HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ MỘT SỐ BỆNH VỀ TIÊU HÓA

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MUC

LUC

<sub>Trang</sub>

CHUONG

r:

BENH

Lf

DAY

TH-I/C

<sub>QUAN</sub>

CmNc

KHO

TIEU

CH[/C

NANG....

2. BENH TRAO

NGUqC

DA DAY-THIJ. C

QUAN

VIEM

DAY

4.LOeT

DA

DAy

rA

rneNc...

<sub>l8</sub>

xuAr

rruvgr

<sub>rrEU HoA Do LoET </sub>

<sub>DA </sub>

<sub>DAy </sub>

<sub>rA </sub>

<sub>rRANG </sub>

<sub>...</sub>
6. C}IAN DOAN

VA

DIEU TRI N}ilE M HELICOBACTER PYLORI..

cHtIoI{G

BpNH

r,f

<sub>c.lN </sub>

<sub>MAT</sub>

7. BENH GAN

RrIgU....

r0.

xuAT

HLryET

rrcu

HoA

cAo

no rANc

Ap

r

uc

rixs

MACH

CUA

I1. CI{AN

POAN

VE XU

rNi

XO GAN CO HQI C}il.]^NG <sub>GAN THAN...</sub>
12.

crrAN

poAN

<sub>vA Xu </sub>

<sub>rnf </sub>

<sub>xo </sub>

<sub>cAN </sub>

<sub>CO Wmpna </sub>

<sub>rrruAx </sub>

<sub>o</sub>

<sub>ICH</sub>

MANG BTING

13. CHAN POAN

VA )(U

rNi

XO GAN CO HQI CHI.]^NG NAO GAN ...74

14. UNG THIJ

grEu rrl0 rB BAo

cAN...

ts.

cHAx

ooAr.r

ve

pmu

<sub>rry </sub>

<sub>sAu LA </sub>

GAN

9t

tz.

muBrra TRLTNG

DUoNG

MAT

tg.gENHGANNrUeUnr6rnoNcDOKIqU....

tq.

xE

GANarrrrip

20. AP )(E GAN DO

VI

KHUAN

cHrIoNG

Bpt\H

r,f

o4I

TRANG

22.TAO

BON <sub>128</sub>

137

z:.

prBu

TRI

TRi

</div>
<span class='text_page_counter'>(3)</span><div class='page_container' data-page=3>

24.

VIEM

LOET

DAI

TRUC TRANG

CHAY

MAU...

25. BE.NI{ CROHN

26.

IACHAY

KEO DAI ...

zT.HercHLrNG

RUer

rics

rnlcu

cHrIor'{G

BENH

r,f

rqv

28.

VIEM

T.LIY CAP...
29.

VrEM

T.rrY

MAN

144

155

166

172

179

187

</div>
<span class='text_page_counter'>(4)</span><div class='page_container' data-page=4>

CHI/ONG

BFNH

Lf

DA DAY

TIII,/. C

<sub>QUAN</sub>

CIITNG

KH6

TITU

CHTIC

NANG

r. DAr

cr.IONG

Chung kh6 ti6u ld ch4m qu5trinh ti€u h6athrlc 6n t4i d4 ddy.

Chtng

kh6
tiOu bao g6m chimg kh6 tiCu thyc thiS vd chr?ng kh6 ti6u

chfc

ndng. Chimg kh6

ti6u

thlrc th6 do c5c nguy€n nh6n gdy

ra:

Lo6t da dny t6 trang, bQnh

li

trdo
ngugc da ddy thgc quin,ung thu dA day, bQnh

li

dudng m4t, bQnh tUy tpng, do
thu6c, bQnh

lf

toan thdn

vi

thric nn. Chimg kh6 ti6u chric

ning

kh6ng tim th6y
nguy6n nh6n thyc thi5.

Ti

lg chrlng kh6 ti€u chrlc n6ng

cing

r6t kh6c nhau theo
tung nu6c: lJc 6,3%o, Nhat Ban 17-23%, Ch6u du l4-27%...8}t1h kh6ng gAy

nguy hi6m tl6n

tinh

mang, nhung 6nh hudng

t6i

ch6t luong cudc s.ing, xu6t

hiQn tirng tlqt <sub>e6y </sub>lo 16ng cho ngudi bQnh.

II. CHANDOAN

Lim

sing

-

Dau bpng ho{c kh6 chiu virng thugng v!

-

An

nhanh no, lirm cho nguoi bQnh kh6ng the 6n h6t

khiii

luqng

thtc

6n binh thudmg vdn an dugc

-

Cim

gi5c

tliy

bgng sau khi

bipt v6i bQnh ly

trio

ngugc d4 day thyc quan

kh6ng c6 t6n thuong ni€m m4c thgc quan tr€n nQi soi.

-

Si6u 6m vd c6c phucrng tiQn ch6n do6n hinh 6nh girip phAn biet <sub>benh ry</sub>
duong m4t vd tgy t4ng.

3. ChAn do6n

xic

dinh

a. Ti0u

chuin

theo Rome

II

-

Eau

III

-

I

hopc nhi6u tri6u chring sau:

+

DAy bUng sau khi 6n

+

An nhanh no

*

Dau vtrng thugng

vi

+

N6ng

r6t

vtng

thucrng

vi

-

Kh6ng c6 bQnh t6n thucrng thyc thiS: n6i soi

-

Thdi

gian xuAt hiQn trieu chimg: t6i thitiu 3 th6ng, xuAt hign tOl tfrieu
tru6c d6 6 thang

4. Phin

lo4i th6 bQnh

Ti6u

chu6n theo Rome

II

-

The gi6ng lo6t: dau tai vDng thuqng

vi

li

triQu chimg nOi Uat

-

The

r6i

lo4n vQn dQng

+

OAy bUng sau

khi

6n, thudrng kh6ng 16 dau, c6 thri bu6n n6n

+

An nhanh no

-

ThC kh6ng ddc hiQu: c6c tri6u chimg kh6ng cti6n hinh nhu hai th6 tr6n,
c6

thti

c6c triQu chimg xu6t hi6n 15n lQn

gita2th6.

Ti6u

chu6n theo Rome

III

-

ThC cl6y bpng sau khi 6n ( Postprandial Distress Syndrome):

+

it

nhAt mQt trong hai triQu chimg:

o

XuAt

hign kho chiu

virng thuqng

vi

in

v6i

I

16n /tuAn

o

Kh6ng gi6m sau khi dai tiQn hoflc trung ti6n

o

Kh6ng lan ra vung ngyc hodc virng bUng kh6c

</div>
<span class='text_page_counter'>(6)</span><div class='page_container' data-page=6>

-2-o

phai loai trir dau do c6c nguyCn nh6n nhu trii mpt vd

rtii

roan vpn itQng

co Oddi.

+

cdc trigu <sub>chimg k6o ddi </sub><sub>trong 3 </sub><sub>th6ng vd </sub><sub>ph6i </sub>

xu6t hiQn tru6c ch6n

do6n tOi ttridu

6

thang.

+

cdc ti€u chu6n h6

tro:

n6ng

vtng

thucr,ng

vi

<sub>nhmg </sub>

xuong

fc,

dau c6 th6 do 5n hodc

giim

di khi

in

nhung cfing c6 th6 dau khi d6i,
c6 thti xu5t frign c6 thrl dAy bpng sau Ln.

<sub>cluorng </sub><sub>m$t: </sub><sub>si0u </sub><sub>6m </sub>

<sub>vd </sub>

<sub>ciic </sub><sub>phuong </sub>

tiQn ch6n do6n hinh 6nh

-

Benh ly tuy t4ng: si6u dm

vd

<sub>cdcphuong tien </sub><sub>cn6n do6n </sub>

<sub>nirr, </sub>

anr,

b. HQi chring ruQt kfch thich

chfng

kh6

ti6u

chric

n[ng

<sub>bitiu </sub>

<sub>tri6u </sub>

<sub>chring </sub><sub>ch6ng </sub>
chdo

v6i

hQi chring ruQt kfch <sub>thfch. HQi chring </sub><sub>ruQt </sub><sub>kfch thfch </sub>

<sub>uie, </sub>

"nie,

ulng ,ai

loan phdn:

<sub>ia </sub>

<sub>l6ng </sub>

<sub>t6o </sub>

<sub>b6n. </sub><sub>TriQu </sub>

chimg dau bpng thudng

gi6m

khi
trung tiQn ho4c clAi tiQn.

III. DIEU

TRI

1. Nguy6n

<sub>tic</sub>

-

chri yiiu ld iriau

<sub>tri </sub>

triQu chrrmg, <sub>ruy </sub><sub>theo </sub><sub>the </sub><sub>benh </sub><sub>drng </sub>

<sub>ro.i </sub>

thu6c kh6c
nhau

-

Gi6m c6ng thEng stress

-

Nguoi

<sub>benh can </sub><sub>nieu </sub><sub>ducvc </sub><sub>benh cria </sub>

minh vd t4o ldng

tin

cria b6nh

nhenvdingudithiythutic

^".ur

vs r(rv ruuB trrr

c

<sub></sub>

---2. Di6u

<sub>tri </sub>

cB th6

a'

c6c

thu5c tfu ch6 bai tidt a

xit

<sub>qua bom pnoton </sub>

@roton pump

inhibitor

PPr)

c6c

lo*i

ppl

nhu: esomepraz <sub>ore </sub>

<sub>20 </sub>

<sub>mgrngiry, </sub>

rabeprazore

<sub>20 </sub>

<sub>mg/ngiry,</sub>

pantoprazole

<sub>40 </sub>

<sub>mgrngiry, </sub>

raruoprazore <sub>30 </sub>

igieii,

<sub>omepmzo </sub>

re

20mg.

st

dung c6c thu6c

ppl

<sub>kic </sub>

hm

giem

# ffi;

<sub>chimg dau trong </sub>

thti

crau

BOY <sub>G</sub>

V <sub>u rRI </sub>

<sub>a[Nn</sub>

</div>
<span class='text_page_counter'>(7)</span><div class='page_container' data-page=7>

-3-vtrngthugngvi,d{cbietlenhtngngudixu6thientriquchimgclaukhid6i'

Thdl

giandtng

thuiSc php thuQc vdo triQu chimg cua bQnh'

b.

C6c thu6c

vfn

dQng dudmg ti6u h6a (prokinetic)

c6c

thur5c vQn dQng duong ti6u h6a co t6c dung lam nhanh qu6 trinh

r6ngcuadpddyth6ngqua:t6ngtruongln:tlthat,dudi'tinglirmr6ngdpddy'

t6ng nhu dQng cira t61rdng. Do do d6

.o ta,

dUng tot

v6i

tnc aay bung sau khi

6n.

c6c

thuiSc str dpng: itopride 50 mg

x

3 vi6n

I

ngiry' mosapride 5 mg

x

vi6n

/

ngay, metoclopromidelg

pg

*

I

vi6n

lng?y, domperidone.l0mg

x

vi6r:/ngiy

.

c6cffiffi;

rl

,rra

Jt

<sub>"a" </sub>

t6c dpng

tt'ong

mong muon nhu: roi
to4n nhip

tim

v6i eT

dal ra;

t[ng ii6,

frofu.til6;

tdi

vir to' m6t kinh' ti6t

sira;

bi6u hien ngo4i

;;'

i6r

,Lr

,ilr6.

iou

rt,'g

riro m6u n6o

vi

vQv

cin

chu

f

kh6ng dung thu5c cho nguOi diAu

tti6n

phuong tiQn giao th6ng vir c6c m6y
moc

c.

DiQt

vi

tnhuAn Helicobacter pylori

(tLP)

O nhfing

ngudi

bi

chrmg kh6

ti6u

chirc

ning

n6u co

nhi6m

{l:.tt1

khi

diet H.P co tfr? tam giam cac triQu chring kh6 ti6u chrlc n+ng

cv 8-10% s6

trudng hgP.

d.

ThaY AOi tOi s6ng vlr thric

In

T6ngcu}ngv4nclQngth6lyc,tranhc5ctresslimgi6m,Ai:Yfoc6ctri6u

chimg kho ti6u

<sub>"lif. </sub>

nang.MOt si5 thirc 6n nhu cvt vir gia

vi

cay nhi6u cflng ldm
tdng citctriQu chimg ctra bQnh'

e.

Thu6c chdng

trflm

cimvi

chiing lo 6u

c6c

thu5c ch6ng tram c6m vd ch6ng

lo

61t

c6

t6c dung lirm

giim

c6c

triQu

chimg

...i"

-;;.CJ

tna

dirng

thuoc

chring

trAm c6m

3 vdng

nhu

amitrityline

vdi

liOu thdP'

</div>
<span class='text_page_counter'>(8)</span><div class='page_container' data-page=8>

-4-Tii

liQu tham kh6o

1.

Harvey RF, Lane JA, Nair P, Egger M, Harvey I, Donovan J, Murray

L

Clinical

trial:

prolonged beneficial effect

of

Helicobacter

pylori

eradication

on

dyspepsia consultations

-

the

Bristol

Helicobacter

Project.

Aliment
Pharmacol Ther. 2010 Aug; 32(3): 394-400.

2.

Mahadeva S,

Goh

KL.

Epidemiology

of

firnctional

dyspepsia: a

global perspectiv e. Wor ld J Gas tro enterol. 2006 May 7 <sub>;12(17): </sub>2661 -6.

3. Miwa

H, Ghoshal UC,

Fock KM,

Gonlachanvit S, Gwee

KA,

Ang

TL,

Chang FY, Hongo M,

Hou

X, Kachintorn (J,

<sub>Ke </sub>

<sub>Lai </sub>

<sub>KH, Lee </sub><sub>KJ, </sub><sub>Lu</sub>
CL, Mahadeva S, Miura S, Park H, Rhee PL, Sugano K, Vilaichone RK, Wong
BC, Bak

YT.

Asian consensus report on functional dyspepsia. <sub>-I Gastroenterol</sub>

Hep at o l. 20 |

2

Apr <sub>;27 </sub>(4):626 -4 I .

-)

"l

</div>
<span class='text_page_counter'>(9)</span><div class='page_container' data-page=9>

-5-BPNH TRAO

NGIJqC

<sub>DAY-THITC QUAN</sub>

D{.r

cr/oNG:

BQnh trdo ngugc dp ddy - thgc quAn (BTNDD-TQ) le mQt bQnh kh6 ph6
bi6n d c6c nudc

Au-M!

vdi

t6n su5t

ttr

-

20% de$ s6.

d

c6c nu6c chAu

A,

tAn suSt c6 khuynh hu6ng gia

ting

trong nhfrng nbm gAy d6y

vi

dao dQng

tt

-

l5%.

Ri€ng d nudc ta, benh ndy chi mdi dugc ltru y tir hon mQt thflp ni€n trd

lai vdi

t!

lQ dugc <sub>Chi nhan </sub>khoang 15-16% trong m6t

vdi

nghi6n

cfu.

MQt

trong nhfrng nguyOn nhdn ldm cho BTNDD-TQ chua dugc quan tdm dring mr?c

d nudc ta ld do triQu chring ditin hinh cria bQnh (bao g6m g n6ng vir g tr6) chua

dugc

tAm so6t

k!,

trong

khi

cric triQu chrlng kh6c

thi

r6t

bi

lAm 15n vd
thudng

tlugc

qui

cho c6c bQnh kh6c nhu

vi6m

lodt d4 diry

<sub>- </sub>

tri'ng,

vi6m
thanh quin, vi6m mffi xoang...

Thinh thoAng trong ngiry c6 th6 xu6t hiQn trdo ngugc d4 diry-thyc qu6n
sau 6n, kh6ng kdm theo bAt

k!

trieu chimg gi, dugc xem ld hi€n tuqng sinh

lf

binh

thudng.

Ngugc

l4i,

theo

HQi

ngfi

d6ng

thu{n

Montreal

nim

2006,

BTNDD-TQ

dugc dinh nghia l2r khi hipn tuqng

trio

ngugc dich

vi

tu

da ddy

l6n

thyc

qu6n

x6y

ra thudng xuy0n hon

vd

gl,y ra c6c triQu chring

kh6

chiu

vdy'hoflc bi6n chung cho b€nh nh6n.

II.

ChAn tlo6n:

1. ChAn tlo6n x6c

tlinh:

a. TriQu chirng lAm sirng:

-

TriQu chirng ldm sang ditin

hhh

ld o n6ng

vi

tr6. Nu6t nghgn cfing ld
trigu chimg

thulng

g4p trong khodmg

l/3

trutrng hqp.

+

O n6ng: ld

cim

giric n6ng r6t d sau xuong uc lan tr) thugng

vi

di

l€n
c6, c6

khi

lan d6n

rung

ha hgng ho4c l€n t6n mang tai.

Trulng

hqp diian hinh'
chimg

o

n6ng xuAt hiQn sau

bta

vi

tu

thiS ciri g4p ngudi v6 phia tru6c

ho{c

nim rgta.

CitctriQu chimg tr€n

tlng

khi uting ruqu, An c6c thuc 6n chua

..;.

.

cay, nhi6u gia

vi

vd ddu md...

+

T16:

ld

su trAo nguo.c dich dqng trong thuc quan 16n hAu hpng. T16

thulng

xiy

ra khi thay d6i tu th6 ho4c do gdng sfc. Dich trd thudng kh6ng

mti

vf, kh6ng chua vd c6 thri l6n thuc 5n chua ti6u h6a.

+

Nuiit

nghgn:

li

cim

giitc nghgn thrlc 6n hay thuc u6ng ngay sau

khi

nu6t. Can

phin

biQt v6i nu6t nghgn do nguy6n nh6n h6u hqng ld thuc 6n kh6ng

di5n tlugc vuqg hA hgng md trdo ngugc l6n

mfii

hoqc vdo

khi quin

vd thudng

kdm theo sac. Tru6c mQt b€nh nhan bi nu6t nghgn,

dt

r6t nhg ho4c thoang qu4
cflng

phii

c6nh gi6c

v6i

ung

thu

thyc

quin

d6 tAm sorit ho4c lo4i

trir

nguy€n
nh6n kh6c.

</div>
<span class='text_page_counter'>(10)</span><div class='page_container' data-page=10>

-6--

Circ

tri6u

chring

it

gdp: cbm giirc cuc nghgn (globus), r?a nudc bgt
^ A, - ' .\

trong miQng, nu6t dau, bu6n ndn, n6n, ndc cr;t...

-

Cdc triQu chimg ngoei thyc

quin:

dau nggc kh6ng do tim, triQu chring
1i6n quan hO hap (ho mpn tinh, khd khd, con hen ph6

quin),

triQu chring 1i6n

quan bqnh tai mfii hgng (khan giQng, vi6m tai

gita,

mdn rdng, dilngmiQng, clau

hgng, vi6m xoang, vi6m hAu hgng, h6i miQng...)
b. TriQu chring c$n I6m

sing:

*

NQi soi tiOu

hoi

tr6n

-

Dugc chi clinh

khi

c6 c5c dAu hi6u b6o clQng c6c bi6n chimg hoflc c6c
bQnh

ly

6c tinh nhu nu6t kh6, nu6t dau, spt c6n, xuAt huytit hay thi6u m6u; ho{c
de tAm so6t nhirng benh nhdn c6 nguy

co

cao

bi

bi6n chftng, hay c6c triQu
chimg kh6ng di6n hinh. Cric bQnh nhdn khdng d6p ung

v6i

di0u

tr!

chu6n

bing

c6c thu6c ric chti

titit

acid hay ph6i

dtng

thu5c kdo ddi cfrng cAn dugc nQi soi

dC chAn do6n

-

NQi soi ti6u h6a tr6n c6 dQ nhay viro khodng 30-40% cho ndn kh6ng
nhat tnict

phii

thyc hiQn thuong qui cho t6t c6 bQnh

nhin

nghi ngo bi
BTNDD-TQ. Kho6ng> 60Yo

trulng

hqp bQnh nhdn c6 triQu chimg trdo nguoc di6n hinh
nhrmg khong c6 hinh anh vi6m thpc quan tr6n nQi soi, duoc

g9i

ld bQnh trdo
nguoc kh6ng vi6m. Tuy nhi6n, nQi soi

lqi

rht hiru fch de ph6t hiQn c6c bi6n
chimg quan trgng cfia bgnh nhu vi6m

thgc

quan, 1o6t, xu6t huytit, hgp thyc
qu6n

vi

thgc qu6n Barrettlung thu thyc quin.

-

Phan lopi BTNDD-TQ dua tr€n t6n thuong vi6m thuc quin:

1.

Benh trdo ngugc c6 vi6m thpc quan (erosive reflux disease - ERD)

2.

Benh

trio

ngugc kh6ng vi6m thyc quin(non-erosive reflux disease
-NERD)

3.

Thgc

quin

Barrett (Barrett's esophagus):

khi

c6 sp dlch chuy6n 16n

tr6n

cria phan

ti6p gi6p bitiu md

trU- 16t tdng (squamocolumnar

junction)

<sub>ctrng </sub>

<sub>sp </sub>

<sub>cria </sub>

<sub>tugng </sub>

<sub>chuytin </sub>

(intestinal metaplasia).

-

Phan

EO C: c6 nhi6u v6t xu6c lan rQng qua nhi6u ni5p ni€m mpc nhrmg chi
<75oh <sub>chu </sub><sub>vi </sub><sub>thuc </sub>qudn.

</div>
<span class='text_page_counter'>(11)</span><div class='page_container' data-page=11>

-7-+

D:

c6 nhidu v6t xudc ni6m m4c lan rQng, chiiSm

it

nhdt 75 Yo

cfit

vi thyc quin.

.i.

<sub>X </sub>

<sub>Quang </sub>

thgc

quin

cin

quang: cht

y6u dugc chi tlinh

khi

nghi
ngd c6c biiSn chimg teo hgp, 1o6t thyc quan, ho4c tho6t v! hoanh'

.!

<sub>Do 6p lgc </sub>

ccr

thit

dudi thyc

quin

(CTDTQ):

dC x6c dinh viQc dat

chinh x6c

Al,

iO Ao pH thyc qu6n vA danh gi6 trudc khi

phiuthuflt

ch5ng trdo
ngugc. Phuong ph6p

niy

r6t

htu

ich trong viQc lo4i

tru

c6c

rdi

loan

vfn

dQng

thlrc

quan hit5m

gip

nhrmg

l4i

c6 nhuoc di6m

ld

kh6ng chinh x6c do

bi

6nh
hu&ng c0a khAu kinh 6ng do vd cu dQng hd hAp.

.!

<sub>Do </sub>

pH

thrp quin

24

giitz dugc xem ld ti6u chudn vang d6 chAn do6n
x6c rllnh. Phucrng ph6p ndy girip xric dlnh

trio

ngugc d4 diry - thr;c quan d bQnh

nh6n c6 triQu chung kdo ddi nhrmg kh6ng c6

bing

chimg cria t6n thucrng vi6m,
d6c biQt td htri thAt bai vdi di6u

tri

khang ti6t acid'

Ti6u

chu6n chAn tlo6n:

-

Trong da sti trudng hqp, chAn do6n chri y6u dya viro h6i benh su, d{c

bi€t

trigu

chring di6n hinh nhu g n6ng vh

tr6.

CAn dua viro

ldi

m6 tA

cta

bgnh nhdn ae pnainipn triQu chung vi thu$t ngfr "g n6ng" c6 th6 lam benh nhan
kh6ng hii5u d6 khai benh.

-

N6u nghi ngd BTNDD-TQ, cO *rC el6u

tri

thrl b6ng thutic irc cht! bom
proton

fidu.tuAn

<sub>epf </sub>

test) trong 2 tuan d6 tlanh gi6 d6p rlng di6u

tri'

-

NQi soi ti€u h6a tr€n kh6ng dugc khuytin c6o thyc hiQn

thulng

qui

khi

c6 trieu chimg trdo nguqc di6n hinh'

-

Nhtng

hulng

harp hiQu chimg kh6ng di6n hinh, kh6ng d6p ung v.oi

<ti6u

tr!thri

hoflc c6 c6c d6u hiQu b6o dQng bi6n chung hay bQnh 6c tinh, c6n

Ti6n srl gia dinh bi ung thu d4 ddy/ung thu thyc quirn
2. ChAn tlo6n phAn biQt:

TriQu chimg

cta

BTNDD-TQ c6 th6 tuong tU c6c bQnh

ly

t4i thqc quan
vd ngodi thpc quan nhu:

-

thit tim

vi.

diy

-

Kh6 ti6u chuc n6ng

-

Dau th6t ngr,rc.

3. ChAn do6n nguy6n nhAn:

Khi

CTDTQ hoat dQng kh6ng

ttit

sc dE dan dt5n

BTNDD-Te.

C6c ytiu

tii

6nh huong A6n ri5i 1o4n ho4r dQng cria

CTDTe

vi

co ch6 bao v€ ch6ng

trio

ngugc c6 the do (1) Su thu

din

thoring qua cria

CTDTe

xiy

ra thudng xuy6n
vd kdo ddi hon, (2) Tho6t

vl

hoanh, (3) Ri5i loan vfln rtQng thuc qu6n, (4)

ciam

ti6t nu6c bot vd

(5)

Ctrc tec nhen

hm

gi6m 6p lgc

CTDTe

nhu c6c thu5c kich
thich thu th6 p,

iic

chi5 thu thd o , thu5c a5l ruuing cholinergic, thu5c gi6n co

tron

(nhu

c6c

thu6c chgn k6nh

calcium,

c6c

-

Didu tritiQt tru H.pylori
4. Ch6n do6n bi5n chrirng:

Can tuu

y

ld kh6ng c6 su song hdnh gifia triQu chtmg l6m sang vd t6n
thuong thpc th6 cria c6c

biiin

chrmg: <sub>Dau nhidu nhrmg chua ch6c d6 c6 t6n</sub>
thuong vi€m thyc quan n4ng; ngugc

l4i

vi6m thyc quan n{ng c6 th€ di6n tit5n

6m thAm cho tttin khi xu6t hign c6c bi5n chimg lo6t, hgp, xu6t huytit.

Bit5n chring thudng

xiy

ra nh6t

h

vi6m thlrc qu6n do triro nguoc

v6i

c6c

h€ qud lodt, teo hgp. Vi6m thpc quan c6 th6 ch6n do6n dya vdo nQi soi. 60%
benh nhan BTQDD-TQ kh6ng c6 beng chung vi6m thyc quan tr€n nQi soi.

Thgc quan Barrett ld biiin chung quan trQng cria

BTNDD-Te,

hi6n diQn

0 8 -15% b6nh nh6n. D6y ld tinh trang ni€m m4c thgc quan bi thay thi5 dan bdi
ni6m m4c d4 day v6i nguy co ung thu h6a (adenocarcinoma) do4n ni6m m4c b!
chuy6n san.

</div>
<span class='text_page_counter'>(13)</span><div class='page_container' data-page=13>

-9-BQ Y TE - HU6NG DAN CHAN DOAN VA DIEU TRIBE.NH TIEU HOA -

10-Lo6t thgc qu6n c6 th6 g6y xu6t huy6t.

Ngoiri ra, c6 th6 c6 c6c bi6n chimg nhu vi6m thanh qu6n, vi6m xoang,
vi6m

mfli

hgng, vi6m phOi ao hit do trdo ngugc, hen ph6 quan xiry ra vho ban
d6m, mdn r6ng...

III. DITU TRI

Mgc

ti6u di6u

trl

-

KiiSm so6t trieu chung d6

cii

thiQn ch6t luqng sting

-

Lem lanh vi6m thgc quan (n6u c6)

giucrng

-

Ngmg

thu5c 16.

-

Tr6nh mflc qudn rlo

chft

(nit ngyc, nlt

lmg)'

-

Trlnh

c6c thutic

nhu

llc

chil

calci,

theophylline,

an

thAn,

anticholinergics

vi

lirm

tlng

trao ngugc'
b. NQi khoa:

-

Ni5u benh nhen

bi

triro ngugc nhq hay trung binh: c6 th6 dtrng thuOc
trung hod acid dich

vi

- antacid (sau nn hay khi.di ngn) vd thu5c rtc chtl thy th6
H2 (H2RA) crich khoang hay phdng

ngla

khi cdn thi€t'

-

Lieu chuAn H2RA cO tne

lu*

gi6m triQu chring d5n 600/o vir d6u hiQu

liurh vi6m 1o6t thgc qu6n tren nQi soi khoimg 5o%.

a

benh nhan suy th?n

phii

didu chinh [Au.

-

Nhtng

ca nh9 c6 th€ dung cric thu5c

lim ting

truong lyc CTDTQ nhu
Metoclopramide, Domperidone; tuy nhi6n kh6ng khuy6n c6o

ding

lAu

dii vi

c6
th€ c6 nhidu t6c dgng <sub>Phg.</sub>

-

PPIs (thut5c r?c ch5 bcrm proton) dugc chimg minh ld c6 hiQu qu6 hon
so

vdi

placebo vd I-DRA

[6u

chuAn trong viQc gi6m tripu chimg cflng nhu ldm
Dnh vtSi thuong tr€n nQi soi. Thdi gian dieu

tri

ln 8 tuan e5i vOi STNDD-TQ c6
vi6m thlrc quun ua 4 tuan d6i

v6i

NERD.

Iftdi

<IAu dung PPI 1 lAr/ngdy tru6c

6n sring 30 phrit.

Li6u

cao nhu Omeprazole

2040

mglngiry

x

2ldn

tru6c

</div>
<span class='text_page_counter'>(14)</span><div class='page_container' data-page=14>

hgp nflng vd c6c triQu chimg k6o

dii.

ViQc sr] dpng l6u

dii

PPI tucrng ilOi an

toan vd higu qud trong vigc duy

tri

phdng ngira

tili

ph6t trong c5c trudrng hgp
vi6m thgc quan, Barrett thpc quan

vi

triQu chimg nang. Tuy nhi6n, cdc dti liQu

cho th6y PPIs c6 thti 6nh huong tltin sy hdp thu Calci vd ldm nAng th6m ti5n

thucrng Oan truyAn

tim,

gdy

tlng

nguy co nhi6m Clostridium

difficile

vi

ldm
t6ng nguy co gdy xucrng chQu hay lo6ng xuong o phU

nt

mdn kinh.

-

thuiic

khing

ti6t

acid
BQnh

trho

nguqc DD-TQ

Famotidineu

a: chinh

liiu

khi suy thQn

c.

NgoSi khoa:

C6c phuong ph6p diAu

hi

ngo4i khoa dugc chi ctinh hong c6c trudmg hqp:

-

DiAu

tri

nQi khoa k6o ddi

vi

ting

li6u cao nhrmg

cii

thiQn rdt

it.

-

Benh nhan kh6ng tuen

tht

diAu

tri

vd mong mu6n phdu thu4t.

rv.

Ktr

LUaN

Benh TNDD-TQ ld mQt benh m4n tinh, ngey cang xu6t hiQn thucrng hcrn d
c6c nudc chdu

A

vi

c6 khuynh hudng t6ng tdn su6t & ViQt Nam. Benh kh6ng
chi 6nh huong itdn ch6t lugng cuQc s5ng do c6c triQu chung

mi

cdn c6 th6 gdy
c6c bilin chimg neng nhu 1o6t thpc quan, hgp thpc quan

vi

h6a ung thu. ViQc
chan doan vd tli6u

tri

cAn dugc xem x6t, cdn

nhic

ky d6 dat k6t qu6 ttit nh6t vOi

Cimetidineu 400 mg ngey 4 len
800 mg ngay 2

An

Ranitidineu 150-300 mg ngdy 2

hnhay

4 lAn
20- 40 mg

ngiy

21rdn

Nizatidineu 150 mg ngay 2

hn

Omeprazole 20- 40 mg mdi ngay hay ngdy 21dn
Esomeprazole 20 - 40 mg m6i ngey hay

ngiy

2ldn

Lansoprazole 15 - 30 mg m5i ngey hay ngdy 2\6rn
Rabeprazole 10

<sub>- </sub>

20 mg mdi ngey hay

ngiy

2ldn

Pantoprazole 20 - 40 mg m6i ngey hay ngdy zl.drn

y re

- su6NG DAN cHAN DoAN vA DrEu rRI BEIIH TrEU H6A

-11-I

</div>
<span class='text_page_counter'>(15)</span><div class='page_container' data-page=15>

chi

phi

hqp

ly

nh6t, cffng nhu tr6nh b6 s6t nhirng bi{ln chrrng nguy hi6m nhu
h6a ung thu.

Tii

liQu tham kh6o

l.

DeVault

KR,

Castell

DO.

Updated guidelines

for the

diagnosis and
treatment

of

gastroesophageal

reflux

disease. Am

J

Gastroenterol. Jan

2005;100(l):

190-200.

2.

Marco G. Patti

MD,

Julian Katz

MD.

Gastroesophageal reflux disease.

Mescape. May 2013.

3.

Yamada T, Alpers DH, Kaplowitz N, Kalloo

A,

Owyang C, Powell DW
(2008). Appoach

to

the

patient

with

gastroesophageal

reflux

disease.

Principles

of

Clinical

Gastroenterologt

lst

Edition.

Wiley-Blackwell
Publishing, Oxford, UK, pg. 83-99.

4. Philip

O. Katz

MD,

Lauren

B.

Gerson

MD.

MSc and Marcelo

F'

Vela

MD.

Diagnosis and management of gastroesophageal reflux disease.

llzl

</div>
<span class='text_page_counter'>(16)</span><div class='page_container' data-page=16>

VTEMD4DAY

r.DArcuoNc

Vi6m d4 ddy (gastritis) ld tinh h4ng vi6m cria ni6m mac d4 diry,

v6i

d4c

tnmg

ld sg thdm nhQp c6c t6 bdo vi6m (bpch cAu da nhAn, bach cAu lympho,

tuong bdo

...).Do

d6, chAn do6n vi6m d4 ddy chi dugc x6c dlnh chic

chin

khi
c6 k6t qu6 m6 b€nh hqc d4 ddy.

Tr6n thuc

tti

l6m sdng,

thu{t

ngfi

"vi6m

diy"

thudng dugc su dgng

ptrO UiCn nhrmg l4i kh6ng chinh x6c khi tt6 c{p d6n tri€u chimg goi

f

r6i lo4n
cria dudng ti€u h6a trdn

(vi

dp: dau thuqng

vi

li€n quan bfla 6n, n6ng

riit

vtrng
thugng

vi,

dAy bqng sau dn

hoic

6n nhanh no

...).

N6u benh nhan c6 ciic triQu

chrmg k0 tr6n chua dugc

thim

dd b6ng c6c x6t nghiQm chan dorln, thu6t

ngt

sri
dqng chinh x6c trong truong hqp ndy

lir

chring kh6 ti€u chua duoc thdm dd
(uninvestigated dyspepsia). Trong trudng hqrp bQnh nh6n

v6i

c6c triQu chimg

n6u tr6n tl6 tlu-o. c nQi soi ghi nhfln ki5t qua nQi soi binh thudng ho4c c6 hinh anh

gqi

<sub>I </sub>

vi€m d4

diy

nhung kh6ng c6 ki5t qu6 m6 bQnh hgc d4 ddry, thudt

ngt

sri

dgng

trong trudng

hqp ndy

ld r6i

lo4n

ti6u h6a chric

ndng

(functional
dyspepsia).

Vi6m d4 ddy (theo dring ttinh nghia v6 m4t m6 bQnh hqc) duoc quan t6m

vi

trong mQt sti

it

trudng hqp c6 th6 gdy triQu chring kh6 chiu cho bpnh nh6n,
vir quan trgng hon htit ld c6 th6 tiiin tri6n thanh c6c t6n thuong ti6n ung thu dp

ddy ldm

ting

nguy co ung thu d4

diy.

II. NGIIYTN

NHAN

C6 nhi6u nguy€n nhdn gdy vi6m d4 ddy (bang 1). Hai nguy€n nh6n vi6m

ddy

ph6 bit5n ld 1L

pylori

vit vi6m dp ddy h6a hgc (cdn dugc ggi ln bQnh da

ddy

-

gastropathy do trong trudmg hqp ndy

hinh

6nh

m6

bQnh

hqc

d4 ddy

thulng

thAm nhflp rdt

it

circ tti

bio

vi6m).

-

Vi€m

d4 ddy do

H. pylori ld

d4ng quan trgng nh6t

vi

H. pylori

ld
nguy€n nhdn chinh dan A6n lodt d4

<sub>diy -t6 </sub>

trang, cric tinh tr4ng vi6m vir t6n
thuong titin ung thu d? day (teo ni6m m4c,

di

sdn ru6t, lo4n

sin

ruOt) vd tidm

nlng

d6n d6n ung thu d? dey. Tuy vgy, do m6i tuong t6c phrlc t4p

gita

3 y6u tO

vd A6c Oi6m

cta

chring

H. pylori

sinh bQnh, dac di€m

di

truy6n cria ngudi bi

r.i i -: , <sub>. t t -^ - </sub> ,( .

nhi€m vd cric y6u td m6i truong (ch6 d0 5n u6ng), chi c6 khodng 15% nguoi
vi€m d4 ddy do H. pylori trong sutit

thdi

gian s5ng c6 thra

bi

lo6t da

diy

<sub>- </sub>

tri
trdng

vi

kho6ng 1% ph6t triiln thanh ung thu d4 ddy.

-

Vi6m d4 ddy h6a hgc x6y ra

khi

c6 sr,r

tiiip

xric cria ni6m m4c d4 diry

vdi

dich mAt (sau ph6u thu4t c6t

tan

phan da ddy ho{c trong c6c hQi chtmg rtii

1o4n

v{n

tlQng d4

de/;

bQnh nh6n sr} dgng aspirin, thu6c khring vi6m kh6ng

</div>
<span class='text_page_counter'>(17)</span><div class='page_container' data-page=17>

-13-steroid vir ruou

bia...

Tuy nhiOn hAu h€t c6c trudng hqp vi6m d4 ddy h6a hqc
kh6ng gdy triQu chimg vd kh6ng gdy tinh treng teo ni€m m4c d4

diy

do d6 co
g6y ung thu da day thAP.

-

C6c trudng hqp bQnh nhan

bi

ddng

thdi

hai t6c dQng

cta

nhi6m H'

pylori

vd vi6m d4

diy

h6a hqc c6 nguy co bi t6n

t!,*g

n4ng n€ hon' Vi6m teo
ioan b0 d4 ddy ld yi5u ti5 nguy co chinh y6u tlua d6n ung thu d4 ddy

1.N

nhin

vi6m d

III. PHAN

LOAI

Vi6m

dg dny c6p: c6c t6n thuong xu6t truy5t vd vi6m

trqt

x?ry ra ngay sau

khi

ni6m m4c dp ddy tii5p

xirc

v6i

c6c ttQc chAt <sub>Gnr{ng </sub>vi€m kh6ng steroid,

rugu

bia,

axit

mSt

...) hoic khi

tinh

tr4ng gi6m

tu6i

m6u

d

de ddy (ch6n
thuong, b6ng, h4 than nhiet, nhi€m khu6n huy6t, h6a

tri

toan thdn ho4c x4

tri

ungthu...)

Vi6m

d9 dny m4n (ph6n lopi Sydney

cii

ti6n)

-

Vi€m d4

diy

kh6ng teo ni6m m4c (cdn gqi ld vi€m da ddy

ffp

B):

do
H. pylori

vi

mQt s6 t6c nh6n kh6c.

