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General medicine
Theme 1
Respiratory system
1. COPD 812-819
2. Pulmonary embolism (Longembolie) 449, 764-766
3. Pneumonia 833-839
4. Carcinoma of the lung 431-440
5. Bronchial asthma 823-833
6. Pneumothorax 864-865
7. Upper respiratory tract infaction 808-811
8. Bronchitits 812-813
9. Emphysema (longemphyseem) 812-813
10. Oesophageal Varices (slokdarmspataders) 254255,333-334
11. Pleural effusion (plauravocht) 863-864
http://www.youtube.com/watch?v=VJtWHQaGLLc
http://www.youtube.com/watch?v=4vCnpkwcr1Y
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1. COPD 812-819
General information disease
Predicted to become the 3rd most common cause of death and 5th most common cause of disability worldwide in 2020.
COPD is disease state characterized by airflow limitation that is not fully reversible. (vernauwde luchtwegen (hier kun je
wat aan doen) en kapotte luchtblaasjes (irreversible))
COPD patients with severe arterial hypoxaemia (onvoldoende zuurstofgehalte van het bloed) may experience profound
nocturnal hypoxaemia. Most deaths of patients with COPD occur at night. These patients should not be given sleeping
tablets.
Causes
COPD is caused by long-term exposure to toxic particles and gases.
In developed countries accounts cigarette smoking for over 90% of the cases.
In developing countries other factors are causing COPD (like inhalation of smoke from biomass fuels used in
heating and cooking in poorly ventilated areas)
→ Only 10-20% of heavy smokers develop COPD
→ Development of COPD is proportional to the number of cigarettes smoked per day.
Other less important underlying causes of COPD:
Climate, air pollution, urbanization, social class and occupation, inherited.
Most consistent pathological finding in COPD is increased numbers of mucus-secreting goblet cells in the bronchial
mucosa. Inflammation is followed by scarring and thickening of the walls which narrows the small airways. This
inflammation can be stopped if the person stops smoking on time.
Symptoms
Airflow limitation (airway narrows)
Air trapping
Patients fail to maintain their respiratory effort → PaCO2 levels increase
Mucus secretion, which blocks the airways
Elastic recoil reduces and airways collapse during expiration → hyperinflation of the lungs, Va/Q mismatch,
increased work of breathing and breathlessness
Patients cope badly with respiratory infections
Productive cough with white or clear sputum, wheeze and breathlessness.
Colds seems to settle on the chest and frequent infective exacerbation occur → symptoms can be worsened by
cold, foggy weather and atmospheric pollution
Systemic effects: including hypertension, osteoporosis, depression, weight loss and reduced muscle mass with
general weakness.
Patients with advanced COPD develop respiratory failure and cor pulmonary (symptoms and signs of fluid
overload secondary to lung disease.)
Diagnostic tools
Lung function tests (FEV1:FVC ratio is reduced and PEFR is low.
Chest X-ray * High-resolution CT scans * Heamoglobin level and PCV * Blood gases
Sputum examination (not useful in ordinary cases) * Electrocardiogram
Echocardiogram * a1-antotrypsin
Treatment
Smoking cessation → persuade the patient to stop smoking
Drug therapy
o Bronchodilators (B-Adrenergic agonists, antimuscarinic drugs, theophyllines)
o Phosphodiesterase type 4 inhibitors, Corticosteroids, Antibiotics, Antimucolytic agents,Diuretic
therapy,Oxygen therapy
Filmpjes
http://www.youtube.com/watch?v=lYW_2Rfuii8
http://www.youtube.com/watch?v=NLkihnKRhq0
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2. Pneumonia (longontsteking) 833-839
General information disease
Pneumonia is defined as an inflammation of the substance of the lungs. It is usually caused by bacteria.
There are several types of pneumonia:
Mycoplasma pneumonia: relatively common and occurs in cycles of 3-4 years
Viral pneumonia: uncommon in adults, influenza A virus or adenovirus infection being the commonest causes.
Pneumonias due to opportunistic Infections: Immunocompromised patients develop pneumonia with all the
usual organisms and with a number of organisms which do not normally cause illness in healthy hosts.
Diffuse pneumonia (bronchopneumonia): Widespread diffuse pneumonia is a common terminal event, occurring
when patients dying from other conditions (e.g. cancer) are unable to cough up
retained secretions, allowing infection to develop throughout the lungs.
Aspiration pneumonia
Causes
Usually bacteria, but it can also be caused by viruses and fungi.
One fifth of the pneumonias is caused by agents such as mycoplasma, pneumococcus, legionella,
chlamydia and coxiella burnetii.
Bacterial pneumonia is more frequent in alcoholics and in HIV-infected individuals as compared to the
general population.
Pneumonias may also result from chemical causes, such as in the aspiration of vomit -radiotherapy -allergic mechanisms
Another cause of pneumonia is mycobacterium tuberculosis.
*About 50% of pneumonia is pneumococcal
Symptoms
Acute illness with cough, purulent sputum, breathelessness, fever and pleuritic[long] pain.
With Strep pneumoniae infection the patient rapidly becomes more ill with a high temperature (up to 39.5°C), pleuritic
pain and a dry cough. A day or two later, rusty coloured sputum is produced and at about the same time the patient may
develop labial herpes simplex. The patient breathes rapidly and shallowly[ondiep], the affected side of the chest moves
less, and signs of consolidation may be present together with a pleural rub[wrijven]
Diagnostic tools
Chest X-ray.
Blood test (In Strep. pneumoniae pneumonia: White blood cell count > 15x10^9/L, ESR> 100 mm/hour, CRP >
100 mg/L
When a patient has a productive cough, another diagnostic tool is a sputum investigation and culture.
Treatment
Depends on cause of the pneumonia
Antibiotics
Oxygen
Intravenous fluids
Thromboprophylaxis
Physiotherapy
Nutritional supplementation
Analgesia
Filmpjes
http://www.youtube.com/watch?v=n1GNua2JvyM
http://www.youtube.com/watch?v=Aa5ZKE87Kaw
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3. Carcinoma of the lung 431-440
General information disease
Lung cancer is a disease characterized by uncontrolled cell growth in tissues of the lung. If left untreated, this growth can
spread beyond the lung in a process called metastasis into nearby tissue and, eventually, into other parts of the body.
Most cancers that start in lung, known as primary lung cancers, are carcinomas that derive from epithelial cells. The main
types of lung cancer are small-cell lung carcinoma (SCLC, more malignant), also called oat cell cancer, and non-small-cell
lung carcinoma (NSCLC).
Een carcinoom is een maligne (kwaadaardige) woekering van epitheelcellen. Het epitheel is een algemene benaming voor
de cellen die aan de oppervlakte liggen van huid en slijmvliezen. Een Adenocarcinoom is een carcinoom dat ontstaat in
klierweefsel. Om als adenocarcinoom gekenmerkt te worden hoeven de cellen niet strikt noodzakelijk deel uit te maken
van een klier zolang de cellen maar een excretiefunctie hebben.
Een goedaardige gezwel dat uitgaat van klierweefsel, wordt adenoom genoemd.
Causes
Tobacco Smoking is highly associated with lung cancer, and causative mechanisms have also been found. One-third of
deaths due to cancer occur due to the cigarette smoking.
Alcohol Alcohol is associated with cancers of the upper respiratory and it also interacts with tobacco in the aetiology of
these tumours.
Diet Dietary factors have been attributed to account for a third of cancer deaths, although it is often difficult to
differentiate these from other epidemiological factors.
Environmental/occupational
Occupational factors: The principal causes now are asbestos (lung and mesothelial cancer) and combustion of fossil fuels
releasing polycyclic hydrocarbons (skin, lung, bladder cancers).
Symptoms
Cough (sometimes coughing up blood)
Chest pain
Cough and pain
Chest infection
Malaise
Weight loss
Shortness of breath
Hoarseness (heesheid)
Distant spread
Diagnostic tools
Chest X-ray
By the time the lung cancer is causing symptoms, it will almost always be visible on chest X-ray. Asymptomatic
tumours may be seen on chest X-ray if they are more than 1 cm in diameter.
CT
Treatment
Treatment and prognosis depend on the histological type of cancer, the stage (degree of spread), and the patient's general
well-being, measured by performance status. Common treatments include surgery, chemotherapy, and radiotherapy.
NSCLC is sometimes treated with surgery, whereas SCLC usually responds better to chemotherapy and radiotherapy.
Survival depends on stage, overall health, and other factors. Overall, 15% of people in the United States diagnosed with
lung cancer survive five years after the diagnosis. Worldwide, lung cancer is the most common cause of cancer-related
death in men and women, and is responsible for 1.38 million deaths annually, as of 2008.
Filmpjes
4
Bronchial Asthma 823-833
General information disease
Common chronic inflammatory condition of the lung airways whose cause is incompletely understood. The
most frequent form has its onset in childhood between the ages of 3 and 5 years
and may either worsen or improve during adolescence. Asthma is a major cause of impaired quality of life with
impact on work, recreational, as well as physical activities and emotions.
- airflow limitation (reversible spontaneously or with treatment_
- airway hyperresponsiveness (to a wide range of stimuli)
- inflammation of the bronchi with T lymphocytes, mast cells, eosinophils with associated plasma exudation,
oedema, smooth muscle hypertrophy, matrix deposition and mucus plugging and epithelial damage
Chronic asthma: inflammation may be accompanied by irreversible airflow limitation as a result of airway wall
remodelling that may involve large and small airways and mucus impaction.
Classified into 2 options:
- extrinsic (implying a definite external cause)
- intrinsic (when no causative agent can be identified)
Causes
Atopy (word to describe a group of disorders, including asthma and hayfever, that appeared):
- genetically
- characteristic skin reactions to common allergens in the environment
- circulating allergen-specific IgE (Early childhood exposure to allergens and maternal smoking has a major
influence on IgE production)
Symptoms
- Wheeze (wheezing attack) – Chest tightness – Cough – Shortness of breath (worsen at night)
-Bronchial hyperresponsiveness (BHR) is demonstrated by asking the patient to inhale gradually increasing
concentrations of either histamine or methacholine (bronchial provocation tests). This induces transient
airflow limitation in susceptible individuals (approximately 20% of the population).
-Attacks of asthma only on extreme exertion, e.g. winter sports enthusiasts wheezing or prolonged periods of
coughing following by a viral infection.
-Seasonal wheeze during the pollen season .
-The varying clinical severity and chronicity of asthma is dependent on an interplay between airway
inflammation and airway wall remodelling
-Characteristic feature of chronic asthma is an alteration of structure and functions of the formed elements of
the airways. These structural changes interact with inflammatory cells and mediators to cause the
characteristic features of a disease. Deposition of matrix proteins, swelling and cellular infiltration cause an
expansion of the submucosa beneath the epithelium. Prominent feature of asthma is hyperplasia of the helical
bands of airway smooth muscle. In addition to increasing in amount, the smooth muscle alters in function to
contract more easily and stay contracted because of a change in actin-myosin cross-link cycling.
-Clinical features of asthma are wheezing attacks and episodic shortness of breath.
-Symptoms are usually worst during the night, this being a particularly good marker of uncontrolled disease.
Cough is a frequent symptom. Number of attacks can vary enormously between patients (few a year, lasting
short or a lot per week, lasting for hours)
Diagnostic tools
No single satisfactory diagnostic test for all asthmatic patients.
- Peak expiratory flow rate (PEFR): useful in demonstrating the variable airflow limitation that characterizes
the disease.
- Spirometry is useful, assessing reversibility. Asthma can be diagnosed by demonstrating a greater than 15%
improvement in FEV1, or PEFR following the inhalation of a bronchodilator.
- Carbon monoxide (CO) transfer test is normal in asthma
- Exercise tests (6 minutes in treadmill at a workload sufficient to increase the heart rate above 160 beats per
minute).
- Histamine/methacholine bronchial provocation test (indication of presence of airway hyperresponsiveness)
- Blood and sputum tests
- Chest X-ray
- Skin tests (skin-prik tests à SPT) to identify allergic casues. Measurement of allergen specific IgE in the serum
is also helpful if SPT facilities are not available.
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- Allergen provocation test
Aims of the treatment are to abolish symptoms, restore normal or best possible lung function, reduce risk of
severe attacks, enable normal growth to occur in children, minimize absence from school or employment.
Treatment
*Inhalers with corticosteroids
Use of therapeuthic agents delivered as aerosols or powders directly into the lungs. Treatment is very
effective in relieving symptoms but does little for the underlying inflammatory nature.
Filmpjes
http://www.youtube.com/watch?v=82gn_rDRpHk
http://www.youtube.com/watch?v=aGDi5tI5vTk
http://www.youtube.com/watch?v=BPGKzUQOm6Q
Pulmonary embolism (longembolie) 449, 764-766
General information disease
Causes
Begins as a blood clot in the deep veins of the legs, which can be caused by a restricted and slow bloodstream
(e.g. lack of exercise after surgery). The blood clot can break free and travels via the bloodstream to the lungs
and blocks an artery. May result in permanent damage to a portion of the lung (or other organs in the body). If
the clot is large, or there are many clots, pulmonary embolism can cause death. Of clinical pulmonary emboli,
10% are fatal.
3 typical clinical presentation of pulmonary emoblism:
- Small/medium pulmonary emoblism
- Massive pulmonary emoblism
- Multiple recurrent pulmonary emobili
Symptoms
Unexplained dyspnoea (shortness of breath)
-Problems breathing
-Coughing (eventually blood)
-May cause pain over the effected lung region
-Sometimes signs related to deep vein thrombosis ( e.g. swelling of leg, pain/tiredness leg etc.)
-Arrhytmia (irregular heartbeat)
Diagnostic tools
- Ultrasound: Using sound waves to detect blot clots in veins.
- CT scans: X ray images of stained blood vessels to detect blood clot.
-Lung ventilation scan: radioactive substance shows how well blood and oxygen are flowing in the lung
-Pulmonary Angiography: X ray images after a dye is injected to blood vessels in lung through a catheter
-Blood tests: D-dimer: measures released substance from blood clots, Only if high levels are detected, clot is
present. Other test can measure the amount of oxygen and carbon dioxide.
-ECG
Treatment
-High flow oxygen (bed rest and analgesia)
- Medicines: - Anticoagulants and blood thinners to decrease the ability of the blood to clot
- Intravenous fluids & inotropic agents to improve pumping of right heart
- Fibrinolytic therapy – special drugs to break up blood clots
- Surgery – rarely necessary
Filmpjes
http://www.youtube.com/watch?v=I0yJTkW9y9s
6
Pneumothorax (klaplong) 864-865
General information disease
Pleura is het sereuze (vochtafscheidende) membraan dat dubbelgeplooid rond elk van de longen ligt en zo een
afscheiding vormt tussen longen en borstholte. Het deel van het dubbelgevouwen vlies dat grenst aan de
longen heet het longvlies of pleura pulmonalis, ook pleura visceralis genoemd. Het gedeelte aan de
buitenkant, dat dus grenst aan de borstholte, heet borstvlies of pleura parietalis.
Tussen deze twee membranen zit een tussenruimte, de pleurale ruimte (pleural cavity), die gevuld is met een
dunne film pleuravocht, die het mogelijk maakt dat de membranen langs elkaar heen bewegen tijdens het
ademen.
Pneumothorax means air in the pleural space. Male-to-female ratio is 6:1, mostly tall and thin patients. A 50%
collapse of the lung will take about 40 days to reabsorb completely once the air leak is closed.
Causes
Causes by the rupture of a pleural bleb, usually apical, and is thought to be due to congenital defects in the
connective tissue of the alveolar walls. Dus: vloeistof tussen borstvlies en longvlies zorgen dat deze aan elkaar
blijven zitten. Als er lucht hiertussen komt door verwonding of ontsteking, klapt de long in omdat hij elastisch
is. Hierdoor kan de long niet meer goed zijn werk doen.
In patients over 40 years old, the usual cause is underlying COPD.
Rarer causes: bronchial asthma, carcinoma, a lung abscess breaking down and leading to bronchopleural
fistula and severe pulmonary fibrosis with cyst formation.
It may be spontaneous (primair, aangeboren afwijkingen or secundair, ziekte of afwijking aan weefsel) or
occur as a result of trauma (accident,like knife or iatrogene pneumothorax causes by medical injury) to the
chest.
Symptoms
-Small pneumothorax
Minimal symptoms, small rim of air. <20% of radiographic volume
-Medium pneumothorax
Aspirate air. Definite 20-50% of radiographic volume.
-Large pneumothorax
Aspirate air, less air. Obvious >50% of radiographic volume. Some shift of trachea and mediastinum
-Tension pneumothorax
Aspirate air, less air. Lung grossly deflated. Marked deviation of trachea and mediastinum
Chest pain. Sudden, sharp chest pain on the same side as the affected lung — this pain doesn't occur in the
center of your chest under the breast bone.
Shortness of breath. This may be mild or severe, depending on how much of your lung is collapsed and
whether you have underlying lung disease.
Diagnostic tools
X-ray
Treatment
Appropriate therapy/treatment
-Small pneumothorax
Resume normal activity but avoid strenuous exercise, Observe at 2 weekly intervals until air reabsorbed
-Medium pneumothorax
Resume normal activity but avoid strenuous exercise, re-expansion  tube not tubbling  remove tube  reX-ray to exclude recurrence
-Large pneumothorax
Pneumothorax remains tube tubbling.
-Tension pneumothorax
Surgery VATS à pleurectomy (drain)
Filmpjes
http://www.youtube.com/watch?v=dtrqaS6H92g
http://www.lmng.nl/Klaplong-oorzaak-diagnose-en-behandeling.php
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Upper respiratory tract infection 808-811
General information disease
Infections of the throat (larynx), or the main airway (trachea), or the airways going into the lungs (bronchi) are
common. These infections are sometimes called laryngitis, tracheitis, or bronchitis. Doctors often just use the
term upper respiratory tract infection (URTI) to include any, or all, of these infections.
Causes
Most URTIs are due to a viral infection. Some due to bacteria. Over 200 different viruses have been isolated in
patients with URIs. The most common virus is called the rhinovirus. Other viruses include the coronavirus,
parainfluenza virus, adenovirus,enterovirus, and respiratory syncytial virus.
Symptoms
Cough is usually the main symptom. Other symptoms include fever, headache, aches and pains. Cold
symptoms may occur if the infection also affects the nose. Symptoms typically peak after 2-3 days, and then
gradually clear. However, the cough may persist after the infection has gone. This is because inflammation in
the airways, caused by the infection, can take a while to settle. It may take 2-3 weeks, after other symptoms
have gone, for a cough to clear completely.
Diagnostic tools
- Bases on history
- Skin-prick testing
- Blood tests (only is skin testing is not possible)
Treatment
A main aim of treatment is to ease symptoms whilst your immune system clears the infection. The most useful
treatments are:
-paracetamol, ibuprofen, or aspirin to reduce fever (high temperature),
-When fever → drinking
-stop smoking
-enough sleep
-Treatment comprises symptomatic support usually via analgesics (pijnstiller) for headache, sore throat and
muscle aches
Filmpjes
http://www.youtube.com/watch?v=4mqV_OXTIt4
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Bronchitis 812-813
General information disease
Bronchitis is an inflammation of the mucous membranes of the bronchi (the larger and medium-sized airways
that carry airflow from the trachea into the more distal parts of the lung parenchyma).Bronchitis can be
divided into two categories: acute and chronic.
Acute bronchitis is characterized by the development of a cough, with or without the production of sputum
(mucus that is expectorated, or "coughed up", from the respiratory tract). Acute bronchitis often occurs during
the course of an acute viral illness such as the common cold or influenza. Viruses cause about 90% of acute
bronchitis cases, whereas bacteria account for about 10%.
Chronic bronchitis, a type of COPD, is characterized by the presence of a productive cough that lasts for three
months or more per year for at least two years. Chronic bronchitis usually develops due to recurrent injury to
the airways caused by inhaled irritants. Cigarette smoking is the most common cause, followed by exposure to
air pollutants such as sulfur dioxide or nitrogen dioxide, and occupational exposure to respiratory irritants.
Individuals exposed to cigarette smoke, chemical lung irritants, or who are immunocompromised have an
increased risk of developing bronchitis. Bronchitis is an inflammation of the lining of your bronchial tubes,
which carry air to and from your lungs. Bronchitis may be either acute or chronic.
Often developing from a cold or other respiratory infection, acute bronchitis is very common. Chronic
bronchitis, a more serious condition, is a constant irritation or inflammation of the lining of the bronchial
tubes, often due to smoking.
Acute bronchitis usually improves within a few days without lasting effects, although you may continue to
cough for weeks. However, if you have repeated bouts of bronchitis, you may have chronic bronchitis, which
requires medical attention. Chronic bronchitis is one of the conditions included in chronic obstructive
pulmonary disease (COPD).
Causes
Acute bronchitis is usually caused by viruses, typically the same viruses that cause colds and influenza.
Antibiotics don't kill viruses, so this type of medication isn't useful in most cases of bronchitis.
The most common cause of chronic bronchitis is smoking cigarettes. Air pollution and dust or toxic gases in
the environment or workplace also can contribute to the condition.
Symptoms
For either acute bronchitis or chronic bronchitis, signs and symptoms may include:
-Cough
-Production of mucus (sputum), which can be clear, white, yellowish-gray or green in colour
-Fatigue
-Slight fever and chills
-Chest discomfort
Diagnostic tools
Stethoscope  to listen closely to the lungs
Auscultation  Wheeze with occasional crackles
In some cases
-Chest X-ray. A chest X-ray can help determine if you have pneumonia or another condition that may explain
your cough.
-Sputum culture. This test checks for the presence of bacteria in sputum produced when you cough. It's
helpful in determining whether you have whooping cough (pertussis) or other illnesses that would be helped
by antibiotics.
-Pulmonary function test. During a pulmonary function test, you blow into a device called a spirometer, which
measures how much air your lungs can hold and how quickly you can get air out of your lungs. This test checks
for signs of asthma or emphysema.
Treatment
Medications
In some circumstances, your doctor may prescribe medications, including:
Antibiotics. bacterial infection
Cough medicine.
Other medications. inhaler and other medications to reduce inflammation and open narrowed
Therapies
Filmpjes
http://www.youtube.com/watch?v=Roahgmt43dA
9
Emphysema (longemphyseem) 812-813
General information disease
Emphysema occurs when the air sacs in your lungs are gradually destroyed, making you progressively more
short of breath. Emphysema is one of several diseases known collectively as chronic obstructive pulmonary
disease (COPD). Smoking is the leading cause of emphysema.
As it worsens, emphysema turns the spherical air sacs — clustered like bunches of grapes — into large,
irregular pockets with gaping holes in their inner walls. This reduces the surface area of the lungs and, in turn,
the amount of oxygen that reaches your bloodstream.
Emphysema also slowly destroys the elastic fibers that hold open the small airways leading to the air sacs. This
allows these airways to collapse when you breathe out, so the air in your lungs can't escape. Treatment may
slow the progression of emphysema, but it can't reverse the damage.
Causes
The main cause of emphysema is long-term exposure to airborne irritants, including:
*Tobacco smoke *Marijuana smoke
*Air pollution*Manufacturing fumes*Coal and silica dust
 Rarely, emphysema is caused by an inherited deficiency of a protein that protects the elastic structures in
the lungs. It is called Alpha-1 antitrypsin deficiency emphysema.
Symptoms
→ sometimes many years without noticing any signs or symptoms.
* Shortness of breath
* Lips and fingernails turn blue or gray
* Not mentally alert
* Heartbeat is very fast
Diagnostic tools
* X-ray
*CT scan
*Lung function tests
- Severe airflow limitation – Va/Q mismatch – alfa1-antitripsin deficiency – increase in TLC
Treatment
Emphysema can't be cured, but treatments can help relieve symptoms and slow the progression of the
disease.
*Smoking cessation drugs.
*Bronchodilators. These drugs can help relieve coughing, shortness of breath and trouble breathing by
relaxing constricted airways, but they're not as effective in treating emphysema as they are in treating asthma
or chronic bronchitis.
* Inhaled steroids. Corticosteroid drugs inhaled as aerosol sprays may help relieve shortness of breath. But
prolonged use can weaken your bones and increase your risk of high blood pressure, cataracts and diabetes.
*Antibiotics.
Therapy
*Pulmonary rehabilitation. breathing exercises and techniques that may help to reduce breathlessness and
improve your ability to exercise.
*Supplemental oxygen
Surgery
Depending on the severity
*Lung volume reduction. In this procedure, surgeons remove small wedges of damaged lung tissue. Removing
the diseased tissue helps the remaining lung tissue work more efficiently and helps improve breathing.
*Lung transplant. Lung transplantation is an option if you have severe emphysema and other options have
failed.
Filmpjes
http://www.youtube.com/watch?v=fVG3MDm9IaE
10
Oesophageal Varices (slokdarmspataders) 254-255, 333-334
General information disease
In medicine (gastroenterology), esophageal varices (or oesophageal varices) are extremely dilated (verwijde)
sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal
hypertension, commonly due to cirrhosis; patients with esophageal varices have a strong tendency to develop
bleeding.
Causes
Verhoogde bloeddruk in de poortader (portale hypertensie). De poortader is een heel belangrijke ader. Hij
voert bloed uit de milt, de alvleesklier, de galblaas en een deel van het spijsverteringskanaal naar de lever.
Bij een te hoge bloeddruk in de poortader gaat het bloed op zoek naar sluipwegen om buiten de poortader en
de lever om, via andere vaten, het hart te bereiken. Zulke sluipwegen zijn bijvoorbeeld de aders in de
slokdarm. Maar deze dunne aders zijn niet gemaakt om zo’n grote hoeveelheid bloed te verwerken. Ze rekken
uit waardoor er spataderen ontstaan. De normale druk in de poortader ligt tussen de 5 tot 10 mm kwikdruk.
Complicaties van portale hypertensie ontwikkelen zich meestal bij een bloeddruk in de poortader boven 12
mm kwikdruk. Twee factoren kunnen de bloeddruk in de vaten van het poortadersysteem verhogen: het
bloedvolume dat door de aders stroomt en een verhoogde weerstand in de bloedstroom in de lever.
Afhankelijk van de plek van de verhoogde weerstand in de bloedstroom, maakt men een onderscheid:
• Een proces VOOR de lever (pre- of extrahepatisch) waarbij de obstructie gebeurt in de poortader voordat
deze de lever binnengaat. De oorzaak is vaak de vorming of aanwezigheid van bloedstolsels. Dit wordt ook wel
trombose van de Vena Porta of portatrombose genoemd. Erfelijke en verworven stollingsafwijkingen zijn
frequente oorzaken van een portatrombose. De verworven stollingsafwijkingen komen vaak voor bij
malnutritie (ondervoeding door opnamestoornissen in de darmen), infecties, chronische darmaandoeningen,
leverziekte en pilgebruik.
• Een proces IN (of ziekte van) de lever (intrahepatisch), waarbij de bloedstroom in de poortader belemmerd
wordt binnen in de lever. Cirrose van de lever is de meest voorkomende intrahepatische oorzaak van portale
hypertensie. Bij levercirrose wordt gezond leverweefsel als gevolg van een ontsteking van de levercellen
vervangen door bindweefsel (littekenweefsel). Hierdoor verandert de structuur van de lever, waardoor het
bloed niet meer vrij door de kleine aderen in de lever kan stromen. Dit heeft weer tot gevolg dat nog meer
levercellen afsterven met weer extra bindweefselvorming tot gevolg. Het is een voortschrijdend proces met
als gevolg dat de druk in de poortader steeds groter wordt.
Levercirrose is het gevolg van verschillende chronische leverziektes zoals bijvoorbeeld: hepatis B, hepatitis C,
Primaire Biliaire Cirrose, auto-immuun hepatitis en levercirrose ten gevolge van alcoholmisbruik.
Andere intrahepatische oorzaken van portale hypertensie zijn:
- schistosomiasis van de lever of bilharzia als gevolg van besmetting met een parasiet
- myeloproliferatieve aandoeningen (stoornissen in het tempo waarin de bloedcellen zich ontwikkelen).
In sommige gevallen is de oorzaak onbekend (idiopatische portale hypertensie).
• Een proces VOORBIJ de lever (supra- of posthepatisch): obstructie van de bloedstroom in de poortader
nadat deze de lever heeft verlaten. Oorzaken zijn ernstig hartfalen en trombose van de leverader (de ader die
bloed uit de lever afvoert), ook wel het syndroom van Budd-Chiari genoemd.
In de westerse landen is de meest voorkomende oorzaak van portale hypertensie een door levercirrose
verhoogde weerstand in de bloedstroom. Alle patiënten met levercirrose worden dan ook regelmatig
gescreend op de aanwezigheid van spataderen. Bij kinderen worden meeer dan 50% van de portatromboses
veroorzaakt door een infectie in de buik. Bij zuigelingen ligt de oorzaak vaak in een navelcatheter die
aangelegd werd tijdens een verblijf in het ziekenhuis. Appendicitis (blindedarmontsteking) is een vaak
voorkomende oorzaak van portatrombose, zoals ook aangeboren afwijkingen van de portale circulatie.
Symptoms
Esophageal varices usually don't cause signs and symptoms unless they bleed. Signs and symptoms of bleeding
esophageal varices include:
-Vomiting blood
-Black, tarry or bloody stools
-Shock, in severe cases
Diagnostic tools
Using a scope to examine your esophagus. During an endoscopy exam, your doctor inserts a thin, flexible,
lighted tube (endoscope) through your mouth and into your esophagus. If any dilated veins are found, they're
graded according to their size and checked for red streaks, which usually indicate a significant risk of bleeding.
Imaging tests. Both computerized tomography (CT) scans and magnetic resonance imaging (MRI) may be used
11
to diagnose esophageal varices. These tests also allow your doctor to examine your liver and circulation in the
portal vein.
Treatment
The primary aim in treating esophageal varices is to prevent bleeding. Bleeding esophageal varices are lifethreatening. If bleeding occurs, treatments are available to try to stop the bleeding.
Treatments to prevent bleeding
Medications to slow flow of blood in the portal vein.
Using a scope to access your esophagus and treat varices
Treatments to stop bleeding
-Using elastic bands to tie off bleeding veins.
-Injecting a solution into bleeding veins.
-Medications to slow blood flow into the portal vein.
-Diverting blood flow away from the portal vein.
-Replacing the diseased liver with a healthy one.
Filmpjes
12
Pleural effusion (plauravocht) 863-864
General information disease
A pleural effusion is an abnormal amount of fluid around the lung. Pleural effusions can result from many
medical conditions. Most pleural effusions are not serious by themselves, but some require treatment to avoid
problems.
Causes
The pleura is a thin membrane that lines the surface of the lungs and the inside of the chest wall outside the
lungs. In pleural effusions, fluid accumulates in the space between the layers of pleura. Normally, only
teaspoons of watery fluid are present in the pleural space, allowing the lungs to move smoothly within the
chest cavity during breathing.
Numerous medical conditions can cause pleural effusions. Some of the more common causes are:
*Congestive heart failure
*Pneumonia
*Liver disease (cirrhosis)
*End-stage renal disease
*Nephrotic syndrome
*Cancer
*Pulmonary embolism
*Lupus and other autoimmune conditions
Excessive fluid may accumulate because the body does not handle fluid properly (such as in congestive heart
failure, or kidney and liver disease). The fluid in pleural effusions also may result from inflammation, such as in
pneumonia, autoimmune disease, and many other conditions.
Symptoms
Pleural effusions often cause no symptoms. Symptoms are more likely when a pleural effusion is moderate or
large-sized, or if inflammation is present. Symptoms of pleural effusions may include:
*Shortness of breath
*Chest pain, especially on breathing in deeply (pleurisy, or pleuritic pain)
*Fever
*Cough
Because pleural effusions are usually caused by underlying medical conditions, symptoms of these conditions
are also often present.
Diagnostic tools
-symptoms and physical examination.
-auscultation (listening with a stethoscope),
-percussion (tapping on the chest),
-Most often, pleural effusions are discovered on imaging tests.
