ze vergelijkbare klinische presentatie + behandeling
4