-

Vi€m teo ni6m m4c d4 diry: bao gOm d4ng vi6m teo d4 ddy da 0 (cdn

gqi

li

vi6m da ddy

fjp

B

ho4c

fip

AB

H. pylori),

vd vi6m teo d4

diy

tg
miSn (cdn ggi ld vi6m da ddY

ffP

A).

a) Nhi6m trtrng

-

Vitrung: H.

pylori,lao,

c6c chtngMycobacteriumY'hhc

-

Si6u

vi:

CMV, HerPes

-

N6m: Candida, Histoplasma, Phycomycosis

-

Kf

sinh trung: giun dfr4 giun luon, Cryptosporidium
b) T6c nh6n h6a hsc (vi6m da daY

{P

-

Thu5c: khang vi€m kh6ng steroid, aspirin, ticlopidin

-

Rugu

-

Dfch m4t

-

Cocaine
c) Tia x4

d) <sub>Qua </sub>trung gian mi6n d!ch: Tg miSn (typ A), H.

pylori,

v6 cdn

e) Nguy6n nhdn kh6'c: b€nh Crohn, Sarcoidosis, bQnh u h4t Wegener

<sub>" </sub>

</div>
<span class='text_page_counter'>(18)</span><div class='page_container' data-page=18>

-14--

Circ dqng vi6m d4 ddy d4c biQt: h6a hoc (dich m{t, khdng vi6m kh6ng
steroid ,.,), vi6m d4 ddy lympho bdo, vidm d4 dity d4ng u h4t, vi6m dq dily c6
tbng b4ch cAu 6i toan, vi6m d4 ddy do nhiSm trung

(vi

trung, si€u

vi,

h-i sinh

t

ong)

IV. CHANDOAN

I

ChAn dodn x6c

tlinh:

, :.,.,

-

Khong c6 m6i li6n quan chdc ch6 giira triQu chung

lim

sdng, hinh anh
n6i soi

vi

m6 bQnh hgc

cta

vi6m d4 dny. HAu h6t c6c trudng h_o. p vi6m d4 ddy

kh6ng triQu chimg vd c6 hinh 6nh nQi soi binh

thulng

chi phrlt hiQn khi hi thi6t.

-

ChAn tlorin x6c rllnh vi€m d4

diy

dya tr€n m6 bQnh hgc: tr6n thuc t6,
hAu h6t ld benh nhdn c6 tri6u chimg ti6u h6a tr6n (dau thuqng

vi,

o hoi g chua,

n6ng r6t thuong

vl,

dAy bUng hodc kh6 chlu thuqng

vi

sau dn

...)

c6 chi rlinh
n6i soi da ddy <sub>vd dugc quyct dinh thuc hi6n </sub><sub>sintr </sub><sub>thi6t </sub><sub>da </sub><sub>ddy </sub><sub>qua nQi </sub><sub>soi </sub><sub>khi </sub><sub>c6</sub>
lodt da ddy

<sub>- </sub>

tri trang

hoic

nghi ngd c6 t6n thucrng tidn ung thu ho{c ung thu
d4 ddy trdn nQi soi.

-

Crich l6y m6u sinh thiiit iI€ x6c dinh chAn doan:

+

miu

theo khuy6n c6o

cta

h6 th6ng Sydney c6i

ti6n (2

m6u vung
hang

vi,

2 m6u vtrng th6n

vi

d

2 phia bd cong nh6 vd bd cong

lon,

1 m6u

J

vtng

g6c bd cong nh6). 5 m6u sinh ttritit ndy n6n d€ vdo 5 19 <sub>ri6ng ghi rd </sub><sub>vi </sub>

tri

sinh

thiiit

grii

drinh gi6 m6 bQnh hqc. Tuy nhi6n 6p a,.rng vao thuc t6.

ia-sdng kh6 do phric t4p, gd,hn4ng chi phi cho benh nhan vd qu6 t6i cho c6c tlon
vi nQi soi vd gi6i ph6u b6nh.

+

Nghi6n criu trong nu6c cho thAy sinh thi6t 3 m6u doc phia bd cong
nh6

(d

vung gifta thAn

vi,

gifa

hang

vi

rung

g6c bd cong nh6) c6

thii

d,i
girip x6c dinh rlugc cric trudng hqp c6 t6n thuong ti6n ung thu. C6c m6u ndy
n€n dugc grli trong hai l9 ri6ng (1

l9

chria m6u sinh thi6t vung th6n

vi,

lg

cdn
l4i chria m6u vung hang v! vd

vtng

g6c bd cong nh6).

2. Xric

ilinh

nguy6n

nhin

vir t6n thuong tidn ung

thu

diy

a. Xr{c

tlinh

nguyOn

nh6n:

tr€n m6 b6nh hoc

thu}ng

c6 th6 x6c

tlinh

dugc
nhi6m

/r

pylori,

dbi

khi

c6 thri

xic

dinh duoc ctic nguy€n nhdn kh6ng thudng
g[p nhu: vi€m <sub>dp ddy c6 tnng b4ch </sub><sub>cAu </sub><sub>rii toan, u </sub><sub>h4t </sub><sub>...</sub>

b.

X:ic tlinh

cic

t6n thuong tidn

ung

thu

diy

(vi0m teo niGm m4c dg
diry, di

sin

ruQt, Io4n srln): Nguy co ti6n tri6n

thinh

ung thu d4 ddy hang nAm

ld 0,1% d benh nhan b! vi6m teo ni6m m4c d4 diry,0,25%o

khi

di sin

ruQt,

0,6%kltt c6 lo4n san d6 thSp

vit6yokhic6

lopn s6n tt6 cao.

v.

DrtuTRI

1 Nguy0n t6c tli6u

tri

-

Di6u

tri

nguydn nh6n (ntiu x6c dinh tluoc)

</div>
<span class='text_page_counter'>(19)</span><div class='page_container' data-page=19>

l5--

Didu

tri

triQu chimg
2 DiBu

tri

cB th5

Dilu

tri

nguy0n

nhin:

-

Di€u

tri

tiet

tni

H. pylori:

girip

cii

thiQn tinh tr4ng vi6m m4n tinh vir
vi6m teo ni6m mac. Tuy nhi€n n6u tru6c khi didu

tri

de c6 di san ruQt ho{c loqn
s6n o d4 ddy

thi

c6c t6n ttruong

niy thulng

kh6ng phvc h6i dugc vd v6n phdi
theo

ddi

nguy co ung

thu

dp dey.

otii

vOi c6c.tru'dng hqp kh6 chua tiQt tru
thanh

c6nj

viQc di€u

t|

bnng Rebamipide (thu5c c6 t6c dgng kh6ng vi€m t4i
ni6m m4c d4 ddy vd kich thich tao Prostaglandin nqi sinh) cho thdy c6 kiit qua
cai thien vd

lim

chdm tiiin trinh vi€m d4

dly,

c6 ttt6

gt"p

ich trong khi cho dgi

mQt phuong ph6p di6u

tri

tiet tru H. pylori hiQu

qui

hon'

-

Vi€m

d4 ddy do t6c nhdn h6a hgc:

Ngmg

sri dgng c6c t6c nh6n h6a
hgc gdy viOm d4 ddy niSu c6 th6 tluqc (ruqu bia, khring vi6m khdng steroid'
aspirin. . .)

-

Vi€m d4 ddy t6ng bach cAu 6i toan du-o. c ttiAu tri

bing

corticoid'

-

Vi6m d4 day do bQnh Crohn ho{c vi€m d4 ddy

ting

lympho bdo kh6ng
phai do H. pylori ttugc diAu

tri vdi

c6c thu6c uc ch6 bom proton'

b. Di6u

tri

triQu chrtng: Tu<rng tq bdi kh6 tiOu

chfc ning

VI. THEO

DOI

ViQc theo d6i

chi

tlugc theo d6i 0 nh6m c6c bQnh nh6n vi€m d4

diy

tinh

trang hoflc tdn thuong tidn ung thu dA ddy

nhim

mqc dich ph6t lriQn ung

thu

da day

khi

cdn A

giai

tloan sdm. HiQn chua c6 khuyiin crio th5ng nh5t

"t,r,g.

Urorrg

aan

cta

ff6i

NQi soi Tieu h6a Ch6u Au vd HOi Gi6i

phSu bpnh

Ch6uAu

(2012) d6 xu6t theo d6i c6c truong hqp vi€m da ddy do

II

vi:

CAn

theo d6i vd d6nh gi6 l4i m6i 3 nam.

-

C6 lo4n san vd quan s6t dugc t6n thuong khu

tni

(c6 1o4n san) tr6n nQi

soi: c6t qua nQi soi tI6 d6nh gi6 m0 bQnh hqc chinh x6c hon'

-

C6 loan san ilQ th6p nhmg kh6ng th6y t6n thuong khu tru tr6n n6i soi:
theo d6i vd ttrtu:h gi6 l4i trong vdng < 12 th6ng

-

C6 loan

sin

tlQ cao nhrmg kh6ng th6y t6n thuong khu tru tr6n n6i soi:
theo ddi vd danh gi6 l4i ngay l4p trlc, vd sau d6 6

-

thing.

</div>
<span class='text_page_counter'>(20)</span><div class='page_container' data-page=20>

6-Tni

[Qu tham kh6o

1.

Rugge

M,

Graham

D. In

Talley

N

(ed). Practical gastroenterology and

Hepatology: Esophagus and stomach. Gastritis.

l"

edition. 2010:

Wiley

-Blackwell. 345

-

52. Singapore.

De Vries

A

et al. Management of precancerous
conditions and lesions in the stomach (MAPS): guideline from the European

Society

of

Gastrointestinal Endoscopy (ESGE), European Helicobacter

Study Group

(EHSG), European Society

of

Pathology (ESP),

and

the
Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy

2012;

44(1):74-94.

</div>
<span class='text_page_counter'>(21)</span><div class='page_container' data-page=21>

-17-LofT

DA

oAv rA

rnANc

DAr

cr/oNc

Lo6t d4

diy

tri trang ld

tinh

trpg

ni6m m4c

bi

tdn thuong bii m4t vuot
qu6 lop co ni6m do tric tlQng crla dich

v!

d4 ddy. D6y ld mQt b€nh d6 duqc bi6t
ttr l6u vd kh6 ph6 bii5n tr6n thi5

gi6i

ctng nhu 0 ViQt Nam.

M[c

dt

tld c6 nhting

tilin

b0 lcrn trong chAn do6n vd tlidu tr!, n6 v6n ld mQt v6n dri suc kh6e l6n bdi
sii luqng benh nhan nhi6u,

tinh

chAt c0a benh le m4n tinh vd dE trii

ph6t,

chi
phi tli6u tr! cao

vi

c6 thti

giy

mQt s6 biiin chung.

II. NGIITTN

NHAN

-

Nhi6m

trtng:

Corticosteroids

Lodt do stress

+

B€nh ph6i t6c nghen man tinh

+

X0

TSng hoat dQng cta t6 bdo G O hang

vi

+

Chiiiu x4

+

Crohn, sarcoidosis

MEc dtr c6 nhiAu nguyCn nhAn g6y loet dA dey t6 trang nhrmg thgc t6

hm

sdng cho th6y c6 3 nguy€n nh6n chinh:

</div>
<span class='text_page_counter'>(22)</span><div class='page_container' data-page=22>

-18-Lo6t do Helicobacter

Pylori:

ld nguy€n nhdn

cht

y6u gAy lodt d4 ddy t6

tring,

vi6m d4 ddy c6p vd man, ung thu d4 ddy.

Tf

lQ nhi6m chung

cta

ngudi ViQt Nam khodng 70% vit ngudi ta th6y

chi 7 - 2o/o s5 ngudi bi nhiem IIP bi lodt d4 ddy t6 trdng.

C6c

khring

vi6m,

gi6m

tlau

NSAID,

vir Aspirin:

hiQn

ld

mQt trong
nhirng nh6m thu5c dtng hiit srlc ph6 bit5n. BQnh nhAn su dpng c6c thu6c niry c6
th6 bi 6 1o6t c6p tinh

vi

thulng

ld nhi6u 6.

Lo6t do stress: thudng giq

tt

cdc benh nhan

nim

c6p criu nhu: thd m6y,
b6ng, chAn thuong sg n6o, nhi6m trung huy6t,

vi6m

tpy

c6p, suy gan, suy

thfln...vdi

t'i

tir

-

100%.

Nhrng

bQnh nh6n nhu

vfy

ff

lQ xu6t huytit
tieu h6a dai th6 dao dQng ttr lO

<sub>-20% </sub>

vd nhtng bi6n chimg ndy ldm n4ng th€m

bQnh chinh, ldm

ting

th0m

tf

lQ trl vong.

rrr.

rRrFu cHirNc

LAM

SANG

vA

cAN

r-,Avr

sAxc

1. TriQu chirng

lim

sirng

Dau bqng

cht

ytiu d

vtng

thugng

vi

ld tripu chimg c6 th6 n6i ld hang
dinh cria b€nh ndy. Dau c6 th6 tr) mrlc dQ kh6 chfu, 6m

i

d6n

dii

dOi. Ttry thuQc

vdo v!

tri

6 lo6t, tinh ch6t dau c6 th6 c6 it nhi€u kh6c biQt:

-

Lodt hanh ta trdng

thulng

xu6t hi€n hic tl6i ho4c sau bfia

in2

<sub>- </sub>

giit,

dau trQi 16n vd d6m, 1n vdo

hoic

sri dgng cric thu6c trung hda acid

thi

<td dau

nhanh.

-

Lo6t d4 ddy: tuy

vi tri

6 loet me v!

tri

vd hu0ng lan cria tinh ch6t dau

c6 th6 kh6c nhau.

Thulng

dau sau 6n trong khoang vdi chgc phrft dr5n vdi gid'

D6p tmg

vdi

bira

in

vir thu5c trung hda acid ctng kdm hon so

v6i

lo6t hanh t6
trdng.

Dau c6 thC am i, k6o

dii

ho4c thdnh con nhtmg c6 tinh chu

k)

vi

thanh
tirng dqt.

Vi

vfly, khai th6c vC ti€n su c ua circ dgt dau trudc il6 r6t cO gia

tri

A5i

vdi

chAn tloan.

C6 th6 c6 c6c triQu chrlng: buiin n6n, n6n, ch6n dn,

cim

gi6c n6ng r6t,
ddy bUng, sgt c6n, g chua.

Kh6m bsng: thudng kh6ng thAy

gi

tlec biQt,

d6i

khi

c6 th6 th6y bvng
trudng ho4c co cimg nhg.

Cin

l6m

sing

a. NQi soi d4 dny t6

trhng:

clugc coi ld phuong phrip c6 gi6

tri

nh6t trong chAn

clo6n x6c dinh lo6t.

Ngoi,i

ra, nQi soi cdn cung cAp c6c th6ng

tin:

vi

tri,

lugng, kich thu6c, tinh ch6t 6 1o6t: c6p hay m4n tinh, n6ng

-

s6u, bd d€u hoac
kh6ng d6u, tt6y s4ch hay c6 ch6t ho4i tri vd c6c t6n thuong kdm theo nhu vi6m,
trqt.

b. Test x6c

tlinh

HP: c6 nhidu phuong ph6p: 2 phuong phrip hay sri dpng nhAt

</div>
<span class='text_page_counter'>(23)</span><div class='page_container' data-page=23>

19--

Ure

test

ld,rn trong qua trinh nQi soi

-

Test thd

C13,Cl4

IV. CHANDOAN

1. ChAn do6n

xic

tlinh

ngugc d4 ddy thpc

quin:

lo6t da ddy t6 trdng tinh cnAt n6i U4t ta
tlau thugng

vi,

lan ra xung quanh ho4c phia sau. Triro ngugc

<sub>- </sub>

tinh

ch6t dien
hinh ld c6m gi6c n6ng r6t

ving

thuqng

vi,

sau xuong uc, lan l6n ngyc, miQng
->

N6i

soi r6t cO giat4 trong chdn do6n ph6n biQt.

-

Ngodi ra, c6 th6

nhim:

vi6m da ddy c6p vir m4n, ung thu da ddy, s6i

trii

m{t, vi€m tgy m4n.

V. BItN

CHLNG

-

Xu6t huylit tieu h6a tr6n: ld bi6n chung

thulng

gpp nh5t.

-

Thtng

ho4c dd i5 loet: gAy vi€m phirc mpc tod,n bO hodc cuc b6.

-

Ung thu h6a: hay g4p 0 cric O toet UO cong nh6, m6n

vi

ho{c tidn mdn

vi.

-

Hep m6n

vi:

thunng g4p vdi c5c 6 lo6t hanh t6 trang.

vr.

DrturRI

1. C6c thuSc tlidu

t{

Cic

thu5c

trung

hda acid dlch

vi

(Antacid)

C6 nhi6u lo4i khric nhau, tru di6m ln pH dlch

vi

<lugc ndng l€n nhanh. Do
vqy,

ctng

gi6m dau nhanh. PhAn lon, trong stl ndy niiu uOng thulic tiling c6ch
cdn c6 t6c dpng b6o vQ ti5 bdo. Nhu-o. c di6m chung ld: t6c dgng ngan, phni dung
nhi6u lan trong ngdy (thuong ld 7 lan), dung 16u kh6ng c6

lgi.

Hi€n it tlugc su
dgng tlon tlQc trong di€u

t4

lodt d4 ddy t6 trang.

Antacid: dung 1i6u nh6 u6ng ngay sau

bta

5n vir c6ch

bfa

6n 2

-

3 gid

ctng

vdi

I

li6u

tru6c

khi tli

ngri. C6c thu5c thuong hay dung: Gastropulgite,
Maalox, Phosphalugel, c6c mu5i magnesi (hydroxyd, carbonate).

b.

Thu6c

rirc

ch5

II2:

gdm

4

thu5c

th6ng

thulng:

Cimetidin, Ranitidin,
Nizatidin vd Famotidin.

-

Thu6c tranh ch6p

vdi

Histamin dAn tli5n uc ch6 thg the

H2

</div>
<span class='text_page_counter'>(24)</span><div class='page_container' data-page=24>

-20-nhanh,

pH

tangrilt

16 sau 1 gid vd it4t t5c dgng

t6i

da ngay

tir

ngiy

Famotidin: 40mg (sdng)

c.

Thu6c

rfrc

ch5

bom proton:

gdm

c6c

thu6c:

Omeprazol, Pantoprazol,
Lansoprazol, Rabeprazol, Esomeprazol.

Do ric

ch6 enzyrn

K+/ H+ -

ATPaza
n6n chring tric dQng vdo kh6u cu5i

cta

quri trinh bei ti6t acid dlch v! n€n dugc
coi ld nh6m thu6c c6 khd ning cao nh6t trong ki6m so6t bai tirit acid dich vi.

t

l6n tru6c

bta

6n sang 1

gid,

c6 thiS

dtng

lidu thri 2

vio

,.1

truoc Dua an cnleu.

d. Sucralfat: c6 t6c dgng khang acid, h5p thu pepsin vd dich m6t, teng bdi

tiiit

dich nhdy

vi

cacbonate, tdng t6ng hqp Prostaglandin nQi sinh,

ting tudi

m6u

ni6m m4c da ddy, girip hOi phuc lop bi6u m6 bA mat. Thu6c: Sucralfate: 1g x 3

lAn/ ngdy.

Cic

Anticholinergic:

do t6c dgng ytiu n6n it dugc dtng.

f. Prostaglandin: Misoprostol ld mQt Prostaglandin

El

<sub>- </sub>

hi€n nay it dugc

dtng

aC Oieu

trl

lo6t.

g. Crlc thu6c kh6ng

IIP:

c6 nhi€u 1o4i hiQn nay hay duoc dirng:

-

Bismusth: t6c dgng tryc tii5p l6n

vi

khuAn ldm

vi

khudn bf

ly

giii

n6n
ldm giAm

mit

dQ vi khuAn trong d4 diry.

-

C6c

khring

sinh: thudng

tlugc

dr)ng

lir:

Amoxicillin,

Tetraxyclin,
Metronidazol, Tinidazol, Clarithromycin, Fluoroquinolone vd Rifabutin.

Cic

biQn ph6p tli6u

tq

k5t hqp k'hnc

-

Ch.i dO 5n u6ng vir sinh ho4t. O mQt s5 benh nhdn chii d0 5n c6 li6n
quan kh6 16 di5n tinh tr4ng

cta

bQnh. Cric thrlc 6n c6

lgi

v6i

ngudi 1o6t d4

diy

t6 trdng bao gtim:

+

Nhtng

rau qua gidu flavonoid nhu t6o, hdnh, gung, trd xanh, trd dAy
leo; nhirng 1o4i niry c6 t6c dqng

fc

chii sp phrit tri6n cria IIP.

</div>
<span class='text_page_counter'>(25)</span><div class='page_container' data-page=25>

-21-+

Nhtrng Od an glau c6c ch6t ch6ng oxy h6a nhu rau quii: qud anh ctdo,

protein c6 ngudn g6c thgc

vft

+

C6 th6 b6 sung ttmg dqt probiotic

vi

vitamin C

+

C6c lo4i thpc phAm c6

khi

ndng ric cht5 bai

tiiit

acid da

diy

nhu nudc
bhp ciri, chu6i. KhAc

vdi

ttinh ki6n cta nhi6u ngudi chutSi te 1o4i qu6 c6

lgi

v6i
benh nhan 1o6t d4 ddy t6 trang.

-

Ngudi

lo6t hanh t6 trang n6n tr6nh crlc lo4i thyc phrim lam t6ng them
tinh trang b€nh nhu:

+

D6

r6n: c6,

thit

rrln, cric 1o4i

thit

d6,

thlt

md, socol4 rugu, dudng

vi

chring ldm gi6m truong lgc co th6t thyc quin du6i.

+

Cafe, trd d4c, nu6c c6 gas, nu6c chria cocain ldm t6ng bdi ti6t acid.

-

VC ch6 dd sinh hopt n6n tr6nh c6c stress, 6n u6ng vd luy€n t6p d€u
dan.

3.

Di6u

tri

crl th6

a. Lo6t do

H.pylori:

thudng ph6i hqp thu6c ch6ng lodt ve kh6ng sinh.

Vi ti

l€

kh6ng

Clarithromycine t4i ViQt Nam >20%

vi

4 lAr/ngdy ho4c
thay PPI+ bismuth bing RBC (ranitidine bismuth citrate)

+

Metronidazole 500

mg

x

2hnlngdy

+

Tetraxycline 1000

mg

x

2lAnlngiy

-

Phric o6

t6

ti6p sria d6i:

+

7 ngiry dAu: PPI

+

Amoxicillin

500mg x 2 vi6n

x

2\dn/ngity

.

_.r

+

<sub>7 </sub>

ngiry

ti6p

theo:

PPI

+

Clarithromycin

+

Metronidazole

hoic

Tinidazole

</div>
<span class='text_page_counter'>(26)</span><div class='page_container' data-page=26>

-

Trong truong hqp H.P

v6n

khang thu5c c6 th€ dtng ph6c d6 thay thii

dtng

14 ngdy

+

PPI

*

Levofloxacin 500mgx

1vi6nx

1 lAn/ngdy

+

Amoxicillin

500mg x 2 vi6n

x

2ldn/rrgily

liQu tham kh6o

1 Chan

FK et

al(2001).

Preventing

recurrent

upper

gastrointestinal
bleedingin patients

with

Helicobacter

pylori

infection

who

are taking
lowdoseaspirin or naproxen. N Engl J Med 344

-

967.

2.

Chan FK, Leung WK(2002). Peptic-ulcer disease. Lancet,360

<sub>- </sub>

933.

3. Leong

RW(2009). Differences

in

peptic

ulcer

between

the

East and

theWest. Gastroenterol Clin North Am 38 - 363.

4. Napolitanol(2009). Refractory

peptic

ulcer

disease.

Gastroenterol
ClinNorth Am 38

<sub>-267.</sub>

5.

Textbook

of

Gastroenterology Tadataka Yamada(2009).

Peptic

ulcer
disease, Volume 1. 936 - 982.

6. P

Malfertheiner,

F

Megraud,

C

O'Morain,

F

Bazzoli,

E

El-Omar, D
Graham,

R

Hunt,

T

Rokkas,

N

Vakil,E

J

Kuipers,

The

European
Helicobacter Study Group (EHSG).Current concepts in the management

of

Helicobacter

pylori

infection: the Maastricht

fV

Consensus Report.
Gut2012;61:646-664.

</div>
<span class='text_page_counter'>(27)</span><div class='page_container' data-page=27>

-23-XUAT HUYTT TITU

HOA

Do

LOET DA DAY TA TRANG

I.

DA,r

ct/oNc

Xu6t huyr5t ti€u h6a <sub>QGITH) </sub>do lodt d4 ddy t6 trang ld mQt cAp cuu NQi

-

Ngo4i khoa, chi6m khoang hon 50% s6 trudng hqp XHTH tr6n.

Ti

lg tri vong
dao ttQng

tt

-

14o/o. HAu hiSt nhirng trudng hqp tu vong xiry ra 6 benh nhan
l6n tu6i,

thulng

c6 bQnh n4ng kdm theo hoflc xu6t

truyit

trii ph6t. Thu6c giirm
ttau ch6ng

vi€m

kh6ng steroid (NSAIDs)

ho[c

aspirin

ld

mQt trong nhirng
nguy€n nh6n hang tlAu gny

XHTH

d ngudi tru6c d6 dE c6 lodt da

diy

t6 trirng

ho[c trudc tl6

chua c6. Stress ld nguy6n nhdn g6y

XHTH d

bQnh nh6n nang
dang di6u tr! tai bqnh viqn.

II. CHANDOAN

1. ChAn do6n x6c <Iinh
a. LAm sirng

-

Ndn

ra m6u, d4i ti6n phdn den

ho[c

ia m6u ndu tl6 trong trudng hqp

, '

.:.
cnay mau nnleu.

-

M4ch nhanh, huytit rip c6 th6

tgt

vd c6

thii

c6 d6u hiQu sOc do m6t
m6u. Da xanh, ni6m mac nhot. C6 th6 c6 cdc bi€u hiQn

cta

m6t m6u c6p tinh:

;,,

cnoang noac ngat.

-

Dauvtngthuqngvi.

-

Ti€n

su lo6t d4

diy

tri trdng (dau thugng

v!, g

hoi,

g

chua

t6i

ph6t
thenh alqt), ti6n sri xu6t huy6t ti6u h6a cao.

2. ChAn tlo6n mric tIQ xu6t huy6t

vt

nguy co

chiy miu

tdi

ph6t

-

D6nh gi6 dya tr6n c6c d6u hiQu gi6m th6

tich

m6u (xem bdi )GJTH
tr0n do tdng 6p lyc tinh m4ch crla).

-

E6nh gia muc d a trdn tinh chAt ch hrit da va

Dich

hft

da ddy Mdu phdn T1i 16 tri vong (%)

Kh6ng c6 mriu D6, n6u, tlen 10

</div>
<span class='text_page_counter'>(28)</span><div class='page_container' data-page=28>

D6 20

Mdu d6

Den 10

Ndu 10

D6 30

-

D6nh gi6 nguy co chiry m6u trii ph6t vd tu vong qua nQi soi (Ph6n 1o4i

Forrest)

Nguy co
cao

Mric

do Hinh Anh tr6n nQi soi

Chiy

m6u

tfiiphdt(%)

Ti

tu

vong (%)
Ia Mrlu phun thimh tia

55 11

Ib Ri m6u

IIa

C6 m4ch m6u nhrmg

khOng chriy m6u 4.t 11

IIb

C6 cgc mriu d6ng 22 7

Nguy co
th6p

IIc

C6 c6n tlen 10 3

III

D6y sach 5 2

D6nh gi6 nguy co

chiy

mriu

t6i

phdt vir

tri

vong dpa vdo l6m sang vd
hinh anh nQi soi: thuong su dr,rng thang tlilim Rockall.

Tty

di6u kiQn c6 thti sri
dpng thang di6m l6m sdng tlon thuAn ho4c thang diiim Rockall

tliy

til) c6 pht5i

hqp

gita

l6m sang vd nQi soi.

Than ili6m Rockatt
Chi s6

- I uori. Di6m

<60 0

60-79 1

80 2

S6c

Nhip tim >100 Dn/phrit 1

2
Huy€t 6p tdm thu<100 mmHg

BQnh di kdm

Thitiu m6u co

tim,

suy

tim,

c6c bQnh

neng khric 2

DirSm
so

lam

sang

Suy th4n, suy gan, di

cin

ung thu
Hinh 6nh n6i soi

Kh6ng th6y t6n thuong, r6ch t6m

vl

Lo6t

d4 ddy

t6

trang,

v5t

trgt,

vi€m

thuc qu6n 1

Thang tli6m
dav ou

Ung thu dudng ti6u h6a tr6n 2

</div>
<span class='text_page_counter'>(29)</span><div class='page_container' data-page=29>

-25-DAu hi6u chAy m6u tr€n n6i soi

O lodt tt6y s4ch, ch6m den phAng t4i 6

lodt 0

M6u d dulng ti6u h6a tr6n, dang chdy
m6u, c6 di6m m4ch, cuc m6u d6ng 2

Thang tlirim Rockall

tliy

dri

tir

0-11, thang di6m IAm sdng

tir

0-7. Ni5u

di6m s5 thang di6m Rockall rlAy tfii S 2,hoQc tli6m s6 Rockall l6m sang beng 0
(kh6ng) thi ti€n luqng nguy co

chiy

m6u t6i ph6t vd

ti

lQ tri vong thAp.

D6nh gi6 nguy co

chiy

mriu trii phdLt dya tr6n mQt s6 chi s5 ldm sang vd
x6t nghiQm: nguoi ta thudng su dung thang didm Blatchford.

Than ili6m Btatch

Thang ditim Blatchford tluo. c

tinh ti,

O-23 tlirim, di6m s5

cing

cao thi
nguy co ch6y m6u t6iphitt cang lon.

C6c chi si5 danh gia Di6m
Huyiit 6p tdm thu (mmHg)

90-99 2

<90

Ure m6u (mmol/l)
6,5-7,9

8-9,9 3

10-24,9 4

>25 6

Huy6t sic tO d benh nhen nam (g/dl)

12-12,9 1

10-11,9 3

<10 6

Huytit sic t6 0 benh nhan

nt

(g/dl)

l0-11,9

<10

Nhirng d6u hiQu kh6c

Mach

>

100 Dn/phrit 1

Ia phdn den 1

NgAt 2

B€nh gan

Suy

tim

BO Y TE . HUdNG DAN CHAN EoAN

va oGu

Tzu BE.NH TIEU HoA

-26-

[-100-109

</div>
<span class='text_page_counter'>(30)</span><div class='page_container' data-page=30>

Chin

tlo6n phAn biQt

C6c xu6t huyrit ti6u h6a caoL'hilc do:

-

Xu6t

huytit

ti6u

h6a do

ting

lqc tinh

m4ch cua:

XHTH

thubng
n[ng, ti6u sri 6 th6 c6 )G{TH nhidu Dn, ctic bi6u hiQn bQnh

li

cta

teng 6p lyc
tinh m4ch cua nhu: vdng da, c6 tru6ng, tuAn hoan bang hQ.

-

K

da ddy, vi€m d4 ddy, vi6m thgc qu6n, vi6m trot t6 trang.

-

R6ch t6m

vi

ch6y m6u (hQi chimg Mallory

<sub>- </sub>

Weiss).

-

Chdy mriu

dulng

m4t

-

Di

d4ng m4ch

-

Polyp thgc qutn, d4 ddy ch6y m6u

-

K thyc quan, lo6t thyc qu6n.

PhAn lon c6c trudng hqp tr6n chdn d6 phdn biQt clugc thlrc hiQn nhd nOi

soi.

III. DITU TRI

l.

Nguy0n

tic:

h6i sric tich cgc, nQi soi cAm m6u vii di6u

tri

li6n 6 lo6t

2. Didu

tri

cB th6

tdt

BN

ph6i dugc d4t tludng truydn

tinh

m4ch. O

BN

c6 rt5i loqn
truy5t OEng, ttflt 2 ttuong truydn tinh m4ch l&n

(

kich thu6c 16-18c) ho4c dflt
catheter tinh mpch trung tAm n6u kh6ng th6 dAt duqc duong truydn tinh m4ch
ngoai bi6n.

+

Phii

<sub>chri ), nhen </sub>bi6t c6c benh

di

kdm e6 aldu

tri

thich hgp, nh6t ld
ngudi gid hay kdm theo cric bQnh vd tim m4c11 hd h6p, th{n vd m4ch n5o.

-

sdi

phu thti tich:

</div>
<span class='text_page_counter'>(31)</span><div class='page_container' data-page=31>

-27-+

BOi phu the tich dugc b6t dAu truy€n tinh m4ch dich mu6i ding truong
20 ml/kg. O da s6 benh nhan truydn 1-2L dfch NaCl 0,9o/o sE di€u chinh dugc
the tich dich bi m6t.

+

N6u sau khi

tti

truyAn dlch ding truong tdi t6ng li€u 50m1,&g md benh

nhdn v6n cdn d5u hiQu s6c cAn truydn dich keo (500-1000m1) d6 bao aam th6
tich trong ldng m4ch.

+

Plasma tu<ri tl6ng l4nh truydn cho bQnh nhen

bi

)GITH

md c6 tinh
tr4ng

r6i

lo4n d6ng m6u. Truydn ti€u cAu cho bQnh nhAn ttang

bi

)GITH md s6

ti6u cAu <50.000/mm3.

-

Chi tlinh truydn m6u:

+

Khi

hemoglobin < 70-80g/m1

+

N6ng dQ hemoglobin

<

100g/l d mQt bQnh nhan bi tut huy6t 6p tu th6
(do hemoglobin sE ti6p tuc b! tut xu5ng sau khi truydn dich muiii ding truong).

+

BN

bi

benh

li

tim

m4ch c6 triQu chimg nhu con dau th6t nggc ho[c
tr6n >60 tu6i cAn dugc truydn m6u dC duy

tri

m6t mric hemoglobin>l009/1.

+ ,

Niiu

x6c ttinh,xu6t huy.it ti6u h6a tr€n k}6ng"do'ttutg Ap lyc tinh m4ch

cria,c6 th6 dtng ngay PPI tludng tinh m4ch hdu cao.

b. Di6u

tri

cAm m6u biing nQi soi 6ng m6m

Kh6ng nh6t thi6t phai thuc hi€n nQi soi ngay

khi

benh nhdn viro viQn

nhrmg

cin

tirin hanh nQi soi sdm

trorg

gid

ddu dC chdn clo6n x6c dinh vd
di€u

tri

nQi soi

cim

m6u n6u c6 chi d!nh. CAm mriu trong24 gid dAu girip giAm

,u6t

try&

trii

ty

lQ ph6u thuQt. Trong trutrng hqp

t4i

bQnh viQn

kh6ng c6 khir

nlng

nQi soi md benh nhen n4ng, ntiu di€u kiQn cho ph6p thi
chuy6n

tdi

benh viQn tuy6n trdn tl6 tit5n hdnh

cim

m6u qua nQi soi. Trudng hqp
kh6ng

th6

chuytin benh nhan, sau

khi h6i

sric

tich

cuc mir huy6t dQng v5n
kh6ng 6n dinh thi hQi chAn v6i b6c

s!

ngo4i khoa dti ph6u thu4t.

Mgc tlich

cria

cim

mriu qua nQi soi:

).,

-

-

Cam miiu co hgc:

dtng

kgp clip c6 t6c dgng t6t trong trudng ho. p dang

chiy

m6u ttr c6c mpch m6u l6n.

Ngiry

nay

c6c bdc

<sub>s! </sub>

nQi soi kh6ng cdn su dgng ti6m cAm m6u clon

thudn

vi

hiQu qu6 th6p.

Niiu

c6 diAu kiQn n6n phiSi frqp ti6m cdm m6u

vdi

c6c

</div>
<span class='text_page_counter'>(32)</span><div class='page_container' data-page=32>

-28-phuong phrip cAm m6u kh6c,

dic

biqt trong trutmg hqp m6u dang ch6y tr) ttQng

m4ch sE ldm giAm

<sub>ry </sub>

fi

vong cfing nhu khA ndng ph6i can thipp

blng

ph6u

thu4t.

Benh nhan v6n c6 nguy co cao ch6y m6u t6i ph6t

khi

hinh 6nh nQi soi
dang chdy m6u hopc nhin thAy di6m mpch

t?i

6

lodt (Forrest d0

IA,IB

hoic

IIA)

phdi ti6n hdnh cAm m6u nQi soi

Benh nhen v6n c6 nguy co

chiy

m6u trii ph6t khi hinh anh nQi soi c6 cpc
mriu d6ng b6m dinh t4i 6 1o6t

(

Forrest dO

IIB)

cAn chn

nhic

viQc ph6 b6 cgc
mriu d6ng. Chi ti6n hdnh d6i

vdi

b6c si nQi soi c6 kinh nghiQm di€u

tri

cAm

m6u vd c6 trang thi6t

bi

t6t. Sau d6 tiiSn hnnh cA m6u nQi soi n6u d6y O loet
dang ch6y mriu hopc nhin thAy di6m m4ch.

BQnh nhAn

it

c6 nguy co ch6y m6u t6i ph6t: tren hinh enh nQi soi 6 lo6t
dity

c6

cln

tlen hopc d6y s4ch (Forrest d0

IIC

hoac

III).

Kh6ng c6n ti6n hanh

cam mau qua ngl sol.

OOi vOl trudng hgrp cAm m6u qua nQi soi thanh c6ng

mi

sau d6 kh6ng c6
d6u hiQu ch6y m6u

tii

phdtkh6ng cAn thi6t phei ti6n hanh nQi soi 14i Dn hai chi
v6i mlrc dfch tlanh giit chiry m6u trli ph6t.

Trutlng

hqp kh6ng cAm tluqc m6u qua nQi soi

hoic

chiy

mdu t6i

phit:

-

Truong hqp di6u

tri

cAm m6u qua nQi soi 16n tIAu kh6ng thd rh c6ng,
can nQi ch6n

vdi

brlc

s!

ngo4i khoa d6 xem x6t khd ndng phSu thu4t. N6u c6

di€u ki€n thi hQi ch6n vdi b6c

s!

diQn quang can thiQp OC ti6n hanh nrit m4ch.

-

Trulng

hqp ch6y

mhttiti

ph6t sau

khi

dE nQi soi cAm m6u

lin

-

Tr6n nQi soi: c6 d6u hiQu cho th5y nguy co chdy m6u tiri phfut cao nhu
Forrest

IA,IB,

IlA,

IIB.

-

llb

gi6mtr6n20glngiry.

-

NCu nghi ngd dang chdy m6u,

d{t

sonde d4 ddy, ntiu c6 th6y mriu d6
tuoi rut sonde ngay.

3. Thu6c

C6c thu6c ric ch6 bom proton dudng tinh m4ch lidu cao tluoc chring minh
ln ldm gidm ch6y mriu t6i phrit vir giAm

ti

IQ phdi phlu thu4t:

</div>
<span class='text_page_counter'>(33)</span><div class='page_container' data-page=33>

-29--

Li€u

dirng: 80mg ti6m

tinh

mach chAm, sau tt6 8mg/ gid truy6n li6n
tuc trong

72

gid sau d6 chuy6n sang deng u6ng

v6i

li6u 40 mg/ngdy tOl ttrieu
28 ngdy tiiip theo (esomeprazol, pantoprazol, omeprazol).