-Chest X-ray film
-CT scan
-Ultrasound
Treatment
Once a pleural effusion is identified on imaging, a fluid sample is usually taken to determine the pleural
effusion's character and seriousness. In a procedure called thoracentesis, a doctor inserts a needle and a
catheter between the ribs, into the pleural space. A small amount of fluid is withdrawn for testing; a large
amount can be removed simultaneously to relieve symptoms.
The goal of treatment is to:, Remove the fluid, Prevent fluid from building up again, Determine and treat the
cause of the fluid buildup, Removing the fluid (thoracentesis) may be done if there is a lot of fluid and it is
causing chest pressure, shortness of breath, or other breathing problems, such as low oxygen levels. Removing
the fluid allows the lung to expand, making breathing easier. The cause of the fluid build up must be treated,
too. If it is due to congestive heart failure, you may receive diuretics (water pills) and other medications to
treat heart failure. Pleural effusions caused by infection are treated with antibiotics.
In people with cancer or infections, the effusion is often treated by using a chest tube for several days to drain
the fluid. Sometimes, small tubes can be left in the pleural cavity for a long time to drain the fluid. In some
cases, the following may be done:, Chemotherapy, Putting medication into the chest that prevents fluid from
building up again after it is drained, Radiation therapy, Surgery
Filmpjes
13
General medicine
Theme 2 Gastrointestinal system
1. Acute gastritis (acute maagvliesontsteking)
2. Bleeding from the oesophagus (complication)
3. Bleeding due to peptic ulcer 248-251
4. Bleeding due to cancer of the upper gastrointestinal tract (complication) 431-440
5. Coeliac disease 264-266
6. Cholecystitis 350-356
7. Crohn's disease 275-278
8. Cholelithiasis (Gallstones) 350-356
9. Chronic hepatitis
10. Cystitis 591-595
11. Diabetes mellitus type 1
12. Diabetes mellitus type 2
13. Gastro-Oesophageal-Reflux-Disease (GORD)238-242
14. Gastric cancer 251-254
15. Hepatitis A, B,C,D,E 316 - 325
16. Hypothyroidism 961-963
17. Hyperthyroidism 963-967
18. Irritable Bowel Syndrome 296-298
19. Liver cirrhosis 328-331
20. Liver carcinoma/ metastasis 347-348
21. Peptic Ulcer disease (Duodenal/ Gastric ulcer)248-251
22. Pancreatic cancer 431-440
23. Pancreatitis (Acute and chronic) 361-366
24. Perforated ulcer (geperforeerde maagzweer)
25. Ulcerative colitis
14
1. Acute gastritis (acute maagvliesontsteking)
General information disease
An acute gastric mucosal inflammation (gastritis) is a short-term or temporary inflammation of the mucous
membrane on the inside of the stomach. Acute gastritis can be broken down into 2 categories: erosive (eg,
superficial erosions, deep erosions, hemorrhagic erosions) and nonerosive (generally caused by Helicobacter
pylori).
Causes
- Infection with a bacteria or a virus.
- Infection with the bacteria Helicobacter pylori
- Long term use of alcoholic beverages
- Long term use of NSAID’s or aspirin
- Regurgitation of bile from the small intestine to the stomach;
Symptoms
- Dull and burning pain in the upper abdomen
- Bloating[opgeblazen gevoel]
- Nausea, sometimes vomiting
- Vomit and stool sometimes contain blood
Diagnostic tools
Gastroscopy (internal view examination of the stomach)
Treatment
An acute gastritis usually heals spontaneously, once the cause is removed. Depending on the cause, a patient
has to stop drinking alcohol, aspirin or anti-inflammatory painkillers.
Filmpjes
15
2. Bleeding from the oesophagus (complication)
General information disease
Mallory-Weiss syndrome causes about 5% of all upper gastrointestinal bleeding. It is bleeding from an arterial
blood vessel in the upper gastrointestinal tract, caused by a mucosal[slijmvlies] gastric tear[bloeding] at or
near the point where the oesophagus and stomach join. Mallory–Weiss syndrome or gastro-esophageal
laceration syndrome refers to bleeding from tears (a Mallory-Weiss tear) in the mucosa at the
junction[kruising] of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.
Most bleeds are minor and discharge is usual within 24 hours. The haemorrhage (bloeding) may be large but
most patients stop spontaneously.
Causes
The diagnose is associated with heavy alcohol use, although it can also be found in patients who are not
alcoholics. The bleeding can be produced by a sudden increase in intra-abdominal pressure. It often occurs
after a bout (a period of illness) of coughing or retching (kokhalzen). There may, however, be no antecedent
history of retching.
Another cause can be hyperemesis gravidarum.(pregnancy nausea)
Symptoms
-Mallory Weiss tear
-Vomiting blood (mostly after a period of vomiting)
-Severe retching
-Melena [zware ontlasting]
-Pallor (extreme paleness)
-Tachycardia
-Hiccups [hik]
-Light-headedness
-Dizziness
-Pain in the stomach
Diagnostic tools
Early endoscopy confirms diagnosis and allows therapy if necessary.
Treatment
Temporary not eating, to prevent vomiting. Drugs to reduce gastric acid production.
Most patients the bleeding stops spontaneously. If the bleeding is severe, a blood transfusion is needed.
When the bleeding doesn’t stop spontaneously, surgery with oversewing of the tear is needed (rare).
Filmpjes
16
3. Bleeding due to peptic ulcer 248-251
General information disease
Causes
Growing peptic ulceration (smoking and alcohol, infection Helicobacter) reaching a blood vessel
Symptoms
The passing of foul smelling black, tarry stools could be one of the first symptoms of a gastric ulcer or a
duodenal ulcer that has started bleeding dark red blood in your stools
● If your ulcer is already at an advanced stage then repeated and different signs of bleeding can be
identified.
● Vomiting of new blood which is bright red in color - this indicates that a gastric ulcer has started
bleeding. This will be accompanied by repeated episodes of nausea.
● Vomiting dark and grainy blood that looks like instant coffee granules. The dark color indicates that
this is old blood.
● unplanned weight loss
● intense and more localized pain in people with penetrating ulcers - the pain may also radiate to your
back
● faintness[zwakheid] and dizziness when standing up - this is due to loss of blood. Over a long period
of time, you may become anemic and feel weak, dizzy, or tired all the time. This is typical of a slow
bleed left untreated.
Diagnostic tools
Endoscopy
Treatment
Acid blockers are commonly prescribed to relieve pain but be warned - the relief is very temporary!
About 3 in every 10 people showing the symptoms of a bleeding ulcer will need surgery to stop the bleeding.
If the bleeding is severe, then endoscopy is the most common surgical procedure used to stop the bleeding. A
doctor uses an endoscope to cauterize or seal the bleeding vessel using a heated electrical probe. Or he may
close it off by injecting solutions into the bleeding vessel. Doctors can also easily see the signs of all the
different types of bleeding when using an endoscope. Blood clots, active spurting, slow oozing of blood from
arteries, as well as swollen blood vessels that are not bleeding yet, can all be detected with the use of an
endoscope. Endoscopy is currently the gold standard for treating bleeding ulcers. Also blood transfusion and
clearance of helicobacter.
Filmpjes
17
4. Bleeding due to cancer of the upper gastrointestinal tract[maagdarmkanaal] (complication)
431-440
General information disease
Gastrointestinal cancer is a term that encompasses a group of cancers that affect the gastrointestinal tract
(kanaal). Types of upper gastrointestinal cancer include:
*esophageal[slokdarm] cancer
*stomach cancer
Causes
The cause of many types of gastro-intestinal cancer is unknown. But there are several risk factors:
-excessive alcohol consumption
-increasing age
-diet high in animal fat
-diet containing high amounts of salted, cured, or poorly preserved foods
-chronic pancreatitis
-obesity
-smoking
Symptoms
For symptoms see gastric cancer and esophageal cancer
Diagnostic tools
* Upper GI series (a barium swallow) An upper GI endoscopy is done to: examine the esophagus, stomach and
·
·
duodenum for bleeding, ulcers, tumours, inflammation, narrowing (stricture)
* Endoscopy
* Biopsy during endoscopy
*Computed tomography (CT) scan It is used to find out the extent of the tumour, see if the cancer has spread
to nearby organs and tissues, see if the cancer has spread to surrounding lymph nodes, see if the cancer has
spread to the liver, lungs or adrenal glands
* MRI scan
* PET scan
Treatment
There are two types of treatment: Curative: focussed on healing (only when diagnosed at an early stage) and
palliative: to relieve the symptoms (no cure possible).
-Endoscopy:
When the tumour is discovered in a very early stage, it is possible to remove the tumour by an endoscopy.
-Another option is an operation: the tumour and nearby tissue are removed.
-Radiation
-Chemoradiation
-Nutrition is also an important part of the treatment.
For gastric cancer it is also possible to remove a part of the stomach or the whole stomach.
Filmpjes
18
5. Coeliac disease 264-266
General information disease
A condition in which there is an inflammation of the mucosa of the upper small bowel that improves
when gluten is withdrawn from the diet and relapses when gluten is reintroduced. Up to 1% of
many population are affected, though most have clinically silent disease. Can present at any age.
Causes
Coeliac disease is caused by a reaction to gliadin, a prolamin (gluten protein) found in wheat, and
similar proteins found in the crops of the tribe Triticeae (which includes other common grains such
as barley and rye).
Upon exposure to gliadin, and specifically to three peptides found in prolamins, the enzyme tissue
transglutaminase modifies the protein, and the immune system cross-reacts with the small-bowel
tissue, causing an inflammatory reaction. That leads to a truncating of the villi lining the small
intestine (called villous atrophy). This interferes with the absorption of nutrients, because the
intestinal villi are responsible for absorption. The only known effective treatment is a lifelong glutenfree diet. While the disease is caused by a reaction to wheat proteins, it is not the same as wheat
allergy.
 partly genetic factors and partly environmental factors (breast-feeding and age of introduction to
gluten in diet)
Symptoms
* Many patients don’t show any symptoms
Symptoms are very variable and often non specific
* Tiredness
* Mailaise
* Anaemia
* Diarrhoea
* Staetorrhoea
* Abdominal pain
* Weight loss
* Mouth ulcers
* Angular stomatitis
* Neuropshychiatric symptoms of anxiety and depression
Diagnostic tools
* Small bowel biopsy
* Histology  shows crypt hyperplasia with chronic inflammatory cells in the lamina propria, and
villous atrophy
* Serology  Persistent diarrhea, folate or iron deficiency, a family history and associated
autoimmune disease are indications for serological testing.
* HLA typing (HLA-DQ2 present in 90-95% of cases, HLA-DQ8 present in 8% of cases)
Treatment
* Replacement minerals and vitamins’, e.g. iron, folic acid, calcium, vitamin D, may be needed
initially to replace body stores.
* Gluten-free diet for life
Filmpjes
http://www.glutenvrij.nl/page/Coeliakie/Wat-is-coeliakie
http://www.mlds.nl/ziekten/140/coeliakie/
19
6. Cholecystitis (galblaasontsteking) 350-356
General information disease
The initial event in acute cholecystitis is obstruction to gall bladder emptying. Such obstruction
results in an increase of gall bladder glandular secretion leading to progressive distension[uitzetting]
which in turn may compromise the vascular supply to the gall bladder. There is also an inflammatory
response secondary to retained bile[gal] within the gall bladder. Infection is a secondary
phenomenon following the vascular and inflammatory events described above.
Usually associated with a moderate leucocytosis and raised inflammatory markers.
Dus: ontsteking van de galblaas. Cholecystitis wordt veelal veroorzaakt door cholelithiasis, de
aanwezigheid van galstenen in de galblaas die vaak de galgang afsluiten.
Causes
* Gallstones are the cause in 95% of the cases.
Symptoms
*Over a number of hours, there is progression with severe localized right upper quadrant abdominal
pain corresponding to parietal peritoneal involvement in the inflammatory process.
*Nausea and vomiting frequently accompany the more severe attacks. More protracted pain,
particularly when associated with fevers and rigors, suggests secondary complications such
cholecystitis.
* Pain is associated with tenderness and muscle guarding or rigidity[stijfheid].
* Occasionally the gall bladder can become distended[uitzetten] by pus (an empyema) and rarely an
acute gangrenous cholecystitis develops which can perforate, with generalized peritonitis.
Diagnostic tools
* An abdominal ultrasound scan, look for gall stones, focal tenderness and thickening of the gail
bladder wall.
* By the inflammation there will be more white blood cells and CRP (c-reactive protein) in the blood.
Treatment
* Conservative, consisting of nil by mouth, intravenous(=directly infusion to the veins) fluids, opiate
analgesia and intravenous antibiotics.
* Surgical removal of the gallbladder, usually delayed for a few days to allow symptoms to settle.
Filmpjes
http://www.youtube.com/watch?v=Tl--uvRoKTc
20
7. Crohn's disease 275-278
General information disease
Chronic inflammation in intestines
Causes
The cause of Crohn's disease is unknown. Some scientists suspect that infection by certain bacteria,
such as strains of mycobacterium, may be the cause of Crohn's disease. To date, however, there has
been no convincing evidence that the disease is caused by infection per se. Crohn's disease is not
contagious. Although diet may affect the symptoms in patients with Crohn's disease, it is unlikely
that diet is responsible for the disease. Some studies show in intestines of individual with Crohn’s
disease, there are higher levels of E. Coli.
Symptoms
The major symptoms are diarrhea, abdominal pain and weight loss.
*Physical signs are few, apart from loss of weight and general ill-health. Aphthous ulceration of the
mouth is often seen.
*Constitutional symptoms of malaise, lethargy[slaapzucht], anorexia, nausea, vomiting and lowgrade fever may be present and in 15% of these patients there are no gastrointestinal symptoms.
Diagnostic tools
Blood tests
■Anaemia is common and is usually the normocytic, normochromic anaemia of chronic disease.
Deficiency of iron and/or folate also occurs. Despite terminal ileal involvement in CD, megaloblastic
anaemia due to B12 deficiency is unusual, although serum B12 levels can be below the normal
range.
■ Raised ESR and CRP and a raised white cell count.
■ Hypoalbuminaemia is present in severe disease.
■ Liver biochemistry may be abnormal.
■ Blood cultures are required if septicemia is suspected.
■ Serological tests: Saccharomyces cerevisiae antibody is usually present while pANCA antibody is
negative.
Stool tests
Endoscopy and radiological imaging
Treatment
* Aim of management is to induce and then maintain clinical remission and achieve mucosal healing
to prevent complications.
* No cigarette smoking
* Control of diarrhea can be controlled with loperamide, codeine, phosphate or co-phenotrope.
 can also be treated with bile salt sequestrants.
* Anemia (if due to vitamin b12), folic acid or iron deficiency, should be treated with the appropriate
haematinics.
* Most patients can be treated as outpatients (patient who is not hospitalized overnight, but who
visits a hospital, clinic or associated facility for diagnosis or treatment)
* Surgical management  approx. 80% of patients will require an operation at some time during the
course of their disease. But surgery should be avoided.
Filmpjes
http://www.youtube.com/watch?v=i7ey8wyI5eo
21
8. Cholelithiasis (Gallstones) 350-356
General information disease
Causes
The formation of cholesterol stones is the consequence of cholesterol crystallization from gall bladder bile.
This is dependent upon three factors:
- cholesterol supersaturation of bile
- crystallization-promoting factors within bile
- motility (beweeglijkheid) of the gall bladder.
The pathogenesis of pigment stones is entirely independent of cholesterol gallstones. There are two main
types of pigment gallstones, black and brown.
Symptoms
* Biliary[gal] colic = the pain associated with the temporary obstruction of the cystic or common bile duct by a
stone usually migrating from the gall bladder. The pain of stone-induced ductular obstruction is severe but
constant and has a crescendo characteristic.
* Pain with over-indulgence with (high fat food). Especially in midevening last till morning.
* Radiation may occur over the right shoulder and right subscapular region.
*Nausea and vomiting frequently accompany the more severe attacks.
* The classical features of common bile duct (CBD) stones are biliary colic, fever and jaundice (acute
cholangitis[galgangontsteking])
* Jaundice is a variable accompaniment and is almost always preceded by abdominal pain.
* Fever is only present in a minority of cases
Diagnostic tools
*Biliary colic as a consequence of a stone in the neck of the gall bladder or cystic duct is unlikely to be
associated with significant abnormality of laboratory tests.
*The serum bilirubin, alkaline phosphatase and aminotransferase levels may be marginally elevated in the
presence of cholecystitis[blaasontsteking] alone
* An elevated neutrophil count and raised inflammatory markers (ESR and CRP) are frequent accompaniments
of cholangitis.
*Serum amylase levels are often mildly elevated in the presence of bile duct obstruction but are markedly so if
stone-related pancreatitis has occurred.
*Prothrombin time may be prolonged if bile duct obstruction has occurred; this reflects decreased
absorption of vitamin K.
*Transabdominal ultrasound This is the initial imaging technique of choice and in many cases the only imaging
technique required.
*Magnetic resonance cholangiography (MRC) delineates the fluid column within the biliary tree and is a
sensitive technique for the detection of common bile duct stones in the presence of a dilated duct.
* An abdominal ultrasound scan is the single most useful investigation for the diagnosis of gallstone-related
disease. Look for:
(a) gallstones within the gall bladder, particularly when these are obstructing the gall bladder neck or cystic
duct
(b) focal tenderness over the underlying gall bladder
(c) thickening of the gall bladder wall. This may also be seen with hypoalbuminaemia, portal hypertension and
acute viral hepatitis. Gallstones are a common finding in an ageing population, and in the absence of specific
symptoms great care should be taken when determining whether the gallstones are responsible for the
symptoms.
Treatment
*Cholecystectomy (open, single-incision, or laparoscopic) is the treatment of choice for virtually all patients
with symptomatic gall bladder stones (remove of gallbladder). Stone dissolution and shock wave lithotripsy
* Endoscopic retrograde cholangiopancreatolography (ERCP) aims to remove bile duct stones
Filmpjes
http://www.youtube.com/watch?v=JV9THQdWYKE
22
9. Chronic hepatitis
General information disease
Chronic hepatitis is defined as any hepatitis lasting for 6 months or longer and is classified according
to the etiology.
Extensive damage and scarring[littekens] of liver (i.e. cirrhosis) leads to weight loss, easy
bruising[blauwe plekken] and bleeding tendencies, peripheral edema (swelling of the legs) and
accumulation of ascites (fluid in the abdominal cavity). Eventually, cirrhosis may lead to various
complications: esophageal varices (enlarged veins in the wall of the esophagus that can cause lifethreatening bleeding) hepatic encephalopathy (confusion and coma) and hepatorenal syndrome
(kidney dysfunction).
Fibrosis is the formation of excess fibrous connective tissue[overmaat vezelig bindweefsel] in an
organ or tissue in a reparative or reactive process. This is as opposed to formation of fibrous tissue
as a normal constituent of an organ or tissue. Scarring is confluent fibrosis that obliterates the
architecture of the underlying organ or tissue.
Causes
Viral:
Hepatitis B ± hepatitis D
Hepatitis C
Autoimmune diseases
Symptoms
The overall severity of the hepatitis is judged by the degree of the hepatitis and inflammation
(grading) and the severity of the fibrosis or cirrhosis (staging).
*Jaundice (indicates advanced liver damage)
*Anorexia (poor appetite)
*Malaise
*Tiredness
*Weakness
 Can also have no symptoms at all
Diagnostic tools
Blood tests
Physical examination (to discover enlargement of the liver)
Treatment
Drugs (e.g. Methyldopa, isoniazid, ketoconazole, nitrofurantoin)
Filmpjes
23
10. Cystitis (Blaasontsteking, urinewegeninfectie) 591-595
General information disease
Cystitis is a urinary bladder inflammation that can result from any one of a number of distinct
syndromes. It is most commonly caused by a bacterial infection in which case it is referred to as a
urinary tract infection.
Causes
E.Coli from bowel flora
Transfer to urinary tract by ascending transurethral route or blood stream, lymphatics or direct
extension
Symptoms
•Frequent micturation
•Painful voiding (dysuria)
•Suprapubic pain[blaaspijn] and tenderness
•Hematuria
•Small urine
Diagnostic tools
A urinalysis may reveal white blood cells (WBCs) or red blood cells (RBCs).
A urine culture (clean catch) or catheterized urine specimen may be performed to determine the
type of bacteria in the urine and the appropriate antibiotic for treatment.
Treatment
Depends on cause
Antibiotics
Fluid intake should be encouraged during treatment
Filmpjes
24
11. Diabetes mellitus type 1
General information disease
Causes
Increased susceptibility to type 1 diabetes is inherited. Children who test positive for two or more
autoantibodies have >80% risk of progression to diabetes. Body does not make any insulin at all. Reason why
this happens to some people and to some people not is not quite clear.
- About 15% of all cases
- Most found under 40s
- Most common type at childhood
There is glucose produced by the food you eat, but there is no insulin produced by the pancreas to get the
glucose into the body so the glucose level in the blood rises and rises, so no energy can be produced. Glucose
wants to get out of the body through the kidneys, so lot or urination.
Symptoms
Lot of urination to get the glucose out of the body, so very thirsty.
Lot of glucose in the urine so thrush, or genital itching.
Slow healing of wounds.
Blurred vision because of glucose build of in the lens in front of the eye.
Tiredness because of no glucose in the cells for energy.
Weight loss, because body still needs energy source to work properly so breaks down its fats stores
-> Symptoms happen quite quickly within a few weeks and can be reversible.
Diagnostic tools
- Glucose tolerance test
- Fasting blood sugar (taking blood after 10-12 hours without eating/drinking)
- Heamoglobin (blood glucose concentration test
- Urine testing for protein, full blood count, urea and electrolytes, liver biochemistry, random lipids
Treatment
Medication:
Tablet > Metformin (biguanide), sulfonylurea, thiazolidinedione
Injection > GLP-1 agonist
Insulin treatment
Filmpjes
http://www.youtube.com/watch?v=jxbbBmbvu7I
25
12. Diabetes mellitus type 2
General information disease
85% of all the diabetes cases. Most common in the over 40s white population.
Also in over 25s in black and south Asian population . Progressive condition
Causes
Body does not produce enough insulin or the insulin it is producing does not work properly. This can be due to
being overweight, because fat can stop insulin doing its work properly. It can also happen with people with a
healthy weight.
Little more complex because slighty more processes at work. There is glucose and insulin produced, but the
glucose can’t always get into the cells because the locks to the cell doors have become ?? up with fat deposits.
So insulin can’t open the cell doors properly for the glucose. In response to this, the pancreas produces even
more insulin. So insulin ánd glucose levels rise, which is more complex. The cells without glucose are sending
out emergency signals to the liver to release stored glucose. Glucose level goes up and therefore pancreas
produces more and more insulin. Till it can’t cope anymore and eventually it goes out.
Symptoms
Urination, Thirst, Tiredness, Weight loss , Slow healing, Thrush or genital itching
The symptoms come along very slowly, some people don’t have any symptoms at all. For that reason, some
people can live with this type diabetes for over 10 years without even knowing.
Diagnostic tools
- Glucose tolerance test
- Fasting blood sugar (taking blood after 10-12 hours without eating/drinking)
- Heamoglobin (blood glucose concentration test)
- Urine testing for protein, full blood count, urea and electrolytes, liver biochemistry, random lipids
Treatment
- Changing in diet (low in sugar, high in starchy carbohydrate, high in fibre, low in fat)
- More physical activity
--> No amount of medication will succeed (and prescribed) where these diet and lifestyles changes have failed.
- Medication
Tablet: Metformin (biguanide), sulfonylurea, thiazolidinedione
Injection: GLP-1 agonist
Insulin treatment
Filmpjes
http://www.youtube.com/watch?v=OXAe3eOjqCk
26
13. Gastro-Oesophageal-Reflux-Disease (GORD)238-242
General information disease
Gastro Oesophageal reflux disease, or GORD, is a chronic disease that occurs when the lower oesophageal
sphincter (sluitspieren) does not close properly and stomach contents leak back, or reflux, into the
oesophagus.
Causes
Small amounts of gastro-oesophageal reflux are normal. The clinical features of reflux occur when the
antireflux mechanisms fail, allowing acidic gastric contents to make prolonged contact with the lower
oesophageal mucosa. The sphincter relaxes transiently independently of a swallow (Transient Lower
Eosophageal Sphincter Relaxation, TLESR) after meals and this is the cause of almost all reflux in normal and
about two-thirds in GORD patients. Factors associated with GORD: Pregnancy, obesity fat, chocolate, coffee or
alcohol, ingestion large meals, cigarette smoking, drugs (calcium-channel blockers, nitrates), systemic
sclerosis, after treatment for achalasia, hiatus hernia (the upper part of the stomach is above the diaphragm).
Symptoms
* Heartburn  burning sensation in the chest. Get worse when bending, stooping or lying down
* Pain on drinking hot liquids or alcohol.
* Correlation between heartburn and oesophagitis is poor. Some patients have mild oesophagitis but severe
heartburn; others have severe oesophagitis without symptoms, and may present with a haematemesis
(vomiting of bright red blood) or iron deficiency anaemia from chronic blood loss. Psychosocial factors are
often determinants of symptom severity. The symptoms are due to reflux.
* Some people have GORD without heartburn. Instead, they experience pain in the chest, hoarseness in the
morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are
choking[stikken] or your throat is tight.
*GORD can also cause a dry cough and bad breath.
If reflux is prolonged or excessive it may cause breakdown of this protection with inflammation of the
oesophagus (oesophagitis). Inflammation of the esophagus (esophagitis) may cause bleeding that is usually
slight but can be massive. The blood may be vomited up or may pass through the digestive tract, resulting in
the passage of dark, tarry stools (melena) or bright red blood, if the bleeding is heavy enough.
Diagnostic tools
*The clinical diagnosis can usually be made without investigation. Unless there are alarm signs, especially
dysphagia (difficulty in swallowing), patients under the age of 45 years can safely be
treated initially without investigations. If investigation is required, there are two aims:
*Endoscopy: If there is oesophagitis or Barrett’s oesophagus, reflux is confirmed.
*Document reflux by intraluminal monitoring 24-hour intraluminal pH monitoring or impedance
combined with manometry is helpful if the PPI test is negative and should always be performed to confirm
reflux before surgery. Excessive reflux is defined as a pH < 4 for more than 4% of the time. There should also
be a good correlation between reflux (pH < 4.0) and symptoms. It is also helpful to assess oesophageal
dysmotility as a potential cause of the symptoms.
Treatment
*Approximately half of patients with reflux symptoms in primary care can be treated successfully with simple
antacids (maagzuurremmers), loss of weight and raising the head of the bed at night.
* Precipitating (uitlokkende) factors should be avoided, with dietary measures, reduction in alcohol
consumption and cessation of smoking.
*Helicobacter pylori eradication in GORD has little effect on the symptoms but is usually advised.
* Drugs: Alginate-containing antacids. Dopamine antagonist prokinetic agents. H2-receptor antogonists.
Proton pump inhalators. If a combination of lifestyle changes and drug therapy does not remedy reflux
symptoms, a Nissen Fundoplication can be a very effective surgical procedure to correct reflux. This procedure
involves wrapping the upper portion of the stomach around the base of the oesophagus to reinforce the
strength of the lower oesophageal sphincter.
Filmpjes
http://www.youtube.com/watch?v=PwVAnwpbC_I
27
14. Gastric cancer 251-254 maagkanker
General information disease
Currently the fourth most common cancer found world-wide and second leading cause of cancer-related
mortality. Incidence increases with age and it is rare under the age of 30 years.
Causes
- H. pylori infection and distal gastric cancer. It is recognized by the IARC as a Group 1 (definite) gastric
carcinogen. It causes chronic gastritis which eventually leads to atrophic gastritis and premalignant intestinal
metaplasia.
- Dietary factors such as diets rich in salt. Dietary nitrates can be converted into nitrosamines by bacteria at
neutral pH, and nitrosamines are known to be carcinogenic in animals (but evidence in human carcinogenesis
is limited). Consumption of diets high in non-starchy vegetables, allium vegetables (e.g. garlic), fruits and low
in salt protect against cancer.
- Smoking tobacco
- Genetic abnormality
- First-degree relatives of patients with gastric cancers (two- or three fold increased relative risk of developing
the disease, but this may be environmental rather than inherited)
- Pernicious anaemia (=body not able to make enough red blood cells due to a DNA defect)
- Partial gastrectomy
Symptoms
- No symptoms
Most common symptom of advanced disease is:
- Epigastric pain (abdominal tenderness). It may be relieved by foods and antacids (= a substance which
neutralizes stomach acidity)
-Anorexia and weight loss
- Vomiting, nausea
- Dysphagia (difficulty with swallowing)
- Later stage: malignant ascites (accumulation of fluid) or jaundice (=dutch: geelzucht) due to liver
enlargement / metastases also occur in bone, brain and lung, producing appropriate symptoms
Diagnostic tools
- Diagnosis: Gastroscopy / Full blood count and liver biochemistry / Barium meal
- Staging: CT scan / Transabdominal ultrasound / endoscopic ultrasound / laparoscopy / PET and CT/PET
Treatment
- Surgery remains the most effective form of treatment if patient is operable
- Combined chemo-radiotherapy
- Peri-operative chemotherapy with epirubicin, cisplatin and infusional t-fluorouracil (ECF) has improved 5year survival in operable gastric and lower oesophagal adenocarcinomas
Filmpjes
http://www.youtube.com/watch?v=yo_F4nq4tX8
28
15. Hepatitis A, B,C,D,E 316 - 325
Hepatitis A
General information disease
Most common viral hepatitis occurring worldwide, often in epidemics. Commonly seen in autumn
and affects children and young adults. Hepatitis A is een zeer besmettelijke leverontsteking
veroorzaakt door het hepatitis A-virus (HAV). Het virus wordt voornamelijk overgedragen via (met
feces) besmet voedsel of drinkwater of door een rechtstreekse fecaal-orale besmetting.
Causes
*Spread of infection is mainly by the faeco-oral route and arises from the ingestion of contaminated
food or water. Overcrowding and poor sanitation spread. No carrier state.
*HAV (hepatitis A) is a picornvirus, has a single serotype as only one epitope is immunodominant.
Replicates the liver, excreted in bile and then excreted in the faeces for about 2 weeks before the
onset of clinical illness and for up to 7 days after.
Symptoms
* Non specific symptoms like nausea, anorexia, distaste for cigarettes. Many recover at this stage
and remain anicteric.
* After 1 or 2 weeks, some patients become jaundiced and symptoms often improve. Persistence of
nausea, vormiting or any mental confusion warrants assessment in hospital. As the jaundice
deepens, the urine becomes dark and stools pale. Liver is moderately enlarged and spleen is
palpable in about 10% of patients. Occasionally, tender lymphadenopathy is seen, with transient
rash in some cases. Thereafter jaundice lessens and in the majority of cases the illness is over within
3-6 weeks. Rarely, disease may be very severe with fulminant hepatitis, liver coma and death.
Diagnostic tools
* Liver biochemistry (prodromal stage, Icteric stage  serum bilirubin reflects level of jaundice)
* Haematological tests  leucopenia with a relative lymphocytosis)
* Viral Markers  Antibodies to HAV
* Other tests
Treatment
* Most patients making a complete recovery
* There is no specific treatment, rest and dietary measures are unhelpful.
* Prevention  control of hepatitis depends on good hygiene. Virus is resistant to chlorination but is
killed by boiling water for 10 minutes.
Hepatitis B
General information disease
HBV is present worldwide with an estimated 360 million carriers. Majority of patients recover
completely, fulminant hepatitis occurring in up to 1%. Hepatitis B can lead to chronic hepatitis,
cirrhosis and hepatocellular carcinoma or have chronic HBV infection.
Causes
* Hepatitis B is causes by HBV and is very contagious. HBV is in blood, sperm and vaginal fluids. It is
transmitted through blood or blood through sexual contact with someone who is carrying the virus.
Hepatitis B is therefore also known as sexually transmitted disease (STD). Also is spreads vertical
(from mother to child in utero)
Symptoms
Acute infection with hepatitis B virus is associated with acute viral hepatitis – an illness that begins
with general ill-health, loss of appetite, nausea, vomiting, body aches, mild fever, and dark urine,
and then progresses to development of jaundice. It has been noted that itchy skin has been an
indication as a possible symptom of all hepatitis virus types. The illness lasts for a few weeks and
then gradually improves in most affected people. A few people may have more severe liver disease
(fulminant hepatic failure), and may die as a result. The infection may be entirely asymptomatic and
may go unrecognized.