-

Oiii

vOl Rabeprazol, dtrng 1i6u 40mg ti6m tinh mach ch6m

+

4mglgiit
truydn li6n tuc trong 72 gid sau d6 chuy6n sang tludng u6ng Hdu 40m glngity

t6i

thi€u 28 ngdy ti6p theo.

-

Trudng hqp kh6ng c6 thu5c

ding

dudng

tinh

m4ch, c6

thii

sri dUng

thu5c

vi€n

<sub>e6p </sub>2

-:

tan tieu ti€u chu6n trong 72 gid dAu. Sau tI6 dtng ti6p

I€u

ti6u chuAn.

-

Cric thu6c

fc

ch6

thu

rh,:-

H2

(ranitidin,

famotidin):

tr€n

thtl

gi6i

kh6ng dugc kh"yCn ciio trong di6u

+

Vasopressin

HiQn chua chimg minh tluqc hiQu qud v6i )GITH do lodt d? day tri trang.

4. Didu

tri

ngo4i khoa:

khi

su dgng c6c phuong ph6p cAm m6u

ndi

soi

vi

thutic thAt bai c6 thii xem xdt di€u

tri

ngo4i khoa ho4c nrit m4ch

5. N6u cr6 HP ph6i tiet

trt

XHTH

tle 6n

dinh

</div>
<span class='text_page_counter'>(34)</span><div class='page_container' data-page=34>

-30-Sa tI6 xfr

tri

XHTH

do lo6t hirnh trfl tr]rng

NOn m6u/ia phin den

(XHTH cao)

xu6t truyiit

Theo d6i th6m tai khoa Phdng
DiAu tri PPI tluong u6ng
- Theo d6i th6m t4i khoa Phdng

- NOi soi
- Di6u triPPI

- XuAt viQn sdm

Cim m6u thAt b?i

Nrit mpch hoflc ph6u
thu6t

Th6t bai
Didu tri nQi soi cim m6u

DiAu tri PPI tinh m4ch liAu cao

Cim m6u thinh c6ng

On tlinh TAi xu6t huy6t

DiQt H.pylori LAp
cam

nQl sol
m6u

Thinh c6ng

C6 nguy co t6i ph6t xu6t huY6t
cao (Fonest IA, IB vt IIA, IIB)

xu6t huy6t n6ng

UOi sric tich cYc t4i mQt don vi

ch6m s6c tich cgc

NOi soi

C6 nguy co t6i ph6t xuAt huYtit
thAp (Fonest IIC vi III)

</div>
<span class='text_page_counter'>(35)</span><div class='page_container' data-page=35>

-31-Tii

liQu

tham

kh6o

1. Barkun

AN,

Bardou

M,

Kuipers

EJet

al(2010). Intemational consensus

recommendations on the management

of

patients

with

nonvariceal upper
gastrointestinal bleeding. Ann Intern Med;l 52:101-13.

2.

Jensen

DM,

Ahlbom

H,

Eklund S et al(2010). Rebleeding

risk for

oozing
peptic ulcer bleeding (PLIB) in a large intemational study

-

a reassessment

based upon a <sub>multivariate analysis. Gastrointest Endosc;71:A8117.</sub>

3.

Jensen

DM,

Machicado GA(2005).

Endoscopic hemostasis

of

ulcer
hemorrhage

with

injection,

thermal,

or

combination

methods. Tech

Gastrointest Endosc;7 :124-3

l.

4.

Sung

J,

Chan

F,

Lau

et

al(2003). The effect

of

endoscopic therapy in
patients receiving omeprazole for bleeding ulcers with nonbleeding visible
vessels

or

adherent clots: a randomized comparison. Ann Intern Med;139:

23743.

5. Textbook

of

Gastroenterology Tadataka Yamada(2009). InJlammatory
bowel disease, Volume

l.

1386

-

1473.

6. Tsoi KKF,

Chan

HCH,

Chiu

PWY

et

al(2010). Second-look endoscopy

with

thermal coagulation

or

injections

for

peptic ulcer bleeding.

A

meta-analysis. J Gastroenterol Hepatol ;25 :8-13.

</div>
<span class='text_page_counter'>(36)</span><div class='page_container' data-page=36>

Z-cHAN DoAN

vA

ottu rry

NnrfnnarzICoBACTERPYLoRr

r. D4.r

cLroNG

Nhi6m khuan Helicobacter

pylori

(Hp) ld mQt trong nhfrng nhi6m khu6n

ptrO

titin

nhAt 0 ngudi, chi6m

tr6n

50% d6n- s6 thi5

gi6i'

D6y ld nguy6n nhAn

thuong <sub>C4p </sub>Cay vi€m d4 ddy m4n

(VDDM),

lo6t d4 ddv

-

tri trang (DD-TT) vd

une thu Ja Ouy

<sub>rufOO). </sub>

Nghi6n

ctu

trong nudc cfing cho th6y nguy co bt lo6t

pd

<sub>- </sub>

<sub>ff </sub>

nluoi

nhi6m

np

cao ghp 27,816n so

v6i

ngudi kh6ng nhi6m Hp'
Tuy

vfy,

nfri6- ffp

kh6ng phdi ludn lu6n d6ng nghia

v6i mic

c6c benh ldm

sdng n4ng, nguy co ph6t triiSn thanh 1o6t

DD-TT

chi

vio

khoing

15%

vi

nguy

co UTDD

khoang 1%.

O

ViCt Nam,

ty

1€ nhiem

Hp

d6nh gi6 dga tr6n x6t
nghiQm huy6t thanh hoc theo c6c nghi6n ciru

rii

r6c

vio

khoing 56Yo

-

75,2o/o;

ty lQ Hp

(+)

trong vi6m d4 ddy m4n ld 53 - 72,8%; trong 1o6t DD-TT

lit

87,2

-89,5olo vd trong UTDD ld 50

-

60%.

II. CHANDOAN

1. C6c

trutmg

hqp tluo;c chi

ilinh

lirm x6t nghiQm chAn tlo6n nhiSm

IIp:

-

Do ph6n 16n c6c

trulng

hqp nhi6m Hp kh6ng gdy c6c bQnh c6nh ldm

sirng, viQc x6i nghiQm tarn so6t rQng rdi cho toirn th6 cQng d0ng hiQn kh6ng phir
hs,p

v6i

tinh hinh

hien

tai.

Kh6ng n6n

chi

dinh

ldm

x6t

nghi€m chAn doan
nhi6m Hp mQt c6ch thudng qui khi ki6m tra sfc kh6e dinh

ki'

biUTDD

+

Can diAu

td

ldu

dii

v6i

c6c thu6c thuQc nh6m khang

vi€m

kh6ng
steroid

+

CAn tli€u

trf

aspirin 16u dai d ngudi c6 c6c yiSu

tti

nguy co cao

bi

lo6t

vd bi6n ch(mg do lo6t

DD

-

TT (>

60 tu6i, ti6n sir lodt d4 ddy

-

t6 trang, sri
dqng d6ng

thdi

thu6c khring d6ng, corticoid

ho{c

c6 kdm bQnh

lf

ph6i

hqp

nanc).

+

B€nh triro nguoc dp dny

<sub>- </sub>

thyc quan can ei6u

tri

duy

tri

k6o dai

bing

nh6m thu5c

fc

ch6 bcrm proton.

+

thi6u

m6u thiiiu

sit

kh6ng gi6i thich elucr. c nguy6n nh6n

+

Ban xu6t huytit gidm ti6u

ciu

v6 cdn

</div>
<span class='text_page_counter'>(37)</span><div class='page_container' data-page=37>

-33-+

Benh nhdn mong mu6n dusc di6u

tri

(sau

khi

di

dugc thAy thu6c tu
v6n)

2,

Cicphuong

ph6p x6t nghipm ch6n tlo6n nhi6m

Hp

nghiQm

huylit

thanh hgc k6m chinh xric nhSt ve kh6ng n6n lua
chgn n6u c6 nhfrng phuong phrip chdn doan Hp kh6c. X6t nghiQm

tim

khring
nguydn trong ph6n cdn cen th€m c6c nghiEn criu trong nu6c d6 drinh gi6.

t

Xdt

nghiCm mO bQnh hoc, nu6i c6y, PCR:

it

phO bitin, m6t

thdi

gian
chd do tI6 chtr

yiiu

chi dirng trong ciic

trulng

hAp cAn phOi hgp

ttrffi

gi6 m6
b€nh hqc (x6t nghiQm mO bgnh hgc), x6c dinh dA khrlng khring sinh khi th6t bai
di6u

tri

itnhetz

hn

(nu6i cdy) vitxdc dlnh chtng Hp trong nghiCn cuu (PCR).

3. Chgn

lga

phuong ph6p x6t nghiQm chAn do6n

Hp

-

Tru6c

khi

ldm circ xdt nghiQm chan dorin

Hp

(ngo4i

tru

x6t nghiCm
huy6t thanh hgc), cAn dung srl dqng khang sinh (kC

ci

khang sinh sri dqng
kh6ng ph6i

vdi

mqc dich

ti€t

tru

Hp)

vi

Bismuth

I

4 tu6n; c6c thu6c thu6c
nh6m thu5c ric chil bom proton vir khring thU th6

H2

> 2 tuan tinh tir li6u dung

,(.

cuol cung,

-

ViQc chgn lua phuong ph6p ch6n doan Hp, ngoiri c6Lc v6n dd nhu lo4i

x6t nghiQm chAn do6n Hp

sin

c6 tai ch6, gi6 thanh x6t nghiQm

...

cdn bdn phir
thudc vdo c6c yiiu t5:

+

C6c triQu chimg brio dQng bqnh nguy hi6m

+

Tidn su <tE c6 len diAu

td

tiQt tru Hp

-

Benh nh6n c6 triQu chimg b6o dQng: Ndn chon lya nh6m x6t nghiQm

chAn dorin x6m

6n

(chi <t!nh nQi soi d4 ddy)

nhim

in

cff

</div>
<span class='text_page_counter'>(38)</span><div class='page_container' data-page=38>

-34-+

c6 dQ nh4y vd dQ d4c hiQu cao tuong duong v6i xdt nghiQm urease nhanh.

+

Trong trudng hgp kh6ng c6 phuong tiQn chAn dorin Hp ndo kh6c, c6

th6 chi dinh

*lt

,ghig.

huyi5t thanh hgc nhrmg cAn th4n trqng khi phdn tich kOt

qu6: x6t nghiQm duong tinh c6 th6 dugc xem ld duong tinh that, x6t nghiQm 6m

tinh

thi

v6n c6 khd ndng 6m

tinh

gi6 cao. Kh6ng

chi

tlinh x6t nghiQm huy€t

thanh hgc ntiu bQnh nh6n dE c6

tii:n

sir tiQt

tru

Hp do k6t qun v6n cdn duong
tinh mQt thdi gian ddi ngay cd sau khi tiQt tru thanh cdng'

TII.

EIIU

TRI

Mgc

ti6u

&

nguy6n

tic

tlilu

tri

Nguy6n t6c diAu

tri

tiet

tru

Hp ln ph6i hqp mQt thuiSc khring ti6t acid d4

ddy mpnh

l6t

hqp vdi ttr hai lo4i khang sinh trd 16n. C6c thu6c khang

titit

acid

,goai

ta.

dQng tr.uc

tiilp

ldm gi6m mQt dQ cria Hp cdn c6 vai trd girin ti6p quan
trgng ld,rn gi6m sy tho6i gi6ng vd tEng tinh th6m

cta

c6c khring sinh

cht

lUc d6

didu

tri

Hp trong m6i trudng acid d4 ddy. Mgc ti6u cria mQt ph6c dd tiQt trir Hp

ti5t la dat duqc

ti

lQ tiet tru thanh c6ng t5i thi6u Z 80%.

</div>
<span class='text_page_counter'>(39)</span><div class='page_container' data-page=39>

-35-2. TGn vir

[6u

cira cric

thuiic th

tro

trir H

3. T0n

ui

ufc

cta

c6c h6c ttd tli6u

t

4. Chgn tga ph6c tld tlidu

tri

-

Ph6c d6 dAu tay (b€nh nhdn chua timg duqc di6u

tri

tiet

tru

Hp): C6
th6 su dqng ph6c d6 ntii tii5p, phric tlO 4 thu6c c6 Bismuth ho4c phric OO + ttrui5c

kh6ng c6 Bismuth.

-

Ph6c dd thir 2 (dA th6t bai di6u

tri

tiQt

trir

1 lAn): Sri dgng phric tl6 4
thu6c c6 Bismuth n6u

trudc

ct6 chua di€u

tri vdi

ph6c dd ndy. Trong trudng

hqp dd su dqng 4 thu6c chria Bismuth ldm ph6c dd dAu tay nhung that bqi thi
sri dlrng phric dd 3 thu5c chria Levofloxacine.

-

Ph6c d6 cuu crinh (da th6t b4i sau didu

tri

ti€t tnr 2 l6n): CAn nu6i c6y
vd ldm khring sinh dd d6 x6c dinh kh6ng sinh diAu

tri

thich h-o,p.

5. MQt

s5luu

<sub>f </sub>

khdc:

ThuSc rfrc ch6 bom proton

(PP!

Kh6ng sinh
Loai vir s6

nn

Oung

A

l000mgx

2ldn/ngiry

B:240

mgx 4 l6n/ngdy

C:500mgx

2ldn/ngity

L:

Levofloxacin 250-500mg

^

':

z

tan

ttgay

M

500mg

x2-

3ldn/ngiry
Te 500mg x 2- 3ldnlngity

Ti

500mgx

2\Nneity

Esomeprazole 20mg x 216,n/ngiry

Laruoprazo\e 30mg

x

2lilngiry

Omeprazole 20mg x 2 lAnlngiy
Pantoprazole 40mg

x

2ldn/ngity
Rabeprazole 20mg x 2\dn/ngity

Trudc

bta

6n chinh 30 - 60 phrit
Thoi tli€m

su dgng

Ngay sau bila 5n

Ghi

chi:

A:

Amoxicilline, B: Bismuth, C: Clarithromycine,

L:

Levofloxacin,

M:

Metronidazole <sub>, </sub>Te: Tetracycline,

Ti:

Tinidazole,

TGn ph6c

tlii

Thli

gian

(ngiv)

Cich

sfr dgng

Ph6c dd 3 thutic

7-14

PPI+A+C

Ph6c dd 3 thu6c c6 Levofloxacin 10

PPI+A+L

l0

ngiy

PPI +

A,

sau tl6

5ngdyPPI+C+Ti

Ph6c tI6 4 thu6c kh6ng c6 Bismuth

l0

PPI+A+C+M/Ti

Ph6c dO 4 thu6c c6 Bismuth

t4

PPI+M+Te+B

t

iE

- HU'dNc

rAN

CnAN SoAN vA

oteu rnisENH

rr6u

HoA

</div>
<span class='text_page_counter'>(40)</span><div class='page_container' data-page=40>

-

Kh6ng dung 14i khring sinh

di

sri dgng trong ph6c Ad eidu

tri

bi

th6t
b4i tru6c d6, dac biet la Clarithromycine (ngo4i tru Amoxicilline) vi

ti

lQ khang

thu5c thri ph6t r6t cao.

-

Khuy€n benh nhan t4m ngtmg hrit thu(ic 16 vd kh6ng u6ng rugu bia

trong

thdi

gian diAu

tri

tiet tru Hp

vi

c6 th6 ldm ginm hiQu

qui

thdnh c6ng cria
ph6c d6.

rv.

KrtM

TRA

HrpU

rIf.T

TRTIVA

rHEO

DOI

TRI

-

CAn ldm x6t nghiQm ki6m tra hiQu

qui

tiQt tru cho tat ca benh nhdn dd
duqc di6u

tri

diQt trir tru6c d6.

-

N6n thpc hipn nQi soi trong

trulng

hqp can

Aa*r

gi6

l4i

t6n thuong
tr6n nQi soi vd

/

ho4c m6 benh hqc nhu lodt da ddy

-

tblringvd

dd c6 c6c t6n
thuong tidn ung thu d4

diy

(vi6m dp diry m4n teo,

di

sirn ruQt

d

d4 ddy, 1o4n

sdn da ddy). Lodt d4 ddy sau tli6u

tri

can Aann gi6 lai

blng

nQi soi + sinh thitit
d€ loai

trir

ciic trudng hqp

UTDD

dpng lo6t. Tiet tru Hp thanh cOng girip ldm

gi6m nhrmg kh6ng ngin ngira tlugc hodn todn nguy co

LrfDD

d c6c bQnh nh6n
nhiSm Hp ct6 c6 c6c t6n thuong tidn ung thu d? dey trudc didu

tri.

Do d6, c6c

benh nhen ndy v6n cen dugc nQi soi d4 ddy d0 theo ddi titin

triiln nhim

phrit
hien

UTDD d giai

do4n sdm. Thdi khoang dC dinh

ki'

nQi soi d4 ddy

+

sinh

thii5t dinh

k!

cdn dugc nghi€n cuu th6m.

-

Trong c6c

trulng

hqp kh6c cO th6 ki6m tra hiQu qud tiQt trir

bing

x6t
nghiQm kh6ng xdm l5n. X6t nghiQm hoi

th0

(

l3C vn

14C) tluoc khuytin c6o

hong

trulng

hqp ndy do c6 gi6

tri

tuong duong v6i x6t nghiQm Urease nhanh.

v.

DUPHONG

Cho diin nay v6n chua c6 v8c xin phdng ngua nhi6m Hp. ViQc phdng ngua
t6i nhiSm hiQn t4i cht yi5u

h

rfia tay

k!

tru6c khi [n, 5n c6c thrlc 6n duo. c ctruAn bi

dring ti6u chu6n vQ sinh thpc ph6m vd uting nudc

tt

c6c ngu6n nudc s4ch, an

toin.

Tiri

liQu tham khfro

-1.

Hunt

R,

Xiao

S,

Megraud

F

et

al

(2010). Helicobacter

pylori

developing

countries:

World

Gastroenterologt Organisation Global
Guidelines.

2. Malfertlreiner

P.,

Megraud

F.,

O'Morain

C. A., et al.

(2012).
"Management

of

Helicobacter

pylori

infection--the

Maastricht

IV/

Florence Consensus Report".Gzrf 6l (5): 646-664.

3.

Fock

KM,

Katelaris

P,

Sugano

K,

al.

(2009). <sub>"Second Asia-Pacific</sub>

Consensus Guidelines

for

Helicobacter

pylori

infection."

J

Gastroenterol Hepatol 24(10): 1 587- 1600.

</div>
<span class='text_page_counter'>(41)</span><div class='page_container' data-page=41>

-37-4.

Hgi

Khoa hgc Ti6u h6a ViQt Nam. Khuytin c5o v0 chdn clo6n vd cli€u

tri

nhiSm Helicobacter

pylori

tpi VigtNam. HeNQi 2013.

</div>
<span class='text_page_counter'>(42)</span><div class='page_container' data-page=42>

-38-CHITONG 2: BENH

Lf

GAN

MAT

BPNH

GAN

RI/qU

DAr

CTIONG

T6n thuong gan ruou lir nguy€n nhdn chinh Oan Ai5n xo gan. Xo gan ruqu

g?p ngey

cing

nhi6u, thudng

tiiin

tri6n nqng

di

kdm

vdi

nhi€u bii5n chring' O

viet

N"-

chul

c6 sO tipu ttrOng k6 cy th6 vC Uenn gan do ruou nhtmg con s6

thdng k€ viQc sri dgng rugu d Viet Nam thi r6t tt6ng b6o dQng. Cric s6 liQu

cta

c6c nudc tr€n th6

gi6i

cho th6y t6n thuong gan rugu g?p cao nhAt trong c6c
bQnh ly vi6m gan do c5c nguyOn nhdn kh6c. Tht5ng k€ cria hiQp hQi gan mat

M!

th6ng b6o ,t5 ligu

th6rg

kA 2004:

<sub>d </sub>

lQ ngudi .16.9 tuqu tai

M!

ld 2/3 s6 ngudi

truong thdnh. HAu h6t

ld

u6ng rugu nhe hay trung binh.

Nhiing

ngudi u5ng
nhi6u ruqu, l4m dgng ruqu chi6m <sub>ry </sub>rc 7,4% trong si5 db 4,65% nghiQn rugu vir

3,81% s5ng phy thuQc vdo ruou. 44% s6 bQnh nh6n tu vong

vi

bQnh

ly

gan mat
ld do nguy€n nhdn rugu. Nguy co xo gan rugu

ting

l€n

khi

u5ng ruou

>

30 g
alcohol/

ngiy,

nguy

"o

rdt cao

khi

uting

>

120 g alcohol/ ngny.

T!

xo

gan

rugu ld 1

%

d ngudi u5ng tu 30

-

609 alcohol

I

tgity, vit ty lQ xo gan

lil

5,7% b

ngudi u5ng ruou

>

120 g alcohol

/

ngny.

Th€ trqng ngudi Vigt Nam nh6 bd,
tinh tr4ng dinh du&ng

cta

ngudi Viet Nam

ctng

thulng

kdm hon n€n nhanh
ch6ng xu6t hiQn c6c triQu chirng 16m sdng cfing nhu tinh tr4ng t6n thucrng gan

m6t

bt

do rugu.

II. CHANEOAN

1. TriQu chimg l6m sirng

b6u

nieu vang da vir suy gan ld

2

d6u hiQu thuong gap nh6t. DAu hiQu

niry

thulng

xdy ra 0 benh nhdn nhdn 14m dyng ruqu

>

100

g

alcohol

/ ngiy'

u6ng rugu nhi6u tuAn tru6c khi xu6t nien trieu chtmg' Tudi thuong gep 40

<sub>- </sub>

60
tu6i. Thudng gap nhiAu d nam hqn le benh nhAn

nt.

Virng da xu6t hiQn nhanh t6ng ddn c6 th6 vang da dam.

Cac O6u hiQu kh6c nhu s6t kdo ddi c6 th6 s6t cao s6t con, tlau m6i co, c6
tru6ng, gAy sirt c6n. Trong

trulng

hqp suy gan nang bQnh nhdn c6 th6 c6 d6u

hi€u cta hQi chimg ndo gan.

Kh6m l6m sirng thudng ph6t hiQn gan to, mdm, c6 thii c6 dau.

Tiiin

su: nghiQn ruou.

Ap

dung bang tli6m

eudit

d6 ph6ng v6n bQnh

nhdn girip xric dinh tinh tr4ng nghiQn ruqu'

</div>
<span class='text_page_counter'>(43)</span><div class='page_container' data-page=43>

-39-cAu h6i

Audit

3 4

)

0 1

CAu h6i

2

d6n4

1an

trong 1

th6ng

2

d6n3
len
trong I

tuin

+ l6n hoAc

nhidu hcrn

trong mQt

tuiln
Hang

th6ng
ho4c

it

hon
Kh6ng

bao gid

l.

B4n c6 thuong xuy6n u6ng
thrlc u6ng c6 cdn?

10 ho4c
nhidu hon

5 ho4c

7

ddng

t

ho4c
2

2.Trungbinh

khi uling, b4n
u5ng bao nhi6u thric u6ng c6

c6n trong

I

Hang ngdy

noac gan

nhu hang

ngery

Hang
thring

Hang

tuAn

it

hcrn

hdng
thang
Kh6ng

bao gid
3. B4n c6

thulng

xuy6n u6ng

nhidu hon 5 ly thric u6ng c6

cdn trong

I

ngiy?

Hang
th6ng

Hang

tuAn

Hang ngdy
hopc g6n

nhu hang

ngdY

Kh6ng
bao gid

It

hcm

ha"g
th6ng
4. Trong n6m ngorii, b4n c6

thulng

xuy€n ci,rn th6y kh6ng
the dirng 14i dugc mQt khi ita

b6t dAu ui5ngz

Hang

tudn

Hang ngdy

no?c gan

nhu hang
ngdy

it

t cvn

hang
thring

Hang
th6ng
Kh6ng

bao gio
5. Trong n6m ngo6i, bao

nhi6u l6n ban kh6ng th6 Uem
soiit dugc hdnh

vi

do u5ng

thrlc uiing chrla cdn?

Hang

th6ng tudn
Kh6ng

bao gid

It

hon
hang
th6ng

6. Trong

nim

ngo6i, b4n c6

^ ' '.

:

thuong xuyen pnal uong vao
buoi sring dt!

llm

co th6 phAn

ch6n sau khi bf say vdo t6i hOm

trubc?

Hang
tu6n

Hang ngdy

no?c gan

nhu hdng
ngay
Kh6ng

bao gid

it ton

hang
thring

Hang
th6ng
7. Trong

nim

ngoiii, ban c6

thulng

xuy€n

cim

th6y tQi 15i

hay hi5i h4n sau khi u6ng thrlc

;.,).^

uong co conT

Hang
tu6n

Hang ngdy

noec gan

nhu hang
ngdy
Kh6ng

bao gid

It

hcrn

hang
thang

Hang
th6ng
8. Trong ndm ngo6i, ban c6

thulng

xuy6n kh6ng nhd
dugc nhirng sg viQc xdy ra

vdo t5i hdm trudc do b4n

: ,. i , :

uong tnuc uong co con
kh6ng?

C6, trong
vdng n6m
KhOng C6, nhung kh6ng phdii trong

vdng ndm ngo6i
9. DE bao gid ban bi thuong

ho{c ldm ngudi kh6c bi

BO Y TE. HU6NG DAN CHAN DOAN VA DIEu

rnl

gE.NH IIEU HoA

-40-3 ho4c 4

Hang

Hang ngdy
hoac gdn
nhu

hing

</div>
<span class='text_page_counter'>(44)</span><div class='page_container' data-page=44>

thuong do say sin chua? ngo6i

10. Dd c6 ngudi th6n, b4n bd,

b6c si hay nh6n vi€n chdm s6c

sric kh6e niro lo ngai ve hdnh

.:i.\

vr uong lnuc uong co con cua

bpn vd khuy6n b4n c6t giem

chua?

Kh6ng C6, nhmg kh6ng

phiitrong

vdng n6m ngo6i

Tdng c6 10 c6u h6i. > 8 d6i

v6i

bQnh nh6n nam vd > 4 tISi

vdi

bQnh nh6n

nt

dugc coi ld nghiQn rugu.
2. TriQu chrimg

cin

lim

sing

Vi6m gan rugu ld t6n thuong n{ng c6 th6

g[p

nhi€u thay dOi cric chi s0

xdt nghiQm. Kh6ng c6 xdt nghiQm ndo ld

tl{c

hiQu cho t6n thuong gan ruqu,

cAn phdi ti5t trqp nhi6u th6ng s6.

HQi chrmg

hty

ho4i

tii

bdo gan transaminase thudng t6ng

nhft

le t6ng
AST tEng cao g6p 2ldn

<sub>- </sub>

6lAn gi6i han cao binh thuong.

ALT

t6ng cao nhrmg

thulng

teng khOng nhi€u

nhu AST.

Ty

le AST/ALT

thuong

>

2. Chi

AST/ALT

> 3

lin

ld gqi y t6n thuong gan ruou

mfc

dQ n{ng. Tuy nhi0n

f}

ndy chi c6 gi6

tri

goi

<sub>f </sub>

chu kh6ng c6 gi6

tri

ch6n tloan, d0 nh4y cflng nhu dQ
d4c hiQu trong chAn do6n kh6ng ttugc danh gi6 cao.

cie

thi6t gi6i thich co ch6

muc ttQ

ALT

teng kh6ng nhiAu trong t6n thuong gan ruqu: ruou g6y cdm ung
depletion pyridoxal 5'-phosphate

vdtdng

st5 luqng

fy

lep thiS c6 cdm ring

vdi

aspartate. Si5 luqng b4ch cAu, d{c bigt b4ch

ciu

da nhdn trung tinh t6ng cao.

Tf

lQ prothrombin binh

thulng

hay gi6m,

INR

thng. Creatinin huy6t thanh

ting,

ddy ld chi sO Oaotr girl mric dg neng cria tdn thuong gan ruqu, lir mQt trong c6c

ti6u chu6n chAn dori.n hQi chung gan thfin.

Nh6m xdt nghiQm girip chAn dortur c6c nguy6n nhdn vi6m gan kh6c c6 th6

ddng thdi x6y ra tr6n ndn vi€m gan rugu.

Khi

vi€m gan rugu

ttit

hqp

vbi

ctrc
vi6m gan kh6c

thulng

E y6u t6 ti6n luo,ng n4ng.

Md

bQnh hgc

^

,. . ,:

Cung cdp c6c bing ch0ng girip kh6ng dinh chdn tloan vi6m gan ruqu.
T6 bdo gan thudng nd

to,

bio

tuong sring, chria nhi6u th6

vti

ua acid
(cfing cdn c6 th6 dirng danh

tt

kh6c ld gan tho6i h6a kinh), vAy xung quanh c6c

tti bdo gan ndy ld b4ch cAu da nhdn trung tinh <sub>eqi </sub>

h

thi5 Mallory. Trong t6 bdo

gan xuAt hiQn c6c gigt

md

lon

ld

d6u higu

cta

tinh

tr4ng gan tho6i h6a md.
Fibrosis (tinh trang xo h6a gan) *uAt hign sorn nh6t d xoang gan

li

khoang gitra

c6c tti

bio

nQi m4c

vi

tii

bio

gan ddy

h

d6u hi€u dii5n hinh cria tinh tr4ng vi6m
gan

ruqu.

Giai

do4n muQn

hon

xu6t

hipn

fibrosis quanh

tinh

m4ch, quanh

BQ Y TE . HU.dNG DAN CHA.N DoAN VA EIEU Tzu BE.NH TIEU HOA

-41-C6, trong
vdng n6m

</div>
<span class='text_page_counter'>(45)</span><div class='page_container' data-page=45>

khoang crla

vi

cu6i cirng ld (cirrhosis) xo gan'

Tty

mric <lQ vi€m gan n{ng hay

nfre .ac t6n thuong xo h6a sd tdng \€n, cbc t6n thuong di kdm nhu ho4i trl t6

bio

gan, tinh trang u mflt.
4. Ch6n do6n

xic

dinh

Chan doan vi€m gan

rugu

dua vdo

bing

chimg sinh

thi6t

gan' Trong
truong ho,p c6

r6i

lo4n

d6ng

m6u hay c6 trudng cdn sinh thitlt gan theo dudng
tinh m4ch canh, tI6 thuong la c6c th6 vi€m gan rugu n{ng. Kh6ng c6 sinh thiiSt

gan nguy co ch6n do6n sai c6 thtl l6n d€n25%.
5. ChAn tlodn

phin

biQt

Gan tho6i h6a md c6p hay m4n

tinh

kh6ng do ruqu c6 th6

g[p

d b€nh
nhdn

vi6m

gan virus. T6n thuong gan do thu6c, bQnh Wilson, bQnh gan

tu

mi6n, thi6u hqt alphal antitrypsin, 6p xe gan, vi€m duong m4t'

ChAn doan ph6n biQt kh6 nhAt lir

v6i

c6c trudng hqp gan th6a h6a md
khong do rugu g+p d c6c bQnh nhdn b6o phi,

tiiiu

dudng' X6c dlnh chAn dorin
bdng c6ch sinh thi6t gan t6n thuong

ctng

g{p

tii

beo gan nd to, ho4i tri, tham
nh4p nhidu tii bdo vi6m, xu6t hign c6c sgi xo trong xoang, c6 tinh tr4ng fibrosis

vir cirrhosis. T6n thuong ri m4t thudng n{ng hon. Tuy nhi0n khdng bao <sub>eid </sub>

<sub>eip</sub>

th6

Mallory

0 bQnh nhdn gan tho6i h6a md kh6ng do ruqu.

Cac Uenn

*an

cmn Aoan vi6m gan ruqu cAn ph6i th6m dd h0 th6ng loai

tru tinh

tr4ng nhi6m

trtng

nhu vi6m ph6i, vi6m phric mac ti6n ph6t, nhi6m

muan ti6t

niQu, c6y m6u, cAy nudc ti6u, nu6i c6y dich mdng bqng

<sub>' </sub>

Chup

X

quang ph6i. Si6u dm gan girip 1o4i tru c6c t6n thuong nhu c6c kh5i u trong gan,
6p xe gan,

tic

m6t.

m. cAc

Ytu

ro rItN

LLIqNG

BpNH

GAN

Rtlgu

X6c dinh mrlc ttQ vi6m gan ruqu lir r6t cAn

ttri6t

dua

ra

cdc ti€u chuAn

ti6n lugng qua d6 girip dd ra c6c chi6n lugc theo ddi, c5c chi dfnh didu

tri'

cal

t'f,6ng ,6 ticn t tqng vi€m gan rugu c6 rAt nlieu g6m c6c th6ng s6 Hm

siurg vd cQn 16m siurg, sinh thi6t gan. Tuy nhi01 ctic.y6u t5 ri6ng rE sE kh6 danh

gi6

mfc

d0 nftrg cta bQnh.

rrcn

ttr6 gi6i c6 r6t nhi6u bang diOm ginp cho di6m
vi€m gan rugu

tir

d6 c6 th6 x6c dinh mrlc tlQ bQnh ning hay nhg' Thdng qua c6c

bang tli6m b6c si sE dd ra c6c chi6n lugc quan

lf

vir theo d6i benh nhan vi€m gan

ruqu.

Chi

Maddrey

Chi

sO Maddrey

c6

dQ nhpy cao nhAt vA thuong

img

dyng trong lAm

</div>
<span class='text_page_counter'>(46)</span><div class='page_container' data-page=46>

-42-vong trong vdng 2 th6ng. Chi s6 Maddrey >28b6t dAu c6 chi dinh di€u trf vi6m
gan rugu,

khi

chi s5

> 32

cdn rip dqng c6c phuong ph6p diAu

tritri0t

d{i nhu

liQu ph6p Corticoid, Pentoxyfilin, hay ghdp gan.

Chi

MELD

Chi so N/ELD (Model for End-stage Liver Disease). Chi si5

MELD

d6nh

gi6 mric d0 nang cria bQnh vi€m gan rugu. Chi si5

IvIEIO

dugc tinh theo c6ng

thric 3.8 x log"bilirubin tinh theo mgldL

+

I 1.2 x

logINR

+ 9.6 x log"creatinine
tinh theo

mg/dl

+ 6,4.

Khi

Chi si5 I\,ELDc6 k6t quA

>

18 ld ti6n luqng r6t t6i
nguy co tri vong cao. K6t hqp

gita

2 th6ng s5 Maddrey vd Chi s5

MELD

cho

lhdy

giit

tri

ti€n luqng vi€m gan ruou vir

xo

gan rugu

v6i

d0 nhay vd d0

dic

hi€u cao. MQt s5 nghi€n crlu chi ra khi c6t ngang gi6 tr! Maddrey >32

vi

Chi s6

MELD

>

18 dQ nhqy trong viQc ti€n luqng bOnh nhdn lA 80-90%, d0

ttic

hiQu ld
60

-

80%. N6u chi tinh riQng chi s6

Ir,GLo

cho thAy khi chi s5

>

18 ld chi dinh
gh6p gan can tnii5t ph6i tlugc

tl[t

ra, n6u chi s6 thay d6i

>

1l

bQnh nhdn cdn

dugc tlua vdo danh s6ch chd gh6p gan.

3. B6ng tli6m Glasgow

B6n tIiGm Gla ow Alcoholic He atitis GAHS

Ti6n lugng

t6i

n6u di6m tr0n

8 (thdi

gian

tinh

di€m

khi

nhflp viQn

tt

ngdy

I

d6n ngity 7).

Bing

di6m Glasgow

tinh

nhi6u th6ng sti nhtmg mrlc dQ

nh4y trong ti6n lugng benh nhan chi d giai do4n dAu nhQp viQn, ti€n luqng xa
thi kdm hon c6c chi s5 Maddrey vir chi sO

VmtO.

Bang diiam ctng kh0ng tinh

dtin c6c cH s6 cria hQi chung t6ng 6p lgc tinh m4ch cria do

v{y

v6i

benh nh6n
vi€m gan rugu hay

xo

gan ruqu cflng

cin

6p dgng bang di6m
Child-Turcotte-Pugh

Bing

di6m Child-Turcotte-Pugh

Ch6n tlo6n

i.I

xo' d viro B6n tli6m

Child-Turcotte-3

<50 50

fuOi

s6 luqng b4ch cAu <15

Ure

(mmoVl)

>_2

<1.5 t.5-2.0

Ti

l€ prothrombin

<7.3 7.3-t4.6 >14.6

Bilirubin

mg/dl

3 di6m

2

diem

<45

>55

<sub>45-55</sub>

Tt

16 Prothrombin %

<28

>35

<sub>28-35</sub>

Albumin m6u g/l

35-50

>50

Bilirubin

mriu mmoVml

<35

Nhi€u

it

C6 truong Kh6ng

Tidn h6n m€ H6n md

Kh6ng
H6n m6 gan

Bo Y TE - HU,6NG DAN CHAN DOAN VA DIEU TRI BENH TIEU H

6a

-43-2

</div>
<span class='text_page_counter'>(47)</span><div class='page_container' data-page=47>

Giai do4n

A:

-

6 di6m, B

:

-9

diOm, C

=

-

15 diOm.

Bdng di6m Child-Turcotte-Pugh

c6

nhidu

uu

di6m: thudng xuy6n 6p
dqng, c6c tt Org tO O6 tintr, hcrn nfta

li

c6n

tinh

diSn nhi6u c6c chi s6 cria hQi

chring tdng 6p lpc

tinh

m4ch crla. Nhuo. c di6m ld thuong 6p dpng d6i

vdi

c6c

bQnh nh6n xo gan, cdn d giai tlo4n vi6m gan bang di6m ndy it c6

gi6t4'

M6i

bang di6m dAu dua

ra

cdc chi s5 khric nhau nhtmg mpc dich cu6i

ctng

ld girip chi

ra

c6c y6u t5 tiCn luong bQnh nhAn gan aUng nhAt

v6i

dQ nh4y
cffng nhu dQ d4c hiQu cao.

M6i

b6ng dii5m c6 tru di6m ri6ng, vi€c vQn dpng c6c

Uang Oi6m

ti6n

lugng bQnh nhdn vi6m gan rugu cAn thay d6i

tiy

tung truong
hqp

"u

th6. Trong c6c trudng hqp ti€n lugng npng cAn

tinh

nhidu chi s5 ti6n

luqng de c6 chi tlinh can thiQp di6u tr! cdn thii5t'

IV. DIEU TRI

1. Ngtrng

rugu:

rl6y ld phuong phrip didu

tri

chinh vd quyi5t

ainl

tna*r

c6ng

cta

.a.

tig,, pnap diAu tri. Dimg ruou c6 thti

cii

thiQn triQu chtmg66% si5 Upnt,

*,an.

K6t qua didu

tri

khrlc biQt r6t c6

i

nghia khi theo d6i bQnh nhin sau 3 thang. N6u

dtng

ruqu

trd

l4i nguy c<v xu6t hiQn c6c d6u hiQu n{ng

cta

bQnh t6ng l€n: xu6t

huyi5t ti6u h6a, hQi chring t6ng 6p lyc tinh m4ch cria, hQi chung ndo gan.

2.chi

dinh

dudng:

cAn cung c6p chtl d0 6n

giiu

calo, giiiu dinh duong,

gidu vitamin cho bQnh nh6n vi6m gan ruqu.
Ch6 dO 6n cung c6p > 2000 Kcal / ngdy.

Tdt

ctr cbc benh nhan vi0m gan rugu ddu c6 tinh tr4ng suy dinh duong,
thiSu

hut

nhidu

lo4i

vitamin v?r mu6i kho6trg:

cin

bti

tung th6m vitamin A,
Vitamin D, Vitamin nh6m B, folate, kEm.

Ch6 dO 6n cung c6p gidu dinh dud'ng, vd vitamin sE h4n ch6 quri trinh di
h6a

cia

co thti c6i thiQn triQu chimg

vi

k6o

dii

thdi

gian s5ng cho bQnh nhAn.

Trong

c6c

trudng hqp

bQnh nqng cAn cung c6p dinh du0ng theo

ci

duong
truydn vd duong an qua sonde. Nu6i duong

bing

sonde cho k6t qu6

t!

lQ s5ng

I

thang kh6ng cao hon liQu ph6p diAu

tri

Corticoid

nhmg

ldm ginm

tf

tu

vong

vii

giAm s5 bQnh nh6n nhiSm

tring

khi theo d6i 1

nim

trong nhiAu nghiOn

cuu kirim chirng ng6u nhi€n.

Nu6i

dudng qua sonde (2000kcal

/

ngiry), sonde

dtng

nu6i du&ng c6 khAu kinh nh6 vd b€nh nhdn chiu

ttpg

t6t hAu nhu kh6ng
gdy cbc

tai

bi6n. pi5 ai6u

tri

thanh cOng cdn thudng xuy6n drlnh gi6 bilan dinh

dudng,

tinh dli

t'i

le calo, mu5i nu6c, vitamin, tr6nh dua thria c6 thi5 1em tAng

nguy co hQi chung n5o gan, thi6u sE ldm tSng qu6 trinh di h6a co th6 d6n di5n
suy dinh du6ng.

3. LiQu

phip

Corticoid

</div>
<span class='text_page_counter'>(48)</span><div class='page_container' data-page=48>

-44-Tdt ca cac bQnh nh6n vi6m gan ruqu co di6m Maddrey <32 kh6ng c6 hQi

chung n6o gan, gi6m bilirubin sau 1 tuAn di€u

tri:

cAn dugc theo d6i s6t, ch6 d0

dinh du0ng nghidm ng[t.

B€nh nh6n v6i truong hgrp bQnh nang

li

b6nh c6 chi s6 Maddrey

>

32 c6

hay kh6ng kdm bQnh n6o gan, hay

chi

Ir,mtp

>18 c6

chi

dlnh

didu

tri

Corticoid.

Li6u

di6u

tri

corticoid:

40mg/ ngdy trong

4 tuin

sau do

giim

aan tieu
trong2

<sub>- </sub>

4 tudn k6 ti€p hodc dimg tr)y vdo tinh tr4ng l6m sing.

ThEc tt) di6u

tri

ban dAu vi6m gan ruqu c6p n4ng ld dirng Prednison v6i
li6u 40mg/ngdy trong 28 ngdy. Gi6m bilirubin trong vdng

ngiy

thf I

dt5n ngdy

thf

7

le d6u hiQu ti€n luqng rl6p ung t6t vOi didu

trf.

Ti€u chuAn

niy

rAt dac

hiQu

nhmg

it nh4y vd kh6ng cho ph6p ti6n luqng

tf

16 trl vong d c6c b6nh nh6n
didu tr!. C6ch ti6n luqng

blng

bAng diiim cria

Lille

di

dugc dua ra. BAng tti6m

t..;

gdm cac ti€u chu6n:

giim

bilirubin

hong vdng

7

ngiry,

tudi

b€nh nhdn, chric
nnng th4n, albumin,

fj'lQ

prothrombin,

bilirubin.

bang di6m nAy chinh x6c
trong vi6c ti€n lugng hon ld chi dua viro d6u hiqu gi6m bilirubin trong 7 ngdy

ft6t

qu6 dga vdo gi6

tr!

ngu&ng 0,45; ti6n luqng s6ng trong vdng 6 th6ng d6i

v6i

ngudng > 0,45 D 25Yo, ngu}ng < 0,45 la 25%

-

85%).

Khi

khdng drip ung

vdi

corticoid 16 rang vdo

ngiy

tht

7 (40% st5 Upnfr nh6n di6u

tri)

cdn xem x6t
chi dfnh dimg corticoid

vi

ich

lqi

ti6p sau d6 ld r6t it.

4. LiQu ph6p

anticytokin

BQnh cen cta vi6m gan ruqu lir dua tr6n co ch6 mi6n dich. ViQc di6u

tri

nhim

c6t dtrt nhirng tl6p tmg mi6n dich. Co chri mi6n dich duqc nh6n mpnh
nn6t ta O4i thpc biro gi6i ph6ng ra ciic Chemokin vd Cytokin, TNF o,

IL1,IL6,

IL8.

Pentoxifflline

ld

1 ric chti t6ng hqp TNF, ld m6t phuong ph6p ttidu

tri

tl6ng tlugc quan t6m, trong

tl6

hi0u

qui

diAu

h!

tlugc

khing

tlinh trong cric

nghi€n criu.

M6t

nghi€n criu

kiilm

chimg ng6u nhi€n mtr d6i k6t qu6 cho th6y
c6i thiQn dugc

tj

16 s6ng sau 6 thang: nh6m diAu tri1d75,5% so

vdi

54% trong
nh6m placebo. So

v6i

Corticoid

thi Pentoxiflline

cii

thiQn ttugc

fj,

l€

sting
nhrmg khdng c6i thiQn duoc ciic kiSt qud xdt nghidm danh gi6 chrlc n6ng gan,

tuy

nhi6n ldm gi6m t1i l€ xu6t hi€n hOi chimg gan th6n. SU kh6c nhau co ban
gifra Pentoxifflline vd Corticoid ld d6nh gi6 tric dpng lAu ddi.

Li€u tli6u

tri

Pentoxiffllin 400mg u6ng 3 l6n / ngdy trong 4 tuAn.

5.Di6u

tri

lgc mriu (gan nhAn t4o)

C6c phucrng ph6p diAu

tri

b5ng

Pentoxifllin

trong vdng

2

thring ntiu
triQu chimg kh6ng cdi thiQn c6

thti chi

dfnh

lqc

m6u

v6i

albumin,

holc

c6c

trudng hqp vi6m gan rugu n4ng c6 t6ng bilirubin m6u nhiAu.

</div>
<span class='text_page_counter'>(49)</span><div class='page_container' data-page=49>

-45-6. Gh6p gan

B6nh gan do

rugu ld

chi

dlnh gh6p gan. Cdc bQnh nhdn dugc chdn

do6n benh gan do rugu

cin

tinh

c6c

chi

s6 ti6n lugng girip sdng 19c vd ph6n
lopi bQnh nhdn. C6c bQnh nhdn c6 tiOu chuAn nflng sE xtip vlro danh s6ch chd

gh6p gan,

vdi

c6c bQnh nhdn c6 tinh tr4ng nguy klch sE dugc uu ti0n ghdp gan.

ii6,

rf,uA" chi clinh gh6p gan khi: Chi s6 Maddrey > 32 kh6n

g

diry rmg tli€u

tri

v6i

liQu ph6p diAu

tr!

corticoid

vi

c6 kdm hay kh6ng kdm theo chi s6 MELD
>18 .

Tiri

li$u

tham

khf,o

1. Robert

S.O'Shea(2010)

Alcoholic Liver

Disease

the

Practice Guideline
Committee

of

the American.Association

for

the Study

of

Liver

Diseases and

the

Practice

Parameters

Committee

of

the

American

College

of

Gastroenterology. Hepatology January 20 10.

2. Lieber CS

(2004).

New

concepts

of

the pathogenesis

of

alcoholic liver
disease,Lead to novel treatments. Curr Gastroenterol Rep;6 : 60-65.

</div>
<span class='text_page_counter'>(50)</span><div class='page_container' data-page=50>

-46-yITM

<sub>TTINtrEN</sub>

DAr

cuoNc

Vi6m

gan

tp

mi6n td t6n thuong gan do

tg

co th6 san sinh kh6ng th6
ch6ng l4i t6 chric gan, dudng mQt hay t6 chuc li0n kr5t cira gan. Tdn thuong gan

thudng dai d6ng kdo ddi. Th€ nhc le the kh6ng

tilin

tri€n

ho[c titin

tri6n r6t
ch4m vd kh6ng dua d6n xo ho[c ung thu gan cdn th€ n4ng ld thi5 vi6m ho4i

tri

ddn dflp ho4c nhidu ttqt titin tri6n t5n c6ng viro tti bdo gan 0,5 rOi cu6i

ctng

dua

-l

tl6n suy gan v2r xo gan nhanh ch6ng..

Dich t6 hgc vi6m gan

ty

miSn: BQnh

<sub>e{p </sub>

6 tdt

cit c6c chring tQc. Vi6m

gan

ty

mi6n ld bQnh khOng thudng g4p theo th6ng k0 chdu Au:

Tj'

lQ m6c bgnh
trong ddn sO Z-tlttOO 000 dan,

ty

lQ mhc m6i hdng n6m 0,1-1,9/100 000 dan.

ChAn dorin ban dAu

thulng d

hia

tu6i tr6

10-30 tu6i. Benh thuong gpp

d

nfi
nhiilu hon nam: tj, lQ nir/nam: 3,6/1

II. CHANDOAN

Chin

ilo6n xrlc

tlinh

a. TriQu chrimg lAm

sing

TriQu chrmg ktrdi dAu c6 thti bi6u hiQn nhirng dqt rAm rQ nhu trong vi€m
gan cilp (1/3 trudng hqp), phan cdn

lai

thudng 6m thAm ldm phAn krn bQnh

nhAn kh6ng

nh{n

bii5t dugc,

thu}ng

chi

bi6u hi€n

bdi

triQu chimg

co ning

chung lir m6i mQt, cdm gi6c n{ng tric virng h4 su}n ph6i, nhidu hic c6 dau co,
dau khop ho4c nhiAu

lfc

chi c6 citm gi6c nhrlc m6i chung chung. Trong nhilng
dqt titin tri6n, c6c triQu chimg thudng phong phri vd rAm rQ hon vdi stit, vang da

. J. , ..), :. ,

vdng m6t, nudc ti6u virng ho4c sdm mdu, dau co vd dau khorp vd nhAt l2r dau tuc

vtng

gan vd

ngfa,

hdng ban. Kh6m thAy gan c6 th6 to, hay teo, 6n tlau trlc, c6

th€ c6 16ch to d giai do4n muQn khi d6 xo gan.

C6c bitiu hiQn ngodi gan c6 thti gap: h6ne ban nrit, xam

d4

vi6m tuy6n
gi6p

ttl

mi6n Hashimoto, vi6m mao m4ch

d!

ring, vi6m cAu

thin,

hQi chung
Sjogren, vi6m tl4i trpc trirng lo6t

chiy

mriu, thi6u mriu,

chiy

m6u do gi6m ti6u
cAu.

Vi6m

khop dang th6p, lupus, tan m6u, Sjogren

Xo

h6a ph6 nang Hen,

Vitiligo,

Lichen, hQi chrlng t6n thuong da tuyiin nQi

ti6t

fjp

1, Xcr

ctug

bi,
Vi6m kt5t m4c, ti6u duong typ 1, bQnh celiac.

Giai tlo4n sau

khi

t15 c6 bir5n chimg xcr gan cdc bi6u hiQn vi6m thudng
gi6m dAn thay vdo d6 lir c6c triQu chimg cria xo gan

v6i

ci

hai hQi chimg: suy
t6 bdo gan vd hQi chung tdngdp lyc tlnh m4ch cta.

b. TriQu chfmg c$n lAm

sing:

-

C6ng thrlc m6u: B4ch cAu, hdng cAu

thulng

giim,

c6 th6 ginm lu6n cd
ti6u cAu, ti5c d0 6ng m6u thudng t5ng cao.

</div>
<span class='text_page_counter'>(51)</span><div class='page_container' data-page=51>

--

Chric nSng gan:

fhay

dOi nhieu.

+

Bilirubin

ting ci

tryc ti6p vd girin tirip.

+

Men transaminase thudng t6'nggip > 3-5 mn binh thuong.

+

ti

l4p thi5, kh6ng th6 khang ti6u th6 gan thAn

<sub>GKM), </sub>

khring th6 kh6ng ASGPR
thudng duong tinh trong vi6m gan tU miEn.

+

Thulng

ting

IG d4c biQt

li

IgG

>

169ll

-

Sinh

thiiit

gan: Ld mQt xdt nghiQm can

tniiit

girip chAn doan nguydn
nh6n vd giai tloan, dQ trAm trQng cria vi6m gan m4n cho hinh anh vi6m ho4i

tu

xdm nhQp tiilu

thty

gan vdi hopi tir

miii

g4m, ho4i tu cAu n6i, ho4i tu m6T rg xen

l6n

vdi

t6 chrlc xo ph6t tri6n nhidu 0 khoang crla xdm nhfp ti6u

thty

vd c6c n6t
tan tAo trong giai do?n sau.

c. ChAn ilo6n x6c

dinh:

dqa tr6n c6c bdng chimg vd sinh thi6t thay d6i tr€n m6

bQnh hgc vd c6c

thim

dd vd x6t nghiQm.

M6 hqc

Vi€m gan th6 hoqt dQng vira hay n4ng, c6 kdm hay
kh6ng vi6m tiiSu thny, ho4i tu trung t6m hay ho4i

tu

cAu n5i, kh6ng c6 t6n thuong duong mdt, kh6ng c6

bine

chung granulome hay citc bpnh gan kh6c
Sinh H6a Btnh

thulng

hay t6ng nhg

Ig

IgG

ting

<sub>ehp 1,5 </sub>lAn gi6i h4n cao binh thudng

Ift6ng

th6

ANA,

SMA,

LKMI,

t6ng> 1/80
v1rus

Amtinh

C6c v6u t6 khric U6ng ruqu

<

2ig/ngiry, kh6ng c6 beng chung vi6m

gan do thu6c

t/ng

dgng bang di6m girip x6c dinh chAn tlo6n vi€m gan

ty

mi6n. Ddy

li

bang ttiiim don 6n c6 th6 d dc tro hdnh Dm san

Di6m

Th so

>l6e/l

>18s/1

TIng

IgG

>U40

>1/8 hay SLA/LP +
c6c

tu KT:

ANA,

SMA,

LKMl

</div>
<span class='text_page_counter'>(52)</span><div class='page_container' data-page=52>

Khing

tllnh vi€m gan <sub>4r mi6n</sub>

Marker virus

Amtintr

i6

di6m c6 thtl nghi d6n vi€m gan t.u mi6n

l7

diiSm khang ttinh ch6n do6n vi6m gan tg mi6n
2. ChAn tlo6n th6

Vi6m gan

tq

miSn Type 1: Vi6m gan lupus,

gip

d nir h6. Xet nghiQm cric

marker miSn dlch thudng duong tinh:

ANA,

SMA vd c6c

tg

khang thd kh6c,
T6ng gammaglobulin, d6p ung

vdi

r?c chai mi6n dich,

Gip

d

cric

d6i

tugng

HLADR3,

DR4

Vi6m gan

tr;

mi6n Type

2:

c6 crlc

LKM

\,LI<NL2, Thuong c6 cric

ty

KT

kh6ng tuyrin gi6p,

KT

kh6ng t6

bio

thanh da ddy, bQnh kh0i ph6t O tr6 em, giai
doqn 2 d

lta

tu6i 35-65,

nii

chi6m 60%. L6m sang nhanh den d6n xo gan, ti6n
tugng tOi hon typ 1.

Vi6m gan tr1 mi6n Typ3: g6n giiing typ 1.
3. ChAn do6n phAn biQt

a. Vi6m gan sieu

virus

Vi6m gan si€u

vi

rus

A

vi

E thudng tg gi6i h4n va r6t hi6m

khi

dua tt6n

vi6m gan m4n. PhAn 16n vi6m gan men ld do virus B,C vd phtii hqp D.
b. Yi6m gan B m4n

Ngodi t6n thuong m6 hgc,

IIBsAg

duong tinh k6o ddi tr6n 6

thrlng,

cdn

tim

th6y

bing

chung virus vi6m gan

B

nhdn l€n: HBeAg

vi

anti HBe,

HBV

DNA

duong tinh v6i ndng dQ cao.

c. Vi0m gan m?n D (Delta)

ChAn dorin dya vdo sp hiQn diQn cria HDVAg

vi

anti

HDV

cit2

typelgG

vd IgM.

d. Vi6m gan m4n C

Anti

HCV

duong tinh vd trong d6 dtim s5 tuqng HCVRNA

thulng

c6 s6

luong cao.

e. Vi€m gan men do thu6c

MQt s6 thutic nh6t ld

khi dtng

k6o ddi

>6

thing,

c6 th6 gdy ra VGM,

thudng

g4p

nh6t

ld:

Clorm6tacine,

acide

tidnilique,

m6thyldopa,

Nitrofrrantoine,

Papaverine,

Oqph6nacdtine, Isoniaside,

Amiodarone,
Aspirine, Ac6taminophen, Vitamin A, Methotrexate, PTU...

C6c t6n thuong do thu6c thuong

h

rAt nang vir xo gan thuong hiQn diQn

tru6c khi ph6t hiQn ra bQnh.

tu,

c6 kdm 16ng dgng lipide-phospho

tli bio

gan trong vi6m

gan man

do

Amiodacrone, khang

th6

antimitochondrie

g[p

6 vi€m

gan do
Isoniaside,

Khing

th6

LKM3

trong vi€m gan do ti6nilique, ktring th6

LM

trong
vi6m gan do dihydralazine...

III. EITU TRI

Chi

tlinh

tlidu

triUit

Uuqc

AST t6ng cao

>

10 tan Uintr thudng

AST t6ng cao > g6p 5 lan binh thudng vd Ig > 2 l6n binh

thulng

MO hgc t6n thuong cAu ni5i, hoai tu khi5i, xo gan, vi6m gan n4ng
2.

Chi dinh

tli6u

tri

c6 th6 cAn

nhic

,

.:

Vi6m

gan

tg

mi6n khOng c6 triQu chimg l6m sdng nhrmg c6 c6c

bing

chimg sinh h6a vd mi6n dich, c6 kt5t qu6 sinh thitlt t6n thuong m6n bQnh hgc

khic

dinh chAn doan vi6m gan.

Phic

aii

Oi6u

tricu

th6:

c6c khi5i u

b.

Chi tlinh tliilu

tri

k5t hqp

gita

corticoid

vh

thuSc rirc ch6

mi6n

dich

Azathioprin

-

Ddithilo

tludng phg thuQc insulin

-

Tdng huyiSt 6p

r6t

hqp
Don

tri

liQu

Azathioprinmg/kg/n gdy
Prednisone
mglngiry
TuAn

ta

30
1 60
1-2
40 20
2
15
3 30

4 25
1-2
15
5 20
1-2
10
6 15
1-2
<10 <10

Duy

tri

so. V 16 - HU6NG oAN criAN DoAN vA DIEU rzu BENH TIET-I HOA

-50-Prednisonmg/ngdy

1-2

t-2

</div>
<span class='text_page_counter'>(54)</span><div class='page_container' data-page=54>

-

Glaucome

-

Trimg c6

lo6ng xuong, gdy xuong.

+

D6p rlng Otii vol nhOm Oc ch6 mi6n dich t5t

Ti6u chudn Ei6u

tri

Ddp rlng di6u

tri

TriQu chrng ldm sirng ciri

thiQn, sinh h6a binh thuong

ALT,

GGT, bilirubin
M6 hgc: kh6ng c6 t6n thuong

gan tren tnen

Di6u

trith6t

bai

Kh6ng ddi hay x5u hon c6c

d6u hieu LS, SH
xu5t hien c5 truong, HC n6o

'

Prednisone hay 60mg/ngdy
hay 30mg/ngdy ki5t hqp
azathioprin I 50mg/ngdy 1

thang(it nh6t)

--: .l ,.:

Neu do gram oan lleu
N6u kh6ng gh6p gan

D6p ung
kh6ng hodn

todryr

C6i thiQn LS vd Sh m0 hsc

nhLmg kh6ng trd va binh
thudng trong vdng 3 n6m k6

tir

T6i ph6t> 2 Dn di6u trf k6o
ddi li0u th6p prednison +

azathioprin

BQ Y TE - HU6NG DAN CHAN DOAN VA OIEU TRI BE.NH TIEU HOA -51

-Corticoid li6u th6p k6o

dii>

-).

o tuan

Theo d6i AST,ALT,

Bili,

IgA:

tuAr/l6n
3 thdngdiAu trf ngrit qudng

immrurosupprresor
Theo

d6i

6thilngl

ldn_2

n6m

T[ng AST,

ALT

</div>
<span class='text_page_counter'>(55)</span><div class='page_container' data-page=55>

-

PhU

nf

c6 thai:

+

Vi6m gan tU miSn kh6ng c6 ch6ng chi dinh mang thai

*

Immunosupressor dung n4p t5t

+

Chi ilinh dtngAzathioprin n6n 1i6u thdp

vi

chuy6n h6a qua rau thai

-

Ei€u

trikh6c

+

Ciclosporin

A:

2-6

-52-XOGAN

I. DAI

CUONG

Xo

gan duoc x6,c dinh nhu mQt qu6 trinh xo h6a lan t6a

vi

su hinh thanh
c6c khtii

ting

sinh (Nodules)

vdi

c6u tnic bAt thudng. DAy duqc coi

li

kiit

qua
cu6i cirng

cta

qu6 trinh tSng sinh

xo

xu6t hi$n

ctng

vdi

c6c t6n thuong gan
mqn tinh. BQnh dugc UiiSt tir ttrl5

kli

thf

5 tru6c c6ng nguy€n

v6i

c6c mO

ti

cria
Hypocrates,

nhmg

t6i

ndm 1819

-

thu4t

ngil

"cirrhosis"

mdi

dugc nha lam

sang ndi ti6ng ngudi Ph6p R. Laennec de xu6t

vdi

giic nghia tir titing Hy L4p:
gan mdu

virrg

cam. Nguy€n nhdn

cht

ydu g6y

xo

gan nhi6m c6c virus vi€m
gan B, C vd tinh tr4ng l4m dgng bia ruqu

II.

NGTIYTN

+

Benh mach m6u:

dudi

<sub>- </sub>

Chdy miiu mfii, ch6y mriu chrin

ring.

+

C6 thrS c6 s6t.

+

Vang da tir nhg tttin n4ng.

+

Pht

2 chi:

GiAn

tinh

m4ch

thyc

qurln

v1i

citc muc dQ khiic nhau (thuong ph6t

hiQn qua nQi soi hopc khi benh nhen bi n6n nhiAu mriu).

+

C6 th6 c6 c6c

r6i

1o4n vd

thin

kinh vd tdm thAn: run tay,

chfm

chpp,

m6t ngri.

C{n

lim

sirng

-

ALT

vd AST: c6 th6 binh thuong

hoic

cao vtra phdri.

-

GGT: thudng cao trong xo gan, nh5t le nhflng trudng hap nghiQn rugu
hopc vdng da.

-

AlbuminthAp, Gamaglubulin tbng, IgG, IgM t6ng.

-

Ti

le Prothrombin gidm.

-

C6ng

thfc

milu: thudng c6 thitiu m6,u nhusc s6c, titiu cAu gi6m.

-

Si6u dm:

+

Nhu m6 kh6ng ddng nhAt, gan s6ng hon binh thuong, phdn

thty

-

Do

tlQ dnn

hdi

gan (Elastography): dC

tllnh

gi6 mric dQ

xo

h6a cria
gan.

Xo

gan tuong fmg

v6i

F4.

K]

thuQt ndy chi srl dpng trong c6c trudng hgp
cdn nghi ngd c6 xo gan hay kh6ng.

-

Sinh thit5t gan: thuong dugc dung

vdi

cdc trudng hqp xo gan giai do4n
sdm <16 ch5n ttorin x6c dinh hoac d6

phin

bi€t c6c khi5i

ting

sinh hong xo gan

vdi ung thu gan.

-

Soi 6 bgng: hiQn it dtmg.

IV. CHANDoAN

1. Ch6n dor{n x6c

tlinh

-

Giai dopn cdn

bt:

+

Dua vdo cdn 16m sdng: nQi soi, si6u 6m, chgp c6t t<rp

vi

tinh, tlo dQ

dan hol gan.

+

N6u kh6ng

16:>

sinh thi6t gan.

-

trulng

hqp c6 tru0ng: lao mdng bgng, hQi chung than hu.

v.

TrtN

LUqNG

vA

BIEN

cHiNG

1. Ti6n

luqng:

phg thuQc

vio

giai ctopn vd c6c bitin chimg cta xo gan'

-

Phan 1o4i dya vdo chrlc nSng gan

PhAn lo Child

<sub></sub>

-Tucorcott-u5i

thOng s6 tuong ung

nr I

-

3 tlitim:

+ ChildA:0-6di6m

+ ChildB:7-9di6m

+

Child C: 10

-

15 di6m

-

Phan lo4i theo giai <Ioqn 16m sirrg:

+

Giai

do4n

0:

kh6ng c6 cO tnrong

>50

35-s0

0-3

Bilirubin

m6u (mg%)
(mmol/l)

<2,8

> 3,5 2,8

<sub>-3,s</sub>

Albumin

mdu(g%)

Vira

it

Kh6ng

CO tru6ng

Kh6ng

1vit2

Benh

li

n6o gan (dQ)

>6
<45

l-4

>55
Thdi gian Prothrombin (gi6y)

Pt5l vOi xo gan met ti€n ph6t

>10

4-10

1-4

Bilirubinm6u

(mg%)

>

170

t7

<sub>-68</sub>

Bilirubin(mmoUl)

BO.

Y-tr-

H,dNG

DAN CHAN DOAN VA OGU Tru BE.NH TIEU HOA

-56-2

<2,0

<35

vd4

4-6

4s-55

</div>
<span class='text_page_counter'>(60)</span><div class='page_container' data-page=60>

+

Giai tloqn

3:

gidn vd tinh m4ch thgc qu6n, phinh

v!

c6 ho4c kh6ng c6
c6 truOng

+

Giai do4n 0 vd

I

dugc coi lh xo gan cdn

bt.

+

Giai tloqn 2 vir 3 dugc coi lir xo gan m6t

bt.

2. Bi6n chri,ng

-

Ch6y m6u do tdng iry lqc tinh m4ch cua: thuong gap nh6t ld gi6n vd
tinh mpch thuc quin, tinh m4ch phinh

vi

d6i khi c6 th6 & than, hang

vi

ho4c t6
trang. EAy ld mQt bi6n chimg n[ng, c6

tj'

lp tu vong cao. Tj'19 xu6t huytit vd tri
vong phg thuQc vdo mric dQ cta xo gan.

-

BQnh

lf

n6o gan: duoc coi ld tinh tr4ng thay d6i chric nang thAn kinh d
ngudi xo gan. D6y cffng ld bi6n chring thudng g4p d nh6m benh nhan ndy. Sy
xu6t hiQn cria bQnh

ly

ndo gan anh huong nhi€u d6n ch6t luong s6ng cfrng nhu

khi

ning

s6ng th6m cria ngudi benh. C6 nhi6u y6u

tii

gAy n6n bQnh

ly

ndy,
trong d6 quan trong nh6t ld vai trd cria Amoniac m6u.

-

C6 trudng: sg xu6t hiQn dlch trong 6 bgng dugc coi lir mQt biiin chung
thii hien mQt budc ngo[t cho bi6t tien lugng kh6ng t6t.

oay

ld h4u qu6 cta viQc

ting

iq

lyc tinh

mach

cta,

sy thay d6i

cta

ddng m6u tltin cric tqng, thay d6i

, <sub>i. -^ </sub> I. .

huy6t dgng, sy

git

mu6i vd nu6c cua thqn.

-

HQi chrmg gan

th{n:

ld tinh tr4ng suy th4n xu6t hiQn d bQnh nhAn

xo

gan c{ii tru6ng c6 Creatinin > 1,5 mmol/ dl. C6 2 th€:

+

Type 1:

titln triiln

trong ph4m

vi

2 tuAn: Creatinin

>

2,5 mmol/

dl

<sub></sub>

I len tuqng xau.

+

T)?e 2: ti6n tri6n ch4m thuong li6n quan dlin chuc nang gan vd mric

dQ c6 trucrng.

-

H4 Natri m6u: bi6n chimg niry g|\p tr 20

<sub>- </sub>

30% benh nhdn

xo

gan vd
dugc khing dinh khi n6ng dQ Natri m6u

<

130 mEq/ I xuAt hiQn tr6n benh nhan
c6 c6 trudng. Ti6n luqng

khi

c6 biiin chimg ndy

li

kh6ng t6t, benh nhan dC di
viro h6n m€ gan.

-

HQi chring gan ph6i: ld tinh tr4ng thi6u m6u d dQng m4ch vir gi5n c6c

m4ch m6u b€n trong ptrOi, tr4u qud ld thitiu oxy, c6 cric Shurt b€n trong ph6i,

gita

hQ th5ng m4ch crla vd m4ch ph5i, tran dich mang ph0i, tang 6p

lyc

ph6i

nguy6n phrit,

r6i

lo4n th6ng

khi

tudi

m6u,

film

XQ

ngqc c6 dqng

khim

ccv hohnh l6n cao.

-

Nhi6m trung dlch c6 truong: cflng ld mQt bi6n chilng thuong g4p d
b€nh nhdn

xo

gan. Phan l6n ld tU ph6t, kh6ng ptr,it hiQn dugc dudng vdo. Da
ph6n

vi

khu6n c6 ng.rdn g5c

tir

tlulng

ti6u h6a

cta

ngudi bQnh,

nu6i

cdy

thiy

chri yiiu ld E. Coli ho{c Streptococci nh6m D. ChAn cto6n x6c dlnh khi b4ch cAu

da nhAn trong dich c6 tru6ng

>

2501 mm3.

</div>
<span class='text_page_counter'>(61)</span><div class='page_container' data-page=61>

-57--

Huy6t

kh6i tinh

m4ch

cta:

ngudi

xo

gan c6 khuynh huong

bi

huyOt

kh6l

O cac

tinh

m4ch s6u, d5c biet

h

tinh

mqch cira. C6

khoing

gdn 40%

bQnh nhdn xo gan c6 nguy co gap bi6n chimg ndy, trong khi ch6y mrlu ti€u h6a
chi khoang 10%.

-

Ung thu bi6u m6 t6

bio

gan: xo gan dugc coi ld yliu

tii

nguy co hdng
ddu g6y ung thu gan nguy€n ph6t. C6 khoAng

>

80Yo cdc

trulng

hqp ung thu

gan xu6t hiQn tr€n gan xcr.

vr.

Drtu

TRI

1. Ch6.tO 5n u6ng sinh hoSt

kg c6n nqng.

Khi

c6 biriu hiQn cria bQnh ly n6o gan, lugng protein gidm
xuting

l-

-

l,2d

Kg cdn nqng. Uu ti€n cung c6p acid amin ph6n nhrinh vd d4m
thgc vQt.

-

Ngudi xo gan rAt n6n c6 mQt

bta

6n t6i trudc khi di ngri.
2. Ei6u

tri

nguy6n

nhin

-

X<r gan

do

virus

vi6m

gan

B:

n6n dirng thu6c

ric

ch6

virus

nhu:
Lamivudine, Entecavir, Tenofovir.

-

Xo

gan

do

virus vi6m gan

C:

c6

th6

xem

xdt

di6u

trl

bang
Peginterferon k6t hgrp

v6i

Ribavicin cho c6c trudng hqp xcr gan giai do4n tIAu'

-

Xo

gan

ruqu:

bQnh nhdn

phii

ngimg sri dgng rucru, c6

thii

xem x6t

dtng

corticoid.

-

Xo

gan m{t ti6n ph6t: dtng Acid Ursodeoxycholic
3. Didu

tri

bi5n chrfrng

-

C6 trudng:

cn6

6n h4n

ch6

mu6i ti5t

trqp

vdi

lgi

tiiiu

kh6ng
aldosterol

vi

furosemid. N6u

n[ng,

c6 th6

niii

th6ng hQ tinh m4ch cria vd tinh

m4ch tr€n gan (TIPS).

-

Benh

lf

n6o gan: ctr,5 AO an h4n chi5 Protein, uu

ti6n

cung c6p acid

amin phdn

nh6nh,

ldm

s4ch ruQt (u5ng

ho{c thqt

lactulose), khring sinh:
Neomycin, Rifaximin, Ciprofloxacin, Metronidazol.

-

Gien vO

tlnh

mpch

thpc

quin:

cAm m6u qua nQi soi, c6c thu6c tric
tlQng diin vQn mqch (Somatostatin, Octreotide, Terlipressin) hoflc c6 th6 ldm
th6ng

gifa

hai hQ thiSng tinh m4ch cria vir chn (TIPS).

-

Nhi6m tnrng

dich

cli

tru&ng:

su

dgng

khrimg

sinh:

Cefotaxim,
Ciprobay, Rifaximin.

</div>
<span class='text_page_counter'>(62)</span><div class='page_container' data-page=62>

-58--

HQi chimg gan th4n:

+

Ngimg

lqi

tiiSu

+

nhic dtngAlbumin.

+

St

dung thu6c

ric

ch6

Recepter

V2

(Lixivaptan,

Satavaptan,

Tolvaptan).

4. Didu

<sub>t4 </sub>

dU phdng

-

Gian vO tinh mqch thyc qu6n: thAt brii gidn qua nQi soi, sri dpng thu0c
ric ch6 beta giao cdm kh6ng chgn lgc.

-

Nhi6m trung dich c6 trudng: Ciprofloxacin, Cephalosphorin tfrr5 ire

:.

-

Benh ly n6o gan: Lactulose.

5. Gh6p gan: cho nhfng

tru]ng

hqp c6 chi d!nh.

Tii

IiQu tham kh6o

1.

Femandez

J

et

al(2000). Diagnosis, treatment,

and

prevention

of

spontaneousbacterial

peritonitis.

Baillieres

Best

Pract

Res

Clin
GastroenterolT4

<sub>- </sub>

975.

2. Garcia

Tsao

et

al(2009).

Management

and

treatment

of

patients

withcirrhosis

and

portal

hypertension:

recommendations

from

the
Department

of

Veterans

Affairs

Hepatitis C Resource Center Programand
the National Hepatitis C Program. Am J

Gastroenterolll4-

1802.

3. Hou

W,

Sanyal AJ(2009).

Ascites:

diagnosis

and

management. Med
ClinNorth Am 93 - 801.

4.

Gines

P

et

al(2004). Management

of

cirrhosis

and

ascites.

N

Engl

J

Med350-1646.

5. Sass

DA,

Chopra KB(2009).

Portal

hypertension

and

variceal
hemonhage.Med Clin North Am93

-

837.

</div>
<span class='text_page_counter'>(63)</span><div class='page_container' data-page=63>

-59-xuAr

HIrytT

Trtu

HOA

cAo

Do

tANc Ar

r,r.l.

c

riNnu4cncrll

EAr

crIoNG

xu6t

huy6t

ti6u h6a

(XIITH)

cao

do

ldng

6p

lyc

tinh

m4ch cria

(ALTMC)

ld xu6t huyi5t do vO

bfi

gidn tinh m4ch thgc quan, d4 ddy hoflc hdnh

t|trdng

md trong d6 phAn lon ld do v0 giSn tinh mpch thyc

quan'

XHTH

mQt bii5n chimg r6t n{ng trong xo gan tl6y

li

nguy6n nh6n hay <sub>CAp gey </sub>tu vong.

Ti

)c{TH

tt

5-15% m6i nam

tty

thu$c mric dQ brii giSn nhd hay lon. Mric

d0

ning cia xo

gan

lim

teng kh6

ning )GITH.

Ti

t6i

xu6t huytit khoang

6o0/o trong mQt n6m n6u kh6ng dugc diAu

tri. Ti

tu

vong do

)GITH

tir

15-20oh lrong 6

tuin

ttAu phg thuQc viio mirc

tlQ

n4ng

cta

xo gan,

tir

0% tt6i xo
gan mric dQ

child Avit3}%

dtii mric d0 child C.

II. CHANDOAN

Lflm

shng

-

N6n ra m6u: thudng xuAt hiQn dQt ngQt, nOn ra m6u d6

tuoi

s5 luqng

ddv

4. ChAn do6n mr?c.10

XHTH

Bin

Cic

d6u h 6m th6

tich

m6u

Nang

Nhe

Trung

binh

80-99 <80

100

fIA

max (mmHg)

</div>
<span class='text_page_counter'>(64)</span><div class='page_container' data-page=64>

-60-M4ch 100-120 >120

z-)

4

Hematoorite y1 0,3-0,4 0,2-0,3 <0 2

ItAt

mau (% V tu6n hoan) <20 20-30 >30

J
2
1
>51

34-51
<34

Bilirubin(pgll)

<30
30-35
>35
Albumin m6u (g/l)

<44
54-44

100-54

Ti

lQ Prothombin

Kh6 ki6m so6t
DE ki6m sorit

kh6ng
C6 truOng

H6n m6
Lo mo

Tinh
Tinh thdn

Bin

mric d

x0

n: theo h6n I

i

cfia

Child

<sub>-Pu</sub>

Child

A:

5-6 di6m

Child B: 7-9 di6m
Child C: 10-15 tti6m

N6u mric dQ xo gan cang n{ng thi

khi

ning

XIITH

t6i ph6t cdng cao

S.ChAn tlo6n phAn biQt

a. C6c xu6t huy6t ti6u h6a cao do

cic

nguy6n nhAn

khic

-

Lodt da ddy t6 trd,ng: lAm siurg vd x6t nghiQm kh6ng c6 bitiu hiQn cria

-. . ., ,I

Pollp

thgc qu6n, d4

diy

ch6Y m6u.

b.Ho ra

miu:

thudng ho ra m6u c6 l6n bqt, c6 t6n thuong ph6i

c. XuAt huy5t ti6u hr6,a th6p: kh6ng c6 n6n ra m6u, u re m6u kh6ng

ting

TII.

DItU

TRI

l.

Didu

tri

XHTH

c6p

tinh:

a. Nguy6n

tic:

ftdi

sric tich cyc, ditiu

tri

cAm m6u vir phdng bi6n chimg h6n
m6 gan

Hiii

sric

-

Tu tht5 b6nh nh6n tIAu thAp

-

Dim

b6o tluong th0: Duy

tri

khd n6ng v4n chuy,6n oxy

milu

cho bQnh

nhdn

(BN)

(

dec biet aOl vOi

BN

c6 tu6i vd/tro{c c6 kdm benh l}?

tim

m4ch):

Cho thd oxy qua x6ng

mti

3-6 Llphitt. N6u bQnh nhdn c6 nguy co trho nguo. c

vdo dudng h6 h6p hohc c6 suy hd h6p can Oat nEi khi quin.

-

Uu

ti6n hang dAu trong

Hdi

sric lir bir lai khr5i luqng tuan hoan d6 6n
dinh huy6t dQng.

BO Y TE - HU6NG DAN CHAN EOAN VA OIEU TRI BE.NH TIEU HOA

-61-90-100
H6ne cAu (

T/l

</div>
<span class='text_page_counter'>(65)</span><div class='page_container' data-page=65>

-

T6t ca

BN

phdi duqc d?t

duqc

dulng

truy6n tinh m4ch

ngo4i bi€n.