29
Diagnostic tools
*Specific tests (to show antigens and antibodies (table 7.7 book)
HBV DNA is the most sensitive index of viral replication.
* Blood tests
* Ultrasound
* CT scan
* MRI scan
* Liver biopsy
Treatment
* It almost always cures by itself. Good nutrition and a good lifestyles promote that. In some cases
virus inhibitors (virusremmers) are prescribed.
* Blood tests will be done during the disease, to control for complications and prevent them in time.
Hepatitis C
General information disease
HCV is transmitted by blood and blood products and was common in people with heamophilio
treated before screening of blood products was introduced. 240 million people worldwide are
infected is estimated. Hepatitis C is een ontsteking van de lever die veroorzaakt wordt door een
virus. Bij hepatitis C gaat het om een ander virus dan bij hepatitis A en B. Het zijn alle drie
leverontstekingen die veroorzaakt worden door infectie met een virus. Ze worden daarom ook wel
virale hepatitis genoemd. Iemand kan echter ook besmet zijn zonder het te merken. In beide
gevallen bent u besmettelijk voor andere mensen, Het kan ongeveer tien tot twintig jaar duren
voordat iemand die besmet is duidelijke klachten krijgt. Hepatitis C wordt in de meeste gevallen
chronisch: ongeveer 80% van de mensen die besmet raken, krijgen een chronische leverontsteking.
Dit wil zeggen dat het hepatitis C virus in het lichaam aanwezig blijft. Hierdoor kan de lever ernstig
ontstoken raken. Bij 20% van de mensen met chronische hepatitis C ontstaat levercirrose.
Causes
* HCV (a single-stranded RNA virus of the Flaviviridae family) is caused by transmission via sex (men
with men, sex workers and attendees at STI clinics. Vertical transmission is very rare.
Symptoms
* Most acute infections are asymptomatic.
* About 10% of patients having a mild-flu-like illness with jaundice and a rise in serum
aminotransferases.
Diagnostic tools
* Blood tests
* HCV RNA can be detected from 1 to 8 weeks after infection. Anti-HCV tests are usually positive 8
week from infection.
* ( Ultrasound, CT scan, MRI scan, liver biopsy)
Treatment
* Hepatitis C mostly becomes chronic, Interferon has been used in acute cases to prevent chronic
disease.
* Needle-stick injuries must be followed and treated early, if there is evidence of HCV viraemia,
usually re-tested for, at 4 weeks.
* Treatment of hepatitis C is complex and differs from person to person.
* Standard treatment: Peginterferonen (stimulate own immune system and inhibit virus division) or
Antiviral Ribavirine (to erase HCV out of the blood and body to prevent further liver damage).
Hepatitis D
General information disease
Hepatitis D is a contagious liver disease, which only occurs in combination with hepatitis B.
Transmission of HDV can occur either via simultaneous infection with HBV (coinfection) or
superimposed on chronic hepatitis B or hepatitis B carrier state (superinfection).
30
Causes
* Caused by hepatitis D virus (HDV or delta virus), which is an incomplete RNA particle enclosed in a
shell or HbsAg and belongs to the deltaviridae family.
* It is unable to replicate on its own but is activated by the presence of HBV.
HDV can occur either as a co-infection (of HDV and HBV) or as a superinfection.
Symptoms
Worsens the symptoms of hepatitis B.
Diagnostic tools
? same as hepatitis B?
Treatment
* No specific treatment or vaccination
* Can be prevented by vaccination for hepatitis B
31
16. Hypothyroidism 961-963
General information disease
HYPOTHYROIDISM = underactivity of the thyroid (schildklier) (usually primary from disease of the thyroid but
secondary to hypothalamic pitutary (hypofyse) disease = reduced TSH drive(T3)).
Causes
- Atrophic (autoimmune) hypothyroidism (afweersysteem keert zich tegen de eigen schilklier) (attack of the
body itself on the thyroid because of antithyroid autoantibodies leading to lymphoid infiltration of the gland
and eventual atrophy and fibrosis). It is associated with other automimmune diseases such as pernicious
anaemia, vitiligo (skin disease), and other endocrine deficiences.
- Schilklierontsteking
- Behandeling voor een te snelle schildklier
- Soms ligt de oorzaak in de hypofyse → Klier in de hersenen die TSH(T3) aanmaakt
- Hashimoto’s thyroiditis produces atrophic changes with regeneration, leading to goitre formation. Goitre is a
swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box). The enlargement is
associated with (dys)functioning of the thyroid gland.
- Postpartum thyroiditis (postpartum = following childbirth) transient phenomenon observed following
pregnancy. It may cause hypo-, hyperthroidism or the two sequentiallly. It results from the modificiation to
the immune system necessary in pregnancy.
- Iodine deficiency
- Dyshormonogenesis due to genetic defects in the synthesis of thyroid hormones
Symptoms
- myxoedema = accumulation of mucopolysaccaride in subcutaneous tissues
- dry-haired, thick-skinned, deep-voiced
- slow patients
- weight gain
- cold intolerance(feeling cold)
- bradycardia (=resting heart rate of under 60 beats per minute)
- constipation
- non-specific tiredness
Diagnostic tools
- Serum TSH, a high TSH level confirms primary hypothyroidism. A low free T4 level (T4 = thyroixine, hormone
of the thyroid) confirms the hypothyroid state (and is also essential to exclude TSH defiency if clinical
hypothyroidism is strongly suspected and TSH is normal or low).
- Anaemia usually normochromic and normocytic in type but may be macrocytic or microcytic
- Increased serum aspartate transferase levels (from muscle and/or liver)
- Increased serum creatine kinase levels associated with myopathy (=muscular disease, muscle fibers do not
function for any one or many reasons resulting in muscular weakness)
- Hypercholesterolaemia and hypertriglyceridaemia
- Hyponatraemia due to an increase in ADH and impaired free water tolerance
Treatment
- Replacement therapy with levothyroixine (thyroixine, i.e. T4) is given for life. Starting dose will depend upon
severity of the deficiency
- Monitoring aim is to restore T4 and TSH to well within normale range.
Filmpjes
http://www.youtube.com/watch?v=7FGI-uLv6EE
http://www.youtube.com/watch?v=Cagna0600pY
32
17. Hyperthyroidism 963-967
General information disease
Thyroid overactivity, thyrotoxicosis. Nearly all cases of hyperthyroidism are causes by intrinsic thyroid disease,
a pituitary (hypofyse) cause is extremely rare.
Causes
- Graves’ disease autoimmune process. Serum IgG antibodies bind to TSH receptors in the thyroid, stimulating
thyroid hormone production, they behave like TSH.
- Solitary toxic adenoma/nodule
- Toxic multinodular goitre
- de Quervain’s thyroiditis transient hyperthyroidism from an acute inflammatory process, probably viral in
origin.
- Postpartum thyroiditis
- Amiodarone-induced thyrotoxicosis amiodarone, a class III antiarrhythmic drug, causes two types of
hyperthyroidism
Symptoms
- Weight loss
- Increased appetite
- Irritability/behaviour change
- Restlessness
- Malaise (discomfort)
- Stiffness
- Muscle weakness
- Tremor (= an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to and fro
movements (oscillations or twitching) of one or more body parts)
- Heat intolerance
- Thirst
- Vomiting
- Diarrhoea
- Goitre (gezwel)
Diagnostic tools
Hyperthyroidism is often clinically obvious but treatment should never be instituted without biochemical
confirmation. Useful positive clinical markers are eye signs, a diffuse goitre, proximal myopathy and wasting.
Weight loss despite a normal or increased appetite is a very useful clinical symptom of hyperthyroidism. The
hyperdynamic circulation with warm peripheries seen with hyperthyroidism can be contrasted with the
clammy hands of anxiety.
- Serum TSH is suppressed in hyperthyroidism
- Raised free T4 or T3 confirms the diagnosed
- TPO and thyroglobulin antibodies are present in most cases of Graves’ disease
Treatment
- Antithyroid drugs
- Radioactive iodine
- Surgery: subtotal thyroidectomy
Filmpjes
http://www.youtube.com/watch?v=uP6czO-gypE
33
18. Irritable Bowel Syndrome 296-298
General information disease
Coexists with chronic fatigue syndrome, fibromyalgia, temporomandibular joint dysfunction. Up to
one in five people report symptoms consistent with IBS.
Causes
Factors that can trigger onset of IBS
- Affective disorders e.g. depression, anxiety
- Psychological stress and trauma
- Gastrointestinal infection
- Antibiotic therapy
- Sexual, physical, verbal abuse
- Pelvic surgery
- Eating disorders
Muscular contractions in your colon are abnormal, which makes food to move to quickly or
slow(hard of watery stool).
Symptoms
Painful periods, Painful following sex
Bloating, abdominal pain, nauseous
Urinary symptoms: frequent, urgency, passing urine at night, not emptying bladder
Other: Joint hypermobility, Back pain,Headaches,Bad breath,Fatigue,Not sleeping
Diagnostic tools
Abdominal pain associated with:
1. Improvement with defecation[ontlasting]
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (appearance) of stool.
Further investigation needed with rectal bleeding, nocturnal pain, fever and weight loss
Raised stool calprotectin or lactoferrin suggests further investigation
Treatment
- Constipation IBS with pharmacological treatment
- Pro and pre biotics
- Dietician
- Psychiatrist
Filmpjes
http://www.youtube.com/watch?v=N5YJ3EPvfmI
http://www.youtube.com/watch?v=eKLqFnAmK6c
http://www.youtube.com/watch?v=U32E1E5mfoA
34
19. Liver cirrhosis 328-331
General information disease
Cirrhosis results from the necrosis[death] of liver cells followed by fibrosis (scar tissue forms) and nodule
formation. The liver architecture is diffusely abnormal and this interferes with liver blood flow and function.
Causes
Common:
-Alcohol (most common cause in the west)
-Hepatitis B ± D
-Hepatitis C
Others:
-Autoimmune hepatitis-Hereditary haemochromatosis-Hepatic venous congestion
-Budd–Chiari syndrome-Wilson’s disease-Drugs (e.g. methotrexate)-α1-Antitrypsin deficiency-Cystic fibrosisNon-alcoholic fatty liver disease-Galactosaemia-Glycogen storage disease-Veno-occlusive disease-Idiopathic
(cryptogenic) -Other viruses
Symptoms
During the early stages, many people with cirrhosis experience no liver damage symptoms. However, as scar
tissue replaces healthy cells, and liver function begins to fail, a person may experience a variety of symptoms
and complications:
Abdominal pain, Abnormal accumulation of fluid in the abdominal cavity (ascites),Bleeding from engorged
veins in your oesophagus or intestines, Dark, cola-colored urine, Easy bruising, Exhaustion, Gallstones, Insulin
resistance and type 2 diabetes, Itchy hands and feet, Lack of appetite, Liver cancer, Liver failure, Loss of
interest in sex, Nausea, Other system malfunctioning such as impotence, kidney dysfunction and failure, and
osteoporosis
Portal hypertension (an increase in blood pressure in veins that carry blood from the abdominal organs to the
liver), Sensitivity to medications, Small, spider-like blood vessels under the skin
Swelling of legs and feet from retained fluid (edema)
Hepatic encephalopathy (toxins in the blood or brain – signs include forgetfulness, confusion, trouble
concentrating; change in sleeping habits; behavioral, personality, and mood changes; and in advanced cases,
delirium and coma), Varix (an abnormally dilated or swollen vein, artery, or lymph vessel), Weakness, Weight
loss, Yellowing of skin and eyes (jaundice)
Diagnostic tools
- Liver function. Serum albumin and prothrombin time are the best indicators of liver function
- Serum electrolytes. A low sodium indicates severe liver
- Serum creatinine. An elevated concentration > 130 μmol/L is a marker of worse prognosis.
In addition, serum α-fetoprotein if > 200 ng/mL is strongly suggestive of the presence of a hepatocellular
carcinoma.
- viral markers
-α1-antitrypsin. Serum copper and serum α1-antitrypsin should always be measured in young cirrhotics.
-Ultrasound examination. This can demonstrate changes in size and shape of the liver
-CT scan hepatosplenomegaly, and dilated collaterals are seen in chronic liver disease.
Liver biopsy
This is usually necessary to confirm the severity and type of liver disease. The core of liver often fragments and
sampling errors may occur in macronodular cirrhosis. Special stains are required for iron and copper, and
various immunocytochemical stains can identify viruses, bile ducts and angiogenic structures.
Treatment
The treatment of liver cirrhosis is dependent on the cause of the disease. There is accumulating evidence that
in the early stages liver fibrosis is reversible, particularly when inflammation is reduced, e.g. by suppressing or
eliminating viruses. When liver cirrhosis occurs, this is irreversible.
The goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms
and complications of cirrhosis.
To prevent further damage, alcohol must be abandoned from the diet.
Low sodium diet (to prevent fluid retention, like ascites)
Medications to control hepatitis
Weight loss, If the cirrhosis is caused by non-alcoholic fatty liver disease.
Filmpjes https://www.mlds.nl/chronische-ziekten/levercirrose/
35
20. Liver carcinoma/ metastasis 347-348
General information disease
The most common liver tumour is a secondary (metastatic) tumour, particularly from the
gastrointestinal tract (from the distribution of the portal blood supply), breast or bronchus. They are
usually multiple.
Primary liver tumours may be benign or malignant, but the most common are malignant.
Hepatocellular carcinoma (HCC, also called malignant hepatoma) is the most common type of liver
cancer. Most cases of HCC are secondary to either a viral hepatitis infection (hepatitis B or C) or
cirrhosis (alcoholism being the most common cause of hepatic cirrhosis
Causes
Carriers of HBV or HCV have an extremely high risk of developing HCC. Also Cirrhosis may lead to
HCC.
Symptoms
Symptoms secondary tumour: weight loss, malaise, upper abdominal pain and
hepatomegaly(enlarged liver), with or without jaundice.
Symptoms HCC: weight loss, anorexia, fever and ache in the right hypochondrium(upper adomen)
and ascites (waterbuik).
Diagnostic tools
Diagnosis for secondary tumour: Ultrasound is primary investigation, with the CT of MRI to define
metastases and look for a primary tumour. The serum alkaline phosphatase is almost invariably
raised.
Diagnosis for HCC: Serum alfa-fetoprotein may be raised, but is normal in at least one third or
patients. Ultrasound scans  show filling defects in 90% of the cases. Enhanced CT scans identify
HCC but it is difficult to confirm diagnosis in lesion < 1 cm. MRI  can further help to delineate
lesions. Tumour biopsy  is used for diagnosis.
Treatment
Treatment secondary tumour: depend on the site of the primary and the burden of the liver
metastases. Best results are obtained in colorectal cancer in patient with few hepatic metastases
* Surgery
* Chemotherapy,
* Radiofrequency ablation of the metastases is an alternative to surgery. Thermal and cryotherapy is
also used.
Treatment HCC : HCC arises in cirrhotic liver in 95% of cases and can be screened and detected by
cross-sectional imaging and a rise in serum alfa-fetoprotein. Surgical resection. Liver transplantation
 offers only opportunity for cure with patients with a small primary but is limited often by the
underlying cause of the hepatitis and cirrhosis. Chemotherapy and radiotherapy are unsuccessful.
Filmpjes
36
21. Peptic Ulcer disease (Duodenal(12ving darm)/ Gastric ulcer)248-251
General information disease
Peptic Ulcer- break in superficial epithelial cells penetrating down to the muscularis mucosa of the
stomach or duodenum, there is a fibrous base and increase in inflammatory cells. Ulcer can be in
different places (duodenal, stomach)
Duodenal ulcer are found in the duodenal cap, the surrounding mucosa appears inflamed,
heamorrhagic of friable
Gastric ulcers are most commonly seen on the lesser curve near the incisura, but can be found in
any part of the stomach.
Causes
 Most peptic ulcers are caused by H. pylori.
Affect approx. 10% of adult population and are two to three times more common than duodenal
ulcers.
Ulcer rates are declining rapidly for younger men and increasing for older individuals (women).
Duodenal ulcer and Gastric ulcer are common in the elderly.
Symptoms
* Recurrent, burning epigastric pain.
* Relation pain to food (variable, not helpful with diagnosis)
* Nausea may accompany the pain (sometimes vomiting)
* Anorexia
* Weight loss
* Persistent and severe pain  may suggest complications such as penetration into other organs
* Back pain  may suggest penetrating posterior ulcer
Can be symptomless.
Diagnostic tools
-Endoscopy-Biopsy urease test gastric biopsy
-Histology- stained sections of gastric mucosa
-Culture- biopsy and stained
Investigation of suspected peptic ulcer disease
*Patients under age 55 who test positive for h. pylori can start eradication
*Exclusion of cancer is required in older patients
*Endoscopy is required of all patients.
Treatment
* Pain may be relieved by anticids.
* Metronidazole, clarithromycin, amoxicillin, tetracycline most commonly used.
* Stop smoking- slows mucosa healing
Filmpjes
http://www.youtube.com/watch?v=lnVjXuyM6xk
37
22. Pancreatic cancer 431-440
General information disease
Pancreatic cancer is a malignant neoplasm originating from transformed cells arising in tissues
forming the pancreas. The most common type of pancreatic cancer, accounting for 95% of these
tumors, is adenocarcinoma (tumors exhibiting glandular architecture on light microscopy) arising
within the exocrine component of the pancreas. Pancreatic cancer is the fourth most common cause
of cancer-related deaths in the United States and the eighth worldwide. Pancreatic cancer has an
extremely poor prognosis: for all stages combined, the 1- and 5-year relative survival rates are 25%
and 6%, respectively;
2 types
1.Head of pancrease and the ampulla of vater
2.Carcinoma localized to the body or tail of pancreas
Causes
-Frequent over 60
-Male
-Smoking
-Alcohol
-Aspirin-Diabetes
-Chronic pancreatitis
-Genetic
-Gene mutations
Symptoms
1. head of pancrease and the ampulla of vater
-Obstruction of bile duct (most common) causing jaundice
-cholestasis[galstuwing]
- abdominal pain and loss of appetite
- itching
- palpable gallbladder
-weight loss
2. carcinoma localized to body or tail
-No symptoms
Some presentations
-Thromboembolic phenomena- blocking of blood vessels by blood clot
-Poly arthritis and skin nodules
Diagnostic tools
-transabdominal ultrasound
-contrast enhanced CT-scan
-laprascopy
-ERCP
-Needle biopsy- not if tumour is operational, need may spread cells
Treatment
-Operate
-5 year survival rate 2-5%
Filmpjes
http://www.youtube.com/watch?v=S1yOs5u1ABQ
http://www.youtube.com/watch?v=6xLkhDJsDGo
38
ACUTE pancreatitis 361-366
General information disease
A process that occurs on the background of a previously normal pancreas (alvleesklier) and can return into
normal after resolution of the episode
Causes
- Gallstones
- Use of (much) alcohol
- Infections (e.g. mumps, Coxsackie B)
- Pancreatic tumours
- Drugs (azathiprine, oestrogens, corticosteroids, didanosine)
- Iatrogenic (e.g. post-surgical, post-ERCP)
- Hyperlipidaemias
- Miscellaneous (trauma, scorpion bite, cardiac surgery)
- Idiopathic (arising spontaneously or from an obscure or unknown cause)
Symptoms
- upper abdominal pain (usually begins in the epigastrium accompanied by nausea and vomiting). As the
inflammation spreads throughout the periotoneal cavity, the pain becomes more intense-> Backpain!
- Attack may follow an alcoholic binge
- in more severe disease the patient may have a tachycardia (=heart rate that exceeds normal range),
hypotension and be oliguric (excretion of abnormal small volume of urine)
- In patients with a gallstone aetiology (=study of causation) the clinical picture may also include the features
of jaundice or cholangitis (=infection of the common bile duct)
Diagnostic tools
- Blood test (serum amylase elevated? Urinary amylase levels may be diagnostic as these remain elevated over
a longer period of time / Serum lipase raised? C reactive protein level / Other baseline investigations include a
full blood count, liver biochemistry, plasma calcium and arterial blood gases)
- Radiology (X-ray, abdominal ultrasound, contrast-enhanced spiral CT scanning, MRI (to assess the degree of
pancreatic damage, ERCP)
Treatment
- Nasogastric suction (Nasogastric suction involves removing solids, liquids, or gasses from the stomach or
small intestine by inserting a tube through the nose and suctioning the gastrointestinal material through the
tube.)
- Prophlactic antiobiotics
- Analgesia requirements
- Feeding
- Anticoagulation (prevention of forming a clot)
Filmpjes
http://www.youtube.com/watch?v=sipQd2S1zcM
39
CHRONIC pancreatitis
General information disease
There is continuing inflammation with irreversible structural changes.
Causes
- Alcohol!!! (accounting for 60-80% of the cases)
- Tropical chronic pancreatitis (aetilogy unknown)
- Hereditary
- Autoimmune
- Cystric fibrosis
Symptoms
- inappropriate activation of enzymes within the pancreas
- increased level of trypsinogen
- Pain, epigastric and often radiates through into the back (may be episodic with short periods of severe pain
or chronic unremitting)
- anorexia (during periods of abdominal pain)
- weight loss (during periods of abdominal pain)
- Exo- and endocrine insufficiency
- Malabsorption of diabetes
- Jaundice
Diagnostic tools
- Serum amylase and lipase levels are rarely significantly elevated in eastablished chronic pancreatitis
- Faecal elastase level
- PABA test
- Transabdominal ultrasound scan
- Contrast-enhanced spiral CT Scan
- MRI with MRCP
- Endoscopic ultrasound
- Diagnostic ERCP
Treatment
- NSAIDS
- Pancreatic enzymes supplements
- Acid suppressor
Filmpjes
http://www.youtube.com/watch?v=-n6niOImK3E
40
24. Perforated ulcer (geperforeerde maagzweer)
General information disease
Frequency of perforation of peptic ulceration is decreasing, partly attributable to medical therapy.
H. pylori: Bacteria found in the stomach, it was present in patients with chronic gastritis and gastric ulcers,
conditions that were not previously believed to have a microbial cause. It is also linked to the development of
duodenal ulcers and stomach cancer. Over 80% of people infected with H. pylori show no symptoms. Acute
infection may appear as an acute gastritis with abdominal pain (stomach ache) or nausea. Where this develops
into chronic gastritis, the symptoms, if present, are often those of non-ulcer dyspepsia: stomach pains,
nausea, bloating, belching, and sometimes vomiting or black stool. Individuals infected with H. pylori have a 10
to 20% lifetime risk of developing peptic ulcers and a 1 to 2% risk of acquiring stomach cancer.
Causes
Peptic ulcer disease. Peptic ulcers, most often caused by bacteria called Helicobacter pylori or by non-steroidal
anti-inflammatory medications that irritate the stomach lining, can perforate or eat completely through the
lining of the stomach or intestine when the peptic ulcer is untreated. This perforation allows digestive juices
and food to leech into the abdominal cavity.
(Causes of peptic ulcer:
Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the esophagus, stomach
or small intestine. The acid can create a painful open sore that may bleed. Your digestive tract is coated with a
mucous layer that normally protects against acid. But if the amount of acid is increased or the amount of
mucus is decreased, you could develop an ulcer. Caused by bacterium Helicobacter pylori and regular use of
pain relievers.
Symptoms
-Severe abdominal pain,
-Abdominal swelling,
-Abdominal tenderness,
-Nausea,
-Vomiting
-Fever
Diagnostic tools
-Taking an erect abdominal/chest X-ray (seeking air under the diaphragm)
-Endoscopy
Treatment
Laparoscopic surgery is usually performed to close the perforation and drain the abdomen
Conservative management (nasogastric suction, intravenous fluids and antibiotics) is used in elderly and sick
patients.
Non-surgical management and observation may be a reasonable initial treatment, except in patients over age
70.
Filmpjes
41
25. Ulcerative colitis
General information disease
Ulcerative colitis is a disease that causes ulcers in the lining of the rectum and colon. It is one of a
group of diseases called inflammatory bowel disease. Ulcers form where inflammation has killed the
cells that usually line the colon. Ulcerative colitis can happen at any age, but it usually starts
between the ages of 15 and 30. It tends to run in families. The most common symptoms are pain in
the abdomen and bloody diarrhea. Other symptoms may include anemia, severe tiredness, weight
loss, loss of appetite, bleeding from the rectum, sores on the skin and joint pain. Children with the
disease may have growth problems. About half of people with ulcerative colitis have mild
symptoms. Several types of drugs can help control ulcerative colitis. Some people have long periods
of remission, when they are free of symptoms. In severe cases, doctors must remove the colon.
Causes
Like Crohn's disease, ulcerative colitis causes inflammation and ulcers in your intestine. But unlike
Crohn's, which can affect the colon in various, separate sections, ulcerative colitis usually affects one
continuous section of the inner lining of the colon beginning with the rectum.
No one is quite sure what triggers ulcerative colitis, but current thinking focuses on the following
possibilities:
*Immune system. Some scientists think a virus or bacterium may trigger ulcerative colitis. The
digestive tract becomes inflamed when your immune system tries to fight off the invading
microorganism (pathogen). It's also possible that inflammation may stem from an autoimmune
reaction in which your body mounts an immune response even though no pathogen is present.
*Heredity. Because you're more likely to develop ulcerative colitis if you have a parent or sibling
with the disease, scientists suspect that genetic makeup may play a contributing role. However,
most people who have ulcerative colitis don't have a family history of this disorder.
Symptoms
Ulcerative colitis symptoms can vary, depending on the severity of inflammation and where it
occurs. For these reasons, doctors often classify ulcerative colitis according to its location.
*Ulcerative proctitis. In this form of ulcerative colitis, inflammation is confined to the area closest to
the anus (rectum), and for some people, rectal bleeding may be the only sign of the disease. Others
may have rectal pain and a feeling of urgency. This form of ulcerative colitis tends to be the mildest.
*Proctosigmoiditis. This form involves the rectum and the lower end of the colon, known as the
sigmoid colon. Bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in
spite of the urge to do so (tenesmus) are common problems associated with this form of the
disease.
*Left-sided colitis. As the name suggests, inflammation extends from the rectum up through the
sigmoid and descending colon, which are located in the upper left part of the abdomen. Signs and
symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended
weight loss.
*Pancolitis. Affecting more than the left colon and often the entire colon, pancolitis causes bouts of
bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight
loss.
*Fulminant colitis. This rare, life-threatening form of colitis affects the entire colon and causes
severe pain, profuse diarrhea and, sometimes, dehydration and shock. People with fulminant colitis
are at risk of serious complications, including colon rupture and toxic megacolon, a condition that
causes the colon to rapidly expand.
The course of ulcerative colitis varies, with periods of acute illness often alternating with periods
of remission. But over time, the severity of the disease usually remains the same. Most people with
a milder condition, such as ulcerative proctitis, won't go on to develop more-severe signs and
symptoms.
 symptoms of ulcerative colitis, such as:
Abdominal pain
42
Blood in your stool
Ongoing bouts of diarrhea that don't respond to over-the-counter (OTC) medications
An unexplained fever lasting more than a day or two
Although ulcerative colitis usually isn't fatal, it's a serious disease that, in some cases, may cause lifethreatening complications.
Diagnostic tools
Blood tests. check for anemia or infection.
Stool sample. The presence of white blood cells in your stool indicates an inflammatory disease,
possibly ulcerative colitis
Colonoscopy. view your entire colon using a thin, flexible, lighted tube with an attached camera.
Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to
examine the sigmoid, the last portion of your colon. But, if your colon is severely inflamed, your
doctor may perform this test instead of a full colonoscopy.
Barium enema. This diagnostic test allows your doctor to evaluate your entire large intestine with an
X-ray.
X-ray. A standard X-ray of your abdominal area may be done to rule out toxic megacolon or a
perforation if these conditions are suspected because of severe symptoms.
CT scan. A CT scan of your abdomen or pelvis may be performed if your doctor suspects a
complication from ulcerative colitis or inflammation of the small intestine that might suggest
Crohn's disease. A CT scan may also reveal how much of the colon is inflamed
Treatment
The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms.
In the best cases, this may lead not only to symptom relief but also to long-term remission.
Ulcerative colitis treatment usually involves either drug therapy or surgery.
Anti-inflammatory drugs
-Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease.
-Sulfasalazine (Azulfidine).
-Mesalamine (Asacol, Lialda, others), balsalazide (Colazal) and olsalazine (Dipentum).
-Corticosteroids.
Immune system suppressors These drugs also reduce inflammation, but they target your immune
system rather than treating inflammation itself.
-Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol
-Cyclosporine (Gengraf, Neoral, Sandimmune).
-Infliximab (Remicade)
-Adalimumab (Humira
Other medications
-Antibiotics
-Anti-diarrheals.
-Iron supplements
Surgery
-If diet and lifestyle changes, drug therapy, or other treatments don't relieve your signs and
symptoms, your doctor may recommend surgery. removing your entire colon and rectum
(proctocolectomy).
Filmpjes
http://www.mayoclinic.com/health/ulcerative-colitis/DS00598
http://www.youtube.com/watch?v=FjUke8TMwhU
43
General medicin
Theme 3
Neurological system
Alzheimer’s disease
Bell’s Palsy
Brain haemorrhage (Intracranial, cerebral,
subdural, epidural)
Brain tumour
Cerebral(brain) infarction
Epilepsy
Hernia nucleus pulposus (HNP)
Intermittent claudication
Mechanical low back pain (lumbago)
Meningitis/encephalitis (hersenvliesontsteking)
(Poly) Neuropathy
Parkinson
Spinal cord compression (i.e. metastatic tumour)
Stroke
Transient ischemic attack (TIA)
http://www.youtube.com/watch?v=m7wRMlThMik
44
Alzheimer’s disease
General information disease
Alzheimer's is the most common cause of dementia — a group of brain disorders that results in the loss of
intellectual and social skills. Although the causes of Alzheimer's are not yet fully understood, its effect on the
brain is clear. Alzheimer's disease damages and kills brain cells. A brain affected by Alzheimer's disease has
many fewer cells and many fewer connections among surviving cells than does a healthy brain. As more and
more brain cells die, Alzheimer's leads to significant brain shrinkage. When doctors examine Alzheimer's brain
tissue under the microscope, they see 2 types of abnormalities that are considered hallmarks of the disease:
- Plaques. These clumps of a protein called beta-amyloid may damage and destroy brain cells in several ways,
including interfering with cell-to-cell communication. Although the ultimate cause of brain-cell death in
Alzheimer's isn't known, the collection of beta-amyloid on the outside of brain cells is a prime suspect.
- Tangles. Brain cells depend on an internal support and transport system to carry nutrients and other
essential materials throughout their long extensions. This system requires the normal structure and
functioning of a protein called tau. In Alzheimer's, threads of tau protein twist into abnormal tangles inside
brain cells, leading to failure of the transport system. This failure is also strongly implicated in the decline and
death of brain cells.
There are two types of AD: Early onset AD (appear before age 60, less common, several genes have been
identified) and the late onset AD (the most common type, occurs in people age 60 and older, the role of genes
is less clear).
Causes
Although the cause of Alzheimer is still not known, you are more likely to get Alzheimer's disease (AD) if you:
- Are older. However, developing AD is not a part of normal aging.
- Have a close blood relative, such as a brother, sister, or parent with AD.
- Have certain genes linked to AD, such as APOE epsilon4 allele
The following may also increase your risk, although this is not well proven:
- Being female, having high blood pressure for a long time, history of head trauma
Symptoms
Alzheimer affects memory, thinking and behaviour. There is progressive loss of ability to learn, retain and
process new information. Other symptoms are:
- Memory loss, disorientation and misinterpretation of spatial relationships, speaking and writing, thinking and
reasoning, making judgements and decisions, planning and performing familiar tasks, changes in personality
and behaviour
Diagnostic tools
Alzheimer's disease is usually diagnosed clinically from the patient history and by clinical observations:
* Overall neurological health (reflexes, muscle tone and strength, ability to get up from a chair and walk across
the room, sense of sight and hearing, coordination, balance)
* Lab tests(decreased glutamate or creatine in the blood)
* Mental status testing
* Neuropsychological testing
* Brain imaging
* CT, MRI, PET
Treatment
Current Alzheimer's disease medications and management strategies may temporarily improve symptoms.