-

Phdi chri

y

nhan bi6t cdcbgnh di

kdm

d€

didutri

thichhqp.

-

edi

php thc tich:

+

Bdi phu th6 tich dugc

bit

dAu truydn tinh m4ch dlch mu6i ding truong
20

mkg.

O da s5 bQnh nhan truy6n 1-2 L

dich

ttdng truong

nhu

glucose 5% (
h4n ch6 NaCl 0,9%

vi

gdy giir mu6i ve

pht

to) sc di6u chinh dugc th6 tich dich
bimAt.

+

N6u sau

khi

tt6 truydn

dich

ttAng tru<rng

tdi

t6ng

[€u

ml/kg

md
benh nhan v6n cdn d6u

hiQu

stic c6n tnryAn dich keo (500-1000

mL)

d6 bao

dam th6 tich trong

ldng

m4ch.

-

Plasma tu<ri tt6ng

lqnh

truy6n cho bQnh nhAn

bi

)GITH

md c6 tinh
trqng r6i lo4n ddng m6u. Truydn ti€u cdu cho bQnh nhdn dang bi

XHTH

md s6
tiiSu cAu < 50.000/mm3.

-

Chi

dinh fruyAn m6u:

+

Khi

hemoglobin <70-809/1

+

N6ng dQ hemoglobin <100 <sub>e/l </sub>0 mQt bQnh nhen

bi

tst huyi5t 6p tu thi5

(do hemoglobin sE tii5p tuc

bitqt

xu6ng sau khi truy6n dlch mu5i d6ng truong);

+

BN

bi

benh 1),

tim

m4ch

c6 triQu chimg nhu con dau

thit

ngyc hoflc

tr€n >60 tu6l cAn dugc truydn m6u tt6 duy

tri

mQt mric hemoglobin >100 g/l

c. Didu

tri

cAm m6u

-

Thu5c ginm 6p lpc tinh m4ch cua, thu6c c6 t6c dpng ldrn co m4ch t4ng

den

tdi

lem ginm 6p lyc tinh m4ch cua: c6 thl5 dung mQt trong c6'c thu6c sau.

+

Octreotide

:

50 pg

ti6m

TM,

ddng

thdi

truydn

tinh

m4ch

li€n

tgc
50pe/h

+

Somatostatin: 250

ti€m

tinh

m4ch, sau tI6 truydn

TM

li€n

tuc
250p,glh

+

Terlipressin: ti€m tinh m4ch1- 2mgctr 6 gid mQt lAn

+

Dtng

thu6c giAm rlp

lgc tinh

mpch crla trong 3

-

5 ngdy, ntiu ph6n
vang dimg thui5c.

-

N6i

soi s6m trong vdng 12 gid dC ti.5n hanh

thit

tinh m4ch thgc quan

ho[c

ti6m histoacryl erSl

vol

vd tinh m4ch tpi da ddy. HiQn nay, ph6i hqp

gira

thu6c ldm giAm

ALTMC

vi

ph6i nQi soi cAm m6u ld biQn ph6p hiru hiQu d6i
di6u

tri

XIITH

do tdng

ALTMC.

-

<sub>{rng </sub>

b6ng chdn t4i thyc quan: tl6y

li

phuong ph6p c6 t6c dpng, fuy
nhi6n gdy nhidu bii5n chrlng nhu: hit dich vdo tludng hO h6p, 1o6t

vi

thring thr,rc

</div>
<span class='text_page_counter'>(66)</span><div class='page_container' data-page=66>

-62-quin,

chi n0n 6p dpng trong khi chd c6c phuong ph6p di€u trf kh6c nhu nQi soi

cAm m6u hoac ldm

ciu

nt5i cria chri qua tinh m4ch c6 (Transhepatic intrajugular
portosystemic shunt

<sub>- </sub>

TIPs ). Ngdy nay

cing

it sri dr,rng.

-

'-

10-20% didu

tri

nOi soi vd nQi khoa that

b?i

khi

d6 phdi ti6n hanh
TIPS, ho4c phAu thuSt n5i crla

<sub>- </sub>

chri

d. Di6u

trf

dg phdng bi6n chrlng h6n mG gan

-

Kh,lng sinh:

Norfloxacine

0,4 g

x

2 vi6n

/ngiy

dtng

5- 7 ngdy' N6u
benh nhan kh6ng ui5ng duo. c dirng khring sinh dg phdng

dulng

ti€m. DOi benh

nh6n

c6

nguy

co

kh6ng thu5c khring sinh nh6m quinolon

c6 th6

dung
ceftriaxone ti0m tinh

m1chl-2flngiry

tu 5- 7 ngdy.

-

Lactulose dudng u6ng 20

<sub>- </sub>

50 gl 24 giir .

2. Didu

tri

dg phdng ch6y m6u
a. BN dn xu6t huy6t ti6u

hoi

-

Ngay

khi

BN

ngtrng chdy m6u, k6t hqp didu

tr!

giem

ALTMC

bsng
chen beta giao

cim

kh6ng chgn lgc

ting

dAn cho

t6i

I'hi

nhip

tim

gi6m 25 %'
Thu5c chgn beta kh6ng chgn 19c vtra c6

kic

dpng tr€n

<sub>Bl </sub>

hm

giem nhlp

tim

tt6ng

thdi

c6 t6c dgng trdn <sub>B2ldm </sub>co m4ch d6n tOi giAm m6u

tdi

m4ch t4ng.

p6i

<sub>vOi </sub><sub>propranolol li€u ktrdi </sub>tIAu 20 mg,

ting

d6n, khi dung thu5c cAn chia 2
En ngdy.

voi

naaotot

tit

AAu

fdu

20 mg/ngdy,

dtng

I

16n ngdy. C6 the ph6i

hqp chgn beta giao c6m kh6ng chqn 19c

v6i

isosorbid mononitrate. Tuy nhidrL

kh6ng

dtng

isosorbid mononitrate don thuAn

vi

kh6ng c6 t6c dpng lnm ginm

ALTMC.

-

NOi soi

thit

tinh

mach thuc quan

(TMTQ)

lai

sau 14

-

2l

ngiy

phdng nguy co chiry mriu

l4i

Titin hanh th6t

TM

thyc quan cho

tdi

khi

kh6ng

"0"

k} a nane th6t dugc. Sau d6 cu 3-6 thring nQi soi ki6m fta

lei dC th6t ntiu c6
c6c brii gi6n *uAt hien.

-

Trong trudng hqp c6 giSn tinh m4ch vung t6m

vi

c6c

bfi

gi6n ndy li6n
tpc

vdi

ciic brii cria

TM

thUc quan, ti6n hdnh ti6m histoacryl t4i biri giEn vung
tdm

vi,

sau d6 ti(5n hanh

thit

ttet

aC cric brii gidn t4i thyc quan.

b. BN chua bi xu6t huy5t tiOu ho6

-

D6i

vdi

t6t ca

BN xo

gan phdi dugc titin hanh nQi soi thgc quan d4
ddy ph6t hien brii gi6n t4i tinh m4ch thgc qudn. D6i vdi trudng ho-p xo gan cdn

btrntiu nQi

soi

md kh6ng th6y gi6n

TMTQ

c6n tii5n hanh soi ki6m tra 14i trong
vdng 3 n6m. Ntiu xo gan m6t

bt

md nQi soi kh6ng c6 gidn TMTQ cen soi kitim
tra l4i m5i

nim

mQt ldn.

-

D6i v6i

BN

xo

gan

khi

nQi soi c6 gi6n

TMTQ

nh6 (dQ

I

theo phdn

chia

mfc

tIQ) c6 th6

dtng

chgn beta kh6ng chgn 19c d6

<sub>4r </sub>

phdng ch6y

<sub>16u</sub>

ti6n ph6t ho{c kh6ng dung. N,5u kh6ng dung chqn beta kh6ng chqn lqc

d''

</div>
<span class='text_page_counter'>(67)</span><div class='page_container' data-page=67>

-63-phdng cAn ti6n hanh soi kiiim tra lai trong vdng 2 ndm d6i xo gan cdn bir. N6u
xo gan m6t

bt

md nQi soi khdng c6 gi6n

TMTQ

c6n soi ki6m tra lai m5i

nim

mQt

lin.

-

Ol5i vOi

BN xo

gan

khi

nQi soi c6 gidn TMTQ

vila

vd 16n (d6

II,

III

theo ph6n

chia

3 mric d6) c6 th0 dirng chgn beta kh6ng chgn lgc d€ dg phdng
chdy m6u ti6n ph6t hoac

thit

TMTQ n€u c6 ch6ng chi dinh v6i thu6c chgn beta

kh6ng chpn lgc. N6u 6p dgng th6t

TMTQ

cAn nQi soi th6t TMTQ

lai

sau 14

-2l

ngity cho

t6i

khi kh6ng cdn

khi

ning th6t duqc. Sau khi

tl6t

triSt TMTQ c6n

ki6m tra lai sau 1-3 thang, tiiip sau t[6 cri 6 thang-l

nim

n6i soi ki5m tra l4i.

-

D6i vdi b6nh nhan sau

thit

tinh m4ch thyc quin n6n dtng PPI [Au d6u

chuAn trong 04 tuAn ldm cho 6 lo6t sau th6t nhanh hdn seo.

Tii

IiQu

tham

kh6o

1.

Sheila Sherlock, Sheila Sherlock (Dame.), James Dooley. Diseases

of

the

Liver and

Biliary

System 2002: 170-176.

2.

Guadalupe Garcia-Tsao, Arun J. Sanyal, Norman D. Grace, William Carey.
Prevention and Management

of

Gastroesophageal Varices and Variceal
Hemorrhage.

AASLD

PRACTICE GUIDELINES. Hepatologt,

Vol.

46,
No. 3,2007: 922-938.

3.

Thomas D.

Boyerl

and,Ziv J. Haskal. AASLD PRACTICE GIIIDELINES

AASLD

Practice

Guidelines:

The

and

Variceal Hemorrhage in Cirrhosis. N Engl J Med2010;362:823-32.

</div>
<span class='text_page_counter'>(68)</span><div class='page_container' data-page=68>

-64-cnAu

ooAN vA

xrlrni

xo

cAN

c6 nor

cHrNc

cAN THAN

DAr

crIoNG

HQi chung gan

fiAn

dE dugc Epstein ndm 1970 md td suy th4n xdLy ra d
benh nhan c6 bQnh gan man tinh. Benh nhan c6 hQi chimg gan th4n

voi

cric t6n
thucmg thfln do h4u qu6 co m4ch th4n d6ng kii, ngugc lei tuAn hodn

ngoii

th$n

14i c6 crlc

biiiu

hiqn gi6n m4ch dang k6, k6t qu6 dan A6n lnm gi6m srlc ciur

thanh m4ch tr6n todn bO he th6ne vd h4 huyiit rip dQng m4ch.

Ti

le tri vong

t6i

geil SON benh nhan trl vong trong vdng 2 tuen khi chan
rlo6n bQnh.

rr.

NGr.rrtN

NHAN

VA

CHf

BENH

SrNH

C6c bpnh nhdn suy gan cdp
2. Co ch6 bQnh sinh

Do ti6n tri6n cria bQnh gan g6y ra c6c thay d6i trong h€ thtSng tudn hoan.

-

Gi6n m4ch t4ng do d6 ldm gi6m thiS tich hiQu rmg dQng m4ch, vd gi6m
huyet 6p trung binh ttQng m4ch.

-

Co m4ch th6n do ho4t h6a he than kinh giao cdrn vir hQ th6ng

renin-angiotensin-aldosterone ld nguyEn nh6n g6y co m4ch thfln.

-

Suy chric

ning

tim

vi

6nh hucrng

cta xo

gan g6y

phi

d4i co

tim

ldm
t5ng hau grinh thrl phrit sau gi6n m4ch.

-

Tdng t6ng hqp cdc chdtho4t m4ch trung gian anh huong 16n ddng m6u

d6n thfln

hoac

huy6t

tlQng

cria

vi

tu6n

hoan

ciu

th4n

nhu,

cysteinyl
leukotrienes, thromboxane

42,

F2-isoprostanes

vir

endothelin- 1.

Vai trd

c6c ch6t

giy

-

NO:

Ld mQt chdt gay gi6n m4ch, tAng trong m6u ngo4i

vi

cria bQnh

</div>
<span class='text_page_counter'>(69)</span><div class='page_container' data-page=69>

-65-endothelin-l 6 tuan hodn

titlu

cAu thQn dugc xem ld co che d6n d6n suy chric
ndng thfln d bQnh nh6n xo gan.

-co

-

Endogenouscannabinoids

-

Vai

trd

cria hQ

vi

ktruAn g6y phan tmg san xu6t nhi€u cytokines g6y
giSn m4ch

Vai

trd cic

chAt g6y co m4ch

thfln

-

Ting

endothelin

III. CHANDOAN

1. Ti6u chuAn chAn dorin hQi chring gan

thfn

-

Xo

gan c6 cd chudng

-

Creatinin mrlu

>

133

pmol/l

(1,5

mg/dl)

-

Kh6ng

cii

thiQn tlugc mrlc t6ng creatinin m6u sau

2

ngdy dung

lgi

ti6u, vd

truydn

albumin (1i6u albumin khuytin c6o

dtrng

lglkekryily tt)i

10Og/ngny).

-

Lo4i tru bQnh nh6n c6 siic.

-

HiQn t4i ho4c thdi di6m gAn ddy khOng c6 dtng c6c thui5c g6y dQc vdi

thAn.

-

KhOng

c6

bQnh

ly

t6n

thuong

nhu

m6

thfln

(protein niQu

>
500mg/ngdy hdng cAu ni6u < 50/vi trudng, khdng c6 t6n thuong nhu m6 th4n
tr€n siOu Am.

-

Sinh phAm

mdi

g6p phen chan dortur hQi chung gan th4n: b4ch cAu

niQu gelatinase-associated lipocalin 105 ng/ml. Girip ph6n biet

vdi

c6c nguy€n
nhdn kh6c gdy ldng azotemia m6u.

2. Ti6u chuAn phg

-

thti

tich nu6c ti6u < 500 ml/ngdy

-

Natri nu6c ti6u

<

10 meq/L

-

Ap

lpc thAm th6u trong nu6c titlu

>

6p lyc thAm th5u trong plasma

-

H6ng cAu trong nu6c ti6u < 5O/trpf

-

Natri trong huy6t thanh

<

130 meq/L
3.

Phin

lo4i

hQi

chftrg

gan

thin

tri

nhiSm khudn

-

Lgc

mriu

gitp

ldm

giirm azotemia vd c6n

bing

diQn

gi6i

gitp

bQnh

nhdn chd gh6p gan, bitin chring tpt huy6t

6phay glp d

benh nhan hQi chrlng

gan than c6 loc m6u.

-

TIPS c6 hiQu qu6 trong di€u

tri

hQi chimg gan

thfn

fype 1.

-

L

-

K6t

hqp truy6n albumin, Octreotide 200 pgrams

ti6m du6i

x

Dn/ngdy vd midodrine

dtng li6u

t6i da 12,5 mg x 3 lAn/ngdy cho th6y hipu qud

</div>
<span class='text_page_counter'>(71)</span><div class='page_container' data-page=71>

-tli€u

tri

cao hon so

v6i

dtng

k6t hqp albumin vd dopamine (ntiu

dtng

don tlQc

octreotide kh6ng cho thdy c6 hiQu quA trong diOu

tri)

vd ph6c dr5 ndy uu ti6n

cho hQi chimg gan th4n type 1.

-

C6c nghiCn criu tla trung tdm cho th6y Terlipressin/ octreotide

tiit

trqp
midodrine/ Norepinephrin k6t hqp

vdi

albumin c6 hiQu qu6 didu

tri

hon so

vdi

nh6m bQnh nh6n kh6ng hoflc c6 dirng albumin don dQc.

DUPHONG HQI

CHINGGAN

THAN

-

Sri dpng ph6i hqp truy,in albumin vd khang sinh cefotaxime

d

benh

nhAn nhiSm trUne dich cO chudng.

Tranh

dtng

c6c thu5c gdy ngQ <IQc

vdi

thQn nhu nh6m thuiic khring

sinh aminoglycosid va NSAIDs

+

Khuy6n c6o khi dtrng c6c thu6c c6n quang

ng-E-

uudNc

DAN cHAN DoAN vA DIEU TRI BENH TIEU HOA

-68-Tni

[Qu

tham

kh6o

l.

Arroyo

V,

Gine'P,

et

al

(1996).

Definition

and diagnostic

criteria

of

refractory ascites and hepatorenal syndrome

in

cirrhosis. Hepatologt 23:

164-t76.

2. Bruce

A. Runyon

(2004).

AASLD

practice guideline. Management

of

Adult Patients With Ascites Due to Cirrhosis. Hepatologt, March, 9-10'

3. Clinical

Practice Guidelines(2010).

EASL clinical

practice guidelines on

the

management

of

ascites,

spontaneous

bacterial peritonitis,

and

hepatorenal syndrome

in

cirrhosis. European Association for the Study

of

the Liver. Journal of

Hepatologt

vol. 53,

397417.

4.

Ginds

P,

Schrier RW(2009). Renal

Failure

in

Cirrhosis. New England
Journal of Medicine;361 :127 9 -1290.

</div>
<span class='text_page_counter'>(72)</span><div class='page_container' data-page=72>

cHAN DoAN

vA

xt/

rni

xo

cAN

c6

NnItvr xnuAN

olcn

uANc

BUNG

o4r

cUoxc:

Nhi6m trung dlch

ming

byng hay vi6m phirc m4c ti6n philt (Spontaneous
Bacterial

Peritonitis:

SPB)

litnhi€m

khuAn

cta

dlch mirng bgng khi vang mflt
c6c ngu6n nhi6m khuAn trong 6 bqng c6 th6 gAy n6n vi6m

phtc

m4c nhu vi6m
ruQt thira, vi6m

trii

mpt...ld bi6n chring

thulng

<sub>eip </sub>

0

bgnh nh6n

xo

gan ti6n
tri6n. Nguy co xu6t hiQn bi6n chimg

niy

khoang 30% d benh nh6n xo gan c6
tru6ng,

t'i

tf

vong 20oh d6n 50%,ld didu kipn thu4n

lgi

dan diSn hQi chung
gan th4n vd hQi chung n6o gan hai nguydn nhdn trgc titip gAy tri vong lon nh6t
d bQnh nh6n xo gan.

II. NGUYTNNHAN

Co ch6 bQnh sinh cria nhi6m khudn dlch mdng bpng chua ilugc hir5u bi6t
c6n kE, theo nhirng hi€u bi6t gan ttdy nh6t vd co ch6 b€nh sinh c6 li€n quan diin

s6u y6u t6 sau: qu6 phrit cta vi khu6n dulng ti6u ho6, t5ng tinh thAm crla ru61, sg
lan truydn

vi

khuAn, bii5n d6i hQ th6ne mi6n dich d b€nh nhAn xo gan, ho4t dQng

thgc bdo cria hQ th6ng li6n vdng nQi md vd co ch6 bdo vQ cria dlch mirng bgng.
NhiSm khuAn dlch mdng bgng thudng xuAt hign sau c6c ytiu t5 nguy co
nhu:

xo

gan mtic d0 nang (Child

<sub>- </sub>

Pugh C), protein dich c6 trudng

<

1 g/dl
valho4c C3 huytit thanh

<

l3mg/dl, billirubin toan ph6n > 2,5 mgldl,xuAt huytlt
ti6u h6a, nhiSm khuAn

titlt

nigu, quti ph6t

vi

khu6n

dulng

ti6u h6a, d4t sonde
titiu hay dpt catheter tinh mach trung tdm, tidn sir nhi6m

trtng

dich c6 truong.

III. CHANDOAN

Lflm

sirng:

-

Dac tli6m l6m sang rAt da d4ng, benh nhan c6 triQu chung di6n hinh
cria nhi6m thuan aicn mdng bgng r6t ttr6p,

l0%

trulng

hqp nhi6m trung dich
mdng bung kh6ng c6 triQu chimg.

-

Ngodi nhfrng triQu chimg chung

cta xo

gan c6

trufng

c6 c6Lc triQu

chung ggi

j:

+

Tri6u chrmg di6n hinh: dau bgng, gi6m nhu dQng cria ru6t c6 th6 c6

tic

ruQt, st5t, dpi tiQn phAn 16ng.

+

Nhirng triQu chimg c6

th6 lien

quan nhi6m trung

dich

mirng bung:
budn n6n vir n6n, dau khop, nhfrng con 6n l?nh, c6 truong kh6ng d6p tmg di6u

tri lqi

tiiiu, xuAt hiQn hQi chirng gan thqn, h4 thdn nhiQt.

+

Hitim hon nhi6m Uru6n bi6u hi$n bdng: hQi chtmg n6o gan, chirc ndng

gan hay chrlc n6ng

thin

ti6n tritin xAu tti, shock nhi6m khudn.

</div>
<span class='text_page_counter'>(73)</span><div class='page_container' data-page=73>

-69-2.

Cin

lffm sirng:

-

X6t

nghiQm bilan vi6m: bpch cAu tdng (chri y6u trung tinh), CRP vd
m6u l6ng t6ng...

-

X6t nghiQm dlch mang bung: bpch cAu da nhdn trung tinh (BCDNTT)
trong dlch mdng bpng

>250

tC bdo/pl, n6u dlch mang bgng co xu6t huy6t hay
ch6n thuong

khi

chgc dd lugng BCDNTT dugc didu chinh l4i trung binh mQt

BCDNTT tu<rng ring vbi25O t6 beo hting

ciu.

-

C6y dich md,ng bpng:

+

L6y

10ml dlch mang bpng

vio

chat cdy m6u cho dQ nh4y cao hon.

+

<sub>Vi </sub>

khu6n

trong

dich

mang

-

Xdt

nghiQm khric

khi

nghi ngd nhi6m khudn dlch mang bqng: dinh
Iuqng protein dlch mang bung; dinh luqng b6 ttr6 Cf ; LDH vd

dulng,

lactat c6

trong d!ch.

3.

ChAn do6n x6c

tlinh:

Dich

mang bqng c6

>

250 BCENTT/p1 (0,025Gn)
ho{c c6y dfch mang bgng ph6t hien c6

vi

khu6n.

4. ChAn tlo6n phAn biQt: Vi6m phirc m4c thrl ph6t: thring t4ng r5ng, vi6m ruQt

v6t thucrn thanh xe thdnh byn

rv.

Drtu

rRI

1. Nguy6n t6c tlidu

tri:

-

Di6u tri khring sinh

sfm

khi nghi ngd c6 nhi6m trung dfch c6 tru6ng.

-

Dg phdng c6c bi6n chimg: hQi chimg gan thQn, h6n m6 gan.

2. Di6u

tri

cg th6
a.

Kh{ng

sinh

-

Cephalosporin thii he s:

+

Cefotaxim: 2

gr

mdi 8h trong 5 ngdy (c6 th6 dring di5n 10 ngdy), ti€m
tinh m4ch ch4m.

Vi6m phric mgc

thri

phdt

Dic

ali6m Vi6m phrflc m4c ti6n

ph6t

>

10 g/l

<10CI

Protein dich

Glucose dich > 50 mgldl

> 225

Ur/l

LDH

dich

<225All

C6y dich MQt lopi vi khu6n

'O

iE

- HUdNG DAN CHAN DOAN VA DIEU TRI BE.NH TIEU HOA

-70-< <sub>50 </sub><sub>mgldl</sub>

</div>
<span class='text_page_counter'>(74)</span><div class='page_container' data-page=74>

+

Ceftiaxone:

2 gr

m6i

12h trong 5

ngiy

(c6 th€

dtng

d6n 10 ngdy),
ti€m tinh mach ch4m.

-

C6c kh6ng sinh khric c6 thC dung thay th6 cephalosporin thti hQ 3:

+

Amoxicillin/clavulanic,

ciproploxacin 200mg

tinh

m4ch

m5i

12h

trong 2 ngdy sau d6 500mg u6ng

m5i

12h trong 5 ngiry.

+

Trudng hqp kh6ng c6 n6n, kh6ng c6 s6c, kh6ng c6 bQnh ndo gan vd
creatinine

<

265 pmol/l

(

<3mg/d1) c6 thd

dtng

dudng u5ng ofloxacin 400mg

x2lAn lngiry thdi gian trung binh 8 ngdy.

-

Nilu bpnh nh6n khOng drip ring cO th6 dieu

tr!

theo khang sinh dO n6u
c6 hoflc ptr6i trqp ttu6c.

Abumin

N6u c6 didu kiQn dtrng albumine

l,sdketrong

gid

dAu

vir

1glkg viro
ngdy thrl 3 c6titc dpng lirm ginm

ti

lQ b€nh nhdn suy th4n, tj, lQ

fil

vong.

c. Chgc thrio dich mhng bgng

Chgc th6o n6n

lim

khi

<te di6u tr! kh6ng sinh sau 24

d$48

gid md b4ch

c6

tru0ng c6 xu6t

truy5t

ti€u

h6a: norfloxacin
400mg hai

hn

m6i ngdy trong 7 ngity.

-

BQnh nh6n c6 luqng protein trong dich

<

lgldl:

norfloxacin 400 mg
m6i ngdy trong su6t thOi gian

nim

viQn.

</div>
<span class='text_page_counter'>(75)</span><div class='page_container' data-page=75>

t-Goi

i

nhi6m trtn dich mdng bung

Choc dd chdn tlo6n

BCDNTT < 250 t6 BCDNTT > 250 rii bao/pl

c6 hay khdng c6 tri hung l6m sdng

d6i Cefotaxim 29 m5i 8h

CAy duong tinh

Khdng cii thiQn

ldm sang

Cai thien lam sang
lAm sdng

Kh6ng c6 bi6u hiQn

C6 biiiu hiQn l6m sdng

Chqc dd

lAn 2

Theo d6i Did tri 5

DiAu tri nhu nhi6m
tn)ng dich mang bung

Kh6ng sinl ph6 rQng

Si€u dm 6 bqng ti€u

khung

Phdc tI6 {Iidu

tri

nhiSm

trtng

dich mdrng bgng

(theo Victor J. Navarro

<sub>- </sub>

Curent Treatment Options in Gastroenterologt - 1999)

Tii

liQu

tham

kh6o

1.

Javier Femiindez and Miguel Navasa (2007): "Bacterial infections in portal
hypertension" . Textbook of Hepatologl 3'd,761

<sub>-770.</sub>

2.

Bruce

A.

Runyon (2009): "Management of Adult Patients with Ascites Due

to

Cirrhosis" AASLD pratice guideline'.

An

Update.

Hepatolog,

Vol.

49,
No. 6, 2087

<sub>- </sub>

2107.

3.

Guadalupe Garcia-Tsao (2009): "Ascites and its complications".chapter 90,
page 2315

-

23l7;Textbook

of

Gastroenterologt,

Fifth

Edition Edited by
Tadataka Yamada. ISBN: 978-l-405-1691 1 -0.

4.

Rimola

A,

Salmeron JM, Clemente G, et al (1995): "Two different dosages

of

cefotaxime

in

the

treatment

of

spontaneous bacterial

peritonitis

cirrhosis: results

of a

prospective, randomized,

multicenter

study".
Hepatologt;27:674.

</div>
<span class='text_page_counter'>(76)</span><div class='page_container' data-page=76>

-72-5.

Llovet JM,

Rodriguez-Iglesias P, Moitinho

E,

al

(1997): "Spontaneous
bacterial peritonitis in patients with cirrhosis undergoing selective intestinal

econtamination.

A

retrospective

study

of

229

spontaneous bacterial
peritonitis episodes" . J Hepatol;26:88.

</div>
<span class='text_page_counter'>(77)</span><div class='page_container' data-page=77>

-73-cHAN DoAN

vA

xr}

rxi

xo

cAN

c6

nor

cnfNc

xAo

cax

D+r

crIoNG

BQnh n6o gan (Hepatic encephalopathy: HE) ldmQt biiSn chung t6m thAn

kinh

nghi€m trong do suy gan c6p vd m4n gdy ra: ld sg bAt thudng tam than
kinh xu6t hign 0 bQnh nhdn c6

r5i

lo4n chrlc n6ng gan sau

khi

d6 1o4i

trir

cric

bQnh n6o kh6c tluo. c Ui6t O6n. Dinh nghia

niy

cria bQnh n6o gan bao gdm c6 hai
lo4i:

riii

loqn chuc ndng gan vd cric d{c di6m bi6u hiQn cira than kinh.

Trong trudng hqp bQnh gan men tinh, cric thu4t

ngt

bQnh ndo gan kh6ng
hAn <sub>fuc (episodic HE) vd </sub>b€nh ndo gan dai ddng <sub>@ersistent </sub>HE) dd dugc d{t ra
vd thuflt ngit bQnh ndo gan

tiim

tdng (minimal HE) dugc thay th6 cho bQnh ndo
cqn ldm sdng (subclinical encephalopathy).

II. CIIANEOAN

Lflm sing

-

D4c di6m triQu chfmg tam than kinh:

khi

ndng tQp trung gi6m,

ngi

gd,

m6t ptr6i hqp vfln dQne ti6n tri6n tdi thd o, sirng sd vd h6n m6.

-

Cric triQu chimg tAm than,

d{c

biQt ld 1o l6ng vd trAm cdm

it

thudng
c4p.

-

Truong hqp c6 suy gan c6p,

,5i

lopn than kinh c6 th6 ti6n tri6n tu thay
d6i tinh tr4ng t6m th6n t6i hdn m€ trong vdi ngdy, c6c con tlQng kinh c6 thti xAy
ra

vi

fj,

tu

vong cao.

d

nhirng benh nhen ndy,

tri

vong thudng ld h4u qud
thorit v! n6o do phir n6o

vi

ting

6p luc n6i sp.

-

NiSu tinh tr4ng bQnh n6o gan x6u di,

phii

x6c dinh c6c ytiu t6 tidm tang

thfc

d6y: xu6t huyiit ti6u h6a, giem th6

tich

m6u, h4 natri m6u, h4

kali

m6u,
gi6m oxy m6u, h4

tlulng

huy6t, nhi6m trung vd sri dgng cric thu6c gi6m dau, an
thAn.

Cin

l6m sirng

-

NgodLi c6c

r5i

loqn chung

6 xo

gan, c6

NH3 fing

(gi6

tri

NH3binh
thudng <0-60 umoUl (<35 ug/dl), trong bQnh n6o gan mric NH3 c6 gi6

tri

khi

ting

g6p tt6i gi6

tri

binh

thulng).

-

C6c test tinh th6n:

+

Danh gi6 muc dQ suy chric

nlng

th6n kinh,

d{c

biQt trong bgnh ndo
gan nhg

hoic

b€nh n6o gan tidm tang.

+

C6c test thuong tlugc su dgng bao gdm test nOl sO

<sub>6NCf; </sub>

vd ttanh gi6

thdi

gian phan ung

tdi

thf

giric

vi

kich thfch thinh gi6c. Di6m tinh thAn benh
ndo gan (PHES) g6m c6 nhidu test

tinh

than NCT-A,

NCTB,

test vE dudng,
test lcf hiQu s5 vir test chAm vdng. C6c test ndy ki6m ha c6c thuc th6 nhu nh4n

</div>
<span class='text_page_counter'>(78)</span><div class='page_container' data-page=78>

-74-thr?c

th!

gi6c, circh dat ceu vd dinh hu6ng kh6ng gian

v6i

v6n dQng nhanh, dQ

chinh x6c, sy chri y vd chric ning

tri

nh6.

-

DiQn n6o d6: bitiu hiQn b6t aAu

v6i

s6ng chdm,

tlng

bi6n d6

vi

m6t
nhip cr binh thuong.

3. Ch6n dorin x6c

dinh

Ch6n do6n bQnh <sub>n5o gan dga tr6n l6m </sub><sub>sdng </sub><sub>vd x6t </sub><sub>nghiQm sau </sub>

<sub>khi </sub>

lo4i

trt

c6c nguydn nh6n

giy

rtii

+

Theo Riordan vd Williams cho phtlp

c

a Massachusetts
Medical Soicie

</div>
<span class='text_page_counter'>(79)</span><div class='page_container' data-page=79>

-75-5. ChAn

tloin

ph6n to4i

Phan loai bQnh ndo gan trong thUc hdnh 16m sirng thudng su dpng ti€u
chuAn West Haven. C6c bQnh nhan o giai dopn

IV

cria phAn lo4i West Haven
dirng thang di6m h6n mC Glasgow dAnh gi6 t6t hcrn.

2: Tihu chudn West Haven cho ldm cua nao
Giai do4n 0: Kh6ng nhfln rabdtthutrng

Giai do4n

I:

Thay d6i nhan thric kh6n

g

d6ngk6, hung phAn hopc lo

ling

Khi

n6ng tpp trung gi6m
Kh6 n6ng cQng ho{c trtr gi6m

Gia do4n

II:

Thd o

M6t phuong hudng v0 thdi gian
Thay AOi tinh c6ch mQt c6ch rd rang
Hanh

vi

kh6ng thich hqrp

Giai do4n III: Ngu gd cl€n ti6n hdn mC nhmg v5n eap img v6i kich thich
Lu lan

MAt phucrng hu6ng nhi6u
C6 hanh

vi

ki'quflc

Giai dopn

IV:

H6n mE

C6c test vA tinh t6m thAn

</div>
<span class='text_page_counter'>(80)</span><div class='page_container' data-page=80>

-76-3. DrEU

TRI

IIinh

:Di€u

tri

Diiu tri giai.iloqn cAp

I- DiA bi dAu fiAn

a. Ph6t hier/diau tri cdc yiiu tri

thtc diy.

b. Quan l! dinh du&ng:

- Bd/h?n ch6 ch6 dO in ki6ng

-

Dinh dudng dudng ruQt neu

hOn m€ kdo ddi

- 86 sung k€m niiu thi6u

c.Lactulose/lactitol duong

uong vd thut

2. Ltta chon th* hai

a. Gidm NH3 vdi:

- Kh6ng sinh

(neomycin, rifaximin, kh6ng

sinh khiic)*

- L-omithineL-aspartate,

benzoate

- acarbose, probiotics,

L-camitine

b. Test flumazenil d HE kh6ng

d6p ung ho{c ti6p xtc trudc vdi
BDZs

L Dtinh giri todn diqn iti logi

ttit

cdc

ii

togn thdn kinh

khdc

2. Hd try (linh drarrg:
a. Bo sta vd ch€ <10 6n dua
tICn rau

b. C6n nhic BCAA

d

cAc

b€nh nhdn kh0ng dung n4p

vdi protein

c. Lactulose/lactitol

d. Bii sung k€m n6u thi6u
3. Can thiqp iliqn quang
a. I rm cac cau nol lon

cua-cht t.u phet

b. T6c/trep cta dudng kinh
TIPS n6u c6

4. Diiu tr! khtic:

a. Giim NH3:

- Khring sinh

(neomycin, rifaximin, kh6ng
sinh khric)*

- L-ornithine L-aspartate,
benzoate

b. Bromocriptine cho c6c d6u
hieu ngoai th6p

5. Ddnh giri OLT

l. Kh ng cd cht <sub>finh ifiiu </sub>fi!

2. Cdn nhiic ctic thoy itdi
trong hoqt tlQng hing ngdy
(n6nh u6ng ruqu...)

3. Lya chgn b?nh nhdn, cdn

nhdc:

- Lactulose/lactitol

- Can thiOp ch6 d0 an u6ng

(ch6 <sub>dO </sub><sub>en </sub>dua tr€n rau,

probiotics... <sub>)</sub>

h6n mA

o

Phdng bQnh 0 giai do?n m6i
l. KiCm so6t c6c yCu td thric tldy
2. H6 trg dinh du6ng:

a. Luqng protein tlua vao

thich hqp tri stave che d0 en
dua tren rau

b.Vitamin

c. B6 sung k€m ntiu thiiiu

3. Lactulose/tactitol n6u cin

4. Drloh giti OLT

Theo Javiq Yaquero, Andres T. Blei, Roget F. Bulteft'otth (2009): "Central nervous syslem and pulmonary

complications o/end-stdge liver disease "

*lfu?fr{r8ryffWfp,

Fifth Edition Edited bv Tadataka vamada

Kh6ng c6

diiu tri

chdc chdn

duqc chi

ra

di

cdi

thi€n h6n mA gan so vdi
placebo d cdrc

th*

nghiem ldm sdng ngdu nhiAn. Phdn lon cdc b€nh nhdn h6n

me gan

diiu tri

c6 hiQu qud sau khi

phiii

ho.p cdc phuong phdp,

&ta

tuAn cdc

hudng ddn dd

xuiit

bdn.

Diiu

tri

h6n me gan tdi phat se tuong t1t nhu h1n mA

gan dai ddng. *neomycine

s*

&fig

ldu ddi yAu

ciu

theo ddi

dinh

ki' de

Mnh

ngQ dQc (thQn, tai). BCAA, acid amin

phin

nhinh, BDZ: benzodiazepine, OLT:

BQnh nio gan E)<r b€nh gan m?n

HE kh6ng li6n tgc HE dai ding HE tidm tang

</div>
<span class='text_page_counter'>(81)</span><div class='page_container' data-page=81>

-ghdp

gan

trqc

tidp,

p.o;

u6ng, TIPS; transjugular intraheptic portosystemic
shunt.

II5 trq

dinh

duong

-

Lugng protein dua vdo trong ph4m

vi

l-2

glk/ngily.

-

H5 trg u6ng acid amin phdn nhrinh c6i thiQn c6 y nghia c6c bQnh nhAn

xo gan c6 bQnh ndo gan kh6ng dung n4p protein.
2. Chi5n

luqc

h4 amoniac

a. Lactulose

-

Lit

cftc disaccharides kh6ng h6p thu, lirm giirm amoniac do t6ng ddo

th6i nito qua ph6n bang c6ch ktit hqp amoniac vdo vi khu6n.

-

LiAu lactulose (45-90 glngity), nhim tao tlugc phdn mAm

24ldnlngiry.

-

Thgt lactulose tl4i trang ld mQt phuong ph6p nhanh vd hiQu qu6 d6 lo4i
bd amoniac voi thu6c tAy ho4c thqt thiio.

b. Khrflng sinh u5ng

-

Neomycin

tlugc

su dung trudc d6y nhrmg do t6c dgng phU (dQc

v6i

than kinh vn than) n€n

it

dugc sri dgng.

-

C6c khang sinh khric: metronidazole, vancomycin vd rifaximin c6 hiQu
qu6 vd durg n4p t5t hon neomycin.

c. Probiotics

Tric dpng kich thich

ngmg ktit

amoniac, trong suy gan c6p hiQu qud

giim

amoniac cfa L-ornithine L-aspartate do kich thich t6ng hqp glutamine co.

-

Li6u lugng: truydn tinh m4ch

l0-20g.

3. Phucrng ph6p h6

trq

gan

-

Trong bQnh suy gan m?n, vai trd

cta

phuong ph6p hO trg gan ae Oidu

tri

bQnh

nio

gan chi thich hqp

v6i

mQt s6

it

bQnh nhdn, duoc su dung phAn lon
d bQnh nhdn c6 dgt c6p

cta

suy gan man.

-

Lqc huy6t tuong khOng loqi b6 albumin, cho ph6p lo4i b6 c6c cnAt AEc

hda tan

vi

kh6ng hda tan trong nu6c giin

v6i

albumin trong m6u.

St

dgng c6c

phuong ph6p h6

trg

gan tti6u

trf

bQnh n6o gan v6n cdn trong

giai

do4n thyc
nghiQm.

</div>
<span class='text_page_counter'>(82)</span><div class='page_container' data-page=82>

-78-4. Gh6p gan

Xt[t

nien h6n mO gan d bQnh nh6n xo gan ld ytiu tO t5 ticn luqng x6u vd

cin

nhanh ch6ng tlanh gi6 bQnh nh6n cho gh6p gan. Lya chgn gh6p gan kh6ng
n6n

th*c

hiQn trong giai doqn cAp cira h6n m€ gan, chd cho d6n khi y6u t6 thric

dAy dugc di6u chinh.

Tni [Qu tham

khio

1.

Javier Vaquero, Andres

T.

Blei, Roger F. Butterworth (2009): "Central

nervous system

and

pulmonary

complicationS

of

end-stage

liver

disease"; chapter 91, page 2327

-

Z335;Textbook

of

Gastroenterologt,
Fifth Edition Edited by Tadataka Yamada. ISBN: 978-1-405-16911-0

2.

Andres

T. Blei,

Juan Co'rdoba (2001): "Hepatic Encephaloparhy' ACG
guidelines

<sub>for </sub>

HE, lhe American Joumal of gastroenterolory

Vol'

96' No'

3.

Peter Ferenci,

MD

of

a randomized study'''

-l

Hepatol2004;41:38.

</div>
<span class='text_page_counter'>(83)</span><div class='page_container' data-page=83>

-79-UNG

THTIBITU

u6

rT sAo

cAN

I. DAr cr.IoNG

Ung thu bi6u m6 ttl bdo gan cdn ggi ld ung thu gan nguy6n ph6t

<sub>- </sub>

ld m6t
trong n6m lo4i ung thu ph6 bii5n nh6t tr6n th6 gi6i.

Tf

16 m6c b€nh kh6c nhau

gitta c6c vDng, trong d6 <sub>cao nh6t ld Ch6u Phi, Trung Qu6c vd D6ng Nam </sub>6.

Nam m6c nhi6u hon nn

<sub>Q- </sub>

61an). TuOi thuong gap

<sub>tu </sub>

<sub>- </sub>

50.

d ViQt Nam,
d6y ld loai ung thu dung hang thu 3. Udc tinh m5i ni.m c6 tr6n 10.000 trudng

hqp

mic

m6i,

tf

le Nam g6p krhoang 4 lan

Nf,

d c6c tinh phia Nam cao hon
phia B6c.

Viet

-

AflatoxinBl

(AFB1)

-

Xo

gan: tta sii ung thu t6 bdo gan ph6t tri6n tr6n ndin gan xo (ChAu 6:

<sub>-90%). </sub>

Xo

gan cang neng thi

khi

ning ung thu gan ciurg cao.

-

MQt sil y6u t6 kh6c: dang tlugc xem x6t d6 ld: gan nhi6m m0, b6o phi,
d6i

dulng,

thu6c H

vi

thu0c

tnffi

thai.

rrr.

TRrpu

cHrNc

LAM

SANG

vA c4N

r,Awr

sAxc

Tripu

chring lAm sdrng

a. Ccr

ning

-

Giai

doan kh6ng c6

tri6u

ch(mg l6m sang 16 rQt: ph6n

lon

c6c b6nh
nhdn dugc ph6t hiQn mQt c6ch

tinh

cd. MQt si5 benh nhan cO kn5i u gan khri

l6n:

4 -5cm cfrng kh6ng c6 tri€u chimg rd rQt

hoic

d6 lAm

vdi

c6c tri0u chimg

cria bQnh gan man tinh nhu: m6t m6i, ch6n 6n, dAy bung, kh6 tiOu, dau nhg ha
sudn phdi, stit nhq, tlau xuong kh6p.

-

Giai do4n c6 triQu chimg: khi c6 triQu chrlng l6m sirrg, bQnh thuong da

d giai tloan mudn. C6c triQu ch&ng

thulng

g[p

li:

-

GAy srit nhanh: c6 th6 trong thdi gian ngin

giim

t6i 4 -5kg.

-

Dau h4

suln

ph6i: ban ttAu dau it, thudng

li

dau 6m

i

h4 sudn phdi, vC

sau c6 th6 dau r6t mpnh su5t ngdy d€m, mQt si5 c6 th6 c6 con dau

dt

dQi do v6
nhdn ung thu.

-

MQt m6i, 6n k6m, bpng day tru&ng.
b. ThFc th6

</div>
<span class='text_page_counter'>(84)</span><div class='page_container' data-page=84>

-80--

Gan

to,

thudng khdng ddu, m4t c6 thri nh8n ho4c l6n nh6n, m4t <tQ

chhc ctug , 6n c6 th6 dau, mQt s6 truong hqp nghe thdy c6 tii5ng th6i'

-

Cric triQu chimg di kdm: c6 truong, tuan hoen bang h0,

ving

da, xuSt
huy6t duoi da.

2. C$n

lim

sirng

-

Alpha-fetoprotein (oFP): ltr mQt protein bdo thai' d ngudi binh thuong

<

t.i

trong gan c6 th6

h

gi6m 6m, t6ng 6m hay h6n hqp. C6 the ph6i hqp

vdi

si6u 6m Doppler

ho[c

Doppler mAu d6 tSng th€m hiQu

qui

cria chAn ttorin.

-

Chup c6t

iop

vi

tinh

(CT)

vd

cQng hu&ng

tii

(MRI):

cho ph6p ph6t

hiQn c6c kht5i ung thu bd. Dac di6m tr€n CT vd

MRI

cia

cec kh5i u gan > 2cm

ngAm thu6c r6t mantr 0 thi dQng m4ch vd tho6t thu6c nhanh d thi tinh m4ch'

-

Chup cirn quang tlQng m4ch gan (Angiography): thudng dugc su dqng
d6 chAn aoan Uroi u gun b6, cha" do6n ph6n biQt vn k6t hqp

v6i

diAu

tri

nirt
m4ch h6a ch6t.

-

Sinh

thiiit

gan c6 huong d6n

cta:

si6u dm, CT ho{c

MRI

bang kim b6

hoic

kim l6n.

IV. CHANDOAN

gitp

cho chAn do6n, ti6n lugng vd di6u

tri

c6c bQnh

nhin

nghi ngd

ung thu gan cAn c6 th€m c6c th6ng tin:

Chup XQ ph6i thlng ho4c CT <sub>PhOi.</sub>
1. ChAn do6n x6c

tlinh

-

C6 bang chimg v6 m6 bQnh hqc hoac t6 bdo hgc.

-

U gan + o,FP > 400ng + nhi6m HBV ho6c HCV.

-

N6u kitim tra tr6n si6u Am th6Y:

+

Nrlu c6 u <

lcm

o

U t6ng kich thudc: thyc hiQn theo quy trinh vdi c6c u

>

lcm'

</div>
<span class='text_page_counter'>(85)</span><div class='page_container' data-page=85>

-81-o

U giir nguy6n kich thu6c: sau 18 thriLng ki6m tra thudng quy: 6 thring

-l2thand

I

\il.

+

D6i

vdi u gan

I

-2 cm: chAn dorln x6c ttinh khi:

o

Hwdmg d.6n chdn itodn ung

tht

gan (HCC):

2. Ch6n tlo6n ph6n biQt

Di

cin

gan
3. ChAn tlodn giai dogn

C6 nhiAu ph6n 1o4i

nhim

chAn dorin giai tlo4n cria ung thu gan nguy6n
ph6t vd tr6n co sd d6 rti| dA xu6t bign phrip di6u

tri

thich hqp. Cric phAn lopi

duo. c coi ld ttit hiQn nay ph6i hQi dri 3 yiiu t5:

-

Kich thudc u

-

Chrlc

ning

gan: dugc drlnh giri theo diiSm Child-Pugh

T6n thuolg tr6n si6u im

Ul-2cm

U>2cm

U<lcm

Ki6m tra si6u 6m 3

th{ne/l dn

(trotrg 18 thdng)

Sau t!6:6 thdng/ I lin

CT' MRJ =>

- ce 2 di6n htnh = HCC

- I tti6n hinh + a['P > 200 ng/mt =
HCC

CT, MRI =>

- I di6n hhh = HCC

- (tFP > 400 ng/ml = HCC

- Xh6ng rli6n hlnh: sinh

thi6t

</div>
<span class='text_page_counter'>(86)</span><div class='page_container' data-page=86>

-82--

Tod.n tr4ng cta bqnh nh6n

)

Theo tt6 phAn logi Barcelona kn6 ph6 bi6n

v6i

clc

giai do4n sau:

+

Giai doan r6t sdm (cdn gqi ld giai do4n O): th6 tr4ng t6t, Child- Pugh
A, u 1 htrtii < 2cm, chua x6m l6n vdo mpch vir chua di

cin'

+

Giai do4n s6m (cdn gqi

li

giai doqnA): th6 tr4ng t6t, u < 3 kh6i, kich
thu6c < 3cm, Child-Pugh A-B, chua xdm lAn m4ch ho[c chua di

cin'

vi

xdm 16n
mach.

v.

DrturRI

Tty

theo giai do4n cta ung thu d6 lpa chon ciic phuong ph6p di6u

c6t b6 khSi ung

thu

-

n6t t5t

eOi vOi c6c u

d

giai do4n s6m

ho[c

khu

hir

6 mQt thiry

ho[c

'n*

tlo'#iifi*

,n

u.

vdo kich thu6c, s5 luqng, ss x6m En mach vd mrlc

dQ ric cta u.

-

Ti

le triLi phrit: 50% - sau 3 ndm,1joh - sau 5

nim.

2. Gh6p gan

-' iien

chua ph6 biiSn vi nguiin gan d6 thay kh6ng nhi€u, gi6 thanh

dit'

-

Benh nhdn

thulng

tlugc chgn theo

ti€u

chu6n

Milan -

niSu 1

u

kich
thu6c < 5 cm. Nl5u nhiAu thi s6 luong < 3 vd kh6ng c6 u

nio

>3 cm'

-

Benh nhdn n6n ttugc nut mach h6a chAt

hoic

ph6

hny

ttr6i

u

Uang

s6ng cao t6n tru6c.

Ph{

hfry

u

Phi

hf,y t<tr5i u

lfng

ti6m cdn ho4c nhiQt cfia s6ng cao tAn

-

Ld phuong ph6p kh6 an toan

vi

hiQu qua'

+

<2

cm: ti6m c6n

vi

tt6t s6ng cao t6n c6 hiQu qu6 nhu nhau'

+

>

2cm: s6ng cao tdn

tiit

hon hnn so v6i ti€m c6n'

</div>
<span class='text_page_counter'>(87)</span><div class='page_container' data-page=87>

-83--

Cisplatin.

c. T6c mgch ph6ng xg

v6i

Yttrium-90:

-

Dua c6c

vi

hat Yttrium-90 ph6t xa v6i

tdu

cao vdo kh6i u.

-

C6c hqt c6 dudng kinh trung binh

tt

<sub>- </sub>

30 nm ve ph6t tia p.

-

Thdi gian brin hriy: 60 phrit - 2 gid.

-

Li6u ph6ng x4

t{p

trung

vio

th6 tich cria u, it t6n h4i tt6n gan kich n6n
hiQu qud cao.

d.

Nft

mSch

vrfi

cic

thu6c

<sub>Qng </sub>

h4t

(eluting beads): hi€n dang dugc img
dgng budc dAu.

Li6u

ph6p

phin

tfr

-

Giai <lo4n muQn: Sorafenib.

-

Giai do4n cuiii: didu tr! triQu chring.

</div>
<span class='text_page_counter'>(88)</span><div class='page_container' data-page=88>

-84-Tni

liQu

tham

kh6o

1. Sherman

M,

Bruix

J,

Porayko

M,

et

a1(2012). Screening for
hepatocellular carcinomar the rationale for the American Association for
the Study of Liver Diseases recommendations.Hepatology;56:793-7 96.

2. Bruix J,

Sherman

M,

Llovet JM, et

aJ(2001). Clinical management

of

hepatocellular carcinoma. Conclusions

of

theBarcelona-200O EASL
Conference. European Association for the Study of the Liver. J Hepatol
2001;35:421430.

3. Poon

D,

Anderson

BO,

Chen

LT, et

al(2009).

Management

of

hepatocellular carcinoma

in

Asia: consensus statement from the Asian

Oncology Summit 2009. Larcet Oncol; 1 0: 1 1 I 1

-l

1 I 8.

4.

El-Serag

HB,

Siegel

AB,

Davila

JA,

et

al(2006).

Treatment and

outcomes

of

treating

of

hepatocellular carcinoma among Medicare
recipients

in

the United

States:

a

populationbased study.

J

Hepatol
2006;44:158-166.

5.

El-Serag

HB,

Kanwal

F(2013). Alpha-fetoprotein

in

hepatocellular
carcinoma surveillance: mend

it

but

not

end

it.

Clin

Gastroenterol
Hepatol;1

1:441443.

</div>
<span class='text_page_counter'>(89)</span><div class='page_container' data-page=89>

-85-CHAN

DoAN

vA

DITU TRI

SAN

LA

GAN

s0

y rE

<sub>HudNc </sub>

oAN cr-rAN DoAN vA

DrE

rrEu

u6a

-86-I. D?I

CTIONG

BQnh san 16 gan gdm hai lo4i: srin 16 gan nh6 vd srln ki gan l&n

Srin 16 gan l6n s6ng vd g6y bQnh trong nhu m6 gan, con s6n Li gan nh6
chi khu trri trong

dulng

m4t

Srin 16 gan lon (SLGL) c6 hai

loii:

Fasciola hepattca hay g4p d cdc nu6c

ChAu Au

vd

Fasciola gigantlca glp

d

c6c nu6c Chdu A trong d6 c6 ViQt Nam
O

Viet

Nam, bQnh san 16 gan

lon

d6 dugc ph6t hiQn & hAu htit crlc tinh
thanh

vi

nhiCu bQnh nh6n dugc ch6n dorin

II.

CHU KJ,

PHAT TRI6N

CfrA SAN

LA

GAN

LdN

Srin 16 gan lon c6 kich thudc 30

x

10-l2mm. Srin 16 gan lon

ky

sinh chri

yiiu d c6c dQng

vit

nhu tr6u bd, ch6, mdo. O ngudi, siin

kj

sinh trong nhu mO

gan, trudng hqp b6t thudng srin c6 thti

kf

sinh trong co, du6i da.. San truong
thanh de

trimg

theo dudng

mflt

xu6ng ruQt vA

ra

ngodi theo

phin vd

m6i
trudng. Tnmg srin 16 gan lon c6 kich thudc 140 x 80pm, Tnmg xu6ng nudc, nd
ra 5u trtrng l6ng vd

ky

si.,h trong 5c <sub>0d </sub>

vit

chri trung gian), ph6t tri6n thdnh 6u

trirng du6i, 6u trung du6i

rdi

kh6i

vi

brim vdo c6c lo4i rau thriy sinh dudi
nudc nhu rau ng6, rau rut vd rau

cii

t4o nang tnmg ho[c boi tg do ffong nu6c.
Ngudi ho4c tr6u bd 6n ph6i thyc v4t

thty

sinh ho[c u6ng nudc 16 c6 Au trung sE

bi

nhiem srin 16 gan 16n.

Au

trirng sau

khi

vdo da ddy, tri

trirrg

c6c v6 nang bi
ph6 hny

gi6i

ph6ng ra 6u trung, Au

trtng

ndy xuy€n qua thdnh t6 trang vdo 6

bpng vd dlin gan cu tru d nhu m6 gan vir gdy bQnh 0 nhu m6 gan bAng cric dQc

t6 chung

ti€t

ra. Ddy ld giai do4n kich thich co th6 phan ring mi6n dich mqnh
mAt. rcrang thii xu6t hiQn trong mriu 2 tu6n sau

khi

siin x6m nhflp, sg tdn t4i
Lhring thC trong m6u

li

co sd cria c6c phan ling mi6n dich girip cho chAn do5n
bQnh. C6c khring th€ trong giai tlo4n ndy

cht

yi5u ld IgG.

Srin

li

gan

lon

ky

sinh ch0 ytSu

d

m6 gan, nhrmg trong giai tlo4n xdm
nh4p san c6 th6

di

chuy6n l4c ch6 vd g6y c6c tdn thuong

b

c6c co quan kh6c
nhu thdnh ruQt, thdnh da dny, thd,nh br,rng, d6i khi c6 trong bao khop (l4c ch5).

Sau giai do4n xdm nhflp vno nhu mO gan

tt

2-3 thang, san xAm nhflp viro
dudng mflt truong thenh vd tt6

trmg.

T4i tIAy s6n truong thanh c6 AC

fy

si*r

gdy bQnh trong nhidu

nim

(c6 thi5

t6i

10 ndm/ n6u kh6ng dugc ph6t hiQn vir diAu

trf. T4i dudng

m{t:

s6n gAy t6n thu<rng biiSu m6 eludng mQt,thc mflt, vi€m vd

xo

ho6 ttudng mflt thrl ph6t, c6 th6 g6y ung thu bitiu m6

dulng

mit

ho{c vi6m tpy

cap.

</div>
<span class='text_page_counter'>(90)</span><div class='page_container' data-page=90>

C6c triQu chung lAm sdrng cria benh do srin

ki

gan

lon

gAy n6n

thulng

kh6ng dac hiQu kh6ng rAm r0 nhu cric lo4i iry xe gando amip

hoic

vi

khuAn,

tty

thuQc vdo giai do4n ph6t tri6n

vi

vi tri

srin

ky

sinh, cfrng nhu s6 luqng 5u

trung srin x6m nhdp viro co th6 ngudi vd phan img cria co th6.

Ldm

sing

-

TriQu chring todn th6n:

+

MCt m6i, bi6ng 6n,

Cric bi6u hi6n di rlng da v6i cilc ntit s6n

cht

yiiu d dDi, mdng

vi

lung

-

Cric triQu chimg ti6u ho6:

li

c6c triQu ch(rng thuong gflp nh5t.

+

Dau bung: thudng c6 bitiu hiQn dau

vtng

h4 sudn

phii.

Tinh ch6t dau

kh6ng d4c hiQu, c6 thtl rlau 6m i, ddi khi

df

dQi, cflng c6 trudng hqp kh6ng dau

bung.

+

BCnh nh6n c6

cim

giitc dAy bpng kh6 ti€u, r5i lo4n ti6u ho6, bu6n n6n.

sinh l?c
ch5 nhu kh6p

"r,

ho{c c6c co quan khilc.

2. C$n

lim

sirng

-

X6t nghiQm c6ng thric m6u: s5 lugng bpch cAu trong mriu ngo4i

vi

th6 tang hoflc binh thuong nhung

t9

lQ bech cAu 6i toan tAng cao

tli

90o/o cdc
trucrng hqp

-

Chan tloan hinh anh: Si6u Am cho th5y hinh anh t6n thuong gan ld
nhirng 6 gidrn Am kh6ng ddng nhAt tap trung

thinh

d6m thudng s6t bao gan
hoflc c6 th6 thAy hinh anh tu dich dudi bao gan.

</div>
<span class='text_page_counter'>(91)</span><div class='page_container' data-page=91>

--

Trong mQt s5

trulng

hqp cAn thitlt c6 th€ chpp cat lop vi tinh gan cflng
cho th6y c6c 6 gi6m 6m t4p trung thdnh dri'rn c6 th6 th6y hinh 6nh giSn

dulng

m$t vd ddy thanh

tlulng

mQt cgc bQ khi s6n chui vdo iluorlg m?t.

-

Ph6t hien knring th6 khring san Li gan lon

(k!

thuat ELISA) lir phucrng

ph6p cho d0 nhey vd iIQ d{c hiQu cao, sau khi vdo co thti 2 tuAn co th,, dA bAt
ttAu sinh khrlng the ch0 ytiu IgG

vi

IgE, vir cric khrlng th6 ndy cdn ttin

t4i

I

n6m

sau khi kh6i benh m6i htit.

-

X6tnghiQmph6n:

+

Tim tnmg

srln 16 gan l6n trong

phin

hay dich m4t chi

khi

srin

di

vio

tlulng

mrit tl€

tnmg

(tuy nhi6n

tj

lQ phrit hiQn dugc trung srin rAt th5p vd cdn
phq thuQc vdo phuong ph6p xdt nghipm). C6n x6t nghiPm phdn trong 3 ngdy
li6n tgc.

+

Cht

ChAn dorin mi6n dich hgc: ELISA ph6t hi€n c6 kh6ng th6 khang s6n Li
gan lcm trong huyt5t thanh hiQu gi6

>

1l32OO.

+

Xdt nghiCm phdn ho4c dich mflt tim thdy fftmgsrln

ll

gan 16n.

4. ChAn tlo6n phAn biQt

-

Ap xe gan do c6c loei

kf

sinh trung kh6c (amip, giun

di4

toxocara...)
hoflc do

vi

khu6n (rip xe dudng m4t...) c6 thiS chpp CT 0 bpng vir chgc hrit 6 6p

-

Ung

thu

gan

(u

gan) benh nhan c6n chgp CT 6 bqng, AFP, n6u cAn

thi6t c6 thri chqc

hft

lAm ti5 bdo hgc ho4c sinh thiiit gan.

IV. BIfN

CHTJNG

Khi

c6c 6 ,ip xe gan do siin ki gan l6n kh6ng tlugc didu

trl

kip thdi c6 thii

, i.

gAy vd vdo mang ph6i vir mirng bgng.

v.

DrEu

rRI

1. Di6u

tri

tl4c hiQu

Thu6c

tlugc

lya

chgn

ae

aleu

tri

ttAc hiQu bpnh san

ll

gan

lon

ld
Triclabendazole2 50mg,

</div>
<span class='text_page_counter'>(92)</span><div class='page_container' data-page=92>

-88--

Li6u luong:

mg&g

cin

nqng. Li€u duy nh6t. U6ng

v6i

nu6c dun
s6i di5 nguQi. U6ng sau khi

in

no.

-

Ch6ng chi dinh: ngudi dang bibenh c6p tinh kh6c; phu nir c6 thai;phq
nir tlang cho con bri; ngudi c6 tidn sri m6n cdm

v6i

thu6c ho{c mQt trong c6c

thanh ph6n cta thu6c; ngudi dang van hanh m6y m6c,

tiu

xe; ngudi bQnh trong
giai doan c6p cria c6c bgnh m4n tinh vri gan, th?n, tim mach. . .

-

Tric dgng kh6ng mong mu6n cria thu6c: ngay sau u6ng thutic c6 th6

gip

cictriOu

chimg:

Dau bqng virng h4

suln

-

Su dqng khang sinh n6u c6 bQi nhi5m.

-

Vdi

c6c trudng hqp c6 6 ap xe gan kich thu6c lon tr6n 5 cm md diAu

tribing

thu5c theo huong d6n kh6ng c6 hi€u qua, c6 th€ phtii hqp v6i chqc hrit
6 6p *e

holc

d6n ltru.

3. Theo d6i vh al6nh gi6 k5t qun

sau 3-6 thang tham

tri

I

ndm mdi htit.

kh6ng gi6m,

c6

thti

tlidu

tri

bene
Triclabendazole lAn

thri

2 v6i li6u

2)mglkg

cin

n4ng, chia

2

l6n u6ng crich
nhau 12 <Itin 24 gid.

vr.

PHdNG BpNH

-

ulu

ve slnn an uong

</div>
<span class='text_page_counter'>(93)</span><div class='page_container' data-page=93>

-89-+

Kh6ng

nn s6ng c6c

loai

rau ngc

dudi

nudc

hoic

tiet

trung sach sE

trudc khi 6n.

+

Kh6ng nn s6ng cric lo4i dQng

vflt

stlng dudi nu6c (nhu

g6i

c6) ho4c

tiQt

tdng

sach sE tru6c khi

in.

+

Kh6ngu6ngnu6cld.

-

Ngudi

nghi ngd nhi6m San 16 gan lon ph6i d6n co sd khrim chta bQnh

d6 ttuqc chAn dorin vd didu tr! klp thdi.

-

Truydn thdng, gi6o duc srlc kho6

-

Chri tlQng ph6t hien

vi

diAu

tri

sdm bQnh S5n ki gan

lm

t4i

vtng

lm

hanh benh.

Tii

liQu

tham

kh6o

1. Clinical

diagnosis

and

treatment

in

an

outbreak

of

Fasciola gigantic
infection in Yunnan Province (2012). Zhongguo Ji Sheng Chong Xue Yu Ji
Sheng Chong

BingZaZhi.

Dec 30;30(6):455-9.

2.

Chitsulo, Montresor, and Savioli (2001). New opportunities for the control
of fascioliasis. Bulletin of the

l{orld

Health Organization.

16May.

3.

Hudng d6n chAn do6n vd tti6u

tri

bQnh s6n

ki

gan l6n d ngudi lon (2006).

Y

t6.

4.

Triclabendazole and Fascioliasis (2001).

A

new drug

to

combat an age old
disease. I4/HO

<sub>fact </sub>

sheel.

N

I 91 . 1998, I 1 May.

</div>
<span class='text_page_counter'>(94)</span><div class='page_container' data-page=94>

-90-VANGDA

DAI

CLIOT'{G

Vang da ld tinh tr4ng nhu5m mdu virng d da vir k6t m4c m6t do bilirubin
tang vuqt qu6 gidi h4n binh thudng trong miiu,

Virrg

Ii

mQt triQu chfng g4p

trong nhiAu bQnh kh6c nhau.

Binh thuong bilirubine toan phan

(Bili

TP) trong m6u Id 0.8- 1.2mgldl'
trong d6

bilirubin

gian tit5p

(bili

GT)

h

0.6- 0.8 mg/dl vd bilirubine

trgc

tiep

(bili

TT) ld 0.2- 0.4 mg/dl .

VAn dC quan trgng ld x6c

dlnh

nguy6n nh6n gdy vdng da,

tir

d6 m6i c6
k6 hoach di€u

tri

hiQu qu6.

II. CHANDOAN

1. ChAn do6n xdc dinh virng da
a. TriQu chrimg

lim

sirng

-

Vang ctng m4c m6t,

ni6-

mpc du6i ludi, vdng da.

-

Nu6c ti6u miru vang s6m.

-

Khi

bilirubin tdng qu6 cao c6 th6 xu6t men triQu

chtug:

ngrta,

n6n,
nhrlc ddu, dau co kh6p,

rlii

1o4n ti6u h6a,

li

bi.

-

C6c triQu chimg kh6c tuy thuQc nguy€n nhdn g6y virng da:

ting

lyc

tinh m4ch

cta,

gan to, tui mflt

to...

b. TriQu chring c$n l0m

sing:

Bilirubin m6u t5ng cao

-

Vang da xu6t hiQn 16 khi

bili

TP > 2.5m9/dl

-

Ving

da du6i l6m sang khi

bili

TP:

2'2.5

mg/dl

c. Ti6u chuAn ch6n

do{n

Bilirubin

TP mriu

ting

cao >7,2mg.ldl ( >19 mmoVl)

2. ChAn do6n phAn biQt

Vang da

do uiing

Quinacrin:

chi

virng

d

da, ni6m m4c kh6ng viurg'
bilirubin m6u binh thudng.

3. ChAn dorin nguy6n

nhin

a. Vdng da

ri

mft

-

Ldm slurg: virng da d4m, phdn c6 thti b4c mdLu, nu6c tiiSu sdm mdu, gan

to, tui m4t to.

-

CQn 16m sirng:

+

Xn

m6u:

Bilirubin

m6u

ting

chri y6u lo4i tr.uc

tiiip,

c6 thd kdm theo

Lipid,

cholesterol, phosphatase

kidm

tang.

Ty

lQ prothrombin gi6m, nghiQm
ph6p Koller(+).

</div>
<span class='text_page_counter'>(95)</span><div class='page_container' data-page=95>

-91-+

Sieu am: dudng mQt gidn, tui mflt to.

+

CT

scanner: dudng

m4t

gi6n, ngodi

ra

cdn c6 th6 th6y s6i

miq

lop vi tinh.

+

Do chdn 6p ttr ngodi vdo: H4ch cuiing gan do cric t4ng trong 6 bung bi
ung thu di cdn d6n hach.Chdn doan dga vdo tri€u chung co quan cO ktr6i u ti6n

phii,

citc dAu 6n ung

thu,

nhSt

h

dua vdo sinh

ttt6t

ldm m6 b€nh.

+

Ung

thu

duong mdt

trong

gan: Vang da thudmg

tu

tt

tdng ch4m,

thulng

t<t5t trqp

vdi

mQt s6 Oi tat bAm sinh iludng m4t nhu nang 6ng mQt

cht

ho{c vi6m

xo

dudng mdt nguy6n phat. Cnan tloan dga vdo si€m dm vd chpp

dulng

mflt nguoc ddng c6 hinh 6nh xdm chi6m

cta

kh5i u trong c6c 6ng mpt
trong gan.

+

Do

s6i

tlulng

mflt: Benh nhan c6 tidn sri s6i

mft

ho[c

giun chui 5ng
mflt. BQnh khdi ph5t voi tam chimg Charcot: Gan to,tui m4t to, dau. Si6u 6m vd
chgp dudng mAt nguoc dong c6 hinh anh soi

nim

trong

tlulng

mat nh6t la

ving

co oddi

vi

b6ng vater.

+

Do vi€m

dulng

mQt m4n tinh g6y xo hgp co oddi, sau ph6u thuQt gdy
vi6m dinh dudng mQt,vi6m tuy m?n, ho4c mQt sO Uenn it g5p kh6c: lao gan, s6n
16 gan, nang gan, sarcoid.ChAn do6n dua vdo

tidn

su vd c6c x6t nghi€m d6c

hi9u.

b. Virng da do t6n thucrng t5

bio

gan

-

Vi6m gan c6p do virut: BEnh ti6n tri6n qua 3 giai doqn nhu: giai tloan
tru6c

ving

da v6i ciic bi6u hiQn gi6ng crim; giai do4n vang da v6i cilc bi6u hiQn

vdng da 16, phdn b4c miru, gan hoi to kh6ng tlau, l6ch hoi to, men transaminase

ting

cao,

bilirubin

tbng cit tr.uc

tiilp

vd girin ti6p. ChAn dorin x6c dlnh dya vdo

truyit

ttrantr trqc.

-

Vi€m gan cAp do rugu: BQnh canh nhi6m dQc ruou, s6t khoang 38 0C,
b4ch cAu vd b4ch cAu trung

tinh

ting

cao, men transaminase

tlng

cao nh6t ld

</div>
<span class='text_page_counter'>(96)</span><div class='page_container' data-page=96>

-92-khi

ALT/AST

16n hon 2

thl

rdt gqi y dec biet khi gamma GT l6n hon 400tI/1,
bilirubin

t[ng

cA tryc ti6p vd gi6n ti6p.

-

Vi€m gan

do

thu6c:

C6 ti€n

su

vta

mdi

dung c6c thu6c

nhu
paracetamol, rifamicin vd

INH, MTU,

PTU... c6 tha: kdm cric bi6u hiQn kh6c

;.. ). , I

nnu ngua, nol me oay, sot.

-

Vi€m gan

tq

mi6n: Bi€u hiQn l6m sdng c6

th6

kh6ng c6 triQu chring,

bQnh ph6t hi6n tinh cd ho4c xuAt hipn triQu chring nqng c6p tinh, chdn doan dya
vdo c6c ch6t

chi

tti6m

trong huyiit

thanh miSn dich thudng hiQn diQn nhu:

ANA:

Khang th6 kh6ng nhAn;

HLA:

Khring nguy€n b4ch cdu ngudi,

LKM:

microsom ganlthan; SLA: Khring nguy€n gan hda tan; SMA:

fhang

the khang
co tron. Tuy nhi6n c6c dAu 6n trdn kh6ng c6 gi6

tr!

d4c hiQu. BQnh thuong tdn
tai cung vdi c6c r5i loan tu mi6n khric kdm theo.

Vi

vQy dd chAn do6n chinh x6c

cdn cAn ph6i lo4i tru vi6m gan do c6c nguy6n nh6n khrlc.

-

Vi€m

gan trong bQnh chuy6n h6a Wilson:

h

benh

di

truy6n l4n tr6n
nhiSm sac th€ thuong, tt4c tnmg

bdi

tich lfly

d6ng trong co th6

vi

c6c b6t
thudng li0n qua dtin gan

vi

thdn

kinh.

TriQu chung ldm sirng: vi6m gan, d6n

dtin

oan chuc

da, tlau bpng vd bu6n n6n, kdm theo c6c dAu hi€u lAm sdng do r6i
n5ng thdn kinh run tay, di chuy6n chflm, kh6ng dimg dugc, kh6 ph6t
Am, kh6 nu5t, dau dAu, D6ng c6 th€ tich

tp

& m6t

v6i

d{c

di6m ttflc

tnmg

li

gi6c mac m6t mdng mdu xanh ndu. C{n l6m sd.ng: X€t nghiQm mriu tlli eto hdm
lugng cemloplasmin thAy gi6m, luqng ddng trong nudc ti6u tSng qu6 100 pgld,
Sinh thi6t gan d6 x6c dinh hdm luqng d6ng

lir

mQt trong nhirng x6t nghiQm
nh4y vir chinh xiic dC chen ilo6n x6c dinh nguoi m6c bQnh Wilson.

-

Xo

gan

mlt

ti6n ph6t. LAm sang c6 vang da tung dqt ngdy cang n4ng,
kdm theo s5t, gan to nhrmg

it

tlau, kh6ng c6 hQi chrlng nhi6m

trtng,

da c6 cdc
u vdng. Can lam sdng: Phosphattase kidm

ting,

GGT tdng,

IgM

teng, khdng th6
khang ty I4p th6 t[ng, ceruloplasmin t6ng.

Ving

da do tan

m{u

-

Lam sd,ng: da vang nh?t,

kin

d6o, thi6u mriu, s5t trong dgt tan m6u

cAp, 16ch to. C6 th€ dau nhrlc xuong, bitin dang xuong sQ, m{q xuong chi.

-

Can

lem

sdng: TEng

bilrubin girin

ti6p

ld

chri

ytiu,

nu6c

ti6u

c6
urobilinogen, c6 khi c6 truytit sic t5.

-

MQt

sii

x6t

nghigm

girip x6c dinh

nguydn nhdn

huy6t

trin:

Test
Coombs, tliQn

di

huyiit

sic

tti,

do

lucrng men

h6ng

cAu: G6PD, Pymvate

Kinase, do srlc b€n thAm th6u.

4. ChAn tlo6n bi5n chri'ng:

Bitin chring vang nhdn

nio:

tdng truong luc co, co gdng, co giat, s5t,

c6 thii d6n

tdi

tri vong hoflc di chimg n4ng nd.

</div>
<span class='text_page_counter'>(97)</span><div class='page_container' data-page=97>

-93-III.

DITU

TRI

1.

Nguy6n

tic

-

Ei€u

tri

theo nguydn nhdn virng da lir co b6n.

-

Di6u

tri

triQu chimg do bilirubin m6u t6ng cao.

2. Vdrng da t6c

mit

-

Nguy€n nhAn do benh

l),

khiii u: u

dAu

tgy, u

b6ng valter, ung thu
tlu&ng mQt trong gan:

+

<sub>Dit </sub>

stent iing m4t.

+

Dua veo th6 trpng benh nhan, ch6n doan giai tto4n bQnh, md bQnh hgc,
gen dQt bi6n c6 the bang phuong ph6p ngo4i khoa, tia xa, h6a ch6t, ligu ph6p

gen trring <lich.

+

Di6u

tri

h6

trg:

ndng cao srlc kh6e,

h6

trg

tlng

cudng mi6n d!ch:
Vitamin, Aslem.

-

Nguy€n nhdn do s6i:

+

D5i

v6i s6i tui m6t

o

Dtng

thuiic girip tan s6i, 6p dpng dt5i

vdi

s6i cholesterol

dudi

1,5cm,

Cit

tui mat bAng m6 md: 6p dpng trong tru&ng hqp m6 nQi soi th6t b4i
ho{c vi6m mri trii mflt.

,

<sub>^,(.</sub>

+

D6i

vdi s6i trong gan vd soi 6ng m4t chri:

o

L6y s6i qua nQi soi nguo. c ddng c6t co oddi, 6p dpng v6i s6i d iing mQt

chri, s6i nh6

du6i

1,5cm, phuong ph6p ndy girip tr6nh dugc ph6u thu{t.

o

T6n s6i ngoai coth6

bing

s6ng, 6p

dgngvdi

s6i to.

o

PhAu thu0t dii

6y

s6i.

+

Didu

tri

h5 tro

bing

3. Virng da do t6n thuong t5 biro gan

-

Khi

vang da

tpm:

+

Lsi

tiiSu: Rdu ng6, b6ng mE

d6,

kh6ngAldosteron 25-l00mg/ngdy

Nghi

ngoi t4i

giulng

trong

thdi

gian todn ph6t, sau tl6 v4n dQng nhq

nhang

+

Ch6 dO 6n:

Giiu

d4m, dudng, vitamin,

giim

md dQng vdt,

ting

cudng
rau

qui

tuoi,

sta

dQc

hoflc

ptrtii hqp

vdi

azathioprine

2

mglkglngay. Nl5u kh6ng tl6p

img

thi

dtng

liQu phrip

ric

ch6 mi6n dlch thay

th6:

Ch6t

ric

ch6

calcineurin
(Cyclosporin

A,

Tacrolimus), Ch6t

tc

ch6

,TOR

(Sirolimus), Corticosteroid

th6

h9 thu

2

(Budenoside, Deflazacort),

Thu6c kh6c

(Cyclophospham,
Methotrexate),

Tri

liQu kh6ng ric ch6 miSn dich (Acid ursodeoxycholie)' Gh6p

gan khi benh nhan

bivi6m

gan

ty

mi6n kh6ng d6p ung vdi b5t ky tlidu

trindo.

+

Vi€m gan trong

bQnh chuy€n

h6a

Wlson:

Thii

ddng

beng

D
penicillamin.

+

Xo

gan m4t ti6n

ph6t:

Acid

ursodeoxycholic

(UDCA): 12

-

mglkg/rgity,

chia ldm

2 l6n:

sring

ve t6i.

T6i

da

20

mglkglngdy.

Cp

th€:

ursolvan 200

mg

1 vidn/sring vd

2

vi6n/t6i. NiSu phi5i hqp

voi

cholestyramin
(Questran), thu6c sE bi giam t6c dpng do thutSc sE

gin

v6i cholesfyramin vd diro

ihai ra ngoei. O nhirng benh nhan c6 triQu chimg ngria, fi6u luqng cria thu5c b6t

dAu

ld

200 mg,

d6

t6ng aan

tdu.

C6c thu6c

irc

ch6 mi6n

dich:
Corticosteroid. Crlc thu5c ch6ng

xo

h6a: Colchicin:

Li6u

luqng: 0,6 mg

x

2
lAn/ngdy,

c6

th6

dung

k6o

dii.

C6c

thu5c kh6c:

Chlorabucil, Malotilat,
Thalidomid, Sylimarin, Bezafibrat.