Two types of drugs are currently used to treat cognitive symptoms:
●
Cholinesterase inhibitors. These drugs work by boosting levels of a cell-to-cell communication
chemical depleted in the brain by Alzheimer's disease. Less than half of those taking these drugs can expect to
have any improvement. Commonly prescribed cholinesterase inhibitors include donepezil (Aricept),
galantamine (Razadyne) and rivastigmine (Exelon). The main side effects of these drugs include diarrhoea,
nausea and sleep disturbances.
●
Memantine (Namenda). This drug works in another brain cell communication network and slows the
progression of symptoms with moderate to severe Alzheimer's disease. It's sometimes used in combination
with a cholinesterase inhibitor.
Filmpjes
http://www.youtube.com/watch?v=9Wv9jrk-gXc
45
Bell’s Palsy
General information disease
Bell's palsy is a form of acute facial paralysis (verlamming) resulting from a dysfunction of the cranial nerve VII.
Bell’s palsy is the most common cause of acute facial nerve paralysis (>80%).
Causes
Bell’s palsy is thought to be due to viral infection (often herpes simplex) causing swelling of nerve within the
tight petrous bone facial canal(inflammatory condition). Nerve swelling and compression in the narrow bone
canal are thought to lead to nerve inhibition, damage or death.
Symptoms
There is unilateral(eenzijdig) facial weakness developing over 24 till 48 hours, sometimes with lost or altered
taste on the tongue and hyperacusis (geluidsimpulsen worden te sterk verwerkt door de hersenen).
Pain behind the ear is common at onset. Patients often suspect a stroke and may be very distressed. Vague
altered facial sensation is often reported although examination of facial sensation(gevoel in gezicht) is normal.
Diagnostic tools
Diagnosis is made on clinical grounds and tests are usually not required. The ear (and palate) should be
examined for vesicles (blaasjes), hearing loss or evidence of local pathology such as cholesteatoma or
malignant otitis externa and parotid tumours should be excluded. Involvement of other cranial nerves means
facial weakness is not due to Bell's palsy. Lyme disease may account for one-quarter of cases of facial palsy in
endemic areas and HIV seroconversion is the commonest cause in parts of Africa.
Treatment
Most people recover spontaneously and achieve near-normal to normal functions. Many show signs of
improvement as early as 10 days after the onset, even without treatment. Early treatment with corticosteroids
(prednisolone 1 mg/kg for 7 days) improves outcome. Evidence to support use of antiviral agents is limited but
aciclovir or valaciclovir is often given in combination with steroids.
Inability to blink in severe facial weakness may lead to exposure keratitis(hoornvliesontsteking). Use of eye
drops is often required and patients should be advised to carefully tape the eye closed at night.
Recovery over 3-8 weeks occurs in at least 85% of patients, even without specific treatment. Patients should
be reassured that the prognosis is good and it is unlikely to recur.
Filmpjes
http://www.youtube.com/watch?v=BY-NkQHc_RA
46
Brain haemorrhage[hersenbloeding] (Intracranial, cerebellar[kleine hersenen], subdural,
epidural)
General information disease
Brain haemorrhage is an haemorrhage that occurs within the brain.
Intracranial haemorrhage is a bleeding within the skull. Intracranial haemorrhage is a serious medical
emergency because the buildup of blood within the skull can lead to increases in intracranial pressure, which
can crush delicate brain tissue or limit its blood supply. Severe increases in intracranial pressure can cause
potentially deadly brain herniation[inklemming]. Onder te verdelen in:
- Cerebellar haemorrhage is a subtype of intracranial hemorrhage that occurs within the brain tissue itself.
- Subdural haemorrhage can cause death unless treated promptly. It is an accumulation of blood in the
subdural space(by the membrane that envelops the brain and spinal cord) following rupture of a vein. This
usually follows head injury.
- Epidural haemorrhage is a bleeding between the skull and the dura[buitenste hersenvlies]. This bleeding
involves arteries and is often due to trauma.
Causes
Intracranial bleeding occurs when a blood vessel within the skull is ruptured or leaks. It can result from
physical trauma (as occurs in head injury) or nontraumatic causes (as occurs in haemorrhagic stroke) such as a
ruptured aneurysm[verwijd bloedvat]. Anticoagulant therapy[discourage formation of blood clots], as well as
disorders with blood clotting can heighten the risk that an intracranial haemorrhage will occur.
Cerebellar haemorrhage can be caused by brain trauma, or it can occur spontaneously in haemorrhagic stroke.
Non-traumatic cerebellar haemorrhage is a spontaneous bleeding into the brain tissue.
Subdural: rupture of a vein, often due to head injury.
Epidural: rupture of arteries, often due to trauma
Risk factors are: the use of aspirin, diabetes, hypertension, menopause, cigarette smoking and alcohol
Symptoms
Intracranial: leads to neurological dysfunction(paralysis)
Cerebellar: head ache, often followed by stupor[verdoving]/coma and signs of
cerebellar/brainstem[hersenstam] origin (like ocular palsies[paralysis of the eye]). Cerebellar haemorrhage
sometimes causes acute hydrocephalus[waterhoofd], a potential surgical emergency
Subdural: Headache, drowsiness[slaperigheid] and confusion are common. Focal deficits, e.g. hemiparesis or
sensory loss, develop. Epilepsy occasionally occurs. Stupor, coma and coning may follow.
Epidural: head ache with lucid interval(temporary improvement in a patient's condition after a traumatic brain
injury, after which the condition deteriorates) followed by paralysis and unconsciousness
Diagnostic tools
Brain haemorrhage can be seen on a CT imaging immediately.
MRI cannot identify acute small bleedings in the first few hours, but later it is as good as an ICT.
Treatment
Control of hypertension is vital. Urgent neurosurgical clot evacuation is occasionally necessary when there is
deepening coma
Filmpjes
http://www.youtube.com/watch?v=DpPWjuV1sfM
47
Brain tumour
General information disease
Primary intracranial tumours account for some 10% of neoplasms. Metastases are the commonest intracranial
tumours. Symptomless meningiomas (benign) are found quite commonly on imaging or at autopsy. The
hallmark of a direct effect of a mass is local progressive deterioration of function. Tumours can occur
anywhere within the brain.
Causes
No one knows the exact causes of brain tumours. Doctors seldom know why one person develops a brain
tumour and another doesn't. Risk factors are:
- Ionizing radiation (from x-rays and other sources)
- Family history (up to 5 out of every 100 brain tumours (5%) are related to known genetic conditions)
Symptoms
Mass lesions[afwijkingen] within the brain produce symptoms and signs by three mechanisms:
- By direct effect - brain is infiltrated and local function is impaired
- By secondary effects of raised intracranial pressure and shift of intracranial contents (e.g.
papilloedema[zichtsvermindering, soms tijdelijk], vomiting, headache)
- By provoking generalized and/or partial seizures[epileptische aanval] and changes in mood
Diagnostic tools
* CT + MRI san
* Biopsy
* MR angiography is used occasionally to define blood supply
* PET is sometimes helpful to locate an occult primary tumour with brain metastases.
* Since metastases are common, routine tests, e.g. chest X-ray, should be performed.
Treatment
Biopsy and tumour removal. While complete surgical removal of a tumour is an objective, it is often not
possible, nor is surgery always necessary.
Cerebral oedema[vocht] surrounding a tumour responds rapidly to steroids: i.v. or oral dexamethasone.
Epilepsy is treated with anticonvulsants.
For gliomas and metastases, radiotherapy is usually given and improves survival, if only slightly
Filmpjes
48
Cerebral(brain) infarction
General information disease
A cerebral infarction is an ischemic[beperking v/d bloedtoevoer] stroke[loss of brain function due to
disturbance of the blood supply in the brain] resulting from a disturbance in the blood vessels supplying blood
to the brain. A cerebral infarction occurs when a blood vessel that supplies a part of the brain becomes
blocked or leakage occurs outside the vessel walls. Cerebral infarctions vary in their severity with one third of
the cases resulting in death.
Causes
An artery in your brain narrow, or becomes completely blocked, preventing normal blood flow. It can be
caused by arteriosclerosis or by a blood clot(can be formed elsewhere in the body). This loss of blood supply
results in the death of that area of tissue. The infarcted region is surrounded by a swollen area which does not
function but is structurally intact. Riskfactors are:
- Diabetes
- Tobacco smoking
- Hypercholesterolemia
- High blood pressure
- Obesity
Symptoms
Infarctions will result in weakness and loss of sensation on the opposite side of the body(limbs) in seconds,
minutes or hours. Physical examination of the head area will reveal abnormal pupil dilation[verwijding], light
reaction and lack of eye movement on opposite side. If the infarction occurs on the left side brain, speech will
be slurred. Headache is unusual. Consciousness is usually preserved.
Diagnostic tools
CT and MRI-scan
Treatment
If cerebral infarction is caused by a thrombus occluding blood flow to an artery supplying the brain, definitive
therapy is aimed at removing the blockage by breaking the clot down (thrombolysis), or by removing it
mechanically (thrombectomy). The use of intravenous rtPA therapy can be advocated remove the blockage.
Weakness is maximal at first; recovery occurs gradually over days, weeks or many months.
Filmpjes
http://www.youtube.com/watch?v=7FR1TsKLoDI
http://www.youtube.com/watch?v=f3gKQevsbig
49
Epilepsy
General information disease
Epilepsy is a disorder that results from the surges in electrical signals inside the brain, causing recurring
seizures. Epilepsy is common. Its population prevalence is 0.7-0.8% (higher in developing countries).
Approximately 440 000 people in the UK have epilepsy. The incidence of epilepsy is age-dependent, being
highest at the extremes of life, most cases starting before the age of 20 or after the age of 60.
Causes
In many cases a cause cannot be identified; however, factors that are associated include:
- Stroke or transient ischemic attack (TIA)
- Dementia, such as Alzheimer's disease
- Traumatic brain injury
- Infections, including brain abscess, meningitis, encephalitis, and AIDS
- Brain problems that are present at birth (congenital brain defect)
- Brain injury that occurs during or near birth
- Neurodegenerative disorders, e.g. Alzheimer's
- Metabolism disorders present at birth (such as phenylketonuria)
- Brain tumour
- Abnormal blood vessels in the brain
- Other illness that damage or destroy brain tissue
- Use of certain medications, including antidepressants, tramadol, cocaine, and amphetamines
Epilepsy seizures usually begin between ages 5 and 20, but they can happen at any age. There may be a family
history of seizures or epilepsy.
Symptoms
Symptoms vary from person to person. The type of seizure depends on the part of the brain affected and
cause of epilepsy. Most of the time, the seizure is similar to the previous one. Some people with epilepsy
have a strange sensation (such as tingling, smelling an odor that isn't actually there, or emotional changes)
before each seizure. This is called an aura. Seizures can last a few seconds till a few minutes. Seizures are
divided by clinical pattern into two main groups:
- Partial seizure: electrical discharge in a limited party of the cortex
* simple partial seizures - without loss of awareness, e.g. one limb jerking (a Jacksonian seizure)
* complex partial seizures - with loss of awareness, e.g. a temporal lobe seizure
- Generalized seizure: electrical discharge in both hemispheres, always associated with loss of consciousness
or awareness
Diagnostic tools
* ECG → abnormal electrical activity can be seen on this test (rhythm, conduction abnormalities, QT interval)
* Blood tests including serum calcium,
* Bitten tongue - side usually (seizure)
* Urinary incontinence
* MRI scan to see if there are abnormalities in the brain
Treatment
If epilepsy seizures are due to a tumor, abnormal blood vessels, or bleeding in the brain, surgery to treat these
disorders may make the seizures stop.
Medication to prevent seizures, called anticonvulsants(taken by mouth), may reduce the number of future
seizures.
Epilepsy that does not get better after two or three anti-seizure drugs have been tried is called "medically
refractory epilepsy."
●
Surgery to remove the abnormal brain cells causing the seizures may be helpful for some patients.
●
Surgery to place a vagus nerve stimulator (VNS) may be recommended. This device is similar to a
heart pacemaker. It can help reduce the number of seizures.
Filmpjes
http://www.youtube.com/watch?v=MNQlq004FkE
50
Hernia nucleus pulposus (HNP)
General information disease
Hernia nucleus pulposus is a medical condition affecting the spine due to trauma, lifting injuries, or idiopathic
(unknown) causes, in which a tear[scheur] in the outer, fibrous ring (buitenste vezelige ring) of an
intervertebral disc [tussenwervelschijf] allows the soft, central portion (nucleus pulposus) to bulge out beyond
the damaged outer rings. This tear in the disc ring may result in the release of inflammatory chemical
mediators which may directly cause severe pain, even in the absence of nerve root compression.
Causes
Disc herniations can result from general wear and tear[slijtage], such as when performing jobs that require
constant sitting and squatting. Traumatic injury to lumbar discs commonly occurs when lifting while bent at
the waist, rather than lifting with the legs while the back is straight. While sitting or bending to lift, internal
pressure on a disc can move from 17 psi (lying down) to over 300 psi (lifting with a rounded back)
- There is also a strong genetic component. Mutation in genes coding for proteins involved in the regulation of
the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc
herniation.
Symptoms
Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue
that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and
unrelenting neck or low back pain that will radiate into the regions served by affected nerve roots that are
irritated or impinged by the herniated material.
Other symptoms may include sensory changes such as numbness, tingling, muscular weakness, paralysis,
paresthesia, and affection of reflexes.
Diagnostic tools
Diagnosis is made by a practitioner based on the history, symptoms, and physical examination. At some point
in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as
spondylolisthesis, degeneration, tumors, metastases and space-occupying lesions, as well as to evaluate the
efficacy of potential treatment options.
* X-ray can be used to exclude other possibilities, and sometimes hernia can be seen.
* CT-scan
* MRI-scan (the best)
Treatment
Most minor herniations heal within several weeks. Anti-inflammatory treatments(NSAIDs) for pain associated
with disc herniation, protrusion, bulge, or disc tear are generally effective. Severe herniations may not heal of
their own accord and may require surgical intervention or an injection with cortisone into the spine to reduce
pain.
Filmpjes
http://www.youtube.com/watch?v=putDjJ9k1u0
51
Intermittent claudication (etalagebenen)
General information disease
Patients with intermittent claudication complain of exertional[inspannings] discomfort most commonly in the
calf[kuit] which is relieved by rest. The pain disappears after a brief rest and the patient can start walking
again until the pain recurs.
Causes
The pain in the leg is due to a narrowing or blocking of the arteries in or to the legs (peripheral arterial disease
which implies significant atherosclerotic blockages resulting in arterial insufficiency).
Common risk factors are:
- Smoking
- Diabetes
- Hypercholesterolaemia
- Hypertension
Symptoms
Patients with rest pain experience severe unremitting[voortdurende] pain in the foot, which stops a patient
from sleeping. It is partially relieved by dangling the foot over the edge of the bed or standing on a cold floor
The lower limbs are cold with dry skin and lack of hair. Pulses may be diminished or absent.
Ulceration[zweervorming] may occur in association with dark discoloration of the toes or gangrene. The
abdomen should be examined for a possible aneurysm..
Diagnostic tools
Injection with contrast fluid can be helpfull, so the arteries can be projected.
Duplex ultrasound using B-mode ultrasound and colour Doppler can provide an accurate anatomical map of
the lower limbs.
Treatment
* Patients should be encouraged to exercise and to avoid obesity.
* Vascular intervention for stable claudication is not generally recommended except in patients with severe or
disabling symptoms.
* Percutaneous transluminal angioplasty(PTA) -> dotteren
* In severe ischaemia with unreconstructable arterial disease an amputation may be necessary. An
amputation may lead to loss of independence, with only 70% of below-knee and 30% of above-knee amputees
achieving full mobility.
Filmpjes
52
Mechanical low back pain (lumbago)
General information disease
Mechanical low back pain starts suddenly, may be recurrent and is helped by rest. It is often precipitated by an
injury and may be unilateral[eenzijdig] or bilateral. It is usually short-lived. Chronic low back pain is a major
cause of disability and time off work and is reduced by appropriate early management. Once a patient
develops low back pain, although the episode itself is usually self-limiting, there is a significantly increased risk
of further back pain episodes.
Should be prevented by proper lifting!
Causes
The majority of lower back pain stems from benign musculoskeletal problems, and are referred to as
nonspecific low back pain; this type may be due to muscle or soft tissues sprain or strain, particularly in
instances where pain arose suddenly during physical loading of the back, with the pain lateral to the spine.
Risk factors for recurrent back pain include:
- female sex
- increasing age
- pre-existing chronic widespread pain (fibromyalgia)
- psychosocial factors such as high levels of psychological distress, poor self-rated health and dissatisfaction
with employment.
Symptoms
The back is stiff and a scoliosis[kromlopen] may be present when the patient is standing. Muscular spasm is
visible and palpable and causes local pain and tenderness. It lessens when sitting or lying.
Diagnostic tools
Typically people are treated symptomatically without exact determination of the underlying cause. Only in
cases with worrisome signs is diagnostic imaging needed. If the pain is of a long duration X-rays(or CT or MRI)
may increase patient satisfaction. However routine imaging may be harmful to a person's health and more
imaging is associated with higher rates of surgery but no resultant benefit. Fewer than 1% of imaging tests
identify the cause of a problem.
Treatment
* Pain relief and physiotherapy are helpful. Acupuncture helps some. Excessive rest should be avoided. Reeducation in lifting and exercises help to prevent recurrent attacks of pain.
* For acute cases that are not debilitating, low back pain may be best treated with conservative self-care,
including: application of heat or cold, and continued activity within the limits of the pain.
* Short term use of pain and anti-inflammatory medications, such as NSAIDs or acetaminophen may help
relieve the symptoms of lower back pain.
* Surgery may be indicated when conservative treatment is not effective in reducing pain or when the patient
develops progressive and functionally limiting neurologic symptoms such as leg weakness, bladder or bowel
incontinence.
Filmpjes
53
Meningitis(hersenvliesontsteking)/encephalitis (hersenontsteking)
General information disease
Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known
collectively as the meninges. Meningitis can be life-threatening because of the inflammation's proximity to the
brain and spinal cord; therefore, the condition is classified as a medical emergency. Bacterial meningitis is
fatal unless treated. It can lead to invalidity.
Encephalitis means acute infection and inflammation of the brain, usually viral.
Causes
Meningitis can be caused by bacteria, viruses or fungi. Baterical meningitis is fatal unless treated.
Microorganisms reach the meninges by direct extension from the ears, nasopharynx(neuskeelholte), cranial
injury(schedel letsel), congenital(aangeboren) meaningeal defect or by bloodstream spread.
Encephalitis: can be caused by viruses, common cause is rabies, HIV or herpes. Can also be caused by a
bacterial infection like Lyme disease.
Symptoms
Meningitis: The clinical features of meningitis are headache, neck stiffness and fever(which can lead to
deliriousness(ijlen)). Photophobia(lichtschuwheid) and vomiting are often present.
Encephalitis: symptoms are the same as with meningitis, like head ache, fever and vomiting. However,
personality and behavioural change is a common early manifestation which progresses to a reduced level of
consciousness and even coma. Seizures are very common and focal neurological deficits, e.g. speech
disturbance, often occur. Long-term complications include memory impairment, personality change and
epilepsy. A meninges abscess can occur and can lead to pus in the meninges.
Diagnostic tools
Meningitis should be considered seriously in anyone with headache and fever and in any sudden headache.
Neck stiffness should be looked for. A lumbar puncture should be performed, to see if its due to a
bacteria/virus/fungi. If there is clinical suspicion of a mass lesion, an immediate CT scan must be performed.
Encephalitis Can be seen on a CT scan or in the blood by elevated amount of white blood cells.
Treatment
Meningitis + encephalitis: In case of bacterial infection, antibiotics should be given. In case of fungi infection:
penicillin. In case of a virus: wait and rest until it is over.
Filmpjes
http://www.youtube.com/watch?v=9MS9-iEoluw (Meningitis)
http://www.youtube.com/watch?v=U0tg9ldezDo (Encephalitis)
54
(Poly) Neuropathy
General information disease
Neuropathy is a disease in which the peripheral nervous tissue is damaged in a number of ways. In the case of
mononeuropathy, only one nerve is damaged. In the case of polyneuropathy, much nerves are damaged.
The following varieties of neuropathy occur (Fig. 20.16):
- Symmetrical mainly sensory polyneuropathy (distal)
- Acute painful neuropathy
- Mononeuropathy (carpal tunnel syndrome)
- Diabetic amyotrophy (asymmetrical motor diabetic neuropathy)
- Autonomic neuropathy
Causes
The vascular hypothesis postulates occlusion of the vasa nervorum(small arteries that provide blood supply to
peripheral nerves) as the prime cause(due to diabetes-> most common cause). This seems likely in isolated
mononeuropathies, but the diffuse symmetrical nature of the common forms of neuropathy implies a
metabolic cause(due to vitamin deficiency). Since hyperglycaemia leads to increased formation of sorbitol and
fructose in Schwann cells, accumulation of these sugars may disrupt function and structure. It can also have an
inheritable cause or can be due to trauma of infection.
Symptoms
Symptoms depend on the type of nerves affected (motor, sensory, or autonomic) and where the nerves are
located in the body. One or more types of nerves may be affected.
- Motor: Common symptoms associated with damage to the motor nerve are muscle weakness, cramps, and
spasms. Loss of balance and coordination may also occur.
- Sensory: Damage to the sensory nerve can produce tingling, numbness, and a burning pain. Pain associated
with this nerve is described in various ways such as the following: burning, freezing, or electric-like, extreme
sensitivity to touch. But it can also lead to reduction in the ability to feel texture and temperature.
- Autonomic: The autonomic nerve damage causes problems with involuntary functions leading to symptoms
such as abnormal blood pressure and heart rate, reduced ability to perspire, constipation, bladder dysfunction
(e.g., incontinence), and sexual dysfunction.
Diagnostic tools
When neuropathy can also cause severe pain occur, which is called neuropathic pain. This pain can best the
physician mapped via the so-DN4 pain scale. When scoring 4 or more, there is clear evidence of neuropathic
pain.
Treatment
A range of drugs that act on the central nervous system such as drugs originally intended as antidepressants
and antiepileptic drugs have been found to be useful in managing neuropathic pain. Commonly used
treatments include using a tricyclic antidepressant (such as amitriptyline) and antiepileptic therapies such as
gabapentin or sodium valproate.
Often, people with neuropathy who live in areas with defined winters (such as the northern United States)
report that their symptoms were much less severe after moving to places with an undefined winter, such as
Florida.
Filmpjes
http://www.youtube.com/watch?v=Tt3J0flYZt8 (goed filmpje!)
55
Parkinson
General information disease
Parkinson is a degenerative disorder of the central nervous system. The motor symptoms of Parkinson's
disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain;
the cause of this cell death is unknown. The pathology of the disease is characterized by the accumulation of a
protein called alpha-synuclein into inclusions called Lewy bodies in neurons, and from insufficient formation
and activity of dopamine produced in certain neurons within parts of the midbrain. Lewy bodies are the
pathological hallmark of the idiopathic disorder, and the distribution of the Lewy bodies throughout the
Parkinsonian brain varies from one individual to another. The anatomical distribution of the Lewy bodies is
often directly related to the expression and degree of the clinical symptoms of each individual.
Causes
The causes of Parkinson are still not fully understood. The relatively uniform worldwide prevalence suggests
that a single environmental agent is not responsible. There may be multiple interacting risk factors including
genetic susceptibility.
Prevalence increases sharply with age, particularly over 70 years with prevalence of 1 in 200 over age 80.
Ageing changes are likely to be an important factor in causation. Prevalence is higher in men (1.5 : 1 M : F)
Epidemiological studies consistently show a small increased risk with rural living and drinking well
water[bronwater]. The chemical compound MPTP, a potent mitochondrial toxin, causes severe Parkinsonism,
leading to suggestions that oxidative stress may be a factor leading to neuronal cell death in idiopathic PD.
Studies consistently show that non-smokers have a higher risk of PD than smokers (even after controlling for
shorter life expectancy in smokers).
Twin studies show there is a significant genetic component in early onset PD (onset before 40).
Symptoms
PD almost always presents with the typical motor symptoms of tremor and slowness of movement but it is
likely that the pathological process starts many years before these symptoms develop. By the time of first
presentation, on average 70% of dopaminergic nigrostriatal cells have already been lost.
Patients develop a variety of nonspecific non-motor symptoms during the approximately seven years,
sometimes longer, before the motor symptoms become manifest. These include:
- Anosmia (loss of smell, present in 90%) - the olfactory bulb is one of the first structures to be affected
- Depression/anxiety (50%)
- Aches and pains
- REM sleep behaviour disorder
- Autonomic features - urinary urgency, hypotension
- Constipation
- Restless legs syndrome.
These develop slowly and insidiously and are often initially attributed to 'old age' by patients. The core motor
features of PD are:
- Akinesia [moeilijk starten van een beweging]
- Tremor[trillen] (70% of the patients)
- Rigidity[stiffness]
- Postural[houding] and gait[loop] disturbance.
- Cognitive impairment is now recognized to be common in late stage PD (80%) and may develop into
dementia.
Diagnostic tools
There is no laboratory test; diagnosis is made by recognizing physical signs. MRI imaging is normal and not
necessary in typical cases. Dopamine transporter (DaT) imaging makes use of a radiolabelled ligand binding to
dopaminergic terminals to assess the extent of nigrostriatal cell loss. It may occasionally be needed to
distinguish PD from other causes of tremor, or drug-induced Parkinsonism, but it cannot discriminate between
PD and other akinetic-rigid syndromes.
Treatment
Dopamine replacement with levodopa or a dopamine agonist (DA) improves motor symptoms and is the basis
of pharmacological therapy. Treatment of non-motor symptoms such as depression, constipation, pain and
sleep disorders is also necessary and significantly improves quality of life.
Filmpjes
http://www.youtube.com/watch?v=v4BLNWf408k
http://www.youtube.com/watch?v=jyBakRkzswU
56
Spinal cord compression (i.e. metastatic tumour)
General information disease
Spinal cord compression develops when the spinal cord is compressed by bone fragments from a vertebral
fracture, a tumor, abscess, ruptured intervertebral disc or other lesion. It is regarded as a medical emergency
independent of its cause, and requires swift diagnosis and treatment to prevent long-term disability due to
irreversible spinal cord injury. The cord extends from C1, the junction with the medulla, to the lower vertebral
body of L1, where it becomes the conus medullaris.
Causes
Causes of spinal cord compression
- Spinal cord tumours
- Extramedullary, (outside the cord) e.g. meningioma or neurofibroma
- Intramedullary (within the cord), e.g. ependymoma or glioma(tumor that starts in the spine) -> are less
common
- Vertebral body destruction by bone metastases, e.g. prostate primary
- Disc and vertebral lesions:
- Chronic degenerative(commonest cause in elderly people) and acute central disc prolapse
- Trauma
- Inflammatory:
- Epidural abscess
- Tuberculosis
- Granulomatous
- Epidural haemorrhage/haematoma
Symptoms
Principal features of chronic and subacute cord compression are spastic paraparesis(partial or complete loss of
voluntary motor function in the pelvic limbs) or tetraparesis(all four limbs), radicular pain at the level of
compression, and sensory loss below the compression (Box 22.27).
Diagnostic tools
*MRI
*Routine tests (e.g. chest X-ray) may indicate a primary neoplasm or infection
Treatment
Surgical exploration is frequently necessary; if decompression is not performed promptly, irreversible cord
damage results. Results are excellent if benign tumours and haematomas are removed early.
Radiotherapy is used to treat cord malignancies, or compression due to inoperable malignant vertebral body
disease causing cord compression.
Filmpjes
57
Stroke
General information disease
Stroke is the rapid loss of brain function due to disturbance in the blood supply to the brain. The disturbance
in the blood supply lasts >24 h or leads to death. There is no cause apparent other than a vascular one. Stroke
is the third most common cause of death (11% of all deaths in the UK) and the leading cause of adult disability
worldwide. Stroke risk increases with age but one-quarter of all strokes occur before the age of 65. The death
rate following stroke is 20-25%.
Causes
The underlying pathology responsible for stroke is either infarction or haemorrhage. Arterial disease and
atherosclerosis is the main pathological process causing stroke. The causes:
Ischaemic(reduced blood supply) stroke/infarction(tissue death due to reduced blood supply) (80%)
- Thrombotic (blood clot)
- Large artery stenosis[vernauwing]
- Small vessel disease(little infarcts in the brain due to hypertension)
- Cardio-embolic(thrombosis due to embolic material in the heart)
- Hypoperfusion (severe hypotension)
Haemorrhagic stroke (17%) (see p. 1104)
- Intracerebral haemorrhage (12%) (see p. 1104)
- Subarachnoid haemorrhage (5%) (see p. 1105)
Other (3%), e.g. arterial dissection(trauma), venous sinus thrombosis, vasculitis(inflammation of blood vessels)
Riskfactors are: hypertension, smoking, alcohol, high cholesterol, obesity and diabetes
Symptoms
Limb weakness on the opposite side to the infarct develops over seconds, minutes or hours (occasionally
longer). There is a hemiparesis(weakness of one side of the body) with facial weakness. Aphasia(disturbance in
formulation an comprehension of language) is usual when the dominant hemisphere is affected. Weak limbs
are at first flaccid[slap] and areflexic. Headache is unusual. Consciousness is usually preserved. Exceptionally,
an epileptic seizure occurs at the onset. After a variable interval, usually several days, reflexes return,
becoming exaggerated. An extensor plantar response[zenuwreactie] appears. Weakness is maximal at first;
recovery occurs gradually over days, weeks or many months.
Diagnostic tools
CT-Scan
MRI
Doppler ultrasound
Treatment
When a stroke has been diagnosed, various other studies may be performed to determine the underlying
cause. In case of a blood clot: A medicine called tissue plasminogen activator (tPA) is given, it can break up
blood clots in the arteries of the brain.
Filmpjes
http://www.youtube.com/watch?v=M_fo6ytlmD0
http://www.youtube.com/watch?v=LAzRf06BFsg
58
Transient ischemic attack (TIA)
General information disease
Transient ischaemic attack (TIA) means a brief episode of neurological dysfunction due to temporary focal
cerebral or retinal ischaemia without infarction, e.g. a weak limb, aphasia(disturbance in formulation and
comprehension of language) or loss of vision, usually lasting seconds or minutes with complete recovery. TIAs
may herald a stroke. The arbitrary time of <24 hours is no longer used. Prospective studies show that 5 years
after a single thromboembolic TIA:
- 30% have had a stroke, a third of these in the first year
- 15% have suffered a myocardial infarct.
Causes
TIAs are usually the result of microemboli, but different mechanisms produce similar clinical events. For
example, TIAs may be caused by a fall in cerebral[hersen] perfusion[doorbloeding] (e.g. a cardiac dysrhythmia,
postural hypotension or decreased flow through atheromatous arteries). Infarction is usually averted by
autoregulation. Rarely, tumours and subdural haematomas cause episodes indistinguishable from
thromboembolic TIAs. Principal sources of emboli to the brain are cardiac thrombus and atheromatous
plaques/thrombus within the aortic arch, carotid and vertebral systems. Cardiac thrombus often results from
atrial fibrillation or myocardial infarction. Cardiac valve disease may be a source of emboli, e.g. calcific
material or vegetations in infective endocarditis. Polycythaemia is also a cause.
Riskfactors are: hypertension, smoking, alcohol, high cholesterol, obesity and diabetes
Symptoms
TIAs cause sudden loss of function, and usually last minutes or hours (by classical definition <24 h, but this is
not used now). The site is often suggested by the type of attack. The most common symptoms are
hemiparesis[halfzijdige verlamming] and aphasia. Other symptoms are:
Amaurosis fugax(temporary loss of vision in one eye), Hemisensory loss(loss of sensation of one side of the
body), Hemianopic visual loss(temporary vision loss respects the vertical midline, usually affects both eyes),
vertigo, vomiting, loss of consciousness (rare) and transient global amnesia (possibly)
Diagnostic tools
Diagnosis of TIA is often based solely upon its description. It is unusual to witness an attack if they are so brief.