Ving

da do huy5t t6n

Didu trihuyi5t trin ld v6n dd co

bin:

-

Truydn m6u:

Kh6ih6ng

cAuttmg dqt di5 huy6t caut6

>

10g%

-

Cht

l6ch

khi

lugng m6u truydn

>

2OO

-

250 mllkglndm, ho4c c6 d6u

hiQu

culng

16ch vd c6 chi dinh tr6n 5 tu6i.

</div>
<span class='text_page_counter'>(99)</span><div class='page_container' data-page=99>

-95--

Gi6m lugng S5t truytit thantr

bing

Desferroxamine ld phr?c hqp c6 rii

lpc cao

v6i sit,

ti6m b6p, ti6m dudi da, tinh mach, fidu 30

-

4}mgkglngdy

x

5-6 ngdy.

</div>
<span class='text_page_counter'>(100)</span><div class='page_container' data-page=100>

trtng

duong
mflt n4ng thudng nhiOm nhidu lo4i vi khuAn trong d6 c6 vi khuAn ky

khi'

-

Nhi6m trirng

dudng

mflt

t4i

cQng tlOng

hay gep

ldr

do

E'coli,
Klebsiella,vi Enterococcus. NhiSm trirng ducrng m$t t4i bQnh viQn

thulng

ld do
Staphylococcus aureus khring

Methicillin,

Enterococcus kh6ng vancomycin,

vd

Pseudomonas.

2. Cric y6u t5 ttru6n

ngh€n

dulng

mflt nhu: s6i

m{t,

giun chui

6ng m4t..

Gan to, mdm, ttau trlc khi kh6m

-

R6i loan ti6u h6a: chan 5n, r6i 1o4n phAn

-

c6

thiS c6 tui mQt to

</div>
<span class='text_page_counter'>(101)</span><div class='page_container' data-page=101>

-97--

Trudng hSp nang c6

s6c,

tinh

then chgm ch4m

<sub>, </sub>

b€nh nhdn c6 thd

bi6u hiQn

li

l6n.
2.

Cin

lim

sing

-

X6t nghiQm m6u:

+

Bitiu

hiQn vi6m nhiSm: b4ch cAu tdng, chri y6u ld b4ch cAu ita nhdn

trung

tinh;

m6u 6ng

tIng,

CRP t6ng, Pro Calcitonin t6ng.

+

U

mdt: tEng bilirubin,

cht

y6u ld bilirubin t4rc ti6p.

+

C6

thi5 bi6u hiQn suy gan, suy

th{n

trong trudng

hqp

nhi6m

tring

n+ng.

+

C6y m6u c6 thiS thAy vi khuAn donhi6m trung huy6t.

-

Chan doan hinh 6nh girip th6m dd hinh

th6i

cfrng nhu nguy6n nh6n

giy

tbc mflt: si6u am, C.T, MRI, nQi soi si6u Am

vi

nQi soi chpp m$t tgy ngugc
ddng (ERCP). Cho th6y c6 giSn

ttulng

m4t trong vd ngodi gan, c6 th6 th6y khi
trong <tudmg mQt, nguy€n nhdn g6y thc mQt. Ngdy nay, nQi soi chpp mat tqy
ngugc ddng

it

dtng

de ch6n tlorin, md

cht

y6u dtrng d,! iti€u

tri

nguyCn nh6n

^ .!

gay tac mat.

3. D6nh gi6

mfc

tIQ

ning

M[rc

tl

cria nhiSm

trt

tludn

t

To o

Gan:

chi s5 INR

>

1.5

khriurg sinh di€u

tri vi

khuAn

<sub>br </sub>

khi khi

c6 nhi6m trung
dudng m6t n4ng.

Mtlrc iI6

Nhe <sub>G)</sub> Trung binh

(II)

Nang

(IIf

Bi€u hiQn suy tang Kh6ng Kh6ng C6

E6p ung di6u

tri

ban

tI6u

C6 Kh6ng Kh0ng

</div>
<span class='text_page_counter'>(102)</span><div class='page_container' data-page=102>

-98--

N6u c6 t6c nghEn dudng m4t ph6i d6m bdo luu th6ng dudng m4t b6ng
d6n luu qua da, d?t stent qua chgp mat tqy ngugc ddng hopc ph6u thuQt'

2. Didu

tri

cg th6

f5t

ntr6t ln di6u

tri

theo kh6ng sinh d0, tuy nhi6n, trong

khi

chd

k6t

qui

kh6ng sinh d6 c6 th6 dicu

hi

theo kinh nghiQm.

Thdi

gian dung thu6c khring
sinh

tt

4-7 rtgiry.

Ntlu

do

cdu khuAn Gram duong ,thu: Enterococcus spp.,
Streptococcus dtng thu6c tdi thi6u 2 tuan.

NK

bQnh

viQn**

NK

cQng tl6ng

Ning**

Trung binh

Nhe
Mtfrc tIQ/

Nht6m KS

Piperacillin/
tazobactam

Piperacillin/tazob
actam
Piperacillin/tazobactam
Penicillin

Cefepime, ho[c

ceftazidime, ho[c

cefozopran + met
ronidazole*
Cefepime, ho[c

ceftazidime, hof,c

cefozopran + met
ronidazole*
Ceftriaxone, hoflc

cefotaxime, holc
cefepime, holc

cefozopran, hofc

ceftazidime + metronida

zole+

Cefoperazone/sulbactam
Ceftriaxone, hoAc

cefotaxime

t

metronidazole*
Cefoperazone/sulb
actam

Cephalosporin

Imipenem/cilasta
tin, meropenem,
doripenem,

ertapenem

Imipenem,/cilasta

tin, meropenem,
doripenem,
ertapenem
Imipenem/cilastatin,
meropenem, doripenem,
ertapenem
Carbapenem

Aztreonam + met
ronidazole*
Aztreonam + met

ronidazole*

Monobactam

Ciprofloxacin, or
levofloxacin, or

pazufloxacin

*

metronid
azole*

Moxifloxacin

Ciprofloxacin,
ho4c levofloxacin,

ho[c

pazufloxacin

t

me
tronidazole*

Moxifloxacin

Fluoroquinolon

</div>
<span class='text_page_counter'>(103)</span><div class='page_container' data-page=103>

-99-*.

<sub>Diiu </sub>

<sub>tri </sub><sub>phiii </sub><sub>hop metronidazole/ tinidazole </sub><sub>vd </sub><sub>clindamycin </sub><sub>c6 </sub>

<sub>tic </sub>

dung t6t v6i vi
khutin ky khi, dp d4ng trong trudng ho.p c6 niii mdt ru6t. Cefoperazone/sulbactam,

moxifloxacin vd carbapenem co tac dung voi vi khuiin ki khl

*x;

<sub>Vancomycin: </sub><sub>khuyin </sub><sub>cdo </sub>

<sub>diiu </sub>

<sub>tri </sub><sub>cho </sub><sub>bdnh </sub><sub>nhdn </sub><sub>nhiSm </sub><sub>khuiin </sub><sub>cQng </sub><sub>cting mtlc </sub>

,.: ,, :

<sub>^ </sub>

,

.-ndng hoSc nhidm khudn bAnh viAn do Enterococcus spp. Niu khdng Vancomycin cho

dttng linezolid hodc daptomycin

v.

DIIPHoNG

-

Ei6u

tri

s6i

m{t

vd nguy€n nhdn gdy

tic

nghCn duong met

-

TAy giun dinh

k,

tltii trudng hqp do giun.

Tii

liQu

tham

kh6o

1.

Joseph S. Solomkin, John E. Mazuski, Ellen J. Baron, Robert G. Sawyer,

Avery

B.

Nathens, Joseph

T. DiPiro,Timothy

Buchman,

E.

patchen
Dellinger, John Jemigan, Sherwood Gorbach, Anthony W. Chow, and John

Bartlett.

Guidelines

for

the

Selection

of

Anti-infective Agents

for

Complicated Intra-abdominal Infections. CID 2003:37 (15 October).

2. Atsushi

Tanaka, Tadahiro Takada,

Yoshifumi

Kawarada,

yuji

Nimura,

Masahiro

Yoshida,Fumihiko

Miura,

Masahiko

Hirota,

Keita

Wad4

Toshihiko Mayumi, Harumi

Gomi,Joseph

S. Solomkin,

Steven

M.
Strasberg, Henry

A.

Pitt, Jacques Belghiti, Eduardo de Santibanes, Robert

Padbury,

Miin-Fu

Chen,

Giulio Belli,

Chen-Guo Ker, Serafin C. Hilvano,
Sheung-Tat

<sub>Fan, and Kui-Hin Liau. </sub>

<sub>Antimicrobial </sub>

<sub>therapy </sub>

<sub>for </sub>

<sub>acute</sub>

cholangitis:

Tokyo

Guidelines.

J

Hepatobiliary pancreat

Surg

(2007)

l4:5947

3.

Massimo Sartelli.

A

focus on intra-abdominal infections.. World Joumal

of

Emergency Surgery 2010, 5:9.

4.

Harumi Gomi. TG13: Updated Tokyo Guidelines

for

the management

of

acute

cholangitis

and

cholecystitis.

Tokyo

Guidelines 2013.

J

Hepatobiliary
Pancreat Sci (2013) 20:1-7

</div>
<span class='text_page_counter'>(104)</span><div class='page_container' data-page=104>

100-BTNH

GANNHrtvruo

rn0uc

Do RLIqU

D+r

cUoNG

BQnh gan nhiSm md khOng do ruqu (Non alcoholic fatty liver disease

-NAFLD)

duqc dlnh nghia td tinh tr4ng

tich

lu!

m0 du6i d4ng triglycerid quri

mric 0 gan

(>

$

bdo gan).

NAFLD

chia ldm

2

nh6m chinh:

(l)gan

nhiSm
md khdng do ruou tton

thuin

(non-alcoholic fatty liver -

NAFL)

ho4c (2) vi6m
gan tho6i h6a m0 kh6ng do ruqu (non-alcoholic steatohepatitis -

NASI!,

d{c
tnmg bdi qu6 trinh tho6i ho6 t6 bdo gan, vi6m ti6u

thuj,c6

hof,c kh6ng kdm xo
ho6 quanh khoang cria, cu6i ctng c6 tn6 a6n d6n xo gan

vi

ung thu gan.

NAILD

la benh

lj

gan ph6 bi6n nh6t 0 c6c nudc c6ng nghiQp phuong

t6ry, v6i

tf

lQ m6c bQnh trong cQng d6ng liL20

<sub>- </sub>

<sub>40% [2], vn </sub>hiQn t4i dang

ting

I€n d c6c nu6c etang phrit triOn d phuong ddng.

NAFLD

vd d4c biQt ld NASH

. t. ,.^

mol

llen quan ro r9r

vdi

b6o phi (b6o bpng, b6o trung tdm),

r6i

loqn dung
nap glucose vd d6i th6o duong typ

2,rdilo4n

lipid m6u, tdng huyiit rip.

II. CHANEOAN

I

TriQu chri'ng lAm

sing

Gan nhiSm md don thu6n kh6ng gdy ra cdc triQu chung l6m sang, thuong
chi ph6t hiQn

tinh

cd. BQnh nh6n c6 th6 c6 c6c yiiu t6 nguy co (thira c6n, d6i
th6o duong, tSng m0 m6u, dirng

thutic...)

n€u 16 mQt sti

thuiic

amiodarone,
corticosteroids. D6i khi benh nhan c6 th6 th6y m€t m6i, 6n kh6ng ngon. Kh6m
l6m sdng c6 th6 c6 gan to, tuy nhi6n do thudng

gip

d benh nh6n b6o phi n6n
kh6 ph6t hiQn md

phii

x6c dinh bAng si6u Am. Gan to

tj'

thuin v6i

mric dQ
n4ng cta gan nhi6m m0.

O giai do4n n4ng, c6 th€ c6 c6c d6u hiQu cria b€nh gan man tinh nhu sao

mpch, gi6n m4ch ch6n chim

du6i

ho[c

c6c dAu hiQu chi di6m tnng 6p lyc

tinh

m4ch crla. Ciic nghi6n criu

d

chdu

A

cho th6y benh

cinh

bpnh gan ti6n
tri6n thuong

it g[p

hon, tuy nhi6n

tri

vong do xo gan mAt

bi

ve ung thu bi6u
m6 tri bdo gan cfing d6 dugc <sub>Chi </sub>nhan e NhAt Ban

vi

Han <sub>Qu6c [a].</sub>

2 Cin

lim

sing

a. ChAn tlo6n hinh

inh

Si6u

im:

gan to, nhu m6

ting

6m so

v6i

nhu mO thAn, mric dQ t6ng am

ti

le
thupn vdi mrlc dQ gan nhi6m md, cdc mpch m6u trong gan nhin k6m 16 hon

vi

c6 hiQn tugng suy giam tin hiQu 6m d c6c

vtng

gan d s6u.

Cit

lOp

vi tinh:

hinh anh

gitmt!

trgng lan tod nhu m6 gan, gan nhi6m md sE

tOi hon so

v6i

l6ch, c6c mach miiu vd dudng m4t.

</div>
<span class='text_page_counter'>(105)</span><div class='page_container' data-page=105>

-Ilinh

1: Gan ECHO tdng dm so voi
thdn vd cdc mach mdu nhin kdm 16.

Ilinh

2: Suy gidm tin hiQu ECHO d
cdc vitng gan d sdu hon

Ilinh

3:

CT gan nhidm md.

Trdi:

khi chua tiAm thuiic cdn quang,

t!

trpng gan
gidm hon so

vdi

ldch, cdc mgch mdu trong gan

rd

hon.

Phdi:

khi tiOm thu6c
cdn quang,

tjt

trgng

cfio

gan

tdng Mn, nhung

d m*c

d0 kdm hon ldch.

Khi

chhnh

<sub>Ech </sub>

>

20 don vi Hounsfield thi c6 thd chdn dodn gan nhidm md tuo'ng

-:,

,-dot dac

<sub>'Luu </sub>

hrcu.

y

lit

cdc biQn phdp chAn do6n hinh 6nh nhu si6u 6m vir CT kh6ng

gifp

phdn biet

NAIL

vd NASH.

b. C6c x6t nghiQm:

Khi

mfc

d0 nang cria

NAFLD

clurg cao, cdc thay c16i vA sinh h6a gap

<sub>vdi</sub>

ty

19 cang nhiAu. DAu

ti€n ld

ting

yGT,

le

GPT

vd

GOT,

vdi

rj

GOT/GPT

<

1 (trong vi6m gan do ruqu, GOT/GPT

>

1. Bi6n AOi ve sinh ho6

tf

le thu?n

vdi

mric ttQ nang cria bQnh). Luu

y

ld c6 10% benh nhen NASH kh6ng

ting

GOT cfing nhu GPT.

BQ Y TE - HUONG DAN CHAN DOAN VA DIEU TRI BENH TIEU

HOA

-IO2-:i nl

'...

qhx

\,

,#

fl<sub>I</sub>

ffi

trIq

t

{

,\,

.*dp klp"

f

*

h

'+"

</div>
<span class='text_page_counter'>(106)</span><div class='page_container' data-page=106>

Khi

ph6t hien tinh trpng gan nhi6m md tr6n si6u 6m, cAn

lim

th6m c6c

x6t nghiQm dC ph6t hiQn cdc bQnh

lyr6i

1o4n chuy6n ho6

nhu

gitm

dung npp

glucose ho{c clSi th6o

dulng,

vd.

rtii

1o4n lipid m6u.

Trudng hqrp NASH nflng d6n Otin xo gan sE c6 bi6u hien suy gi6m chric
nAng gan nhu

giim

albumin,

giim

fj'

16 prothrombin, t6ng

bilirubin... vit

cbc

bi6u hiqn cria

ting

5p lgc tinh mpch cria nhu 16ch to, cO truong, tuAn hodn bang
hQ bgng, gi6n tinh mpch thgc quan...

c. Sinh

thi5t

gan:

MO benh hgc ld ti6u chuAn

ving

c16 chAn do6n

NAFLD,

t14c biQt ld ch6n

doSn

NASH vd

danh

gi6 giai

clopn

xo

girip

ti6n

lugng.

Tuy

nhi6n cl6y ln
phucrng ph6p xdm nhpp, c6 nguy co tai bii5n

vi

thulng

clugc sri dpng tr6n 16m

sirng.

M6

benh hgc dya tr€n 2 thang diiim: (1) mric d6 ho4t ctQng cria NASH
dga tr6n

%

G

bdo gan tho6i ho6 m0, mric ctQ vi€m ti6u thuj, vd

t6

bio

gan
trucrng to dpng b6ng (balloon) vd(2)

mfc

clQ xo ho6.

Sinh thii5t gan kh6ng cAn chi ctinh cho c6c benh nhan tinh cd ph6t hiQn

r .i

gan nhi6m md tr6n si6u 6m, kh6ng c6 triQu chimg lAm sing

vi

c6c xdt nghiQm
men gan

binh

thudng. N€n sinh

thiiit

gan

<sub>o </sub>

c6c bgnh nhan

NAFLD

c6 hQi

chimg chuy6n ho6 hoflc c6 di6m

NAFLD

Fibrosis Score cao ho{c

c6

cdc benh

l!

earrkh6c kdm theo cAn phAn biQt.

Ilinh

inh

trdi:

cdc gipt md kich thu'6c l6n d gan nhi6m md (nhu\m HE)

<sub>t3l</sub>

inh

phdi:

thodi hoa md m*c d0 trung binh vd thay ddi vi€m chfi ydu 6 quanh

tTnh msch trung tdm d NASH (HE, 40x) <sub>[5J.</sub>
d.

Cic

phuong ph6p chAn tlo6n kh6ng xflm nh$p

GAn ddy, mQt si5 phuong ph6p khdng x6m nh$p dugc dua ra

nhim

d6nh

gi6 mric clQ vi6m vd xo ho6 gan

nhim

thay thti cho sinh thiiSt gan. C6c phucrng

ph6p dang dugc nghiOn cr?u img dUng d NAFLD bao gdm: dAnh gi6 mric dQ xo

BQ Y TE - HU6NG DAN CHAN DOAN VA DIEU TRI BE. NH TIEU HOA

;

</div>
<span class='text_page_counter'>(107)</span><div class='page_container' data-page=107>

-103-gan b6ng si6u 6m Fibroscan, d6nh gi6 mric dQ

xo

gan

bing

cQng hu&ng

tt

MRE, cric x6t nghiQm nhu Fibro test, NASH test...

HiQn

nay

l6m sirng dang 6p dgng thang di6m

NAILD

Fibrosis Score,

dqa tr€n 6 bitin s5 ld tu6i,

BMI,

tinh tr4ng t6ng

tlulng

m6u, s5 luqng ti6u cAu,

albumin vn

t!

AST/ALT

(tinh theo cdng thric

:

-1.675 + 0.037 x tudi (nam)

+

O.Og4

x BMI

(kg/m2)

+

1.13

x

r6i

lo4n dung n4p Glucose/<l6i thrio duong
(ntlu c6

:

kh6ng:

0) + 0.99 x AST/ALT

<sub>- </sub>

0.013 x sO luqng titiu cAu (xt0e/l)

-

0.66 x

albumin

(g/dl)

hoac

c6

th6

tinh tU

dQng

tr€n

trang

web:
)

<sub>t6l. </sub>

Chi sO > 0.85 ggi y xo ho6 gan tit5n tri6n, chi sO <

-1.455 lo4i

trir

xo ho6 gan titin tritin v6i d0 nhay 90%o vit dQ ttAc hiQu 60%. Chi

si5 > O.OZO x6c dinh c6 xcy ho6 ti6n tri€n vdi d0 nhay 67% vitttQ

dic

hi€u 97%.
3 ChAn

tloin

phAn biQt

Eti

ch6n do6n

NAFLD

cdn ph6i c6 (1)

bing

chung v€ tinh tr4ng nhi6m
md gan <sub>ltren </sub>cnAn tlo6n hinh 6nh

hoic

md bQnh hgc) vd

phii

1o4i

tni

tlugc c6c

nguydn nhan

thf

ph6t gAy tich

lu!

m0 d gan kh6c nhu:

1. Benh gan nhi6m md do ruou.
2. Vi6m gan vi rut C (genotyp 3)

.:

J.

Vlem gan tu mlen

4. Benh

ly

gan do

riii

loqn chuytin h6a

(ri

s6t,

rl

ddng,thi6u hut alpha

1-antitrypsin).

5. Thu6c: amiodarone, methotrexate, tamoxifen, corticosteroids
6. Benh gan nhiSm md c6p & phg nir mang thai

H6i

chimg Reye

8. Nhin tt6i

CAn

luu

i

<sub>NAILD </sub>

c6 thiS ph6i hqp

vdi

c6c bQnh

lj

d

gan khric nhu
vi6m gan

vi

rut.

IrI.

DrfN

BItN TIINHTtx

uarr,n

Tu gan nhiSm md kh6ng do rugu -> vi6m gan nhiEm md kh6ng do rugu
-> vi6m gan nhiSm mO kh6ng do rugu + xor h6a -> xo gzrn.

Gan nhi6m mO tlon thu6n kh6ng c6 tinh tr4ng vi€m vd

xs

tren m0 bpnh
hAc

thulng

sE khdng tirin trii5n

vi

di6n

biiin

lanh tinh. NASH ti6n luqng x6u
hon vd c6 thli ti6n tri€n thanh xo gan. O My,

ty

NAFLD

chung cr cQng d6ng

ld khoang 20oh, chi c6 2

<sub>- </sub>

3Yo c6 NASH vd khoang 20% b6nh nhan NASH tirin
tri6n thanh xo gan.

Tuy

nhi€n nguy co

titin

tri€n

xo

gan cira

NASH lai

tlng

cao

d

mQt s6

nh6m bQnh nh6n tl4c biet, d6 ld b6o phi, drii thrio tludng vir ngudi 16n

tu6i

Khi

m6c bQnh b6o

phi,

gan nhi6m

md

<sub>elp </sub>

0

90% c6c

trulng

hqp,

vi

NASH
chi6m 40%,

xo

gan chi6m khoang 13

*

l4%.

Ti

NAFLD d

b€nh nh6n d6i

</div>
<span class='text_page_counter'>(108)</span><div class='page_container' data-page=108>

104-thrio dudng khoang 50Yo

vit

mOt

nua

si5

tgntr

nhdn

d6

NASH,

xo

h6a
khodng 20%.BQnh nh6n b6o phi nang c6 kdm ddith6o duong

thi

gdr l00%c6
gan nhi6m md,50%o c6

NASH

vli

19% c6 xo gan. Tu6i cfing

h

yCu t6 dy bao

ti6n luqng, n6u NASH d benh nhan tr6n 45 tu6i c6 nguy co cao g6p tO lan tir5n

tri6n xo h6a (40%) so v6i NASH d b€nh nhdn du6i 45 tu6i (4%).

IV.

DIDU

TRI

NAFL

kh6ng kdm tinh trgng vi6m gan c6 ti6n lugng t5t n6n didu

tri

chi han ch6,0 cecbenh nhan NASH.

1. Thay a6i ti6i s5ng

Thay ddi trSi s6ng bao g6m gi6m cdn nang bang ctrt5 Og an gidm calo ktit

ho. p

ting

cudng ho4t dQng th6

lyc

c6 th6

lim

gi6m men gan vd c6i thi6n <sub>tinh</sub>

trpng nhi6m md gan tr6n si6u 6m.CU th,5, chri d6 en

giim25%

lugng calo hang

ngiy

(ngudi binh thudng trung binh khodng 2500 calol ngdy),

trrffi

sri dqng
acid b6o da

vi

dudng fructose c6 trong

thtc

6n nhanh vd nudc gidi kh6t,tdtrg
lugng acid brio kh6ng b6o hod c6 omega 3, omega 6. Trucrng hqp bQnh nhan
b6o phi

n[ng

c6 th6

phii

rip dgng cric biQn ph6p co hpc kh6c nhu nQi soi tlpt
b6ng hoi trong da ddy ho{c phAu thuQt

thit

dai da ddy gidm bdo... H4n ch6 sri
dgng rugu, bia.

Tfp

tht5 dqc mric dQ trung binh, 3

-

4lN

tudn, dat tlu-o. c t6ng

nhip tim khoang 60

<sub>- </sub>

75o/o mric ti5i da theo <sub>tu6i.D6nh ei6 lai hi€u </sub>qudr cria thay
O6i t6i sOng sau 6 thAng, ntiu v6n chua d4t hiQu qu6, c6 th€ 6p dung thdm cric

biQn phrip kh6c nhu

ding

thu6c.
2. Thuiic tli6u

tri

a. Thu6c

tlugc

khuy5n c6o tlidu

tri

NASH

- Thiazolidinedione

<sub>- </sub>

thu5c Drm gi6m tl6 kh6ng

insulin

Pioglitazone duoc khuy6n c6o srl dpng aC OiCu

tri

c6c bQnh nhan NASH.
Thu6c ldm cdi thiQn m4nh sg khring insulin

d

m6 mO, gidm thorii hori md vd

thh

trqng vi6m 0 m6 gan. Pioglitazone [Au tlugc su dpng tu 30

-

45mg/ r,Lgiry.

Tuy nhi€n c6c thu nghiQm l6m sang dugc titin hdmh tr6n c6c bqnh nh6n kh6ng

mic

d6i thrlo iluong, vd hiQu

qui

l6u

dii

cfing chua <sub>x6c dinh ttugc [7].</sub>

Vitamin

<sub>- </sub>

thu6c chSng oxy hori

Vitamin E

v6i

li6u

800 don

vi/ ngiy

tl6 dugc chimg minh ldm c6i thiQn

tinh tr4ng m6 bgnh hgc 0 bQnh nhdn NASH khdng c6

tlii

th6o tluong.
b.

Thuiic

c6 th6 cri tr{c dgng O6 Oidu

triNASH

- Acid Ursodeoxycholic

([IDCA)

I;'DCA dA ttugc chimg minh c6 hiQu

qui

ti6n 16m sirng d c6c nghiOn cftu
thpc nghi€m

NASH.

Tr6n lAm sang. c6

2

nghiOn cuu nh6 th6y didu

tr!

v6i

UDCA c6 cdi thiQn vd x6t nghi€m

vi

m6 hgc, tuy nhi€n d 2 nghiCn criu lon hon

v6i

liAu th6p 13

-

l5mglkg

vi

lidu cao 23

-

2$mgkg 14i kh6ng cho th6y c6i

</div>
<span class='text_page_counter'>(109)</span><div class='page_container' data-page=109>

l0s-thi€n x6t nghiQm men gan vd m6 bQnh hqc gan' MQt nghiOn criu ng6u nhi€n da

trung tAm d Ph6p

vdi

li€u di6u

tri

cao hon 28

<sub>-35mglkg </sub>

trong 1

nim d

126

benh nhen

NASH

cho

thdy citi thiQn dang k€ vd 6n dinh n6ng dQ

ALT,

vai

thiQn mirc d6 I'hang insulin vd thang di6m xo. Tuy nhi6n do thi6u c6c nghiGn

cuu c6i thiQn

tinh

tr4ng m0 bQnh hqc n6n

UDCA

vAn chua ilugc khuy6n c6o
ttAy ttri d6 di6u

triNASH

[7].

Acid

b6o c6 omega-3

Acid

b6o c6 omega-3 c6

dlc

tinh ch6ng vi6m, ch6ng 6

xy

ho6 vd ch6ng
thorii ho6 md. Tuy nhi6n hiQn nay

vin

thi6u c6c

df

kiQn 16m sang nghi€n cuu
tla trung tam,

d6i

chimg ng6u nhi€n pha

IIb

dang ti6n hanh n€n chua khuy6n
c6o sri dqng d benh nhan NASH.

Pentoxililline

Nghi6n crlu thpc nghiQm cho th6y Pentoxifilline c6 t6c dqng tr6n NASH.
Nam 2011, 1 nghiOn cuu ng6u nhi6n

diii

chung 0 55 benh nhan NASH cho thAy
hiQu qud cei thien men gan vd m6 bQnh hqc

gita

nh6m dung Pentoxifilline so

vdi

gi6 dugc. Tuy nhi€n, cAn ph6i c6 nhi€u nghiCn crlu ring hQ k6t qud nay.
c. Thu5c kh6ng hiQu qu6 tl6i

vdi

NASH

HiQn

nay, qua nhidu

nghidn

cr?u

thu

nghigm

l6m

sang

cho

thAy

Metformin

khdng ldm cdi thiqn rO rQt tr6n m0 benh hgc,

vi

v4y khOng dugc
khuyt5n c6o srl dgng cho c6c benh nhan NASH. Tu<rng tg, cffng kh6ng c6

bing

chimg cho th6y statin c6 hiQu qu6 cai thiQn m6 bgnh hqc d benh nhan NASH.

Tuy

nhi6n statin v6n dugc chi dinh tt6 di6u

tri

cric tinh trpng

r6i

lo4n chuy6n
ho6 kdm theo.

3. Di6u

tri

tinh

tryng r5i

lo4n chuy6n ho6

Ki6m

sorit

t6t tinh

tr4ng

r6i

1o4n

dulng

mrlu,

rili

1o4n

lipid

m6u,

tlng

huyiit ap vd c6c y5u t6 nguy co tim mpch kh6c dugc khuy6n c6o n6u c6.

4.PhfuthiQn strm vir

xri

tri

kip thtri

cic

bi6n chring cfia

vi

xo gan.

Khi NASH tiiin

tri6n dtin giai doan

xo

gan, can sang lgc ph6t hiQn gi5n

tinh

m4ch thgc quan

<sub>- </sub>

diy,

ung thu gan dinh

ky

nham ph6t hiQn

vi

xri

tri

kip thdi cdc bi6n chimg niry.

Tni

[Qu

tham

khio

1. David

E.

Cohen, Frank

A. Anania

(2009),

'Nonalcoholic

Fatty Liver
Disease", Current Diagno s is

&

Treatment Gas troenterology, Hepato l

og

&

Endoscopy, Mc Graw

Hill,

p.467-472

2. Malcolm

K.

Robinson,

Norton

J.

Greenberger (2009), "Treatment

of

obesity: The Impact of Bariatric surgery", Current Diagnosis

&

Treatment
Gastroenterologt, Hepatologt & Endoscopy, Mc Graw Hill, p.210-221

</div>
<span class='text_page_counter'>(110)</span><div class='page_container' data-page=110>

106-3.

E. Kuntz, H. D. Kuntz (2008), "Metabolic disorders and storage diseases",

Hepatologt

<sub>- </sub>

Textbook and Atlas, Springer, p.595-605

4.

Shivakumar

Chitturi,

Geoffrey

C. Farrell,

Etsuko Hashimoto, Toshiji
Saibara, George

K.K. Lau

and Jose D.Solland

(2007),'Non-alcoholic

Fatry Liver Disease in the Asia-Pacihc Region: Definitions and Overview
of Proposed Guidelines", J Gas tr oenterol Hepatol. ; 2 2 (6) : 7 7 8 -8 7

5. Brent

A.

Neuschwander-Tetri

(2006),

'NASH",

Zakim and

Boyer's
Hepatologt

<sub>-A </sub>

textbook

ofliver

disease, Saunders Elsevier p.10j1-63

6.

Naga Chalasani et

al

(2012), "The Diagnosis and Management

of

Non-Alcoholic Fatty

Liver

Disease: Practice

Guideline

by

the

American
Association

for

the

Study

of

Liver

Diseases,

American College

of

Gastroenterology,

and

the

American Gastroenterological Association",

Hepatologt, Vol.55, No.6, 2012

7. Vlad

Ratziu

(2013), "Pharmacological agents

for

NASH", Nat.

Rev.

Gastroenterol. Hepatol. I 0, 676-685

</div>
<span class='text_page_counter'>(111)</span><div class='page_container' data-page=111>

107-APXE GANAMIP

I. DAI CIIONG

-

Ap

xe

gan amip

ld

bQnh

c6 t6n

thuong

mri

t4i

gan

do

amips-Entamoeba

histolyica. Ap

xe gan mip chiiSm 80Yo cdc nguyCn nhAn g6y 6p xe
gan.

-

NhiSm

amip

-Entamoeba histolytica

ld

nguy6n nhan

tt

vong dimg
hanh

thf

3 do

kj

sinh trung, trong tl6 90% nguoi nhi6m E.histolytica kh6ng c6
triQu chimg

vi

chi c6 10% benh nh6n c6 c6c triQu chung nhi6m amip o ruQt hay

tt

gan

-

Ty

le nhi6m Entamoeba chi6m 10% den s6 tren th6 gi6i vd chri ytiu

li

nhi6m thr5 amip kh6ng gdy bqnh Entaomoeba dispar-minuta.

-

Amip

2lo4i:

+

Entamoeba histolytica: duong

kinh

20-40pm,

th6

an hdng

ciu,

gdy
b€nh

*

Entamoeba dispar-minuta;

dulng

kinh 10-20pm, th6 en h6ng cAu, gdy

bQnh

-

Amip

c6 2 chu

k!

phrit tri6n:

+

Chu

k)

kh6ng gAy b6nh-Chu kj,bdo nang. Amip d trong ruQt du6i

bio

nang

+

Chu

k!

g6n bQnh: amips c6 th6 g6y t6n thuong vi6m tlpi trdng. Amip
theo c6c

tinh

m4ch m4c treo d4i trang vdo gan, gdy n6n vi6m gan, tao c6c

vi

truytit

tn5i,

tic

m4ch gan. Nhi6u 6

vi

huytit kh6i hqp l4i

v6i

nhau t4o n6n 6 6p

xe gan

-

Thudng g}p d gan phAi, c6 th6 mQt 6 hay nhi€u O

II. CHAN DOAN

AP XN GAN

AMIP

l.

ChAn

doin

x6c

tlinh

a. TriQu chrimg lAm shng

-

fn6

Aien hinh

(

60-70% <sub>). </sub>B€m nhAn c6 dAy tlu c6c tri€u chimg crJra

Tam chimg Fontan

+

S0t: si5t c6 th€ nhg 37-38 dO, hodc stit cao, kdm r6t run, siSt tri6n mi6n

ho4c s5t thAnh con. Si5t tiruOng ld triQu chimg

tliu

ti6n, 3-4 ngdy sau BN xu6t
hiQn dau h4

suln

phdi, gan to, cflng c6

khi

stit xu6t hign tt6ng thdi

v6i

2 triQu

chimg tlau h4 sudn phAi vd gan to

+

Dau h? sudn phdi

vi

virng gan: Mric tIQ dau khric nhau

thulng

dau tric
n{ng, xuy6n l6n vai

phii

tdng l6n khi cu dQng, ho.

+

Gan to dau: gan to mdm

vta

phii.

An kO suon duong tfnh

+

BN kh6ng c6 vdng m6t vang da

</div>
<span class='text_page_counter'>(112)</span><div class='page_container' data-page=112>

viro md, rg

tim

g6y

trd,n mri mirng

tim

+

ThC ph6i vir mirng phOi: AN c6 th6 kh4c ra

mt

s6 c6 la, ho{c c6 triQu

chimg cria trdn dlch mang ph6i

+

Th6 c6 tran dich mdng tim: triQu chimg trdn dich ming tim n6i b4t

+

Th€ gin ung

thu

gan (15-16%): gan to chimg nhu ung thu gan
b.TriQu chri'ng

cin

l6m

sing

-

X6t nghiQm m6u

+

Tti

bio

m6u ngo4i

vi:

BC t6ng r6t

it

gap t6ng BC ua axit, t6c dQ m6u

cit

tE

O bsng hay cQng huong

tt

bgng: c6 d0 nhay 88-95% tuy
nhi€n ciic d6u hiQu trdn chpp c6t

tE

6 bgng hay cQng hu&ng

tir

kh6ng c6 tinh
ch6t Oic hi6u: t6n thuong

g\tm ty

trgng

vdi

rb

n6t mdm, ng6m ch6t c6n

quang 16 d bd ngo4i

vi

O ap xe. Chgp CT c6 dtrng thu5c

cin

quang girip cho
phdn biQt O ep xe gan vdi t6n thuong khi5i u gan ho4i

tu

+

Chgp ttQng m4ch gan:

tlugc

chi

dinh

khi

muiin

ph6n biQt

v6i

t6n
thuong u gan ho4i

tti

+

Xa hinh gan

v6i

Technetium 99m, Gallium c6 gi6

tri

ph6n biQt

gita

6p xe gan vd tdn thuong u gan hoai trl tuy nhi6n tl6y kh6ng

phii

ld xdt nghiQm

</div>
<span class='text_page_counter'>(113)</span><div class='page_container' data-page=113>

-109-tlugc lya chgn dAu ti6n.

0

6p xe gan amip kh6ng c6 b4ch cAu

<sub>-t6n </sub>

thuong lanh
tr6n x4 hinh gan-

vtng

n6ng hay bd t6n thuong c6 ho4t tinh ph6ng x4

-

Chgc dd

6

6p xe

du6i

sy huong d5n cria si6u 6m byng hay Cat top
bpng: m0 s6 c6 la kh6ng

mti

-

X6t

nghiQm ph6n- c6c triQu chimg gqi

y:

hdng cAu trong ph6n, Bach
cAu da nhdn trung

tinh it,

Tinh th6 Charcot Leyden. Xdt nghiQm ndy c6 gi6

trl

tli

citc co sd kh6ng c6 di6u kiQn ldm xdt nghiQm huy6t thanh chAn do6n v6i
amip hay khrlng nguy6n trong ph6n

Ky

thuat

EIA

duo.

c

sri

dqng

rQng

rii

thay

thii

IIIA

(Indirect

hemagglutination), CIE (Immunoelectrophoresis)

+

Phet hi€n nhi6m E.histoly'tica trongg5%o truong hqp amip ngodi 6ng

ti€u

h6a, 70% nhi6m amip 6ng

ti6u

h6a

vd

l}Yo

b€nh nh6n khdng c6 triQu

chimg 16m sang

+

Xdt nghi€m cdn duong tinh sau 6-12 thdngdiAu

tri

diQt amip

+

X6t

nghiCm dm

tinh trong

l0%

b6nh nh6n nhi6m amip d gan. Trong
tru&ng hqp ndy n€n

lim

xdt nghiQm l4i sau 1 tuAn

3. Ch6n

tlo{n

phAn biQt rip xe gan amips
a. Ung

thu

gan

-

BN

c6 hQi chung suy tti bdo gan, HC tnng 6p lgc tinh mqch cua

</div>
<span class='text_page_counter'>(114)</span><div class='page_container' data-page=114>

l0-
-111-BQ Y TE - HU.ONG DAN CHAN ooAN

ve

oI

rnl

eENH TIEU HOA

-

Chirc

ning

gan

r6i

loan: AST,

ALI

ting

Bilirubin

m6u t6ng, Albumin
giAm, Prothrombin

giim

-

AFP

ting

cao

-

t6

bao hgc, hoflc sin]r ttriiit gan: ung thu bi6u m6 til bdo gan

b. Ap xe

tludng

mit

do s6i

hoic

giun

tliia

Si6u 6m bpng: nhiAu 6 gidm 6m hay tr6ng 6m, c6 th€ c6 khi trong ii 6p

-

Mri tr6ng c6 miri

thtii

-

C6y ra

vi

khuan thu}ng ld vi khu6n Gram dm

-

X4 hinh gan v6i Technetium 99m, Gallium c6 gi6

tri

phdn biQt

gita

6p xe gan do amip vd iip xe gan do

vi

khu6n. Ap xe gan do

vi

khuAn c6 chria
nhi€u B4ch cAu+6n thuong l4nh tr6n x4 hinh gan- vDng d6 hay

ving

c6 ho4t
tinh ph6ng x4 tflp trung d trung tdm

d. Vcri vi6m

trii

mflt

tui

mat dey, c6 thti xu6t hiQn

dich quanh tui mpt

Vfi

vi6m ph6i,

tran

vio

nhu m6 ph6i lem

BN

khac ra

mt

-

Vd

vdo mang ngodi tim-thudng g4p

v6i

6p xe ph6n thity 7,8 hogc 6p

xe gan tr6i. BN dot ngQt kh6 th6

dr

doi, tim t6i khtun

tim

sE thdy cric d6u higu

</div>
<span class='text_page_counter'>(115)</span><div class='page_container' data-page=115>

-

Vd

vdo 6 bgng g6y vi€m

phtc

m4c tod,n th6- bi6n chrlng ndy

rlt

hay

gip.