Consciousness is usually preserved in TIA. There may be clinical evidence of a source of embolus, like atrial
fibrillation, recent myocardial infarction. In case of a more severe Tia, investigations should include Doppler of
internal carotid arteries, cardiac echo, ECG and 24 h tape CT/MR brain including angiography.
Treatment
Treat(if necessary) with medical therapy(same as in case of stroke) and surgical treatment if appropriate
Filmpjes
http://www.youtube.com/watch?v=uWec-83ufVg
http://www.youtube.com/watch?v=3CInkjVReDA
59
General medicine
Theme 4
Cardiovascular system
Abdominal Aortic Aneurysm 786
Angina Pectoris 728-732
Cardiac Arrest 693-694
Cardiac Arrhythmias 697-714
Chronic or Acute ischaemia of the leg (intermittent claudation)
Coronary Artery Disease = ischaemic heart disease 723-736
Gastro-oesophageal reflux disease (GORD)
(Congestive) heart failure 717-723
Hyperlipidemia/hypercholesterolemia 1034-1039
Hypertension 777-784
Myocardial infarction 733-740
Pericarditis 774-777
Peripheral arterial disease/vascular disease 784-789
Sudden cardiac death 770 (table 14.48)
Valvular heart disease 740-751
Varicose veins 789
(Arterial and) Venous thrombosis 424-429
http://www.youtube.com/watch?v=te_SY3MeWys
60
(Abdominal) Aortic Aneurysm 786
General information disease
Aortic aneurysm is a localized dilatation (ballooning) of the abdominal aorta. It occurs most commonly below
the renal arteries. The incidence increases with age, being present in 5% of the population >60 years. They
occur five times more frequently in men and in one in four male children of an affected individual.
Causes
An exact cause of AAA is not known. Aneurysms may occur secondary to atherosclerosis, infection (syphilis,
Escherichia coli, Salmonella) and trauma, or may be genetic (Marfan's syndrome, Ehlers-Danlos syndrome).
Riskfactors are:
- Tabocco smoking
- Alcohol and hypertension
Symptoms
Rapid expansion or rupture of this dilatation can cause severe pain (radiating to the back).
A ruptured aortic aneurysm causes:
- hypotension(verlaagde bloeddruk)
- tachycardia(hartkloppingen),
- profound anaemia and sudden death. The symptoms of rupture may mimic[nabootsen] renal colic,
diverticulitis(inflammation of large intestine) and severe lower abdominal or testicular pain. Gradual erosion
of the vertebral bodies may cause nonspecific back pain. The aneurysm may embolize distally(far from point
of reference). Inflammatory aneurysms can obstruct adjacent[aangrenzende] structures, e.g. ureter,
duodenum[12-vingerige darm] and vena cava[holle ader].
Diagnostic tools
Most aneurysms are asymptomatic and are found on routine abdominal examination, plain X-ray or during
urological investigations. An aneurysm is suspected if a pulsatile[pulsvormige], expansile abdominal mass is
felt. The presence of an AAA should alert a clinician to the possibility of popliteal aneurysms. Patients may
present with 'trash feet', dusky discoloration of the digits secondary to emboli from the aortic thrombus.
Patients diagnosed with an AAA may require further assessment with MRI or CT to assess the anatomical
relationship to the renal and visceral vessels and for patients referred for intervention.
* X-ray
* Ultrasound
* MRI
* CT
Treatment
Patients with aneurysmal disease need careful control of hypertension, to stop smoking and to have lipidlowering medication. Patients with AAA <5.5 cm are followed up by regular ultrasound surveillance. Patients
with AAA>5,5 cm will have an operation.
Filmpjes
http://www.youtube.com/watch?v=FbjFQvwSzYk
61
Angina Pectoris 728-732
General information disease
Angina pectoris is chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm of the
coronary arteries. The Health Survey for England 2006 reported a prevalence of angina of 14.2% in men aged
65-74 years and 8.3% in women aged 65-74 years old. In the UK, an estimated 2 million people over the age of
35 years have had angina.`
Causes
The main cause of angina pectoris is Coronary Artery Disease, due to atherosclerosis of the arteries feeding
the heart. Risk factors are:
- Age (≥ 55 years for men, ≥ 65 for women)
- Cigarette smoking
- Diabetes mellitus (DM)
- Dyslipidemia
- Family history of premature cardiovascular disease (men <55 years, female <65 years old)
- Hypertension (HTN)
- Kidney disease (microalbuminuria or GFR<60 mL/min)
- Obesity (BMI ≥ 30 kg/m2)
- Physical inactivity
- Prolonged psychosocial stress
Symptoms
The chest pain is generally described as 'heavy', 'tight' or 'gripping'. Typically, the pain is
central/retrosternal(situated or occurring behind the sternum[borstbeen]) and may radiate to the jaw[kaak]
and/or arms. Angina can range from a mild ache to a most severe pain that provokes sweating and fear. There
may be associated breathlessness. Classical angina pectoris is characterized by:
- constricting discomfort in the front of the chest, arms, neck, jaw;
- provoked by physical exertion, especially after meals and in cold, windy weather or by anger or excitement
- relieved (usually within minutes) with rest or glyceryl trinitrate. Occasionally, it disappears with continued
exertion ('walking through the pain').
Typical angina has all three features, atypical angina two out of the three, and non-anginal chest pain one or
less of these features.
Angina is stable when it is not a new symptom and when there is no change in the frequency or severity of
attacks.
Diagnostic tools
The diagnosis of angina is largely based on the clinical history. There are usually no abnormal findings in
angina, although occasionally a fourth heart sound may be heard. During an attack, transient ST depression, T
wave inversion or other changes of the shape of the T wave may appear with an ECG.
* cardiac catheterization or CT coronary angiography
* functional imaging (SPECT, stress-echocardiography, stress-magnetic resonance imaging)
Treatment
Patients should be informed as to the nature of their condition and reassured that the prognosis is good
(annual mortality <2%). Underlying problems, such as anaemia or hyperthyroidism, should be treated.
Management of co-existent conditions, such as diabetes and hypertension, should be optimized. Risk factors
should be evaluated and steps made to correct them where possible; e.g. smoking must be stopped,
hypercholesterolaemia should be identified and treated (see below), weight loss, where appropriate, and
62
regular exercise should be encouraged.
Low-dose aspirin is indicated.
Patients can be treated with intravenous nitroglycerin.
If patients remain symptomatic then a beta-blocker can be combined with a dihydropyridine calcium channel
receptor antagonist (e.g. amlodipine)
Filmpjes
http://www.youtube.com/watch?v=GIWb4-a7A6A
Cardiac Arrest (hartstilstand) 693-694
General information disease
Cardiac arrest is the end of normal circulation of the blood due to failure of the heart to contract effectively. A
cardiac arrest is different from (but may be caused by) a heart attack, where blood flow to the muscle of the
heart is impaired. Arrested blood circulation prevents delivery of oxygen to the body. Cardiac arrest is
potentially reversible if treated early. Unexpected cardiac arrest sometimes leads to death almost
immediately
Causes
Most death are due to ventricular fibrillation[onregelmatig hart] or rapid ventricular tachycardia, and a small
proportion are due to severe bradyarrhythmias(slowness of the heart beat) and the remain is due to
asystole(no cardiac electrical activity). Coronary artery disease accounts for approximately 80% of sudden
cardiac deaths in western society. Transient ischaemia is suspected as the major trigger factor, however, only
a small proportion of survivors have clinical evidence of acute myocardial infarction.
Symptoms
Lack of oxygen to the brain causes loss of consciousness, which then results in abnormal or absent breathing.
Brain injury is likely if cardiac arrest goes untreated for more than five minutes.
Diagnostic tools
A cardiac arrest is usually diagnosed clinically by the absence of a pulse. In many cases lack of carotid pulse is
the gold standard for diagnosing cardiac arrest. The pulse can be seen on a:
* ECG
Treatment
For the best chance of survival and neurological recovery, immediate and decisive treatment is imperative.
* ventricular fibrillation or pulseless ventricular tachycardia is readily treated with defibrillation,
cardiopulmonary resuscitation(reanimeren met handen) and drugs(adrenaline)
* asystole can be treated with vasopressin and cardiopulmonary resuscitation
* Implantable cardioverter-defibrillator. This device can deliver a shock when the heart is arrhythmic or starts
to fibrillate (willekeurig samentrekken van hartkamers/boezems waardoor er geen bloed meer wordt
rondgepompt)
Filmpjes
http://www.youtube.com/watch?v=2dyOcwJfXUM
63
Cardiac Arrhythmias 697-714
General information disease
An abnormality of the cardiac rhythm is called a cardiac arrhythmias. The heartbeat may be too fast or too
slow, and may be regular or irregular. A heartbeat that is too fast(>100 bpm) is called tachycardia and a
heartbeat that is too slow(<60 BPM) is called bradycardia. In adults the normal resting heart rate ranges from
60 to 80 beats per minute.
Causes
Cardiac arrhythmias can be caused by abnormalities in the sinus node(the normal cardiac
pacemaker/electrical sign). The rate of sinus mode is modulated by the autonomic nervous system. A
reduction of parasympathetic tone or an increase in sympathetic stimulation leads to tachycardia(for example
during inspiration); conversely, increased parasympathetic tone an decreased sympathetic stimulation
produces bradycardia(during expiration). Abnormalities of automaticity, which could arise from a single cell,
and abnormalities of conduction, which require abnormal interaction between cells, account for both
bradycardia and tachycardia.
These abnormalities can be due to : hypothermia[onderkoeld], hypothyroidism, cholestatic jaundice, raised
intracranial pressure, neutrally mediated syndrome, myocardial infarction, emotional stress, or present at
birth
Symptoms
Arrhythmias may cause sudden death, syncope[flauwvallen], heart failure, chest pain, dizziness,
palpitations(abnormal heart beats), shortness of breath or no symptoms at all.
Diagnostic tools
Auscultation of the heartbeat with a stethoscope, or feeling for peripheral pulses.
* ECG
Treatment
* Defibrillation is the only intervention that can restore a healthy heart rhythm
* Pacemaker(regulates rhythm of the heart)
* Implantable cardioverter-defibrillator. This device can deliver a shock when the hearts starts to
fibrillate(willekeurig samentrekken van hartkamers/boezems waardoor er geen bloed meer wordt
rondgepompt, zie filmpje)
* Medication (blood thinners like aspirin to prevent blood clots)
Filmpjes
http://www.youtube.com/watch?v=zOyXvOst7y0
64
Chronic or acute ischaemia of the leg (intermittent claudication (etalagebenen)) 784-786
General information disease
Patients with intermittent claudication(chronic ischaemia of the leg) complain of exertional[inspannings]
discomfort most commonly in the calf[kuit] which is relieved by rest. The pain disappears after a brief rest and
the patient can start walking again until the pain recurs.
In case of acute ischaemia of the leg, there is a sudden lack of blood flow to the legs. This is due to embolism
or thrombosis. Symptoms are pulsless leg, pale in color, cold feeling, burning or tingling feeling or paralysed
leg.
Causes
The pain in the leg is due to a narrowing or blocking(acute) of the arteries in or to the legs (peripheral arterial
disease which implies significant atherosclerotic blockages resulting in arterial insufficiency).
Common risk factors are:
- Smoking
- Diabetes
- Hypercholesterolaemia
- Hypertension
Symptoms
Patients with rest pain experience severe unremitting[voortdurende] pain in the foot, which stops a patient
from sleeping. It is partially relieved by dangling the foot over the edge of the bed or standing on a cold floor
The lower limbs are cold with dry skin and lack of hair. Pulses may be diminished or absent.
Ulceration[zweervorming] may occur in association with dark discoloration of the toes or gangrene. The
abdomen should be examined for a possible aneurysm..
Diagnostic tools
Injection with contrast fluid can be helpfull, so the arteries can be projected.
Duplex ultrasound using B-mode ultrasound and colour Doppler can provide an accurate anatomical map of
the lower limbs.
Treatment
* Patients should be encouraged to exercise and to avoid obesity.
* Vascular intervention for stable claudication is not generally recommended except in patients with severe or
disabling symptoms.
* Percutaneous transluminal angioplasty(PTA) -> dotteren
* In case of acute ischaemia, surgery can be helpful, they can make a bypass
* In severe ischaemia with unreconstructable arterial disease an amputation may be necessary. An
amputation may lead to loss of independence, with only 70% of below-knee and 30% of above-knee amputees
achieving full mobility.
Filmpjes
65
Coronary Artery Disease = ischaemic heart disease(myocardial ischaemia) 723-736
General information disease
Coronary artery disease (CAD) is the result of the accumulation of atheromatous plaques [this plaque is made
up of fat, cholesterol etc.] within the walls of the coronary arteries that supply the myocardium (the muscle of
the heart) with oxygen and nutrients. Ischaemic heart disease most commonly occurs as a result of obstructive
coronary artery disease (CAD) in the form of coronary atherosclerosis. Ischaemic heart disease occurs when
there is an imbalance between the supply of oxygen (and other essential myocardial nutrients) and the
myocardial demand for these substances.
CAD is the largest single cause of death in the UK and many parts of the world. However, over the last decade,
the mortality rate in the UK has fallen considerably. In 2009, 1 in 5 male and 1 in 8 female deaths were from
coronary artery disease; approximately 82 000 deaths in the UK
Causes
Coronary blood flow to the myocardium may be reduced by a mechanical obstruction that is due to:
- Atheroma (atherosclerosis-> see picture->)
- Thrombosis
- Spasm
- Embolus
- Coronary ostial stenosis(narrowing of the arteries due
to aortitis or artherosclerosis)
- Coronary arteritis (inflammation of the walls of the
arteries)
There can be a decrease in the flow of oxygenated blood
to the myocardium that is due to:
- Anaemia
- Carboxyhaemoglobulinaemia (carbonmonoxide and
haemoglobin in red blood cells)
- Hypotension causing decreased coronary perfusion pressure
Risk factors are: age, male sex, positive family history, hyperlipidaemia, smoking, hypertension, diabetes, lack
of exercise, obesity, gout[jicht], alcohol
Symptoms
Can be asymptomatic, with myocardial infarctions going unrecognized. Angina pectoris is a consequence of
CAD, even like other heart diseases.
Diagnostic tools
A high cholesterol level in the blood and high blood pressure can indicate CAD.
* CT coronary angiography
Treatment
* Medical treatment: Aspirin, Omega 3 to reduce cholesterol
* Cornoray intervention (stent-implantation->dotteren)
* Coronary artery bypass
Filmpjes
http://www.youtube.com/watch?v=qnbUhMogDNI
66
Gastro-oesophageal reflux disease (spier tussen de slokdarm en maag is ontregeld) (GORD) 238
General information disease
GORD is usually caused by changes in the barrier between the stomach and the esophagus (het terugvloeien
van maagzuur in de slokdarm). Between swallows, the muscles of the oesophagus are relaxed except for those
of the sphincters. Small amounts of gastro-oesophageal reflux are normal. With GORD, there is abnormal
relaxation of the lower esophageal sphincter(sluitspier). This relaxation may be permanent or temporary.
Causes
Factors associated with GORD are:
- Pregnancy or obesity
- Fat, chocolate, coffee or alcohol ingestion
- Large meals
- Cigarette smoking
- Drugs - antimuscarinic, calcium-channel blockers, nitrates
- Systemic sclerosis
- After treatment for achalasia
- Hiatus hernia
Symptoms
When the antireflux mechanism fails, heartburn and swallow problems occur. The heart burning is
aggravated(erger) by bending, stooping(buigen) or lying down which promote acid exposure. Regurgitation of
food and acid into the mouth occurs, particularly on bending or lying flat. The patient complains of pain on
drinking hot liquids of alcohol. Symptoms should reduce with antacids.
Diagnostic tools
The clinical diagnosis can usually be made without investigation. Unless there are alarm signs, especially
dysphagia(swallow problems), patients under the age of 45 years can safely be treated initially without
investigations. If investigation is required, there are two options:
* Endoscopy
* Intraluminal monitoring (24-hour intraluminal pH monitoring) If pH<4 for >4% of the time -> GORD
Treatment
GORD can be treated by oral antacids, by raising the head of the bed at night, loss of weight and by surgery.
Reduction of alcohol, caffeine consumption and smoking can reduce symptoms.
Filmpjes
http://www.youtube.com/watch?v=PwVAnwpbC_I
67
(Congestive) Heart failure 714-723
General information disease
Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that
impairs the ability of the heart to function as a pump to support a physiological circulation. In the UK, overall
incidence is about 2 in 1000. Approximately 23 million people worldwide have heart failure. The prognosis of
heart failure has improved over the past 10 years, but the mortality rate is still high with approximately 50% of
patients dead at 5 years. Heart failure accounts for 5% of admissions to hospital medical wards.
Cardiac asthma is a medical symptom, of wheezing, coughing or shortness of breath which may be due to
congestive heart failure. It is known as cardiac asthma because the symptoms may mimic asthma. One study
found one third of all patients involved who have symptoms of cardiac asthma also have congestive heart
failure. Healthy heart functioning = 60% or more, Heart failure functioning = 40% or less
Causes
Main causes
 Ischaemic heart disease (35-40%)
 Cardiomyopathy (dilated) (30-34%)
 Hypertension (15-20%)
Other causes
 Cardiomyopathy [verslechtering vd hartspier]
 Valvular heart disease [kleppen]
 Congenital heart disease [defect in structure of the heart)
 Alcohol and drugs (chemotherapy - trastuzumab, imatinib)
 Hyperdynamic circulation (anaemia, thyrotoxicosis, haemochromatosis, Paget's disease)
 Right heart failure (RV infarct, pulmonary hypertension, pulmonary embolism, (COPD))
 Tricuspid incompetence[lekkende hartklep]
 Arrhythmias (atrial fibrillation, bradycardia (complete heart block, the sick sinus syndrome))
 Pericardial disease (membrane that surrounds the heart)
 Infections (Chagas' disease), e.g. myocarditis
Symptoms
Symptoms and signs of heart failure are:
- Exertional dyspnoea(excessive shortness of breath after exercise)
- Paroxysmal nocturnal dyspnoea(severe shortness of breath causing coughing at night)
- Orthopnoea(shortness of breath (dyspnea) which occurs when lying flat)
- Fatigue and weakness
- Swelling (oedema) in your legs, ankles and feet
- Rapid or irregular heartbeat
- Reduced ability to exercise
- Persistent cough or wheezing with white or pink blood-tinged phlegm
- Swelling of your abdomen (ascites)
- Sudden weight gain from fluid retention
- Lack of appetite and nausea
- Difficulty concentrating or decreased alertness
Diagnostic tools
Essential features: Symptoms and signs of heart failure (e.g. breathlessness, fatigue, ankle swelling)
And objective evidence of cardiac dysfunction (at rest, e.g. echocardiogram)
In cases where the diagnosis is in doubt: Response to treatment directed towards heart failure
* X-ray -> pulmonary oedema, fluid in fissures etc.
*ECG
Treatment
Measures to prevent heart failure include cessation of smoking, alcohol and illicit drugs.
The cause of heart failure must be indicated and treated, like treatment of hypertension, diabetes and
hypercholesterolaemia.
* People with fluid should get diuretics
* Angiotensin-converting enzyme inhibitors(ACEI)
* Beta blockers (improve functional status)
Filmpjes
http://www.youtube.com/watch?v=GnpLm9fzYxU
68
Hyperlipidaemia/hypercholesterolemia (hoog cholesterol) 1034-1039
General information disease
Hypercholesterolemia is the presence of high levels of cholesterol in the blood. Hyperlipidaemia results from
genetic predisposition[aanleg] interacting with an individual’s diet. It can increase the chance of
cardiovascular diseases.
Causes
- Hypothyroidism
- Diabetes mellitus (when poorly controlled)
- Obesity
- Renal impairment
- Nephrotic syndrome
- Dysglobulinaemia [afwijkende samenstelling van de eiwitten]
- Hepatic dysfunction (liver dysfunction)
- Alcohol in susceptible individuals
- Drugs:
Oral contraceptives in susceptible individuals
Retinoids, thiazide diuretics, corticosteroids, op'DDD (used in the treatment of Cushing's syndrome),
sirolimus (and other immunosuppressive agents)
Symptoms
Hyperlipidaemia normally causes no symptoms so it can be unnoticed for several years. It usually runs in
families so any individual with an arterial disease, stroke or heart attack at a young age in the family history,
are more probable to have this condition. It can lead to stenosis, atherosclerosis.
Diagnostic tools
Blood tests -> measuring the cholesterol level. Under 5,0 mmol/L is normal, between 5,0 and 6,4 the
cholesterol is a bit too high, above 6,5 mmol/L it is too high and drug therapy is warranted.
Treatment
- Lipid-lowering diet
- Statins are the most widely used lipid-lowering agents
Filmpjes
http://www.youtube.com/watch?v=Yyr67JBiU0Q
http://www.youtube.com/watch?v=7NTeOgumV_k
69
Hypertension 777-784
General information disease
Elevated arterial blood pressure is a major cause of premature vascular disease leading to cerebrovascular
events, ischaemic heart disease and peripheral vascular disease. Hypertension is very common in the
developed world. Depending on the diagnostic criteria, hypertension is present in 20-30% of the adult
population. Hypertensives have a six-fold increase in stroke (both haemorrhagic and atherothrombotic) and
there is a three-fold increase in cardiac death.
Category
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Blood pressure
Optimal
<120 and
<80
Normal
120-129 and/or
<80-84
High normala
130-139 and/or
85-89
140-159 and/or
90-99
160-179 and/or
100-109
Hypertension
Grade 1 (mild)
Grade 2
(moderate)
Grade 3 (severe) ≥180
≥110
Isolated systolic hypertension
Grade 1
140-149
<90
Grade 2
>160
<90
Causes
The majority(80-90%) of patients has primary elevation of blood pressure-> unknown cause. Risk factors are:
- Genetic factors ( still remains a large, still largely unidentified genetic component)
- Fetal factors(low birth weight)
- Environmental factors (obesity, alcohol intake, sodium intake, stess)
- Blood vessels with thickener walls, arterial stiffness
- NSAIDS
Symptoms
The patient with mild hypertension is usually
asymptomatic. Higher levels of blood
pressure may be associated with headaches,
epistaxis(bleeding of the nose) or
nocturia(urinate at night). Hypertension can
lead to:-------------------
Diagnostic tools
Measuring the blood pressure. Elevated blood pressure is usually the only abnormal sign. Signs of an
underlying cause should be sought, such as renal artery bruits in renovascular hypertension, or radiofemoral
delay in coarctation of the aorta.
Hypertension grade 2(160 mmHG) -> treatment
70
Treatment
Lose weight, more exercise (30 min a day), reduce fat intake and salt intake, increase fish oil intake.
If this not helps, drugs are: ACE inhibitors or angiotensin receptor antagonists; beta-blockers; calcium-channel
blockers or diuretics.
Filmpjes
http://www.youtube.com/watch?v=4jRy-YlZONA
Myocardial infarction (heart attack) 733-740
General information disease
Myocardial infarction occurs when cardiac myocytes(part of the heart muscle) die
due to myocardial ischaemia (=restiction of blood supply).
Acute coronary syndromes (ACS) include:
- ST-elevation myocardial infarction (STEMI)
- Non-ST-elevation myocardial infarction (NSTEMI)
- Unstable angina (UA) -> a thrombus
Causes
Myocardial infarction is caused by the interruption of blood supply to a part of the
heart, causing heart cells to die. This can be due to an embolism. Risk factors are:
- artherosclerosis
- stress of physical exertion[inspanning]
- high blood pressure, diabetes, smoking, obesity, alcohol
Symptoms
Symptoms:
- chest pain( (typically radiating to the left arm or left side of the neck),
- chest pain at rest,
- deterioration of pre-existing angina (drukkend gevoel).
Atypical symptoms are
- indigestion[spijsverteringsproblemen]
- pleuritic chest pain(sharp pain with inhalation)
- dyspnoea.
Diagnostic tools
In case of a myocardinal infarction, biochemical markers in the blood are elevated
(troponin and CK-MB)
* ECG-> a ST depression and T wave inversion can be seen
* MRI
Treatment
* Drugs (thrombolytic therapy, antiplatelets/aspirin, heparin, beta-blockers, ACEinhibitors etc.)
* Percutaneous coronary intervention (PCI) = (coronary) angioplasty = ‘Dottering’
* Coronary artery graft bypass surgery (CABG)
Filmpjes
http://www.youtube.com/watch?v=YdaJJ7JPGME
http://www.youtube.com/watch?v=n8P3n6GKBSY
71
Pericarditis (ontsteking van het hartzakje) 774-777
General information disease
The pericardium acts as a protective covering for the heart. Pericarditis is
an inflammation of the pericardium (the fibrous sac surrounding the
heart).
Causes
In most cases a cause is not identified. But pericarditis can be caused by:
- Viruses (Coxsackie B virus and echovirus)
- Post-myocardial infarction pericarditis (after a myocardial infarction)
- Uraemic pericarditis (irritation by toxins)
- Bacterial pericarditis (staphylococcus aureus)
- Tuberculous pericarditis
- Fungal pericarditis
- Malignant pericarditis
Symptoms
- Sharp central chest pain by movement, respiration and lying down. It is
typically relieved by sitting forward
- Chest pain may refer to the neck or shoulders
- fever
- Pericardial effusion -> may cause dyspnoea
Diagnostic tools
The diagnosis is based on serological tests of pericardial fluid and
identification of organisms in pericardial or myocardial biopsies.
* ECG : widespread concave-upwards (saddle-shaped) ST elevation,
reciprocal ST depression
* CT and cardiac MR may be helpful for in cases with thickened (>4 mm) or
inflamed (abnormal delayed enhancement) pericardium.
Treatment
If a cause is found, this should be treated. Bed rest and oral NSAIDs (highdose aspirin indometacin or ibuprofen) are effective in most patients.
Aspirin is the drug of choice for patients with a recent myocardial
infarction.
Corticosteroids should be reserved for patients with a known immune
cause as their use is associated with an increased rate of recurrence.
Filmpjes
.
(a) Acute pericarditis. Note the raised ST
segment, concave upwards(arrow).
(b) Chronic phase of pericarditis
associated with a pericardial effusion.
Note the T wave flattening and inversion,
and the alternation of the QRS amplitude
(QRS alternans).
(c) The same patient after evacuation of
the pericardial fluid. Note that the QRS
voltage has increased and the T waves
have returned to normal.
72
Peripheral arterial disease/vascular disease 784-789
General information disease
Pheripheral arterial or vascular disease refers to the obstruction of large arteries not within the coronary,
aortic arch vasculature, or brain but by the limbs. Limb ischaemia may be classified as chronic or acute.
Chronic lower limb ischaemia
Peripheral arterial disease can be described using the Fontaine classification:
 Stage I - asymptomatic
 Stage II - intermittent claudication (discomfort in the calf, relieved by a short period of rest)
 Stage III - rest pain/nocturnal pain (unremitting pain in the foot, which stops a patient from sleeping)
 Stage IV – ulceration or necrosis/gangrene (death of body tissue)
Causes
Peripheral vascular disease (PVD) is commonly caused by atherosclerosis, inflammatory processes leading to
stenosis, an embolism, or thrombus formation. It is present in 7% of middle-aged men and 4.5% of middleaged women, but these patients are more likely to die of myocardial infarction or stroke than lose their leg.
Common risk factors are:
- Smoking
- Diabetes
- Hypercholesterolaemia
- Hypertension.
Symptoms
The lower limbs are cold with dry skin and lack of hair. Pulses may be diminished or absent. Ulceration may
occur in association with dark discoloration of the toes or gangrene. The abdomen should be examined for a
possible aneurysm.
Diagnostic tools
Injection with contrast fluid can be helpfull, so the arteries can be projected.
Duplex ultrasound using B-mode ultrasound and colour Doppler can provide an accurate anatomical map of
the lower limbs
Treatment
* Patients should be encouraged to exercise and to avoid obesity.
* Vascular intervention for stable claudication is not generally recommended except in patients with severe or
disabling symptoms.
* Percutaneous transluminal angioplasty(PTA) -> dotteren
* In case of acute ischaemia, surgery can be helpful, they can make a bypass
* In severe ischaemia with unreconstructable arterial disease an amputation may be necessary. An
amputation may lead to loss of independence, with only 70% of below-knee and 30% of above-knee amputees
achieving full mobility.
Filmpjes
73
Sudden cardiac death 770 (table 14.48)
General information disease
Sudden cardiac death is natural death from cardiac causes, heralded by abrupt loss of consciousness within
one hour of the onset of acute symptoms. It is natural, rapid, and unexpected. Other forms of sudden death
may be noncardiac in origin, examples include respiratory arrest (such as airway obstruction in cases of
choking or asphyxiation), toxicity or poisoning, anaphylaxis, or trauma.
Causes
The most common cause is hypertrophic cardiomyopathy (a portion of the myocardium is hypertrophied
(thickened) without any obvious cause) and affects 1 in 500 of the population.
Other causes(table 14.48) are:
 Coronary artery disease
o Acute myocardial infarction - STEMI
o Chronic ischaemic heart disease
o Following coronary artery bypass surgery
o After successful resuscitation for cardiac arrest
o Congenital anomaly of coronary arteries
o Coronary artery embolism
o Coronary arteritis
 Non-coronary artery disease
o Hypertrophic cardiomyopathy
o Dilated[verwijde] cardiomyopathy (ischaemic or idiopathic)
o Arrhythmogenic right ventricular cardiomyopathy
o Congenital long QT syndrome
o Brugada syndrome
o Valvular heart disease (aortic stenosis, mitral valve prolapse) ± infective endocarditis
o Cyanotic heart disease (tetralogy of Fallot, transposition)
o Acyanotic heart disease (ventricular septal defect, patent ductus arteriosus)
Symptoms
Loss of consciousness
No pulse
Diagnostic tools
Person died
Treatment
The presence of these cardiac risk factors is associated with an increased risk of sudden death (Table 14.48),
and patients with two or more should be assessed for implantable cardioverter-defibrillator (ICD). In patients
in whom the risk is less, amiodarone(helpt bij hartritmestoornissen) is an appropriate alternative.
In patients in whom the risk is less, amiodarone is an appropriate alternative(Amiodaron vertraagt de
impulsgeleiding door de zenuwen en vermindert de prikkelbaarheid van de hartspier. Hierdoor vertraagt de
hartslag en wordt de hartslag terug regelmatiger).
Filmpjes
74
Valvular heart disease 740-751
General information disease
Valvular heart disease is any disease process involving one or more of the valves of the heart (the aortic and
mitral valves on the left and the pulmonary and tricuspid valves on the right).
Valvular stenosis occurs when a valve opening is smaller than normal due to stiffness. All 4 valves can be
stenotic (hardened, restricting blood flow). Valvular regurgitation occurs when a valve does not close tightly(
leaky valve).
Right side of the heart:
- tricuspid stenosis (diameter is reduced -> abdominal pain, swelling, peripheral oedema and dyspnoea)
- tricuspid regurgitation (backflow of blood into the right atrium-> dyspnoea)
- pulmonic stenosis (reduction of blood flow to the lungs-> fatigue, syncope and dysnpoea)
- pulmonic regurgitation (dilatation of the pulmonary valve ring -> murmur[ruis])
Left side of the heart:
- mitral stenosis (normally 4-6 cm, this is reduced <1. severe dysnoea -> right heart failure)
- mitral regurgitation (backflow of blood into the left atrium-> dyspnoea, orthopnoea and fatigue)
- aortic stenosis (left ventricular failure -> chest pain, breathlessness, syncope, fatigue)
- aortic regurgitation (backflow of blood into the left ventricle -> angina, left ventricular failure)
Causes
Valve problems may be congenital (inborn) or acquired (due to another cause later in life).
Can also caused by rheumatic fever.
Symptoms
Usually no symptoms until the valve is stenosed or the regurgitation is moderately severe. At this stage,
exercise-induced syncope, angina and dyspnoea develop.
Diagnostic tools
* Chest X-ray
- tricuspid stenosis: prominent right atrial bulge (uitpuiling)
- tricuspid regurgitation: dilatation of the right ventricle with thickening of the valve
- pulmonic stenosis: enlargement of the right ventricle and right atrium
- pulmonic regurgitation: usually no symptoms and treatment is rarely nessecary
- mitral stenosis: an enlarged left atrium
- mitral regurgitation: left atrial and ventricular enlargement
- aortic stenosis: smaller heart with a dilated aorta
- aortic regurgitation: left ventricular enlargement and dilatation of the aorta
* ECG shows deviations
Treatment
Treatment may be with medication but often (depending on the severity) involves valve repair or replacement
(insertion of an artificial heart valve).
* Anticoagultation to prevent thrombus
* Diuretics to treat dyspnoea
Filmpjes
75
Varicose veins (spataderen) 789
General information disease
Varicose veins are swollen veins and can be observed through the skin. They are often blue and bulging. Any
vein in your body can become varicose, but the veins in the legs are most commonly affected.
Causes
Varicose veins is due to dysfunctioning of the valves. The walls of the veins stretch and become less flexible,
which weakens the valves and stops them from working properly. Blood then leaks backwards and builds up in
the vein, causing it to swell. The reason why your valves stop working, is not fully understood. But risk factors
are: obesity, standing a lot, smoking, high blood pressure, pregnancy and age.
Symptoms
In case of varicose veins, the skin may change colour and become irritated or swollen. If varicose veins cause
complications, such as inflammation or bleeding, your skin changes or ulcers start to form. These symptoms
worsen when standing too long or at night.
Diagnostic tools
Can be seen at the skin.
Treatment
* Surgery (ligaton and stripping) verwijderen van de ader
* Laser
* Sclerotherapy (affected vein is injected with a chemical to seal it closed)
Even after surgery it may come back
Filmpjes
http://www.youtube.com/watch?v=VPeXRCc8w24 (goed filmpje! Uit college)
76
(Arterial and) venous thrombosis 424-429 and 789
General information disease
A thrombus is defined as a solid mass formed in the circulation from the constituents of the blood during life.
Fragments of thrombi (emboli) may break off and block vessels downstream. Thromboembolic disease is
much more common than abnormal bleeding; nearly half of adult deaths in England and Wales are due to
coronary artery thrombosis, cerebral artery thrombosis or pulmonary embolism.
Arterial thrombosis
This usually occurs in association with atheroma(thickened wall of artery, due to atherosclerosis), which tends
to form at areas of turbulent blood flow such as the bifurcation[splitsing] of arteries. Plaque rupture leads to
the exposure of blood containing factor VIIa to tissue factor within the plaque, which may trigger blood
coagulation and lead to thrombus formation.
Venous thrombosis
Venous thrombosis often occurs in normal vessels. Major causes of venous thrombosis are stasis[stilstand]
and hypercoagulability[sneller stollen dan normal]. A thrombus results from a complex series of events
involving coagulation factors, platelets, red blood cells and the vessel wall. The majority of venous thrombi
occur in the deep veins of the leg. This results in complete occlusion of the vessel or embolization that
produces distal obstruction. It is also a common problem after surgery.
Causes
Risk factors are:
- Age, reduced mobility, atherosclerosis, obesity, varicose veins, pregnancy, trauma, malignancy, recent
myocardial infarction and stroke.
It also can occur with changes in blood cells such as polycythaemia and thrombocythaemia, and with
coagulation abnormalities.
Symptoms
In deep vein thrombosis the individual may be asymptomatic, presenting with clinical features of pulmonary
embolism. A major presenting feature is pain in the calf, often with swelling, redness and engorged[gezwollen]
superficial[oppervlakkige] veins. The affected calf is often warmer and there may be ankle oedema.
Diagnostic tools
* Ultrasound
* Doppler
* Venogram
Treatment
The main aim of therapy is to prevent pulmonary embolism, and all patients with thrombi above the knee
must be anticoagulated. Anticoagulation (with e.g. heparin) of below-knee thrombi is now recommended for 6
weeks, as 30% of patients will have an extension of the clot proximally. Bed rest is advised until the patient is
fully anticoagulated. The patient should then be mobilized, with an elastic stocking giving graduated pressure
over the leg
Arterial thrombosis: Platelet[bloedplaatjes] activation by:
- Aspirin, dipyridamole, clopidogrel, prasugrel
Venous thrombosis: Heparin(activates antithrombin)
Filmpjes
http://www.youtube.com/watch?v=uRZIRq1va88
77
General medicin
Theme 5
Urology
1. Bacterial infection 114-139
2. Candidiasis 139-140, 170-171
3. Chlamydia trachomatis infection 133, 164
4. Glomerulonephritis 573-575
5. Gonorrhoeal disease 163-164
6. Herpes simplex virus infection 168-169
7. Prostatitis 591-592
8. Pyelonephritis 591-592
9. Urinary tract infection / cystitis 591-595
10. Renal disease 561-572
11. Renal (kidney) stones 665
12. Renal calculi 600-604
13. Renal tumour
14. Renal insufficiency / chronic renal failure as a
result of diabetes or hypertension
15. Sexually transmitted disease 160-194
16. Trichomonas Vaginalis infection 170
17. Extra Uterine pregnancy/eptopic pregnancy
18. Pelvic inflammatory disease
78
1. Bacterial infection 114-139
General information disease
Bacteria are living things that have only one cell. Under a microscope, they look like balls, rods, or
spirals. They are so small that a line of 1,000 could fit across a pencil eraser. Most bacteria won't
hurt you - less than 1 percent of the different types make people sick. Many are helpful. Some
bacteria help to digest food, destroy disease-causing cells, and give the body needed vitamins.
Bacteria are also used in making healthy foods like yogurt and cheese.
But infectious bacteria can make you ill. They reproduce quickly in your body. Many give off
chemicals called toxins, which can damage tissue and make you sick. Examples of bacteria that
cause infections include Streptococcus, Staphylococcus, and E. coli.
Causes
Symptoms
Diagnostic tools
The history and examination usually localizes the infection to a specific organ or body site. A
systematic response may accompany such localized disease or, in the case of bloodstream
infections, be the primary mode of presentation. The microbiological diagnosis is difficult to
establish in most community-managed infections and even in hospital where there is ready acces to
diagnostic laboratories, only a minority of infections are documented. For these reasons, a clinical
approach to bacterial diseases has been adopted.
Treatment
Antibiotics are usual treatment. When you take antibiotics, follow the directions carefully. Each time
you take antibiotics, you increase the chances that bacteria in your body will learn to resist them.
Later, you could get or spread an infection that those antibiotics cannot cure.
Filmpjes
79
2. Candidiasis 139-140, 170-171
General information disease
Most common fungal infection in humans. Candida are small asexual fungi and are found
worldwide.
De gist Candida albicans komt van nature voor op het lichaam, vooral op de huid en de slijmvliezen
en bijvoorbeeld in de mond en de darmen.
Candidiasis, een infectie, kan ontstaan als de gist de gelegenheid krijgt zich in korte tijd sterk te
vermenigvuldigen en doordringt in bijvoorbeeld een huidplooi of de slijmvliezen.
Candida albicans voelt zich het prettigst in een warme, vochtige omgeving, bijvoorbeeld op warme
plekjes op het lichaam, maar ook in aarde en afval.
Infecties met Candida albicans kunnen op verschillende plaatsen van het lichaam voorkomen, zoals:
■op het mondslijmvlies, ook wel bekend als mondspruw. Dit kan erg pijnlijk zijn. Deze infectie komt
met name voor bij kinderen en bij mensen met een sterk verminderde weerstand, bijvoorbeeld bij
een chemokuur.
■in de vagina. De klachten bestaan uit irritatie van de huid en slijmvliezen, hevige jeuk en
afscheiding.
■op de huid. Dit treedt met name op, op vochtige en warme plekken van het lichaam, zoals in
huidplooien. De bekende luieruitslag bij baby’s is ook een voorbeeld van een infectie met Candida
albicans. De huid is rood en vochtig en op de huid kunnen kleine met vocht gevulde blaasjes
ontstaan.
■in het bloed. Dit gebeurt incidenteel. Hierdoor ontstaat een levensbedreigende, “gegeneraliseerde
infectie”, die gepaard gaat met ontstekingen aan bijvoorbeeld de nieren en de lever. Deze
belangrijke organen functioneren hierdoor niet goed of helemaal niet meer. Mensen met een
gegeneraliseerde Candida-infectie zijn erg ziek en hebben hoge koorts, hoger dan 40 °C. Deze
infectie komt vrijwel alleen voor bij mensen die al ernstig ziek zijn of die als gevolg van een
medische behandeling heel weinig weerstand hebben. Voorbeelden hiervan zijn een chemokuur,
immunotherapie bij orgaantransplantatie, een ingrijpende buikoperatie, een HIV-infectie en AIDS.
Causes
Predominantly causes by candida albicans although other species of candida are increasingly
recognized.
Symptoms
Any organ in the body can be invaded by candida, but vaginal infection and oral thrush are the most
common forms. This latter is seen in the very young, in the elderly, following antibiotic therapy and
in those who are immunosuppresed.
Candidal oesophagitis presents with painfull pysphagia.
Cutaneous candidiasis typically occurs in intertriginous areas. It is also a cause of paronychia.
Balanitis and vaginal infectin are also common.
Dissemination of candidiasis may lead to haematogenous spread, with meningitis, pulmonary
involvement, endocarditis or osteomyelitis.
Diagnostic tools
The fungi can be demonstrated in scrapings from infected lesions, tissue secretions or in invasive
disease, from blood cultures.
Treatment
Treatment varies depending on the site and severity of infection. Oral lesions respond to local
nystatin or amphotericin B, or systematic fluconazole. For systematic infections, parental therapy
with amphotericin B, fluconazole, voriconazole or caspofungin is necessary.
Filmpjes
http://nl.wikipedia.org/wiki/Candidiasis
80
3. Chlamydia trachomatis infection 133, 164
General information disease
Chlamydia (kluh-MID-ee-uh) is a common sexually transmitted illness. You may not know you have
chlamydia because many people never develop the signs or symptoms, which may include genital
pain and a discharge from the vagina or penis.
Chlamydia affects both men and women and occurs in all age groups, though it's most prevalent
among young women. Chlamydia isn't difficult to treat once you know you have it. If it's left
untreated, however, chlamydia can lead to more-serious health problems.
Causes
Is caused by genitial infection of the intracellular bacteria Chlymydia Trachomatis. Common sit of
infection for women is the endocervix, which can occur unnoticed (asymptomic).
Symptoms
up to 80% is asymptomic
- vaginal discharge
- post-coital or intramenstrual bleeding
- lower abdominal pain
- Reactive artrithis have been related to C.trachomatis
Painful urination, Lower abdominal pain, Discharge from the penis in men, Painful sexual
intercourse in women, Testicular pain in men
Diagnostic tools
Nucleic acid amplification test (NAAT)
Cell culture techniques ( gold standard 100% sensitive)
Direct fluorescent antibody (DIF) and enzyme immunoassay (EIA) are less reliable
Endocervical and uretheral swabs are taken
Treatment
most common: tetracyclines or macrolyde antibiotics
Tracing sexual contacts
Filmpjes
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4. Glomerulonephritis 573-575
General information disease
Glomerulonephritis is inflammation of the tiny filters in your kidneys (glomeruli). Glomeruli remove
excess fluid, electrolytes and waste from your bloodstream and pass them into your urine. Also
called glomerular disease, glomerulonephritis can be acute — a sudden attack of inflammation — or
chronic — coming on gradually.
If glomerulonephritis occurs on its own, it's known as primary glomerulonephritis. If another
disease, such as lupus or diabetes, is the cause, it's called secondary glomerulonephritis. If severe or
prolonged, the inflammation associated with glomerulonephritis can damage your kidneys.
Treatment depends on the type of glomerulonephritis you have.
Causes
A variety of conditions can cause glomerulonephritis, ranging from infections that affect your
kidneys to diseases that affect your whole body, including your kidneys. Sometimes the cause is
unknown. Here are some examples of conditions that can lead to inflammation of the kidneys'
glomeruli:
Infections
-Post-streptococcal glomerulonephritis. Glomerulonephritis may develop a week or two after
recovery from a strep throat infection or, rarely, a skin infection (impetigo).
-Bacterial endocarditis. Bacteria can occasionally spread through your bloodstream and lodge in
your heart, causing an infection of one or more of your heart valves.
Immune diseases
- Lupus. A chronic inflammatory disease, lupus can affect many parts of your body, including your
skin, joints, kidneys, blood cells, heart and lungs.
- Goodpasture's syndrome. A rare immunological lung disorder that may mimic pneumonia,
Goodpasture's syndrome causes bleeding (hemorrhage) into your lungs as well as
glomerulonephritis.
IgA nephropathy. Characterized by recurrent episodes of blood in the urine, this primary glomerular
disease results from deposits of immunoglobulin A (IgA) in the glomeruli
Vasculitis
- Polyarteritis. This form of vasculitis affects small and medium blood vessels in many parts of your
body, such as your heart, kidneys and intestines.
-Wegener's granulomatosis. This form of vasculitis affects small and medium blood vessels in your
lungs, upper airways and kidneys.
Conditions that are likely to cause scarring of the glomeruli
-High blood pressure. Damage to your kidneys and their ability to perform their normal functions
can occur as a result of high blood pressure. Glomerulonephritis can also cause high blood pressure
because it reduces kidney function.
- Diabetic kidney disease. Diabetic kidney disease (diabetic nephropathy) can affect anyone with
diabetes. Diabetic nephropathy usually takes years to develop. Good control of blood sugar levels
and blood pressure may prevent or slow kidney damage.
-Focal segmental glomerulosclerosis. Characterized by scattered scarring of some of the glomeruli,
this condition may result from another disease or occur for no known reason.
Chronic glomerulonephritis sometimes develops after a bout of acute glomerulonephritis. In some
people there's no history of kidney disease, so the first indication of chronic glomerulonephritis is
chronic kidney failure. Infrequently, chronic glomerulonephritis runs in families. One inherited form,
Alport syndrome, may also involve hearing or vision impairment.
Symptoms
Signs and symptoms of glomerulonephritis may depend on whether you have the acute or chronic
form, and the cause. Your first indication that something is wrong may come from symptoms or
from the results of a routine urinalysis. Signs and symptoms may include:
-Pink or cola-colored urine from red blood cells in your urine (hematuria)
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- Foamy urine due to excess protein (proteinuria)
-High blood pressure (hypertension)
- Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen
- Fatigue from anemia or kidney failure
Diagnostic tools
Specific signs and symptoms may suggest glomerulonephritis, but the condition often comes to light
when a routine urinalysis is abnormal. Tests to assess your kidney function and make a diagnosis of
glomerulonephritis include:
- Urine test. A urinalysis may show red blood cells and red cell casts in your urine, an indicator of
possible damage to the glomeruli. Urinalysis results may also show white blood cells, a common
indicator of infection or inflammation, and increased protein, which may indicate nephron damage.
Other indicators, such as increased blood levels of creatinine or urea, are red flags.
-Blood tests. These can provide information about kidney damage and impairment of the glomeruli
by measuring levels of waste products, such as creatinine and blood urea nitrogen.
- Imaging tests. If your doctor detects evidence of damage, he or she may recommend diagnostic
studies that allow visualization of your kidneys, such as a kidney X-ray, an ultrasound examination or
a computerized tomography (CT) scan.
- Kidney biopsy. This procedure involves using a special needle to extract small pieces of kidney
tissue for microscopic examination to help determine the cause of the inflammation. A kidney
biopsy is almost always necessary to confirm a diagnosis of glomerulonephritis.
Treatment
Treatment of glomerulonephritis and your outcome depend on:
-Whether you have an acute or chronic form of the disease
-The underlying cause
- The type and severity of your signs and symptoms
Some cases of acute glomerulonephritis, especially those that follow a strep infection, tend to
improve on their own and often require no specific treatment.
In general, the goal of treatment is to protect your kidneys from further damage.
--> Treatment for high blood pressure
--> Treatment for an underlying cause
If there's an underlying cause for your kidney inflammation, your doctor may prescribe other drugs
to treat the underlying problem, in addition to treatment to control any hypertension:
-Strep or other bacterial infection.
-IgA nephropathy. Both fish oil supplements and certain immune-suppressing drugs have been
successful in some people with IgA nephropathy. Further research is being done.
-Goodpasture's syndrome. Plasmapheresis is sometimes used to treat people with Goodpasture's
syndrome. Plasmapheresis is a mechanical process that removes antibodies from your blood by
taking some of your plasma out of your blood and replacing it with other fluid or donated plasma.
-->Therapies for associated kidney failure
For acute glomerulonephritis and acute kidney failure, dialysis can help remove excess fluid and
control high blood pressure. The only long-term therapies for end-stage kidney failure are kidney
dialysis and kidney transplantation. When a transplant isn't possible, often because of poor general
health, dialysis becomes the only option.
Filmpjes
http://www.youtube.com/watch?v=64Xuw1hz5HY
http://nl.wikipedia.org/wiki/Glomerulonefritis
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5. Gonorrhoeal disease 163-164
General information disease
Gonorrhea is an infection caused by a sexually transmitted bacterium that can infect both males and
females. Gonorrhea most often affects the urethra, rectum or throat. In females, gonorrhea can also
infect the cervix.
Causes
Gonorrhoea is caused by the gram-negative intracellular diplococcus Neisseria gonorrhoae. The
infection site is the epithelium of especially the urogenital tract, rectum, pharynx and conjunctivae.
Infection through sexual intercourse or vertical (mother to child)
Symptoms
50% of the women is asymptomatic, only 10% in men
Symptoms men:
-Dysuris, urethral discharge
-Complecations infections of the epididymis, prostate or rectal MSM(procritis with pain, discharge
and ich)
Symptoms women: -increased/altered vaginal discharge
-Pelvic pain ( ascending infection)
-Dysuria
-Intermenstrual bleeding
-Infertitlity
Diagnostic tools
Culturing on selective media
-NAAT
-Micropsy of Gram-stained secretions
-Blood cultures and synovial fluid test, when GC is disseminated
- Urine test
- Swab of affected area
Treatment
Antibiotics depending on history patient and test which strain
Filmpjes
84
6. Herpes simplex virus infection 168-169
General information disease
Genital herpes is a common sexually transmitted infection that affects both men and women.
Features of genital herpes include pain, itching and sores in your genital area. But many infected
people have no signs or symptoms of genital herpes. An infected person can be contagious, even if
he or she has no visible sores.
Genital herpes is caused by the herpes simplex virus (HSV). Sexual contact is the primary way that
the virus spreads. After the initial infection, the virus lies dormant in your body and can reactivate
several times a year.
There's no cure for genital herpes, but medications can ease symptoms and reduce the risk of
infecting others. Condoms also can help prevent transmission of the virus.
Causes
Transmission of the virus occurs during close contact with an infected person. Genital herpes is due
to Herpes simplex virus type 2, but genital contact with oral lesions of HSV 1 can also cause genital
herpes. The infection site of the virus is the mucosal membrane of e.g. the genital tract, rectum,
mouth and oropharynx.
Two types of herpes simplex virus infections can cause genital herpes:
HSV-1. This is the type that usually causes cold sores or fever blisters around your mouth, though it
can be spread to your genital area during oral sex.
HSV-2. This is the type that commonly causes genital herpes. The virus spreads through sexual
contact and skin-to-skin contact. HSV-2 is very common and highly contagious, whether or not you
have an open sore.Because the virus dies quickly outside of the body, it's nearly impossible to get
the infection through contact with toilets, towels or other objects used by an infected person.
Symptoms
-fever
-Myalgia (muscle pain)
- Headach
-Painful shallow ulcers
-Atypical lesions
--only 10 % is asymptomatic
-Rectal infection: florid proctitis (inflammation rectum)
-Aseptic meningitis and /or involvement of the sacral autonomic plexus leading to retension of urine
Diagnostic tools
- detection of the virus from within lesions
-Taking Swabs from the lesions and detect HSV by PCR
-After 8-12 weeks type specific immune responses can be found.
Treatment
Antiviral medications --> Aciclovir, famciclovir or valaciclovir is given several times a day, when
lesions are still forming. Rest, analgesia(reliefing pain) and antipyretics (reducing fever) are advised.
Also saltwater bathing can be soothing (verzachtend).
Filmpjes
85
7. Prostatitis 591-592
General information disease
Prostatitis is swelling and inflammation of the prostate gland, a walnut-sized gland located directly
below the bladder in men. The prostate gland produces fluid (semen) that nourishes and transports
sperm.
4 kinds of prostatitis: Acute bacterial prostatitis, chronic bacterial prostatitis, chronis prostatitis not
caused by bacteria, prostatitis that doesn’t cause symptoms.
Causes
Caused by common strains of bacteria. The infection may start when bacteria carried in urine leaks
into your prostate. Chronic bacterial prostatitis may be the result of small amounts of bacteria that
aren't eliminated with antibiotics because they "hide" in the prostate. Some men with chronic
prostatitis have pain but no evidence of an inflamed prostate.
In most cases of prostatitis, the cause is never identified. Causes other than bacterial infection can
include: An immune system disorder, A nervous system disorder, Injury to the prostate or prostate
area.
Symptoms
Prostatitis symptoms vary depending on the cause. They may include:
-Pain or burning sensation when urinating (dysuria)
-Difficulty urinating, such as dribbling or hesitant urination
-Frequent urination, particularly at night (nocturia)
-Urgent need to urinate
-Pain in the abdomen, groin or lower back
-Pain in the area between the scrotum and rectum (perineum)
-Pain or discomfort of the penis or testicles
-Painful orgasms (ejaculations)
-Flu-like symptoms (with bacterial prostatitis)
Diagnostic tools
- Physical examination
- Blood culture
- Urine and semen test
- Examination with a viewing scope (cystoscopy)
- Bladder tests (Urodynamic tests)
Treatment
Prostatitis treatments vary depending on the underlying cause.
- Antibiotics
- Alphablockers --> These medications help relax the bladder neck and the muscle fibers where your
prostate joins your bladder
- Pain relievers (aspirin, ibuprofen)
- Prostate massage
Filmpjes
86
8. Pyelonephritis (nierbekkenontsteking) 591-592
General information disease
Pyelonephritis is an ascending urinary tract infection that has reached the pyelum or pelvis of the
kidney. It is a form of nephritis that is also referred to as pyelitis. Severe cases of pyelonephritis can
lead to pyonephrosis (pus accumulation around the kidney), urosepsis (a systemic inflammatory
response of the body to infection), kidney failure and even death.
Kidney infection (pyelonephritis) is a specific type of urinary tract infection (UTI) that generally
begins in your urethra or bladder and travels up into your kidneys.
A kidney infection requires prompt medical attention. If not treated properly, a kidney infection can
permanently damage your kidneys or the bacteria can spread to your bloodstream and cause a lifethreatening infection.
Causes
- Bowel organisms (bacteria) that enter the urinary tract through the tube that carries urine from
your body (urethra) and begin to multiply.
- Most cases start off as lower urinary tract infections (mainly cystitis and prostatitis)
Risk factors:
Mechanical:structural abnormalities in the urinary tract
Constitutional: diabetes mellitus, immunocompromised states
Behavioral: change in sexual partner within the last year, spermicide use
Positive family history: close family members with frequent urinary tract infections
Symptoms
- Fever
- Accelerated heart rate
- Painful urination
- Abdominal pain radiating to the back
- Nausea and often associated vomiting
- Tenderness at the costovertebral angle (on the affected side)
- May be accompanied by signs of septic shock (including rapid breathing, decreased blood pressure,
violent shivering, occasionally delirium)
Symptoms of acute peolonephritis generally develop rapidly over a few hours or a day.
Chronic phelonephritis
- Persistent flank or abdominal pain
- Signs of infection (eg fever, unintentional weight loss, malaise, decreased appetite)
- Lower urinary tract symptoms
- Blood in urine
Diagnostic tools
- Diagnose based on signs and symptoms
- Urine sample to determine whether bacteria, blood or pus is in your urine.
- CFU > 100000
Treatment
- Antibiotic therapy for kidney infections
- Surgical intervention (such as uteroscopy, percutaneous nephrostomy, percutaneous
nephrolithotomy)
- Treatment of any underlying causes to prevent its recurrence
Filmpjes
http://www.youtube.com/watch?v=dcU25hGW4LQ
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9. Urinary tract infection / Lower: cystitis (bladder infection) 591-595
General information disease
A urinary tract infection (UTI) is an infection in any part of your urinary system — your kidneys,
ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the
urethra.Women are at greater risk of developing a UTI than men are. Infection limited to your
bladder can be painful and annoying. However, serious consequences can occur if a UTI spreads to
your kidneys. When it affects the lower urinary tract it is known as a simple cystitis (a bladder
infection) and when it affects the upper urinary tract it is known as pyelonephritis (a kidney
infection). Cystitis (sis-TI-tis) is the medical term for inflammation of the bladder. Most of the time,
the inflammation is caused by a bacterial infection, and it's called a urinary tract infection (UTI). A
bladder infection can be painful and annoying, and it can become a serious health problem if the
infection spreads to your kidneys.
Causes
Bacterial cystitis
UTIs typically occur when bacteria outside the body enter the urinary tract through the urethra and
begin to multiply. Most cases of cystitis are caused by a type of Escherichia coli (E. coli) bacteria.
Bacterial bladder infections may occur in women as a result of sexual intercourse. But even sexually
inactive girls and women are susceptible to lower urinary tract infections because the female genital
area often harbors bacteria that can cause cystitis.
The two main types of bacterial bladder infections are:
* Community-acquired bladder infections. These infections occur when people who aren't in a
medical care facility develop a bladder infection. Bladder infections are more common in women
than in men.
* Hospital-acquired bladder infections. These infections, also called nosocomial (nos-o-KO-me-ul)
infections, occur in people in a medical care facility, such as a hospital or nursing home.
Noninfectious cystitis
Although bacterial infections are the most common cause of cystitis, a number of noninfectious
factors also may cause the bladder to become inflamed. Some examples:
Interstitial cystitis. Drug-induced cystitis. Radiation cystitis. Foreign-body cystitis. Chemical cystitis.
Cystitis associated with other conditions.
Symptoms
Cystitis signs and symptoms often include:
-A strong, persistent urge to urinate
-A burning sensation when urinating
-Passing frequent, small amounts of urine
-Blood in the urine (hematuria)
-Passing cloudy or strong-smelling urine
-Discomfort in the pelvic area
-A feeling of pressure in the lower abdomen
-Low-grade fever
Diagnostic tools
-Urine analysis
-Cystoscopy
-Imaging tests (x-ray or ultrasound)
Treatment
Cystitis caused by bacterial infection is generally treated with antibiotics. Treatment for
noninfectious cystitis depends on the underlying cause
Filmpjes
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10. Renal disease 561-572
General information disease
Renal failure (also kidney failure or renal insufficiency) is a medical condition in which the kidneys
fail to adequately filter waste products from the blood. The two main forms are acute kidney injury,
which is often reversible with adequate treatment, and chronic kidney disease, which is often not
reversible. In both cases, there is usually an underlying cause.
Renal failure is mainly determined by a decrease in glomerular filtration rate, the rate at which
blood is filtered in the glomeruli of the kidney. This is detected by a decrease in or absence of urine
production or determination of waste products (creatinine or urea) in the blood. Depending on the
cause, hematuria (blood loss in the urine) and proteinuria (protein loss in the urine) may be noted.
In renal failure, there may be problems with increased fluid in the body (leading to swelling),
increased acid levels, raised levels of potassium, decreased levels of calcium, increased levels of
phosphate, and in later stages anemia. Bone health may also be affected. Long-term kidney
problems are associated with an increased risk of cardiovascular disease.
Causes
Acute kidney injury (AKI), previously called acute renal failure (ARF), is a rapidly progressive loss of
renal function, generally characterized by oliguria (decreased urine production, quantified as less
than 400 mL per day in adults,[6] less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants);
and fluid and electrolyte imbalance. AKI can result from a variety of causes, generally classified as
prerenal, intrinsic, and postrenal. The underlying cause must be identified and treated to arrest the
progress, and dialysis may be necessary to bridge the time gap required for treating these
fundamental causes.
Chronic kidney disease (CKD) can also develop slowly and, initially, show few symptoms. CKD can be
the long term consequence of irreversible acute disease or part of a disease progression.
Symptoms
Symptoms of kidney failure include
High levels of urea in the blood, which can result in: Vomiting and/or diarrhea, which may lead to
dehydration
Nausea
Weight loss
Nocturnal urination
More frequent urination, or in greater amounts than usual, with pale urine
Less frequent urination, or in smaller amounts than usual, with dark coloured urine
Blood in the urine
Pressure, or difficulty urinating
Unusual amounts of urination, usually in large quantities
Diagnostic tools
Chronic kidney failure is measured in five stages, which are calculated using a patient’s GFR, or
glomerular filtration rate. Stage 1 CKD is mildly diminished renal function, with few overt symptoms.
Stages 2 and 3 need increasing levels of supportive care from their medical providers to slow and
treat their renal dysfunction. Patients in stages 4 and 5 usually require preparation of the patient
towards active treatment in order to survive. Stage 5 CKD is considered a severe illness and requires
some form of renal replacement therapy (dialysis) or kidney transplant whenever feasible.
Glomerular filtration rate A normal GFR varies according to many factors, including sex, age, body
size and ethnicity. Renal professionals consider the glomerular filtration rate (GFR) to be the best
overall index of kidney function. The National Kidney Foundation offers an easy to use on-line GFR
calculator. for anyone who is interested in knowing their glomerular filtration rate.(A serum
creatinine level, a simple blood test, is needed to use the calculator).
Treatment
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11. Renal (kidney) stones 665
General information disease
Kidney stones (renal lithiasis) are small, hard deposits that form inside your kidneys. The stones are
made of mineral and acid salts. Kidney stones have many causes and can affect any part of your
urinary tract — from your kidneys to your bladder. Often, stones form when the urine becomes
concentrated, allowing minerals to crystallize and stick together.
Passing kidney stones can be quite painful, but the stones usually cause no permanent damage.
Depending on your situation, you may need nothing more than to take pain medication and drink
lots of water to pass a kidney stone. In other instances, surgery may be needed
Type 1 (‘distal’) renal tubular acidosis =this is due to a failure of H+excretion in the distal tubule.
It consists of:
- acidosis
- Hypokalaemia (few exceptions)
- inability to lower the urine pH below 5.3 despite systemic acidosis
- lower urinary ammonium production
Causes
Kidney stones often have no definite, single cause, although several factors may increase your risk.
Kidney stones form when your urine contains more crystal-forming substances — such as calcium,
oxalate and uric acid — than the fluid in your urine can dilute. At the same time, your urine may lack
substances that keep crystals from sticking together, creating an ideal environment for kidney
stones to form.
These features may be present only in the face of increased acid production, hence the need for an
acid load test in diagnosis. Other features include:
- low urinary citrate (owing to increased citrate absorption in the proximal tubule where it can be
converted to bicarbonate)
- hyperculciuria
These abnormalities result in osteomalacia, renal stone formation and recurrent urinary infections.
Osteomalacia caused by buffering of H+ by Ca2 + in bone, resulting in depletion of calcium from
bone. Renal stone formation is caused by hypercalciuria, hypocitraturia (citrate inhibits calcium
phosphate precipitation), and alkaline urine (which favours precipitation of calcium phosphate).
Recurrent rinary infections are caused by renal stones. Both autosomal dominant and recessive
inheritance patterns have been reported in primary distal RTA. Patients in South East Asia with an
autosomal dominant type have a milder phenotype and may have an associated ovalocytosis. In this
form the Cl−–HCO3− exchanger in the basolateral surface of intercalated cells is mutated. However,
in the autosomal recessive distal RTA, a substantial proportion of patients have sensorineural
deafness, and this is associated with a loss of function mutation in the H+-ATPase at the apical
surface of intercalated cells.
Symptoms
- Can be formed and passed without causing symptoms
- Uteral obstruction (causing postrenal azotemia, hydronephrosis=distension and dilation of the
renal pelvis and calyces)
A kidney stone may not cause symptoms until it moves around within your kidney or passes into
your ureter — the tube connecting the kidney and bladder. At that point, these signs and symptoms
may occur: Severe pain in the side and back, below the ribs, Pain that spreads to the lower abdomen
and groin, Pain that comes in waves and fluctuates in intensity, Pain on urination, Pink, red or brown
urine, Cloudy or foul-smelling urine, Nausea and vomiting, Persistent urge to urinate, Urinating
more often than usual, Fever and chills if an infection is present.
Pain caused by a kidney stone may change — for instance, shifting to a different location or
increasing in intensity — as the stone moves through your urinary tract.
Diagnostic tools
-Blood tests. Blood tests may reveal too much calcium or uric acid in your blood.
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-Urine tests. excreting too many stone-forming minerals or too few stone-preventing substances.
-Imaging tests. Imaging tests (e.g. X-ray) may show kidney stones in your urinary tract.
-Analysis of passed stones. urinate through a strainer to catch stones that you pass.
Treatment
- Can be formed and passed without causing symptoms
- Uteral obstruction (causing postrenal azotemia, hydronephrosis=distension and dilation of the
renal pelvis and calyces)
Small stones with minimal symptoms
-Drinking water.
-Pain relievers
-Medical therapy
Large stones and those that cause symptoms
-Using sound waves to break up stones.
-Surgery to remove very large stones in the kidney.
-Using a scope to remove stones
-Parathyroid gland surgery.
Filmpjes
http://www.youtube.com/watch?v=Blfg_q4Lqww
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12. Renal calculi 600-604
General information disease
Renal stones are very common worldwide, with a lifetime risk of about 10%. Prevalence of stone
disease is much higher in the Middle East. Most stones occur in the upper urinary tract and are
composed of calcium oxalate and phosphate, these are common in men. Mixed infective stones,
which account for about 15 of al calculi, are twice as common in women as in men. The overall male
to female ratio of stone disease is 2:1. Stone disease is frequently a recurrent problem.
Causes
- Dehydration
- Hypercalcaemia
-Hypercaluiria
-Hyperoxaluria
-Hyperuricaemia and hyperuricosuria
-Infection
-Cystinuria
-Renal tubular acidosis
-Primary renal disease
-Drugs
Symptoms
A kidney stone may not cause symptoms until it moves around within your kidney or passes into
your ureter — the tube connecting the kidney and bladder. At that point, these signs and symptoms
may occur:
-Severe pain in the side and back, below the ribs
-Pain that spreads to the lower abdomen and groin
-Pain that comes in waves and fluctuates in intensity
-Pain on urination
-Pink, red or brown urine
-Cloudy or foul-smelling urine
-Nausea and vomiting
-Persistent urge to urinate
-Urinating more often than usual
-Fever and chills if an infection is present
Pain caused by a kidney stone may change — for instance, shifting to a different location or
increasing in intensity — as the stone moves through your urinary tract.
Diagnostic tools
- Mid-stream specimen of urine for culture
- Serum urea, electrolyte, creatinine (eGFR) and calcium levels
- Plain adbominal X-ray
- CT-KUB (best diagnostic test, because ureteric stones can be missed in ultrasound)
CT KUD = CT of kidney, ureter and bladder.
Treatment
- Adequate analgesia (NSAID)
Stones less than 0.5 cm pass spontaneously
- Drinking water, pain relievers, medical therapy
Stones > 1 cm usually require urological or radiological intervention.
- Using sound waves to break up stones. Surgery to remove very large stones in the kidney. Using a
scope to remove stones. Parathyroid gland surgery. (open surgery rarely needed.)
Filmpjes
92
13. Renal tumour
General information disease
Most frequent one is RCC, Renal cell carcinoma. Kidney cancer develops most often in people over
40, but no one knows the exact causes of this disease. Doctors can seldom explain why one person
develops kidney cancer and another does not.
Research has shown that people with certain risk factors are more likely than others to develop
kidney cancer. A risk factor is anything that increases a person's chance of developing a disease.
Causes
Risk factors:
- Smoking- Obesity- High blood pressure- Long-term dialysis (treatment for people whose kidneys do
not work well)- Von hippel-lindau (VHL) syndrom - Occupation (contact with chemicals)- Gender (
Males more likelu)
Symptoms
Common symptoms of kidney cancer include:
•Blood in the urine (making the urine slightly rusty to deep red)•Pain in the side that does not go
away•A lump or mass in the side or the abdomen•Weight loss•Fever•Feeling very tired or having a
general feeling of poor health
Most often, these symptoms do not mean cancer. An infection, a cyst, or another problem also can
cause the same symptoms. A person with any of these symptoms should see a doctor so that any
problem can be diagnosed and treated as early as possible.
Diagnostic tools
If a patient has symptoms that suggest kidney cancer, the doctor may perform one or more of the
following procedures:
•Physical exam: The doctor checks general signs of health and tests for fever and high blood
pressure. The doctor also feels the abdomen and side for tumors.
•Urine tests: Urine is checked for blood and other signs of disease.
•Blood tests: The lab checks the blood to see how well the kidneys are working. The lab may check
the level of several substances, such as creatinine. A high level of creatinine may mean the kidneys
are not doing their job.
•Intravenous pyelogram (IVP): The doctor injects dye into a vein in the arm. The dye travels through
the body and collects in the kidneys. The dye makes them show up on x-rays. A series of x-rays then
tracks the dye as it moves through the kidneys to the ureters and bladder. The x-rays can show a
kidney tumor or other problems.
•CT scan (CAT scan): An x-ray machine linked to a computer takes a series of detailed pictures of the
kidneys. The patient may receive an injection of dye so the kidneys show up clearly in the pictures. A
CT scan can show a kidney tumor.
•Ultrasound test: The ultrasound device uses sound waves that people cannot hear. The waves
bounce off the kidneys, and a computer uses the echoes to create a picture called a sonogram. A
solid tumor or cyst shows up on a sonogram.
•Biopsy: In some cases, the doctor may do a biopsy. A biopsy is the removal of tissue to look for
cancer cells. The doctor inserts a thin needle through the skin into the kidney to remove a small
amount of tissue. The doctor may use ultrasound or x-rays to guide the needle. A pathologist uses a
microscope to look for cancer cells in the tissue.
•Surgery: In most cases, based on the results of the CT scan, ultrasound, and x-rays, the doctor has
enough information to recommend surgery to remove part or the entire kidney. A pathologist
makes the final diagnosis by examining the tissue under a microscope.
Treatment
People with kidney cancer may have surgery, arterial embolization, radiation therapy, biological
therapy, orchemotherapy. Some may have a combination of treatments.
Filmpjes
93
14. Renal insufficiency / chronic renal failure as a result of diabetes or hypertension
as a result of hypertension
General information disease
The kidneys play a key role in keeping a person's blood pressure in a healthy range, and blood
pressure, in turn, can affect the health of the kidneys. High blood pressure, also called hypertension,
can damage the kidneys and lead to chronic kidney disease (CKD).
High blood pressure makes the heart work harder and, over time, can damage blood vessels
throughout the body. If the blood vessels in the kidneys are damaged, they may stop removing
wastes and extra fluid from the body. The extra fluid in the blood vessels may then raise blood
pressure even more. It's a dangerous cycle.
High blood pressure is one of the leading causes of kidney failure, also called end-stage renal disease
(ESRD). People with kidney failure must either receive a kidney transplant or have regular bloodcleansing treatments called dialysis.
Causes
Everyone has some risk of developing kidney failure from high blood pressure. African Americans,
however, are more likely than Caucasians to have high blood pressure and its related kidney
problems—even when their blood pressure is only mildly elevated. In fact, African Americans are six
times more likely than Caucasians to develop hypertension-related kidney failure.
People with diabetes also have a greater risk of developing kidney failure. Early management of high
blood pressure is especially important for African Americans with diabetes.
Symptoms
Early kidney disease is a silent problem, like high blood pressure, and does not have any symptoms.
People may have CKD but not know it because they do not feel sick. A person's glomerular filtration
rate (GFR) is a measure of how well the kidneys are filtering wastes from the blood. GFR is estimated
from a routine measurement of creatinine in the blood. The result is called the estimated GFR
(eGFR).
The symptoms kidney disease were a burning in only one kidney. There is blood in urine. Irritation in
urethra. I also have soreness in kidney area only on the right side.
Creatinine is a waste product formed by the normal breakdown of muscle cells. Healthy kidneys take
creatinine out of the blood and put it into the urine to leave the body. When the kidneys are not
working well, creatinine builds up in the blood.
An eGFR with a value below 60 milliliters per minute (mL/min) suggests some kidney damage has
occurred. The score means that a person's kidneys are not working at full strength.
Another sign of CKD is proteinuria, or protein in the urine. Healthy kidneys take wastes out of the
blood but leave protein. Impaired kidneys may fail to separate a blood protein called albumin from
the wastes. At first, only small amounts of albumin may leak into the urine, a condition known as
microalbuminuria, a sign of failing kidney function. As kidney function worsens, the amount of
albumin and other proteins in the urine increases, and the condition is called proteinuria. CKD is
present when more than 30 milligrams of albumin per gram of creatinine is excreted in urine, with
or without decreased eGFR.
Diagnostic tools
Treatment
Filmpjes
94
as a result of diabetes
General information disease
Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a
serious condition in which the kidneys fail to rid the body of wastes. Kidney failure is the final stage
of chronic kidney disease (CKD).
Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases.
Even when diabetes is controlled, the disease can lead to chronic kidney disease and kidney failure.
Most people with diabetes do not develop chronic kidney disease that is severe enough to progress
to kidney failure. Nearly 24 million people in the United States have diabetes, and nearly 180,000
people are living with kidney failure as a result of diabetes. People with kidney failure undergo
dialysis, an artificial blood-cleaning process, or transplantation to receive a healthy kidney from a
donor. Most U.S. citizens who develop kidney failure are eligible for federally funded care. In 2005,
care for patients with kidney failure cost the United States nearly $32 billion.
Causes
Symptoms
•
Symptoms of chronic kidney disease vary greatly and can include the need to urinate
frequently, especially at night; swelling of the legs and puffiness around the eyes, high blood
pressure, fatigue and weakness; loss of appetite, nausea and vomiting; itching and easy bruising;
shortness of breath; headaches, sleep problems, restless legs syndrome; chest pain; bleeding; bone
pain; and decreased interest in sex and erectile dysfunction.
•
Treatment of diabetes includes control of blood glucose levels, high blood pressure, and
diet; medications to treat edema and anemia, dialysis, or kidney transplant.
•
Controlling blood glucose levels and blood pressure is the most effective way to prevent or
delay kidney disease.
Diabetic kidney disease takes many years to develop. In some people, the filtering function of the
kidneys is actually higher than normal in the first few years of their diabetes. Over several years,
people who are developing kidney disease will have small amounts of the blood protein albumin
begin to leak into their urine. This first stage of chronic kidney disease is calledmicroalbuminuria.
The kidney's filtration function usually remains normal during this period.
As the disease progresses, more albumin leaks into the urine. This stage may be called
macroalbuminuria or proteinuria. As the amount of albumin in the urine increases, the kidneys'
filtering function usually begins to drop. The body retains various wastes as filtration falls. As kidney
damage develops, blood pressure often rises as well.
Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually 15 to 25 years will
pass before kidney failure occurs. For people who live with diabetes for more than 25 years without
any signs of kidney failure, the risk of ever developing it decreases.
Diagnostic tools
People with diabetes should be screened regularly for kidney disease. The two key markers for
kidney disease are eGFR and urine albumin.
•eGFR. eGFR stands for estimated glomerular filtration rate. Each kidney contains about 1 million
tiny filters made up of blood vessels. These filters are called glomeruli. Kidney function can be
checked by estimating how much blood the glomeruli filter in a minute. The calculation of eGFR is
based on the amount of creatinine, a waste product, found in a blood sample. As the level of
creatinine goes up, the eGFR goes down.
Kidney disease is present when eGFR is less than 60 milliliters per minute.
•Urine albumin. Urine albumin is measured by comparing the amount of albumin to the amount of
creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large
amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to
creatinine is a sign of kidney damage.
Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of
creatinine, with or without decreased eGFR.
95
Treatment
When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney
transplant. As recently as the 1970s, medical experts commonly excluded people with diabetes from
dialysis and transplantation, in part because the experts felt damage caused by diabetes would
offset benefits of the treatments. Today, because of better control of diabetes and improved rates
of survival following treatment, doctors do not hesitate to offer dialysis and kidney transplantation
to people with diabetes. Currently, the survival of kidneys transplanted into people with diabetes is
about the same as the survival of transplants in people without diabetes. Dialysis for people with
diabetes also works well in the short run. Even so, people with diabetes who receive transplants or
dialysis experience higher morbidity and mortality because of coexisting complications of diabetes—
such as damage to the heart, eyes, and nerves.
Filmpjes
15. Sexually transmitted disease 160-194
General information disease
See Herpes, Gonorrhoea, Chlamydia etc.
Causes
Symptoms
Diagnostic tools
Treatment
Filmpjes
96
16. Trichomonas Vaginalis infection 170
General information disease
Trichomonas vaginalis is a flagellated protozoon which is predominantly sexually transmitted. It is
able to attach to squamous epithelium and can infect the vagina and urethra. Trichomonas may be
acquired perinatally in babies born to infected mothers. Trichomoniasis is considered the most
common curable STD. In the United States, an estimated 3.7 million people have the infection, but
only about 30% develop any symptoms of trichomoniasis. Infection is more common in women than
in men, and older women are more likely than younger women to have been infected.
Causes
Caused by a tiny protozoan parasite, sexually transmitted.
Symptoms
About 70% of infected people do not have any signs or symptoms. When trichomoniasis does cause
symptoms, they can range from mild irritation to severe inflammation.
Some women have no symptoms. Symptoms usually appear 5 to 28 days after exposure and can
include:
-Yellow-green (sometimes frothy) vaginal discharge with a foul odor
-Discomfort during sex and when passing urine
-Irritation and itching in the genital area
-Lower abdominal pain in rare cases
Infected women may, unusually, be asymptomatic. Commonly the major complaints are of vaginal
discharge, which is offensive and of local irritation.
Frothy, yellowish vaginal discharge and erythematous vaginal walls. Cervix may have multiple small
haemorrhagic areas (strawberry cervix).
Men usually present as the asymptomatic sexual partners of infected women, although they may
complain of urethral discharge, irritation or urinary frequency.
Trichomonas infection in pregnancy has been associated with pre-term delivery and low birth
weight.
Diagnostic tools
Phase-contrast, dark-ground microscopy of a drop of vaginal discharge show TV swimming with a
characteristic motion in 40-80% of female patients. Similar preparation from the male urethra will
only be positive in about 30% of cases.
Many polymorphonuclear leucocytes are also seen.
Culture techniques are good and confirm the diagnosis.
Trichomonas is sometimes observed on cervical cytology with 60-80% accuracy in diagnosis.
Treatment
Metronidazole is the treatment of choice, either 2 g orally as a single dose of 400 mg twice daily for
7 days. If resistant to metronidazole, then nimorazole.
Topical therapy with intravaginal tinidazole can be effective, but if extravaginal infection exists this
may not be eradicated and vaginal infection reoccurs. Male partners should be treated, especially as
they are likely to be asymptomatic and more difficult to detect.
Filmpjes
http://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm
97
17. Extra uterine pregnancy/eptopic pregnancy
General information disease
A pregnancy that is not in the usual place and is located outside the inner lining of the uterus
Causes
An ectopic pregnancy is often caused by a condition that blocks or slows the movement of a
fertilized egg through the fallopian tube to the uterus. Such causes include:
•Birth defect in the fallopian tubes
•Complications of a ruptured appendix
•Endometriosis
•Having an ectopic pregnancy before
•Scarring from past infections or surgery
The following also increase your risk for an ectopic pregnancy:
•Age over 35
•Getting pregnant while having an intrauterine device (IUD)
•Had surgery to untie tubes (tubal sterilization) to become pregnant
•Having had many sexual partners
•In vitro fertilization
•Having your tubes tied (tubal ligation) - more likely 2 or more years after the procedure
Sometimes the cause is unknown. Hormones may play a role. Ectopic pregnancies occur in 1 in every
40 to 1 in every 100 pregnancies.
The most common site for an ectopic pregnancy is within one of the tubes through which the egg
passes from the ovary to the uterus. However, in rare cases, ectopic pregnancies can occur in the
ovary, stomach area, or cervix.
Symptoms
An early ectopic pregnancy often feels like a normal pregnancy. A woman with an ectopic pregnancy
may experience common signs of early pregnancy, such as:
•A missed menstrual period. •Tender breasts.•Fatigue.•Nausea.•Increased urination.
Other symptoms of ectopic pregnancy may include:
•Abnormal vaginal bleeding•Low back pain•Mild cramping on one side of the pelvis •No periods
•Pain in the lower belly or pelvic area
If the area around the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They
may include:
•Fainting or feel faint•Intense pressure in the rectum•Low blood pressure•Pain in the shoulder area
•Severe, sharp, and sudden pain in the lower abdomen
Diagnostic tools
•A pelvic exam, which may show tenderness in the pelvic area.
•A pregnancy test and vaginal ultrasound will be done.
•HCG is a hormone normally produced during pregnancy. Checking blood levels of this hormone
(quantitative HCG blood test) can diagnose pregnancy. The hCG levels are usually lower than normal
if the pregnancy is ectopic
•If a diagnosis of ectopic pregnancy has still not been confirmed, a laparoscopy may be performed.
Treatment
Ectopic pregnancies is a life-threatening condition. The pregnancy cannot continue to birth (term).
The developing cells must be removed to save the mother's life.
If the area of the ectopic pregnancy breaks open (ruptures) fast medical help is required. Rupture
can lead to shock, an emergency condition.
Filmpjes
98
18. Pelvic inflammatory disease
General information disease
Pelvic inflammatory disease, commonly called PID, is an infection of the female reproductive organs.
PID is one of the most serious complications of a sexually transmitted disease in women: It can lead
to irreversible damage to the uterus, ovaries, fallopian tubes, or other parts of the female
reproductive system, and is the primary preventable cause of infertility in women.
Causes
Normally, the cervix prevents bacteria that enter the vagina from spreading to the internal
reproductive organs. If the cervix is exposed to a sexually transmitted disease -- such as gonorrhea
and/or chlamydia -- the cervix itself becomes infected and less able to prevent the spread of
organisms to the internal organs. PID occurs when the disease-causing organisms travel from the
cervix to the upper genital tract. Untreated gonorrhea and chlamydia cause about 90% of all cases
of PID. Other causes include abortion, childbirth, and pelvic procedures.
Symptoms
The symptoms of PID can vary, but may include the following:
•Dull pain or tenderness in the stomach or lower abdominal area, or pain in the right upper
abdomen.
•Abnormal vaginal discharge that is yellow or green in color or that has an unusual odor.•Painful
urination.•Chills or high fever.•Nausea and vomiting.•Pain during sex.
There are several things which would put a woman at risk for PID, including:
•Women with sexually transmitted diseases -- especially gonorrhea and chlamydia -- are at greater
risk for developing PID.
•Women who have had a prior episode of PID are at higher risk for another episode.
•Sexually active teenagers are more likely to develop PID than are older women.
•Women with many sexual partners are at greater risk for sexually transmitted diseases (STDs) and
PID.
Some studies suggest that douching may contribute to PID. Douching may push bacteria into the
upper genital tract and may mask the discharge that could alert a woman to seek medical attention.
Diagnostic tools
* Pelvic exam, analysis of vaginal discharge, cervical cultures, urine tests
* To confirm diagnosis or to determine how widespread the infection is --> Pelvic ultrasound,
endometrial biopsy, laparoscopy.
Treatment
* Antibiotics.
* If serious, you have to be treat in hospital (intravenous antibiotics or rarely surgery)
Filmpjes
http://www.youtube.com/watch?v=u1DcB8hIKvA
99
General medicine
Theme 6
Oncology
Four major types of cancer:
1. Epithelial cells => carcinoma
2. Non-hematopoietic mesenchymal cells(bone, fat, muscle, cartilage[kraakbeen] => sarcoma
3. Hematopoietic cells (blood cellular stam cells)
bone marrow-derived cells that normally mature in the bloodstream => Leukemia
bone marrow-derived cells that normally mature in the lymphatic system => Lymphoma
4. Germ cells [kiemcellen, dus bij geslachtsdelen]=> Germinoma
Benign prostate hypertrophy-prostate cancer 481-482
Bladder cancer
Brain tumour 1131-1133
Breast disease (benign and malignant) 473-476
Carcinoma 431-440
Colorectal carcinoma 289-291
Gastric cancer 251-254
Glioblastoma 1131-1132
Liver carcinoma 347-348
Lumbago (staat bij theme 3-> Mechanical low back pain)
Lung carcinoma 471-473
Meningioma 1132
Mesothelioma 855
Oesophageal cancer 244-246
Pancreatic cancer 431-440
Prostatitis
Renal tumour 634-635
http://www.youtube.com/watch?v=zVGunqu0buw
100
Benign prostate hypertrophy (vergrote prostaat)-prostate cancer/carcinoma 481-482
General information disease
The prostate is a part of the male reproductive system that helps make and store seminal fluid[zaadvloeistof].
It is located in the pelvis, under the urinary bladder. Benign enlargement of the prostate gland[klier] occurs
most often in men over the age of 60 years. It is unknown in eunuchs[besnedenen]. Such enlargement can be
benign, or malignant. Most prostate cancers are slow growing. However, there are cases of aggressive
prostate cancers. The cancer cells may metastasize (spread) from the prostate to other parts of the body,
particularly the bones and lymph nodes.
Causes
The cause is unknown. Microscopically, hyperplasia(increased number of cells) affects the glandular and
connective tissue elements of the prostate. Risk factors are:
- obesity, age and family history
Symptoms
Enlargement of the gland stretches and distorts the urethra, obstructing bladder outflow.
- Frequency of urination, usually first noted as nocturia(urinating at night), is a common early symptom.
- Difficulty or delay in initiating urination, with variability and reduced forcefulness of the urinary stream and
post-void dribbling, are often present.
- Acute retention[vasthouden] of urine (see below) or retention with overflow incontinence may occur.
- Prostate cancer may cause pain, difficulty in urinating, erectile dysfunction and hematuria(blood in urine)
- Avanced prostate cancer can spread to other parts of the body, causing bone pain, back pain, anaemia, and
weight loss
Diagnostic tools
A benign prostate feels smooth.
- Rectal examination[via de anus voelen, zie plaatje].
In case of prostate cancer:
- Blood tests, raised serum PSA(prostate specific antigen)
- Followed by a ultrasound-guided needle biopsy.
- Pelvic MRI
- Ultrasound of testicles, prostate and kidney, to rule out
Treatment
* Watchful watiting: Patients with mild-to-moderate symptoms should be managed by 'watchful waiting',
because symptoms following therapy are sometimes greater than those with no therapy at all. (75% over
the age of 80, die with, but not because of, their prostate cancer).
* Medically: finasteride or alpha-blockers such as tamsulosin, to reduce prostate size
* Urethal catheter drainage: most used by acute retention.
Prostate cancer:
* Surgery (if medical treatment fails)
* Radio therapy
Avanced prostate cancer:
* Androgen receptor blockers and radiotherapy, compared with endocrine
Filmpjes
http://www.youtube.com/watch?v=1AiY_G-l6Ic (kort)
http://www.youtube.com/watch?v=7YA1fumPaf0 (lang)
101
Bladder cancer
General information disease
Bladder cancer is cancer that forms in tissues of the bladder (the organ that stores urine). It is a disease in
which abnormal cells multiply without control in the bladder. Bladder cancer is any of several types of
malignancy arising from the epithelial lining (i.e., the urothelium) of the urinary bladder. The most common
type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell
carcinoma or more properly urothelial cell carcinoma. Bladder cancer typically affects older adults, though it
can occur at any age. 5-year survival in men is 71% and in women 61%.
Causes
Risk factors are:
- Smoking
- Chemicals
- Infections
Symptoms
Symptoms are:
- Haematuria (blood in urine)
- Desire to urinate small amounts in short intervals
- High frequency in urination
- Dysuria: Inability to hold the urine for any length of time after the initial desire or burning sensation while
passing urine
Diagnostic tools
* Urine analysis
* CT
* Cytoscopy
Treatment
* Surgery
* Chemotherapy
* Radiaton
Filmpjes
http://www.youtube.com/watch?v=w331LUpSZOY
102
Brain tumour 1131-1133
General information disease
Primary intracranial tumours account for some 10% of neoplasms. Metastases are the commonest intracranial
tumours. Symptomless meningiomas (benign) are found quite commonly on imaging or at autopsy. The
hallmark of a direct effect of a mass is local progressive deterioration of function. Tumours can occur
anywhere within the brain.
Causes
No one knows the exact causes of brain tumours. Doctors seldom know why one person develops a brain
tumour and another doesn't. Risk factors are:
- Ionizing radiation (from x-rays and other sources)
- Family history (up to 5 out of every 100 brain tumours (5%) are related to known genetic conditions)
Symptoms
Mass lesions[afwijkingen] within the brain produce symptoms and signs by three mechanisms:
- By direct effect - brain is infiltrated and local function is impaired
- By secondary effects of raised intracranial pressure and shift of intracranial contents (e.g.
papilloedema[zichtsvermindering, soms tijdelijk], vomiting, headache)
- By provoking generalized and/or partial seizures[epileptische aanval] and changes in mood
Diagnostic tools
* CT + MRI san
* Biopsy
* MR angiography is used occasionally to define blood supply
* PET is sometimes helpful to locate an occult primary tumour with brain metastases.
* Since metastases are common, routine tests, e.g. chest X-ray, should be performed.
Treatment
Biopsy and tumour removal. While complete surgical removal of a tumour is an objective, it is often not
possible, nor is surgery always necessary.
Cerebral oedema[vocht] surrounding a tumour responds rapidly to steroids: i.v. or oral dexamethasone.
Epilepsy is treated with anticonvulsants.
For gliomas and metastases, radiotherapy is usually given and improves survival, if only slightly
Filmpjes
103
Breast disease (benign and malignant) 473-476
General information disease
Breast cancer is a type of cancer originating from breast tissue,
most commonly from the inner lining of milk ducts or the lobules
that supply the ducts with milk. Cancers originating from ducts are
known as ductal carcinomas, while those originating from lobules
are known as lobular carcinomas(see picture for difference).
Breast cancer is the most common cancer in women who do not
smoke. Screening programmes and improvements in multimodality
treatment have improved overall survival and rates of cure. Breastconserving surgery has greatly ameliorated the psychosexual impact
of the disease.
Causes
The majority of breast cancers arise from the epithelial cells of
the milk ducts and reproduce their histological features in a
variety of patterns(see table), of which the most common is an
infiltrating ductal carcinoma.
Inherited breastcancer(BRCA1 or BRCA2)
Inherited breast cancer is due to a mutation in the BRCA1 or
BRCA2 gene. In normal cells, these genes help prevent cancer
by making proteins that keep the cells from growing
abnormally. If you have inherited a mutated copy of either
gene from a parent, you have a high risk of developing breast
cancer during your lifetime, even as developing ovarian
cancer.
Approximately 10% of women have familial breast cancer and
3% have detectable mutations in the BRCA1 and 2 genes and
TP53. Life time risk is 65-85% by the age of 70.
Breast cancer histology



Non-invasive
o Ductal cancer in situ(alleen daar,
not yet invaded through the
epithelial basement membrane)
o Lobular cancer in situ
Invasive
o Infiltrating ductal cancer
o Infiltrating lobular cancer
o Mucinous cancer
o Medullary cancer
o Papillary cancer
o Tubular cancer
Other
o Adenoid cystic, secretory, apocrine
cancers
o Paget's disease of the nipple
o Phyllodes tumour
The hormonal environment exerts a major effect on the expression of the breast cancer potential and is
related to reproductive behaviour, diet, exercise, weight and exogenous hormones from oral contraception
and postmenopausal hormone replacement therapy.
Symptoms
Symptoms can be swelling of all or part of the breast, skin irritation or dimpling, breast pain, nipple pain or the
nipple turning inward and redness, scaliness, or thickening of the nipple or breast skin.
Diagnostic tools
* Mammography (lumps can be seen)
* Ultrasound
* MRI
* Biopsy of the breast (malignant cells can be found)
Treatment
* Surgery (lumpectomy [weghalen tumor] and node biopsy
[klier weghalen bij oksel])
* Radiotherapy
* Chemotherapy (or a combination of both radio+chemo)
Filmpjes
http://www.youtube.com/watch?v=l2lRZuEK4Y0
104
Carcinoma 431-440
General information disease
Carcinoma is the medical term for the most common type of cancer occurring in humans. A carcinoma is a
tumour tissue derived from putative epithelial cells whose genome[DNA v/d cel] has become altered or
damaged to such an extent that the cells become transformed, and begin to exhibit abnormal malignant
properties.
Carcinoma in situ (or CIS) = a small, localized carcinoma that has not yet invaded through the epithelial
basement membrane. CIS is a pre-invasive cancer, and not a pre-malignant entity
Nearly all cases of CIS will continue to grow and progress until they begin to infiltrate and penetrate into and
through the basal membrane or other/adjacent structures. Once invasion occurs, they are no longer
considered CIS lesions, but truly invasive carcinomas.
- Lung: Carcinoma comprises >98% of all lung cancers.
- Breast: Nearly all breast cancers are ductal carcinoma.
- Prostate: The most common form of carcinoma of the prostate is adenocarcinoma.
- Colon and rectum: Nearly all malignancies of the colon and rectum are either adenocarcinoma or squamous
cell carcinoma.
- Pancreas: Pancreatic carcinoma is almost always of the adenocarcinoma type and is highly lethal[dodelijk].
Causes
For most patients,
the cause of their
cancer is unknown.
Probably mix of
individual genetic
predispositions
[aanleg] and
environmental
factors as:
- Tobacco
- Alcohol
- Diet
- Obesity
- Sun exposure
- Medication and
radiation
Symptoms
•
•
•
•
•
•
•
•
•
Persistent hoarseness, coughing
Persistent difficulties swallowing
New or changing birth marks
Thickening or spot of the skin with desquamation (exposed to sunlight)
Lump anywhere on the body lasting for longer than 4 weeks
Abnormal vaginal discharge or blood loss
Changing defecation pattern without a reason
Problems with micturition
Unintended weight loss
Diagnostic tools
* Biopsy
* Check lymph nodes
* X-ray, ultrasound, CT-scan, MRI, PET-scan
Treatment
* Surgery,
* Radiotherapy, chemotherapy (or both, chemoradiation)
* Targeted therapy: immunotherapy(map) or radioimmunotherapy(nib)
Filmpjes
http://www.youtube.com/watch?v=LEpTTolebqo
105
Colorectal[dikke+endeldarm] carcinoma 289-291
General information disease
Colorectal cancer (CRC) is the third most common cancer worldwide and the second most common cause of
cancer death in the UK. Each year approximately 40 000 new cases are diagnosed in England and Wales (68%
colon, 32% rectal cancer) and it is registered as the cause of death in about half this number. The prevalence
rate per 100 000 (at all ages) is 53.5 for men and 36.7 for women. Approximately 20% of patients in the UK
have distant metastases at diagnosis. The disease is much more common in westernized countries than in Asia
or Africa.
Causes
Most colorectal cancers
develop as a result of a
stepwise progression from
normal mucosa[slijmvlies} to
adenoma[gezwel] to invasive
cancer.
Family history is, next to age,
the most common risk factor
for CRC.
Most colorectal cancers are
sporadic (70%) and occur in
individuals without a strong
family history. The other
party is due to genetics.
Distribution of sporadic
colorectal cancer is shown in
the figure ->
Symptoms
Symptoms:
- Change in bowel habit with looser and more frequent stools,
- Rectal bleeding,
- Tenesmus[pijn bij poepen/plassen] and symptoms of anaemia. (hard stool is not a symptom!)
Diagnostic tools
* Colonoscopy
* CT
* PET scan
Treatment
* surgery,
* chemotherapy,
* chemoradiation
Filmpjes
http://www.youtube.com/watch?v=VZ8hbrMeTu0 (vanaf 0:20)
106
Gastric cancer (maagkanker) 251-254
General information disease
Currently the fourth most common cancer found world-wide and second leading cause of cancer-related
mortality. Incidence increases with age and it is rare under the age of 30 years.
Causes
- H. pylori infection and distal gastric cancer. It is recognized by the IARC as a Group 1 (definite) gastric
carcinogen. It causes chronic gastritis which eventually leads to atrophic gastritis and premalignant intestinal
metaplasia.
- Dietary factors such as diets rich in salt. Dietary nitrates can be converted into nitrosamines by bacteria at
neutral pH, and nitrosamines are known to be carcinogenic in animals (but evidence in human carcinogenesis
is limited). Consumption of diets high in non-starchy vegetables, allium vegetables (e.g. garlic), fruits and low
in salt protect against cancer.
- Smoking tabbaco
- Genetic abnormality
- First-degree relatives of patients with gastric cancers (two- or three fold increased relative risk of developing
the disease, but this may be environmental rather than inherited)
- Pernicious anaemia (=body not able to make enough red blood cells due to a DNA defect)
- Partial gastrectomy
Symptoms
- No symptoms
Most common symptom of advanced disease is:
- Epigastric pain (abdominal tenderness). It may be relieved by foods and antacids (= a substance which
neutralizes stomach acidity)
-Anorexia and weight loss
- Vomiting, nausea
- Dysphagia (difficulty with swallowing)
- Later stage: malignant ascites (accumulation of fluid) or jaundice (=dutch: geelzucht) due to liver
enlargement / metastases also occur in bone, brain and lung, producing appropriate symptoms
Diagnostic tools
- Diagnosis: Gastroscopy / Full blood count and liver biochemistry / Barium meal
- Staging: CT scan / Transabdominal ultrasound / endoscopic ultrasound / laparoscopy / PET and CT/PET
Treatment
- Surgery remains the most effective form of treatment if patient is operable
- Combined chemo-radiotherapy
- Peri-operative chemotherapy with epirubicin, cisplatin and infusional t-fluorouracil (ECF) has improved 5year survival in operable gastric and lower oesophagal adenocarcinomas
Filmpjes
http://www.youtube.com/watch?v=yo_F4nq4tX8
107
Glioblastoma (hersentumor) 1131-1132
General information disease
These malignant tumours of neuroepithelial origin are usually seen within the hemispheres[hersenhelften],
but occasionally in the cerebellum, brainstem or cord. They tend to spread by direct extension, virtually never
metastasizing outside the CNS
Causes
Their cause is unknown. Gliomas are occasionally associated with neurofibromatosis.
- Astrocytomas are gliomas that arise from astrocytes(nerve cell in brain and spinal cord). They are classified
histologically into grades I-IV. Grade I astrocytomas grow slowly over many years, while grade IV tumours
(glioblastoma multiforme) cause death within several months. Cystic astrocytomas of childhood are relatively
benign, and usually cerebellar.
- Oligodendrogliomas arise from oligodendrocytes(type of brain cell, same function as Schwann cells). They
grow slowly, usually over several decades. Calcification is common
Symptoms
Mass lesions[afwijkingen] within the brain produce symptoms and signs by three mechanisms:
- By direct effect - brain is infiltrated and local function is impaired
- By secondary effects of raised intracranial pressure and shift of intracranial contents (e.g.
papilloedema[zichtsvermindering, soms tijdelijk], vomiting, headache)
- By provoking generalized and/or partial seizures[epileptische aanval] and changes in mood
Diagnostic tools
* CT + MRI san
* Biopsy
* MR angiography is used occasionally to define blood supply
* PET is sometimes helpful to locate an occult primary tumour with brain metastases.
* Since metastases are common, routine tests, e.g. chest X-ray, should be performed
Treatment
Biopsy and tumour removal. While complete surgical removal of a tumour is an objective, it is often not
possible, nor is surgery always necessary.
Cerebral oedema[vocht] surrounding a tumour responds rapidly to steroids: i.v. or oral dexamethasone.
Epilepsy is treated with anticonvulsants.
For gliomas and metastases, radiotherapy is usually given and improves survival, if only slightly
Filmpjes
108
Liver carcinoma/ metastasis 347-348
General information disease
The most common liver tumour is a secondary (metastatic) tumour, particularly from the gastrointestinal tract
(from the distribution of the portal blood supply), breast or bronchus. They are usually multiple.
Primary liver tumours may be benign or malignant, but the most common are malignant. Hepatocellular
carcinoma (HCC, also called malignant hepatoma) is the most common type of liver cancer. Most cases of HCC
are secondary to either a viral hepatitis infection (hepatitis B or C) or cirrhosis (alcoholism being the most
common cause of hepatic cirrhosis).
Causes
Carriers of HBV or HCV have an extremely high risk of developing HCC. Also Cirrhosis may lead to HCC.
Further: tobacco, alcohol, diet, asbestos and drugs
Symptoms
Symptoms secondary tumour: weight loss, malaise, upper abdominal pain and hepatomegaly, with or without
jaundice.
Symptoms HCC: weight loss, anorexia, fever and ache in the right hypochondrium and ascites (waterbuik).
Diagnostic tools
Diagnosis for secondary tumour: Ultrasound is primary investigation, with the CT of MRI to define metastases
and look for a primary tumour. The serum alkaline phosphatase is almost invariably raised.
Diagnosis for HCC: Serum alfa-fetoprotein may be raised, but is normal in at least one third or patients.
Ultrasound scans  show filling defects in 90% of the cases. Enhanced CT scans identify HCC but it is
difficult to confirm diagnosis in lesion < 1 cm. MRI  can further help to delineate lesions. Tumour biopsy  is
used for diagnosis.
Treatment
Treatment secondary tumour: depend on the site of the primary and the burden of the liver metastases. Best
results are obtained in colorectal cancer in patient with few hepatic metastases. If the primary tumour is
removed and hepatic resection is performed, reasonable survival rates are possible. Chemotherapy is used,
particularly with breast cancer. Radiofrequency ablation of the metastases is an alternative to surgery.
Thermal and cryotherapy is also used.
Treatment HCC : HCC arises in cirrhotic liver in 95% of cases and can be screened and detected by crosssectional imaging and a rise in serum alfa-fetoprotein. Surgical resection. Liver transplantation  offers only
opportunity for cure with patients with a small primary but is limited often by the underlying cause of the
hepatitis and cirrhosis. Chemotherapy and radiotherapy are unsuccessful.
Filmpjes
109
Lung carcinoma (longkanker) 471-473
General information disease
Lung cancer is a disease characterized by uncontrolled cell growth in tissues of the lung. If left untreated, this
growth can spread beyond the lung in a process called metastasis into nearby tissue and, eventually, into
other parts of the body. Most cancers that start in lung, known as primary lung cancers, are carcinomas that
derive from epithelial cells. Overall 5-year survival has remained approximately 15%. The current treatment
reflects the fact that the majority of patients are diagnosed at an advanced stage with a poor prognosis and
therefore there are many trials assessing different screening strategies to try and achieve earlier diagnosis and
more curative treatment.
The main types of lung cancer:
- small-cell lung carcinoma (SCLC): metastasize early
- non-small-cell lung carcinoma (NSCLC): can be divided into different forms, metastasize bit later
Causes
- Smoking
- asbestos
- genetics
- air pollution
The lung is a common place for metastasis of tumors from other parts of the body. Secondary cancers are
classified by the site of origin; e.g., breast cancer that has spread to the lung is called metastatic breast cancer.
Metastases often have a characteristic round appearance on chest radiograph.
Symptoms
- coughing
- breathlessness
- haemoptysis (coughing up fresh or old blood)
- chest pain
- wheeze
- hoarse voice [hees]
-recurrent infection
Frequently metastasizing to liver, bone, adrenal glands, brain, skin
Diagnostic tools
* CT scan
* Chest X-ray
* PET imaging to look for metastasizes
Treatment
* Surgery (can cure non-small cell)
* Radiation (to cure or treat symptoms)
* Chemotherapy
Filmpjes
110
Meningioma (benign brain tumor) 1132
General information disease
Meningiomas are a diverse set of tumors arising from the meninges, the membranous layers surrounding the
central nervous system. Meningiomas are benign tumours and may grow to a large size, usually over years.
They often occur along the intracranial venous sinuses, which they may invade.
Causes
Causes are:
- sporadic
- radiation
- brain injury
- sometimes familial
Symptoms
Many meningioma’s are asymptomatic, and are found quite commonly on imaging or at autopsy
Those close to the skull erode bone or cause local hyperostosis(excessive growth of bone)
Symptoms depend on the location of the tumour, but often:
- focal seizures
- weakness in legs and incontinence
- diplopia (double vision)
Diagnostic tools
* CT
* MRI
Treatment
* removing by surgery
* stereotactic radiotherapy
Filmpjes
111
Mesothelioma 855
General information disease
Mesothelioma is a rare form of cancer that develops from transformed cells originating in the mesothelium,
the protective lining that covers many of the internal organs of the body. The most common anatomical site
for the development of mesothelioma is the pleura (the outer lining of the lungs and internal chest wall), but it
can also arise in the peritoneum (the lining of the abdominal cavity), and the pericardium (the sac that
surrounds the heart), or the tunica vaginalis (a sac that surrounds the testis). 2100 deaths/year in the UK.
Causes
- It is usually caused by exposure to asbesto
Symptoms
The most common presentation of mesothelioma is a pleural effusion, typically with persistent chest wall
pain, which should raise the index of suspicion even if the initial pleural fluid or biopsy samples are nondiagnostic.. Symptoms listed:
- restrictive ventilator defect
- pleuritic pain [chest wall pain]
- increasing dyspnoea shortness of breath due to pleural effusion(fluid between the lung and the chest wall)
- unexplained weight loss
Diagnostic tools
* X-ray, pleural effusion can be seen, usually unilateral
* Video-assisted thoracoscopic lung biopsy is often needed to obtain sufficient tissue for diagnosis
Treatment
Some early promise is emerging from clinical trials of chemotherapy, sometimes combined with surgery, but
the outlook for most patients remains very limited.
Filmpjes
http://www.youtube.com/watch?v=92kanB5K6iw
112
Oesophageal cancer (slokdarm kanker) 244-246
General information disease
This is the sixth most common cancer worldwide. There are 2 types
- primarily squamous cell cancer (55%) squamous cell cancer arises from the cells that line the upper part of
the oesophagus.
- adenocarcinoma (45% of all tumours) Adenocarcinoma arises from glandular cells that are present at the
junction of the oesophagus and stomach
Causes
Risk factors are:
- tobacco smoking
- alcohol
- Coeliac disease
- obesity
- red meat
Symptoms
Early oesophageal cancer typically causes no signs or symptoms.
Symptoms: dysphagia(difficulty in swallowing), difficulty in swallowing solids and after a few weeks also
liquids, eating causes pain and weight loss. Further:
-Coughing or hoarseness
-Achalasia (smooth muscle layer of the oesophagus cannot move food anymore)
-Fatique
Diagnostic tools
* Endoscopy
* Barium swallow (medical imaging procedure used to examine the upper gastrointestinal)
Treatment
* surgery
* chemoradiation.
Filmpjes
113
Pancreatic cancer 431-440
General information disease
Pancreatic cancer is a malignant neoplasm originating from transformed cells arising in tissues forming the
pancreas. The most common type of pancreatic cancer, accounting for 95% of these tumors, is
adenocarcinoma (tumors exhibiting glandular architecture on light microscopy) arising within the exocrine
component of the pancreas. Pancreatic cancer is the fourth most common cause of cancer-related deaths in
the United States and the eighth worldwide. Pancreatic cancer has an extremely poor prognosis: for all stages
combined, the 1- and 5-year relative survival rates are 25% and 6%, respectively;
2 types
1.Head of pancrease and the ampulla of vater
2.Carcinoma localized to the body or tail of pancreas
Causes
-Frequent over 60
-Male
-Smoking
-Alcohol
-Aspirin-Diabetes
-Chronic pancreatitis
-Genetic
-Gene mutations
Symptoms
1. head of pancrease and the ampulla of vater
-Obstruction of bile duct (most common) causing jaundice-cholestasis- itching
- palpable gallbladder
-weight loss
2. carcinoma localized to body or tail
-No symptoms
Some presentations
-Thromboembolic phenomena- blocking of blood vessels by blood clot
-Poly arthritis and skin nodules
Diagnostic tools
-transabdominal ultrasound
-contrast enhanced CT-scan
-laprascopy
-ERCP
-Needle biopsy- not if tumour is operational, need may spread cells
Treatment
-Operate
-5 year survival rate 2-5%
Filmpjes
http://www.youtube.com/watch?v=S1yOs5u1ABQ
http://www.youtube.com/watch?v=6xLkhDJsDGo
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Prostatitis 594 (zal wel niet veel voorkomen, in het boek staat er heel weinig over en op wiki ook)
General information disease
Prostatitis is an inflammation of the prostate gland.
Bacterial prostatitis is a relapsing infection which is difficult to treat. It presents as perineal[bekkenbodem]
pain, recurrent epididymo-orchitis[ontseking zaadbal/bijbal] and prostatic tenderness[gevoeligheid], with pus
in expressed prostatic secretion.
Acute vs. chronic
Causes
Infection with bacteria, funghi, virus
Symptoms
Pain and swelling of the prostate due to an infection
Diagnostic tools
* Urine investigation (high PSA)
Treatment
* Antibiotic
Treatment is for 4-6 weeks with drugs that penetrate into the prostate, such as trimethoprim or ciprofloxacin.
Long-term low-dose treatment may be required.
Prostadynia (prostatic pain in the absence of active infection) may be a very persistent consequence to
bacterial prostatitis. Amitriptyline and carbamazepine may alleviate the symptoms
Filmpjes
115
Renal tumour (kidney cancer) 634-635
General information disease
Renal cell carcinoma arise from proximal tubular[buisvormig] epithelium. They are the most common renal
tumour in adults. They rarely present before the age of 40 years, the average age of presentation being 55
years. Renal cell carcinomas are highly vascular tumours; microscopically most tumours are composed of large
cells containing clear cytoplasm.
Causes
- Smoking
- Genetic (genetic linkage with Hippel-Lindau disease)
Symptoms
Patients are often asymptomatic but can present with:
- haematuria
- loin pain[lende pijn] and a mass in the flank.
Malaise, anorexia and weight loss (30%) occur, and 5% of patients have polycythaemia (see p. 404).
Some 30% of patients have hypertension (due to secretion of renin[=hormoon] by the tumour) and anaemia,
due to depression of erythropoietin in approximately the same number.
Pyrexia(fever) is present in about one-fifth of patients and approximately one-third present with metastases.
Rarely, a left-sided varicocele[verwijde bloedvaten in balzak] may be associated with left-sided tumours that
have invaded the renal vein and caused obstruction to drainage of the left testicular vein.
Diagnostic tools
* Ultrasound
* CT scan
* MRI for tumour staging
Treatment
* Nephrectomy (removal of kidney)
In case of metastasis: surgery and:
* Radiation
* Chemotherapy
* Immunotherapy
Filmpjes
116
General medicin
Other diseases
Depression 1168-1174
Herniated disk
HIV 171-184
Osteoporosis (Rheumatology) 552-556
Premature menopause
Rheumatic heart disease 690, 740-741, 746
Skin infection left arm
Spondylodiscitis
Spondylolisthesis
Tinnitus 1049-1050
Tuberculosis 839-844
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Depression 1168-1174
General information disease
A depression is characterized by disturbances of mood, speech, energy and ideas. Whereas
everyone will at some time or other feel “fed up” or “down dumps”. It is when such symptoms
become qualitatively different, pervasive or interfere with normal function that a depressive illness
has occurred.
Causes
The cause is multi-factorial and a mixture of genetic and environmental factors.
- Physical factors: e.g. polymorphisms in genes regulating monoamines and their receptors,
abnormalities in the brain involving regions that are associated with both emotional and cognitive
abnormalities associated with depression, reduced concentration of brain derived neurotrophic
factor.
- Environmental/ social factors: Sleep pattern, Childhood traumas, personality (emotional and
perfectionist), social factors such as divorce, Stress.
Symptoms
A depression is a disorder without somatic symptoms, only psychotic symptoms are present.
-Fatigue and headaches are the two most common physical symptoms.
- Also insomnia, poor appetite and weight loss are clinical features of a depression.
The symptoms should last for at least 2 weeks in order to be dealt with as an illness.
Diagnostic tools
Corroborative history can be valuable in helping to exclude differential diagnosis such as alcohol
misuse and elucidating maintaining factors such as a poor relationship with a partner.
Physical investigations should be guided by the history and examination: they often will include
- measurement of free T4 and TSH
- calcium, sodium
- potassium
- mean corpuscular volume
- γ-glutamyl transpeptidase
- haemoglobin with cell count, ESR
Treatment
Mixture of CBT and antidepressant
Filmpjes
http://www.youtube.com/watch?v=IeZCmqePLzM
http://www.youtube.com/watch?v=qVEueGutbSs
118
Herniated disk
General information disease
Some herniated disks can be painful. The location of your symptoms may vary, depending on where
the herniated disk is located along your spine. Most herniated disks occur in your lower back
(lumbar spine), although they can also occur in your neck (cervical spine).
Causes
Disk herniation is most often the result of a gradual, aging-related wear and tear called disk
degeneration. As you age, your spinal disks lose some of their water content. That makes them less
flexible and more prone to tearing or rupturing with even a minor strain or twist.
Factors that increase your risk of a herniated disk may include:
- Age: Herniated disks are most common in middle age, especially between 35 and 45, due to agingrelated degeneration of the disks.
- Weight: Excess body weight causes extra stress on the disks in your lower back.
- Occupation: People with physically demanding jobs have a greater risk of back problems.
Repetitive lifting, pulling, pushing, bending sideways and twisting also may increase your risk of a
herniated disk
Symptoms
The most common signs and symptoms of a herniated disk are:
•
Arm or leg pain. If your herniated disk is in your lower back, you'll typically feel the most
intense pain in your buttocks, thigh and leg below the knee. It may also involve part of the foot. If
your herniated disk is in your neck, the pain will typically be most intense in the shoulder and arm.
This pain may shoot into your arm or leg when you cough, sneeze or move your spine into certain
positions.
•
Numbness or tingling. People who have a herniated disk often experience numbness
[verdovend] or tingling in the body part served by the affected nerves.
•
Weakness. Muscles served by the affected nerves tend to weaken. This may cause you to
stumble[struikelen], or impair your ability to lift or hold items.
Seek medical attention if your neck or back pain travels down your arm or leg, or if it's accompanied
by numbness, tingling or weakness
Diagnostic tools
In most cases of herniated disk, a physical exam and a medical history are all that's needed to make
a diagnosis. If your doctor suspects another condition or needs to see which nerves are affected, he
or she may order one or more of the following tests.
*X-ray: to rule out other causes of back pain, such as an infection, tumor, spinal alignment issues or
a broken bone.
*CT
*MRI
* Myelogram. A dye is injected into the spinal fluid, and then X-rays are taken. This test can show
pressure on your spinal cord or nerves due to multiple herniated disks or other conditions.
Nerve tests
* Electromyograms and nerve conduction studies measure how well electrical impulses are moving
along nerve tissue. This can help pinpoint the location of the nerve damage.
Treatment
* Short term use of pain and anti-inflammatory medications, such as NSAIDs or acetaminophen may
help relieve the symptoms of lower back pain.
* Surgery
Filmpjes
119
HIV= Human immunodeficiency virus 171-184
General information disease
HIV is an human immunodeficiency virus infection. Retroviruses are characterized by the possession
of the enzyme reverse transcriptase, which allows viral RNA to be transcribed into DNA and thence
incorporated into the host cell genome. This, combined with a high rate of viral turnover, leads to
considerable genetic variation and a diversity of viral subtypes or clades. On the basis of DNA
sequencing, HIV-1 is divided into three groups, which probably represent three zoonotic transfer
from the chanpanzee but do not differ clinically in human.
Two types, HIV-1 and HIV-2.
- HIV-1 is the most frequently occurring strain globally.
- HIV-2 is almost entirely confined to West-Africa, although there is evidence of some spread to
Europe.
Causes
HIV can be transmitted via semen, cervical[baarmoederhals] secretions and blood. The majority of
infections is caused by:
- Sexual intercourse (passage of HIV appears to be more efficient from men to women, and to the
receptive partner in anal intercourse, than vice versa.)
- Mother to child (transplacentally, perinatally, breast feeding). Vertical transmission is the most
common route of HIV infection in children
- Contaminated blood, blood products and organ donations
- Contaminated needles (intravenous drug misuse, injections, needle-stick injuries
Symptoms
Within a month or two of HIV entering the body, 40-90% experience flulike symptoms known as
acute retroviral syndrome (ARS). But sometimes HIV symptoms don’t appear for years.
As immunosuppression progresses the patient is susceptible to an increasing range of opportunistic
infections and tumours, certain of which meet the criteria for the diagnosis of AIDS
Effects of HIV infection:
- Neurological diseases (dementia, polyneuropathy, autonomic neuropathy)
- Eye disease (cytomegalovirus retinitis = sight-threatening)
- Mucocutaneous manifestations (prurititis =itching feeling, dutch: jeuk)
- Haematological complications (lymphopenia(low level of lymphocytes in the blood), anaemia,
neutropenia=common but often mild, isolated thrombocytopenia, pancytopenia)
- Gastrointestinal effects (weight loss, diarrhoea, wasting as a consequence of anorexia (usually),
infections of gastrointestinal tract)
- Renal complications
- Endocrine complications
- Cardiac complications
- Respiratory complications
Diagnostic tools
- detection of virus-specific antibodies (anti-HIV) à detection of IgG antibody to envelope
components. And direct identification of viral material
- low amount of lymphocytes in the blood
Treatment
- restore and improve immune function by cocktail of medicines:
* ARVs: Antiretroviral drugs
*Reverse transcriptase inhibitors, protease inhibitors, integrase inhibitors, co-receptor blockers,
fusion in hibitors,
Filmpjes
http://www.youtube.com/watch?v=8Csh94TGySQ
http://www.youtube.com/watch?v=ej7MaNEZ09g
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Osteoporosis (Rheumatology) 552-556
Osteoporosis is defined as 'a disease characterized by low bone mass and micro-architectural
deterioration of bone tissue, leading to enhanced bone fragility and an increase in fracture risk'. The
World Health Organization (WHO) defines osteoporosis as a bone density of 2.5 standard deviations
(SDs) below the young healthy adult mean value (T-score ≤-2.5) or lower. Values between -1 and 2.5 SDs below the young adult mean are termed 'osteopenia'.
Causes
Genetic factors are the single most significant influence on peak bone mass,
- but multiple genes are involved, including collagen type 1A1 (p. 494), vitamin D receptor and
oestrogen receptor genes.
-Nutritional factors, sex hormone status and physical activity also affect peak mass
121
- Oestrogen deficiency is a major factor in the pathogenesis of accelerated bone loss.
- In the elderly, vitamin D insufficiency and consequent hyperparathyroidism are pathogenetic
factors.
Additional factors are:
hyperparathyroidism, hyperthyroidism and malabsorption each increase the risk of the person
having a low bone mass and are BMD dependent.
However, other risk factors such as previous fracture, increasing age, glucocorticoid therapy,
smoking and falls increase the risk of fracture, on top of the risk associated with their particular low
bone mass.
Symptoms
Increase in fracture risk
Fractures due to osteoporosis are a major cause of morbidity and mortality in elderly populations,
with osteoporotic fractures of the spine causing acute pain or deformity and postural back pain.
Diagnostic tools
* plain radiographs usually show a fracture
* CT or ultrasound
Treatment
* bisphosphonate
Filmpjes
http://www.youtube.com/watch?v=rHyeZhcoZcQ
Premature menopause (vervroegde overgang)
General information disease
Premature menopause is the loss of function of the ovaries before age 40.
Causes
Causes (before age 40):
- Ovarian failure, which may be autoimmune.
- Identifiable genetic causes such as the fragile X pre-mutation but is most commonly of unknown
aetiology (although often familial).
- May occur surgically, like radiotherapy to the ovaries and with ovarian disease.
Symptoms
- Irregular or missed periods
- Periods that are heavier or lighter than usual
- Hot flashes (a sudden feeling of warmth that spreads over the upper body)
These symptoms are a sign that the ovaries are producing less estrogen.
- Vaginal dryness (the vagina may also become thinner and less flexible)
- Bladder irritability and worsening of loss of bladder control (incontinence)
- Emotional changes (irritability, mood swings, mild depression)
- Dry skin, eyes, or mouth
- Sleeplessness
- Decreased sex drive
Diagnostic tools
* FSH(follicle-stimulating hormone) measurement: repeat LH/FSH levels are necessary before giving
a diagnosis of premature menopause because of the psychological impact of this diagnosis and the
possibility that a single elevation of LH/FSH might simply be the mid-cycle ovulatory surge.
* Low levels of estradiol, a form of estrogen, can indicate that your ovaries are starting to fail.
Treatment
* HRT( Hormone replacement therapy) HRT can be very good at relieving moderate to severe
menopausal symptoms and preventing bone loss.
Filmpjes
122
123
Rheumatic heart disease
General information disease
Rheumatic heart disease is the most dreaded complication of rheumatic fever. The term "rheumatic
heart disease" refers to the chronic heart valve[klep] damage that can occur after a person has had
an episode of acute rheumatic fever. This valve damage can eventually lead to heart failure.
Causes
Once rheumatic valvular disease begins, it tends to continually worsen over time. Repeated
episodes of rheumatic fever can accelerate the deterioration of the heart valves. Rheumatic heart
disease, the mitral valve becomes laden with heavy deposits of calcium, which disrupt the normal
function of the valve. Rheumatic heart disease can lead to mitral regurgitation(leaky valve), mitral
stenosis and aortic valve damage.
The mechanical valve problems (both stenosis and regurgitation) caused by rheumatic heart disease
can tremendously increase the workload on the heart muscle, and as a result heart failure
frequently develops, often after a period of many years.
Symptoms
- Atrial fibrillation (irregular beat, due to the atria who contract irregular)
Diagnostic tools
* ECG
Treatment
* Antibiotics
* Anti-inflammatory medicines (aspirine)
Filmpjes
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Skin infection 1195-1203
General information disease
Infection of the skin is distinguished from dermatitis, which is inflammation of the skin, but a skin
infection can result in skin inflammation. Skin inflammation due to skin infection is called infective
dermatitis.
The skin's normal bacterial flora prevents colonization by pathogenic organisms. A break in
epidermal integrity by trauma, leg ulcers, fungal infections (e.g. athlete's foot) or abnormal scaling
of the skin (e.g. in eczema) can allow infection. Nasal carriage of bacteria can be a source of
reinfection.
Causes
- Bacteria (Impetigo, cellulitis)
- Viral (Viral exanthema, Herpes, warts)
- Fungal (Tinea corporis, tinea cruris, tinea pedis)
Symptoms
- Rash[uitslag]
Diagnostic tools
* Blood count (white bloods cells elevated)
Treatment
* Antibiotics
* taking good care of any break in the skin
Filmpjes
125
Spondylodiscitis
General information disease
Another name for Spondylodiscitis is Discitis. Discitis is rare and is normally only seen in children
under the age of 10.
Causes
A person with discitis (diskitis) has swelling or irritation of the space between the bones of the spine
caused by a viral or bacterial infection. Discitis is considered when there is osteomyelitis of a
vertebral body (in the spine). In most cases, discitis spreads through the bloodstream to the spine
from another location in the body. Possible sites include pneumonia, urinary tract infection, and a
soft tissue infection. Staphylococcus aureus is the organism most commonly found.
Symptoms
The symptoms of discitis include
- a low grade fever,
- chills,
- stiffness in the back,
- back pain,
- abdominal pain,
- irritability, and
- difficulty getting up and standing.
Diagnostic tools
* Recent bacterial infection or procedures on the spinal column?
* inflammatory process indicators like blood sedimentation rate (BSR), C-reactive protein (CRP) and
white blood cell count (leukocytes) are elevated
* If spondylodiscitis is suspected, tissue material from the suspected vertebral segment can be
obtained by fine needle aspiration or punch biopsies.
Treatment
* nonsteroidal anti-inflammatory medications
* narcotic pain medications to reduce pain
* antibiotics
Filmpjes
126
Spondylolisthesis
General information disease
It is a condition in which a bone (vertebra) in the spine slips out of the proper position onto the
bone below it.
Causes
In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar
vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area
of the spine or sudden injury (acute trauma).
In adults, the most common cause is abnormal wear on the cartilage and bones (such as arthritis).
Bone disease and fractures can also cause spondylolisthesis. Certain sport activities -- such as
gymnastics, weight lifting, and football -- put a great deal of stress on the bones in the lower back.
They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a
stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to
become weak and shift out of place.
Symptoms
Spondylolisthesis may vary from mild to severe. A person with spondylolisthesis may have no
symptoms.
Symptoms may include:
•
Lower back pain
•
Muscle tightness (tight hamstring muscle)
•
Pain, numbness, or tingling in the thighs and buttocks
•
Stiffness
•
Tenderness in the area of the slipped disc
•
Weakness in the legs
Diagnostic tools
Your doctor or nurse will examine you and feel your spine. You will be asked to raise your leg
straight out in front of you. This may be uncomfortable or painful.
X-ray of the spine can show if a bone in the spine is out of place or broken.
Treatment
* Most patients get better with exercises to stretch and strengthen lower back muscles.
Your healthcare provider may also recommend:
•
Back brace to limit spine movement
•
Pain medicine
•
Physical therapy
Surgery may be needed to fuse the slipped vertebrae if you have:
•
Severe pain that does not get better with treatment
•
A severe slip of a spine bone
•
Weakness of muscles in one or both of your legs
Filmpjes
127
Tinnitus (oorsuizen) 1049-150
General information disease
This is a sensation of a sound when there is no auditory stimulus. It can occur without hearing loss
and results from heightened awareness of neural activity in the auditory pathways.
Causes
It usually does not have a serious cause but vascular malformation, e.g. aneurysms, or vascular
tumours can be associated. Can also be caused by hearing loss or trauma. Tinnitus occurs due to
awareness of neural activity in the auditory pathways that our brains are made more conscious of.
Symptoms
Patients describe a hissing or ringing in their ears and this can cause much distress.
Diagnostic tools
Patient’s story
Treatment
* Difficult, a tinnitus masker(mechanically produced continuous soft sound) can help
Filmpjes
128
Tuberculosis 839-844
General information disease
It is estimated that one-third of the world's population are infected with tuberculosis. The majority
of cases (around 65%) are seen in Africa and Asia (India and China). Tuberculosis is an airborne
infection spread via respiratory droplets. Tuberculosis typically attacks the lungs, but can also affect
other parts of the body. Only a small number of bacteria need to be inhaled to develop infection but
not all those who are infected develop active disease. The outcome of exposure is dictated by a
number of factors including the host's immune response.
Causes
Tuberculosis is caused by four main mycobacterial species collectively termed Mycobacterium
tuberculosis complex (MTb):
 Mycobacterium tuberculosis
 Mycobacterium bovis
 Mycobacterium africanum
 Mycobacterium microti.
Symptoms
Patients are frequently symptomatic with a productive cough and occasionally haemoptysis along
with systemic symptoms of weight loss, fevers and sweats (commonly at the end of the day and
through the night). Where there is laryngeal involvement, hoarse voice and a severe cough are
found. If disease involves the pleura, then pleuritic pain is a frequent presenting complaint.
Diagnostic tools
* X-ray of the chest
Rapid identification of the presence of bacteria by immediate stains[vlekken] is essential and should
be performed within 24 hours; culture of the sample allows determination of the antibiotic
sensitivity of the infecting strain.
Treatment
* Prednison
* 2HRZE
Prevention relies on screening programs and vaccination.
Filmpjes
http://www.youtube.com/watch?v=7-P9XIdmZes
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