BN tlQt ngQt dau bgng, siit tang l6n, byng cimg tlau todn bqng, khrim byng
th6y c6 phan rlng thanh bpng. Chgc dd O br;ng- c6 mri s6cla

. i,

-

Vd

viro

6

bgng gAy vi6m phric m4c khu

tni-

6 rip xe vd vdo 6 bpng
nhrmg nay lflp tric bi ciic m4c n6i vd cric t4ng bao v6y t4o n€n 6 mrj khu trri

-

vi

khuAn y6m khi,

vi

khuAn gram
6m

III. DItU

TRI:

BQnh chri yiiu di6u

tr!

nQi khoa, chi di6u

tr!

ngopi khoa khi c6

bi6n chung ho4c diAu tr! nQi khoa th6t b?i

Dtng

thu5c diQt amips
a. NguyGn

tic

chung

-

Trong pnan ton ciic trudng hqp apxe gan amip khdng c6 bitin chrlng,

dtng

thu5c di6t amip c6 th6 didu tr! thdnh c6ng hong pnan ton c6c

trulng

hqp

-

Dtng

thutic diQt amip d gan, sau it6 dirng thu6c diQt amip d ruQt (ViQt
nam lir nu6c c6

vtng

dfch t6 cao v6i amip)

-

C6c thu5c c6 th6 chia thirnh 3 nh6m chinh

+

Metronidazole, Tinidazole, Emetine, Dehydroemetine,
Chloroquin-DiQt amip o gan

+

Tetracycline

dtng

trong trudng hqp c6 ph6i hqp vi€m d4i trdng do

amip

+

Diloxanide furoate, Paromycin, Iodoquinol: c6 t6c dpng diQt amip 6

ruQt

-

Kh6ng n€n

t6t

trqp hai lo4i thuiic diQt amip d gan

Thuiic

dtng

cg th6

-

Nh6m 5 nitro-imidazole:

+

Metronidazole

l000mg/ngdy

ho4c

30-50mg/kg/ngdy

xl0-15

ngdy
(ut5ng

ho{c

truydn).

Ntlu

dtng

u5ng chia

3

l6n trong ngdy, n6u truydn

finh

m4ch

dtng

li€u 500mg/6gid vdi ngudi lon ho4c T,Smglkglngity m6i 6 gid trong

ngiy

v6i tr€ em

+

Tinidazole

2

glngity

<sub>- </sub>

I

l6n xlO ngdy

+

Ornidazole

2/ngity-

1 l6n xlO ngdy

</div>
<span class='text_page_counter'>(116)</span><div class='page_container' data-page=116>

-112--

Dehydroemetine, Chloroquine hiQn nay kh6ng dugc khuy6n c6o

dtng

do t6c dpng php tr€n tluong tim m4ch vir ti6u h6a

-

x

vio

mdrng

tim

Si5 l6n chpc phq thuQc kich thu6c 6 6p xe

3. PhAu

thuit

-

Khi

di6u tr! nOi khoath6t bai

-

Khi

c6 bii5n chring: vo 6 6p xe

vio

dai

tring,

6 bqng, hay mdng

tim

Tii

IiQu tham kh6o

1.

Nguy6n th! VAn H6ng (2012) Ap xe gan amrp. BQnh hpc nQi khoa tQp 2

2.

OttoMP., Gesrome P., RappC et

al

(2013). False negative serologies in
amebic liver abscess: Report of two cases. J Travel Med; 20(2) : I

j

l -3

3. LeoM.,

Mannweiler

E. (2006).

Evaluation

of

Entamoeba

histolltica

antigen

and

antibody

point

of

care tests

for

the rapid

diagnosis

of

amebiasis. J Clin Micorobiol; 44(12): 4569-7

I

4. Khan

U.,

Mirdha

BR.,

Samataray

JC.,

et

al

(2006). Detection

of

Entamoeba

histolltica

using polymerase chain

rection

in

pus

samples

from amebic liver abscess.

IndianJ

Gastroeneterol; 25(2); 55-7

5. Khan

R.,

Hamid

S.,

Abid S et

al

(2008). Predictive factors

for

early
aspiration in liver abscess . World J Gastroenterol

;

14 (1 3) : 2089-93

6.

Khanna

S.,

Chaudhary

D.,

Kumar

A

et

al

(2005). Experience

with

aspiration in cases of amebic liver abscess in an endemic area. Eur

J

Clin

Microbiol Infect Dis; 24

(Q:

a28-430

7.

BlessmannJ.,

Binh

FID., Hung

DM

et

al

(2003) Treatment

of

amoebic
liver abscess with metronidazole alone or in combination with ultrasound
guided needle aspiration

:

a

comparative, prospective and randomized

study. Trop Med Int Health; 8(l

l):

1030-4

</div>
<span class='text_page_counter'>(117)</span><div class='page_container' data-page=117>

13-8.

Maltz

G.,

Knauer

CM., et al

(1991).

Amebic

liver

abscess:

a

15 year
experience. Am J Gastroenterol; 86

(6):

704-10.

9.

Raymond T., Chung., Friedman LS 2006. Bacterial, Parasitic and Fungal

infections

of

the liver,

including

liver

abcessess;. Sleisenger and
Fordtrans's gastrointestinal and liver disease. 8'h editition;

t73t-1755

10. Stalnikowitz

DK.,

Carmona Sanchez R(1999).

Amebic

liver

absess.

Schiff's diseases of the liver. Eight edition edited by Shiff ER., Sorell

W,

Maddrey

WC.

Lippincott-Raven Publishers.Philadelphia

1999;

1527-1533

11. Ayles HM., De

Cook

KM

1999. Hepatic abscesses and cysts

:

Liver
disease Edite by LS Fried man., EB

Keffi

373-391.

</div>
<span class='text_page_counter'>(118)</span><div class='page_container' data-page=118>

-114-Ap

xr

cAN

Do

vr xnuAN

r.

D+r

CTIONG

Ap

xe gan do

vi

khu6n ld t6n thuong mri t4i gan g6y ra do

vi

khu6n. BQnh

dugc m6

tn

lAn dAu

ti€n bdi

Bright

1836

vii

nim

1938 Ochsner d6 c6ng b0
nhirng nghiCn cuu dAu ti6n vA 6p xe gan do

vi

khuAn.

2. Dich tG

-

Ti

le bQnh

mic

thay d6i

tty

theo khu vgc, tai Hoa

Ky

ty l9 m6c trung
binh ld 8-15 trudng hqp/100.000 den

v6i

1/7000 benh nhan nh@p vi€n.

Tl

nam/n&: 2:1, loa tu6i

thulng

m6c bQnh 40-60

-

BQnh thudng gflp d nguoi c6 bQnh

li

tlutrng mpt d4c biQt

li

ung thu
dudng mQt

ttr

tru6c ho{c tr6n benh nhan

bi

benh mpn

tinh

nhu:

BN

c6 ph6u
thu4t hay ldm nQi soi tru6c d6 trudc d6, bQnh Crohn, ch6n thuong,

trii

thrlad6i
th6o tludng, dang dtng c6c thu6c gi6m miSn dlch ho{c bQnh ric tinh.

3. Nguy6n

nhin

vir sinh

I

bQnh

-

Thudng

do

vi

khuAn gdy b€nh c6 ngudn g6c

ttr

dudng m4t hay
dudng ruQt.

VK

6i khi chi6m

tj

le

18-112 nguy0n nhdn g6y bQnh. Escherichia

Coli vir,

Klebsiella

pneumoniae

li

thuong

gip

nh6t. Bacteroides species,

Streptococcus species

ctng

dang

tlng

l6n.

C6c

vi

khuAn hii5m

gip

h

Salmonella, Haemophilus

-

T6n thuong thuong ld da 6. 600/o cbc

trulng

hqp thuong 0 gan

phii,

20-25% d ce 2

thiy,

15% d thiry tr6i

BQnh sinh cfra 6p xe gan

vi khuin

-

BQnh

lf

duong m4t: hay gflp nh6t

<sub>Ql-30%\, </sub>

thuong do t6c m4t (do
nguydn nhdn s6i mQt hay

ung

thu dudng m4t, sau phSu thu{t itdt stent d6n lrru
duong m4t, ni5i mat ruQt)

vi

gdy vi€m dudng mat aan tOi ap xe gan.

-

Euong tinh mpch crla: ttr c6c vi€m nhi6m t4i vung bqng nhu vi€m trii

thira, vi6m ruQt thira,

vi€m

mri bC than.

Vi

ktluAn gAy huyiSt rur6i tintr m4ch cria

vdsaud6

gAry6pxegan.

-

Dudng tlQng m4ch gan:

vi

khuan

tu

m6u d6n do nhi6m khuAn toirn

thin

nhu vi6m nQi tAm mac, vi€m dudng ti6t niQu.

-

C5c con

dulng

kh6c: khoAng 50% sd bQnh nh6n khOng 16 dudng viro,
thudng gQp iry xe gan d ngudi

bi

d6i th6o dudng ho4c c6 bQnh ric tinh. C6 th€

tir con

dulng

lan tran trgc titip ho{c sau ch6n thuong hopc do nguy€n nhdn t6c

nghEn

mi

khOng tim th6y 6 nguy€n phrit

II. CHANDOI.N

f . ChAn tlo6n x6c

tlinh

a. TriQu chring lAm sirng

</div>
<span class='text_page_counter'>(119)</span><div class='page_container' data-page=119>

-115--

Dau h4 sudn phdi dau 6m

i,

c6 th6 c6 con dau qu{n gan trong trudng
hqp nguy€n nh6n

do

s6i dudng m4t.

-

Sdt cao 39- 40o, c6 r6t run.

-

Gan to m6m

vi

dau khi th6m kh6m. An kc

suln

duong tinh, Rung gan

Ngodi ra, chAn do6n hinh Anh c6 th6 ph6t hiQn th6y nguy6n nh6n gdy

tic

m4t nhu s6i m{t, giun trong tludng m4t.

III. EITU TRI

Khing

sinh
a. Nguy6n

tic:

f5t

nn6t

h

lya

chgn theo kh6ng sinh dd. Trong

khi

chd

tlqi

n6n

dtng

khang sinh c6 ho4t phd rQng, nliu b€nh nh6n

n[ng

sr] dpng ngay khring sinh c6
t6c dqng mqnh vd c6 ho4t ph6 rQng nhu carbapenem.

b.C6c thu5c cg th6

Lr;a. chgn s6 1

Khring sinh ric

ch6

penicillin

/

B-lactamase c6 ho4t ph6 rQng

Ampicillin/sulbactam

TM

<sub>1,5-3 9/6 </sub>gid
Piperacillin/tazobactam TM 4,5 <sub>9/6 gitr</sub>

Aminoglycosid

Gentamycin

TB

ho{c

pha

loing

ti€m

tinh
m4ch 80 mgl8 gid

</div>
<span class='text_page_counter'>(120)</span><div class='page_container' data-page=120>

-1r6-Ceftriaxon TMr2-4

<sub>e/l </sub>

ldn/24 gid ceftazidim

TM

1-2 gl12 gii,

Cefepim

TM

l-2gll2

giit

Monobactam

Ni5u c6 nhi6m khudn ky khi dirng mQt trong 4 1o4i khrlng tr6n + metronidazol

TM

5OO 8 10

L

nsii2

Fluoroquinolon Ciprofloxacin 500mg u6ng ho4c TIW12 gid
Levofloxacin 500mg u6ng ho4c TlW24 gid
Moxifloxacin u6 TM 4OO o

Ntiu

c6 nhi6m khuAn

ky khi

dung mQt

trong

3

1o4i Fluoroquinolon tr€n +
metronidazol

TM

500 m 8 10

Carbapenem Meropenem

TM

1gl8 gid

Imipenem/Cilastatin

TM

1-2

!12

gii,

Dori

enem TM 0,5 8 o

Ph6c

ild

c th6

Thdi gian

Di

irng v6i

Lactamines
Lua chon dAu ti6n

4-6 tudn
Ofloxacine 400mg

sau d6 200mg x2
lngity +
Metronidazole
500mg x3/ngdy

Tuong tU

Ceftriaxone 1-2glngdy
hay Cefotaxime
4-6flngiry+ Metronidazole

500mg x3lngiry
Tuong t.u +Gentamicine

7-SmgkgmQt fidu duy
nh6t trong 48 gid
Ap xe gan do

vi

khu6n th6ng

thulng

Huy6t tlQng

kh6ng 0n <Iinh

4-6 tuan
Ofloxacine 400mg

sau d6 200mg x2
lngity +
Metronidazole
500mg x3lngdy
Ceftriaxone l-Zglngiry

hay Cefotaxime

4-6 gl ngiry + Metronidazole

500mg x3lngdy
+Gentamicine 7 -Smelkg

mQt liAu duy nh6t trong
48 gio

Nguy co ph6t t6n
vi khudn cao ph6i

hqp v6i chdm s6c
d4c biQt

BQYTE-HU.ONC DAu csAN EOAN VA EIEU TRI BENH TIEU HOA -117

</div>
<span class='text_page_counter'>(121)</span><div class='page_container' data-page=121>

2. DAn

luu

6 6p *e
a.Chgc

hrit

5p xe

-

Euoc thyc hiQn dAu ti€n ndm 1950. CAn chgc hrit 6 ap xe tt6 nu6i c6y

vi

khu6n, lnm khrlng sinh ttd d6 chgn lya kh6ng sinh thich hqp. Kich thudc 6 6p

xe cAn chgc

hft

mt

khi 5 6p r," l6n tr6n 5 cm

-

ViQc chgc hrit 6p

xe

trong 6p xe gan do

vi

khuAn cAn thgc hi6n s6m vd

v6i

kich thudc b6 hon so

v6i

6p xe gan amip. 56

lin

chgc tiry thuQc viro 6 6p xe
b. DAn trm

mt

qua da duoi sg huong d6n cia si€u Am hay chgp

cit

lop bgng fong
truong hgp chgc hrit 6p xe th6t bai. Phuong phap ndy thUc hi€n l6n dau ti6n nem 1970

V6i

BN

c6 d+t stent dudng mflt c6n chir 1y': thay stent kich thudc lon hcrn

(Stent qua da, chgp mQt

tgy

ngugc ddng hay ph6u

thuit).

Ni5u 6 6p xe th6ng
vdo

dulng

mQt c6n ph6i

dtng

stent c6

kich

thudc thich hqp. N5u kh6ng c6
th6ng vdo dudng mrit- d6n

lm

mri

c. N5u chgc hrftt

mt

vi

d6n

lru

th6t

b4i tiSn

htnh

ph6u

thugt

d6 d6n luu.
Phuong ph6p

niy

c6 th6 th5m dd toan bQ gan <sub>nhAt , </sub>ld phuong ph6p

din

luu mrl
t5t ntr6t

khi

si6u 6m khOng tham dd tlugc hi5t 6 6p xe, tcrit trqp O6n tuu Ouong

mflt khi cAn thitlt, th6m dd duqc 6 nhiSm khuAn nguy€n phrit
3. Didu

tri

trq'

-

Ki6m so6t t6t tluong huytit ni5u c6 <t6i thrio

ttulng.

-

Ei6u

tri

vi

khu6n nguy€n ph6t n6u c6.

BQ Y T6 - HU6NG DAN CHAN DOAN VA DIEU TRI BENH TIEU HoA

-118-Tni

liQu

tham

kh6o

1. Gyorffy

EJ.,

Frey CF.,

Silva

J

Jr

et al

(1987) Pyogenic

liver

abcess.

Diagnostic and therapeutic strategies. Ann Surg; 206 (6):699-705

2.

Tsai FC., Huyang

YT.,

Chang

LY

et a1(2008) Pyogenic

liver

abscess as

endemic disease, Taiwan. Emerg Infect Dis; 14 (10): 1592-600

3.

Pastagia

M.,

Armugam

V.,

et

al

(2008). Klebsiella

pneumoniae liver

abscesse

in

a public hospital

in

<sub>Queen, </sub>NewYork. Travel Med Infect Dis;
6(4):228-33

4.

Cheng

HC.,

Chang

WL.,

Chen

WY

et al

(2008). Long term outcome

of

pyogenic

liver

abscess; factors related

with

abscess recurrence.

J

Clin
Gastroenterol; a2(l 0): 1 1 10-5

5. GiorgioA., De

Stefano G., DiSarmo

A

al

(2006): Percutaneous needle
aspiration

of

multiple pyogenic abscess of the

liver:

13 years single center
experience. AJR Am J Roentgenol

<sub>; </sub>

187(6): 1585-90

</div>
<span class='text_page_counter'>(122)</span><div class='page_container' data-page=122>

7.

Joseph

S.

Solomkin, John

E. et

al

Guidelines

for

the

Selection

of

Anti-infective Agents for complicated Intra-abdominal Infections.

clD

2003:37
(15 October).

8. AjazA

M,

Shams ULB, Khawaja

A

R,et al (2010). Pyogenic liver abscess:

Changing pattems in approach. World J Gastrointest ;2(12):395-401.

9. Fung

CP,

Lin

YT,

Lin

JC

et

al

(20l2)Klebsiella

pneumoniae in

gastrointestinal

tract

and pyogenic

liver

abscess.Emerg

Infect

Dis.

2012

Aug;18(8):1322-5.

l0.Raymond

T.,

Chung., Friedman

LS

2006. Bacterial, Parasitic and Fungal

infections

of

the liver,

including

liver

abcessess;. Sleisenger and

Fordtrans's gastrointestinal and liver disease' Sth editition; 1731-1755

11.Ayles HM., De Cook

KM

1999. Hepatic abscesses and cysts : Liver disease

Edite by LS Fried man., EB Keeffe373-391.

</div>
<span class='text_page_counter'>(123)</span><div class='page_container' data-page=123>

l9-56I

MAT

DAr

lQ ndy c6 th6 16n

tdi

40% bbenhnh6n

nt

>65 fu6i m6c bQnh s6i

mft

2.

Sinh

lf

bQnh

-

S6i

m{t

duoc hinh thanh bdi c6c thanh phdn m6t b6t ttruong

-

80% s6i

mflt

ld

s6i Cholesterol (50Yo cholesterol monohydrate phdi
hqp

voi

mu5i canxi, s6c ti5

mft,

protein vd axit b6o)

-

20% s6i mflt ld s6i s6c t6 m4t (calium bilirubinate, <20% cholesterol)

-

tii

chlu anh huong

cia

ciic y6u t6: tdng luong
bilirubin kh6ng hda tan khdng ktit hqp

lL

CHAN

DoAN

sor

MAT

1. S6i

tfi

mit:Sdi

m$t c6 th6 ph6t hiQn bdi con tlau qu4n gan

vi

trong rAt nhi6u
trudng hgp BN dugc ph6t hiQn tinh cd khi ldm si6u Am bqng

a. S6i

BN

c6 phan ring nhe ha sudn ph6i. DAu hi6u Murphy c6 th6 duong
tinh

-

Trigu chimg c{n l6m sing:

</div>
<span class='text_page_counter'>(124)</span><div class='page_container' data-page=124>

-120-+

TAng cao nhq Bilirubin, Photphataza kidm, t5ng nhg men gan

+

ChAn do6n hinh 6nh

o

Si6u 6m bgng: Hinh cdur 6m trdn ho4c oval c6 the di dQng

vi

c6 hinh

cirn 6m phia sau. Trong trudng hqp kh6ng di6n hinh: hinh cdn 6m kh6ng di

dQng

vi

kh6ng c6 b6ng cirn <sub>Phia </sub>sau

o

Si6u Am nQi soi: dQ nhay vd d0 dac hiQu cao hon si0u 6rn bgng

-

Cric thdm dd kh6c

+

Chqp bung kh6ng chuAn

bi:

c6 thO ph6t hiQn s6i

trii mft

cin

quang
(g[p

trong

l0-l5o/os6i Cholesterol, 50% s6i sac ti5): hinh tui mat h6a sri, s6i d
h6ng trdng

+

Chyp

dulng

m{t

c6 udng thu6c can quang : hiQn t4i

it

dirng' ThAm dd

niry dugc thay th'6 bdi si6u 6m bqng

+

Xa hinh

mdt (Tc99m

N

iminodiacetic

axit-HIDA,

DIDA,

DISIDA):

dugc chi dlnh trong truong h-o-p t6c nghEn duong m4t , vi6m

trii mft

c6p hay

mpn tinh

b. S6i

trii

mit

c6 bi6n chring
Vi0m

trii

mflt c6p

Vi6m

tui

m4t cAp

thulng

xdry ra sau

khi

tEc nghcn

tui

mflt do s6i.theo 3

co ch6: vi6m co hoc do tnng 6p lyc trong tui mQt vd gian

tui

m4t g6ry thi€u m6u

nu6i

du6ng

ni€m

m4c

vd

thdnh

tui

m@t,

vi6m

h6a

hgc do gi6i

ph6ng c6c

lysolecithirivd cric y6u t6 vi6m kh6c vd cu6i

ctng

1d do

vi

khuAn d6ng vai trd

50-85%

-

TriQu chimg ldm sang

+

Dauh4suonph6i

+

Budn ndn, n6n

+

S6t cao

+

Kh6m:

phan rmg nhq

d

suln

tiri m{t

>4cm theo

chiiu

rQng, >10cm theo chi6u

dii),

xu6t hiQn dich quanh

tti

mAt, c6 khi d thanh tui mflt

Vi0m

tfi

m{t

m4n

tinh

-

Dau ha sudn Ph6i

</div>
<span class='text_page_counter'>(125)</span><div class='page_container' data-page=125>

-t2l--

Kh6m: ph6n img nhe ha sudn ph6i, ddu hiQu Murphy+

-

ChAn dorin hinh 6nh: si€u dm bpng- d6u higu ddy thenh

tfi

met
c. Ch6n

iloin

phAn biQt

-

C6c bQnh ly' khrlc cria ti6u h6a

+

Lodt dp ddy

HTT

+

Vi6m tgy c5p

+

ViCmru6tthiranim

du6i gan

+

Vi€m bao quanh gan-HC Fitz Hugh Curtis

+

Vi€m gan

virut

tui

mflt

c6p kh6ng do

s6i.

l0%

c6c trudng hqp vi6m

tti

m{t

kh6ng do s6i do ch5n thucrng, c6c bQnh hQ th6ng, s5t thucrng han

d.Ch6n tlo6n bi6n chri,ng

-

Vi6m

trii

mft

hoai

tu:

thudng

do

c6c

vi

khuAn

ky khi

Clostridium
Welchii, Clostridium Perfringens hoflc

vi

t<tru6n ai khi nhu E.Coli. Bitin chring

ndy

thulng

xu6t hiQn d ngudi gid, c6 b6nh tt6i thrio dudng kdm theo

+

XQ

bqng kh6ng chuAn

bung,
s6t cao 400C, phan tmg thanh bpng, dau khi

thim

truc trdng

-

Ap

xe du6i

hoinh:

clau ha su&n ph6i li6n

tpc,

siit, thay d6i toiur
tr4ng, BC t6ng cao

-

Rd mpt ti6u h6a: c6 th6 16

vio

t6 trang ho[c rd vdo d4i trang

+

C6c trieu chimg s6i mdt giAm

di

vd vi6n s6i

di

chuyrin vdo 5ng ti6u
h6a. N6u vi0n s6i qu6to c6 th6 g6y t8c ruQt

+

Ch6n doriql

hinh

anh: hinh anh mrlc nudc

hoi,

hinh md

cta

vi6n s6i
trong 6 bgng. C6 khi qua phim bqng kh6ng chuan bi hoflc si6u 6m bgng

-

thulng

+

Si6u 6m nQi soi: vi€n s6i ldm t5c cO mi m6t

vi

doan hgp <ing gan
3. S6i

ilulng

mft

chinh:

-

Vi6n

s6i

di

chuy6n vdo dudng m4t chinh

gip

trong

10-15%

BN

s6i
mpt. S6i dudng m4t chinh thudng

li

s6i sdc t5,

-

C6c y6u

t6

nguy

co :

nhi6m

ky

sinh trung tludng m$t-giun

dia,

citc
b€nh bAm sinh

dulng

mat nhu b6nh Caroli, gi6n hgp hay

xo

chit hqp duong
m4t, c6 gen MDR3 d6n di5n

rtii

lo4n bdi tii5t vdo

dulng

m{t.

-

BN

c6 th6 khOng c6 triQu chimg trong

i6t

ntridu

nim

v?r vi€n sdi di

chuy6n vdo trong t6 trdng tuy nhi6n trong phAn l6n c6c

trulng

hqp s6i

ttulng

mit

chinh sd giry cdccon dau quen gan cirng vdi c6c bi6n chimg nhiSm trung
a. ChAn tlo6n x6c {Iinh

-

TriQu chrmg l6m sdng

+

Tri€u chrmg di6n hinh cria s6i dudng mAt chinh ld dau h4

gid

sau con dau: nu6c ti6u s6m miru, phdn

b4c

miu

+

Kh6m: gan to

vla

ph6i, trii

mit

kh6ng so thdy

-

TriQu chimg c4n ldm sing

+

bio

m6u ngo4i v!: B4ch cAu t5ng, tiic dQ m6u l6ng t6ng, CRP

tlng

+

Photphataza ki6m teng, GGT t6ng

+

Bilirubin

t6ng

chi

y6u ld bilirubin tryc titip >85,5-5mg/Dl, t6ng t6i da
I6n dt5n 256,5

mot/l-15me/dl (khi

tAng cao hon n€n ngtri d6n ung

thu

dutrng
ma0

*

Men

gan tdng vira ph6i

thulng

tdng

du6i 5

lAn. Trong trudng hqp
n4ng c6 thC t6ng g6p 10len

+

TAng nhe amylase do <sub>Ph6n </sub>ung tUY

+

D6ng m6u: r6i loan h5p thu vitamin

K

sring hai ndng, ddy thanh duong mflt do vi€m nhi6m. Hinh anh gi6m 6m cria
papille

thf

phrit sau hign tugng viOm do vi6n s6i

di

chuy6n vdo trong b6ng

Vater

+

ChUp

m{t tpy

nguoc ddng c6 dO nhay vd ttQ tl6c hi€u cao hqn 90%.
Xu6t hign hinh khuyt5t trdn phim. Vira c6 t6c dgng ch6n dorin vira c6 tric dqng
di6u

tri

b. ChAn tlorin bi6n chring

-

NhiSm

kluan

Ouong m6t: xin xem bdi nhi6m khuAn duong

mft

-

X<r gan m6t thri phrit
c. Ch6n

tloin

phAn biQt

-

U b6ng Vater

-

Vi€m gan

virut

-

Giun duong mflt

-

Xo

gan ir mAt ti6n ph6t

III. DITU

TRI

1. BiQn ph6p chung

-

Nhap vi6n theo d6i tai khoa ti6u h6a ho4c dcrn vi phSu thu@t gan mflt

-

NiSu BN budn nOn:

+

N6u nOn tlflt sonde da ddy

+

Thu6c ch5ng n6n

o

Metoclopramid: 10-20mg- ti6m b6p, nh6c <sub>Qi </sub>sau

m5i

4-6 gitt.

o

Prochloperazine:

5-l0mg-nhic

l4i sau 1-2 gid

-

ndi

php nu6c vir diQn gi6i

-

Giam dau vir co th6t theo

dulng

ti6m

+

Dicyclomine 20mg-40mgti0m b6p, nh6c l4i sau 6 gid

+

Thu5c gi6m dau: Thui5c gi6m dau ch5ngvi€m kh6ng steroids

o

Meperidine

50-l50mg

ti6m b6p

ho{c

ti€m

du6i

nhic lai

sau 3-4
gid. Nt5u dau mrlc d0

ning

c6 th6 truy€n tinh mach v6i li6u t5-35mg/gid

</div>
<span class='text_page_counter'>(128)</span><div class='page_container' data-page=128>

-124-o

Ketorolac:

ti6m

tinh

m4ch 30mg/

m6i

O giO kh6ng

vugt

qu6
l2)mglngity. Ti0m b6p

v6i

li€u 60mg/m5i 6 gio.

Khi

bQnh nh6n dd dau nhanh
ch6ng chuy6n sang

dulng

u{lng 20-40mg, nh6c l4i sau m5i 6 gio

o

Indomethacin

75-l50mg u6ng

1

1i0u

duy

nh6t hoAc chia

d6i,

1i6u

khdng vuqt qu6 1500mg/ngdy

-

VitaminKl

20mg

-

Klr,ing sinh theo ducrng ti6m truydn tinh m4ch:

+

Theo khuy6n c6o cria hiQp hQi benh ti6u h6a

M!,

chi dlnh

ding

khang

sinh

o

B4ch cAu m6u

ngoaivi>l2,5Gll,

benh nhan c6 siit>38,5 d9 C

o

Ngudi gia>60 tu6i

o

D6i th6o

dulng

o

BQnh nhAn co suy gidLm miSn dlch

+

Cric kh6ng sinh su dqng

2. Eidu

tri

tl4c hiQu

a. S6i

trii

m$t

-

S6i tui m4t khdng c6 bi6n chring:

+

Phiu thuflt: BN du lich, BN c6 nhidu dqt dau

+

Didu tr! nQi khoa

Lua chon ddu ti6n

Diring

vdi

lactamines

Thdi gian
di6u

tri

Vi€m tui mflt

cap

uuy6t aEng
kh6ng 6n dinh

Ceftriaxone l-2glngiry
hay Cefotaxime

4-6 gl ngiry + Metronidazole

500mg

x3lngiy

Tuong tU *Gentamicine

7-8mg&g mQt li6u duy
nh6t trong 48 gid

Ofloxacine 400mg

sau tl6 200mg x2
lngiry +
Metronidazole
500mg x3lngdy

Tuong tU

5-7

rgity

Vi€m dudng
mflt chinh
Vi6m tludng

m$t sau NQi soi

mflt h;y ngucrc

ddng
Huytit tlEng
kh6ng 6n dinh

Tuong tg vi6m tui mQt

c5p + Gentamicine
7-8mglkg m6t

ldu

duy nhSt

trong 48 gid

7-10 ngdy

</div>
<span class='text_page_counter'>(129)</span><div class='page_container' data-page=129>

.125-o

Vdi

c6c thu6c c6 chrla axit mflt; vi€n s6i <15mm, chrlc ndng

trii

m{t

binh

S6i

hii

m$t kdm vi6m trii m4t m4n: ph6u thu4t do nguy co ung thu

-

t4m thdi mflt qua nQi soi. Khang sinh phr) ho. p

.. .. ':

-

Vdi

ngudi gid ddn

lm

mflt tpy ho{c vdi ngudi trd phdu thuQt l6y 6i

-

S6i ducrng m$t chinh

v6i

vi6m

hii

m{t

cAp: phlu thuflt don thudn ho4c

l6y s6i qua n6i soi sau tt6

phiu

thu4t

-

S6i t6n luu

-

Trong

trulng

hqp BN <50 tu6i, vi6n s6i <15mm trin s6i

BQ Y TE - HUdNG DAN CHAN EoAN VA DIEU TRI BE. NH TIEU HoA

-126-Tni

[Qu

tham

kh6o

1.

Greenberger NJ., Paumgartner G et al 2010. Diseaes of the Gallbladder

and Bilducts.

Hanison's

Gastroenterologt and Hepatologt. Edittors
Fauci AS., Kasper DL., L6ng DL., Braunwald E., Hauser SL., Jamerson

JL:439-458.

2. Apstein

MD.,

Carey

MC

et

al

1996. Pathogennesis

of

cholesterol
gallstones.

A

parsimonious hypothesis. Eur J Clin Invest;

26:343

3.

Attasaranya S et al 2008. Choledocholithiasis ascending cholangitis and

gallstones pancreatititis. Med C lin North; 92-925

4.

Elwood DR 2008. Cholecystitis. Surg Clin North Am; 88:1241.

5. Freeman

ML et

al

1996.

Complications

of

endoscopic

biliary

sphinterotomy N Engl J Med; 335-909

6.

Hofmann

AF

2009.

Bil

acids, trying

to

understand their chemistry and
biology with the hope of helping patients.

Hepatologt;49:

1403.

7.

Lambert F., Miquel JF (2008). Gallstone disease: from genes to evidence

</div>
<span class='text_page_counter'>(130)</span><div class='page_container' data-page=130>

8.

Paumpartner G 2008. Non surgical management

of

gallstone disease in
Sleisenger and

Fordtran's

Gastrointestinal and

Liver

disease. 7ed

M

Feldman et al (eds). Philadelphia, Saunders: I 107-1

I

115.

9.

Partinase et al 20Q6. Cholesterol gallstone disease. Lancet

368

250.

l0.Shiffman

M

et

al

1995. Prophylaxis against gallstone formation with

ursodeoxycholic acid in patients. Ann Intern Med; 122:999

ll.Zallekas

J., Munsens JL 2008. Complications

of

gallstones

theMirrizzi

syndrome, gallstone ileus, gallstone pancreatitis complications

of

lost
gallstones. Surg Clin Norh Ann; 88: 1345.

</div>
<span class='text_page_counter'>(131)</span><div class='page_container' data-page=131>

-127-CHT,ONG 3:

BTNH

Lf

DAI

TRANG

rAo

n6N

T6o b6n la benh phti bitin, theo th6ng k€ dich t6 hgc cria

M!,

co 2Yo ddn
s5

Uy

bi

t5o b6n, mQt nf,m c6

ti

2-3 triQu ngudi

My

dugc

citc btrc si k€ toa

thuiSc nhu4n trudng, g2.OO0 <sub>ca ctugc </sub><sub>cho </sub><sub>nhdp viQn </sub>

<sub>vi </sub>

lf

<sub>tri</sub>

vong

lndmc6 li6n quan hay kdm theo t6o b6nr.

Tt

thap ni€n 90,

vli

chc phucrng ti6n chAn do6n mdi , ngudi

ta

ddtim ra
clugc mQt s6 nguy6n nh6n thpc thti cria t6o b6n, vir cl6 di6u

tri

bing thri thupt vd
ph6u thupt c6c nguy6n nhdn thyc thiS ndy.

Nhirng th6ch

thfc

trong chAn ilo6n hiQn nay ld

1.

T6o b6n

li

cli ti6u kh6ng thuong xuy6n, trong c6ng trinh nghiCn

cfu

cria Pard 2001 triQu chimg r4n glngsrtc chii5m

ty

lQ 81%, phdn crlng chi6m

ty

lQ 71%, trong hic triQu chrlng il6y bpng chitim

q

vi

cli cAu du6i 3

lAr/

ngdy 360A,

vi

vpy triQu chimg

rdn

<sub>eing </sub>sr?c ld triQu chrlng chinh cria t6o
b6n chrl kh6ng ph6i triQu chimg

tli

ti6u

kh6ng

thulng

xuy6n la

trieu

chimg

chinh.

2.

T6o b6n ld vAn d6 ngo4i khoa, t6o b6n c6 thti diAu

tri

ngopi khoa?

Theo th6ng kC cdra Anthony Lembo 2003

thi c6

d6n

4l%

bqnh nhdn t6o b6n ld
do nguyOn nh6n gi6m ilQng clpi trdng vn bC

tic

ducrng ra, ddy ld 2 nguy6n nh6n

phii

diAu

tri

beng ngo4i khoa.

I. CHAN DOAN

I

Lflm sing:

Chan doan t6o b6n dpa theo ti6u chu6n Rome

III

nhu sau: C6 2 hay hon

2

ti€u chuAn sau, t5i thi6u 3 thdng(khdng cAn li6n tpc) trong 6 th6ng:

-

-

Phai drng tay girip de di cAu

>

Il4

s6lAn di cAu

-

Di ciu

< 3 ten / tuAn

-

Kh6ng

ti6u

ph6n 16ng

vd

kh6ng dri

ti6u

chuAn hQi chtmg ruQt kich
thich

2.

ChAn do6n nguy6n nhffn

Theo tdc

gitr Anthony Lembo (10/2003) diAu

tra

1.000 bQnh nh6n t6o
b6nr, k6t qu6:

BQ Y TE - HUONG DAN CHAN EOAN VA DIEU TRI BE. NH TIEU HOA

</div>
<span class='text_page_counter'>(132)</span><div class='page_container' data-page=132>

-

Dai

trang co b6p

BT

|

+

Thu6c ch5ng trAm

cim

+

Thu5c

fc

chii 5

[IT3

trong .liAu

tri

IBS t]re ti6u ch6y
b. Gi6m ilQng tl4i trirng

<sub>- </sub>

SIow

transit

(137o)

Nguy6n

nhdn

thulng

g4p

nh6t

trong

gi6m

dQng

d4i

trang

li

bQnh

Hirschsprung (Megacolon), nguy6n nh6n thir hai ld do thitSu t6 biro trung gian

cajal

& du6i ni6m mac v2r co thirnh ruot (Interstitial cells

of

cajal)(ICC), tuy

nnien au s6 hien nay kh0ng tim rO dugc nguy6n nhdn cp th€.

c. tIQi chri'ng

t{c

ngh6n

du}ng

ra (Obstructed defecation

-25o/")

-

Sa tryc trang kieu tui (Rectocele)

-

</div>
<span class='text_page_counter'>(133)</span><div class='page_container' data-page=133>

-129--

Encopresis ( T16 em

<sub>- </sub>

<sub>tu6i hoc dudng )</sub>

-

Sa san chpu

chri'n

tilc

duln

-

X

quang ho4t tlQng tlpi trang (Colonic tran sit Sitzmarks)

defecography)

l{tnlr t : Vl thtn{c Sitxmmla; lnnh 3 : Vi€a thuSc Sitemart* cd 24 v&ng c$n

quBn€i

K6t

qufr:

1.

T6o b6n d4i trdng co b6p <sub>binh thunng , </sub>s5 vdng c6n quang cdn lpi
duoi20Yo (4 vdng) tr6n phim chpp bUng viro ngdy

tht

3 (hinh 3).

2.

T6o b6n do gi6m ctQng clpi <sub>trdng , </sub>sO vdng can quang cdn I4i tr6n

s0% (20 vdng

<sub>) </sub>

nim

rhi rdc trcn khung dai trdng tr6n phim chup bpng vdo
ngey

thf

3 (hinh a).

BQYTE - HU6NG DAN CHAN EOAN VA DIEUTR] BENH TIEU HOA

-130-ra

</div>
<span class='text_page_counter'>(134)</span><div class='page_container' data-page=134>

3.

T6o b6n do hQi chimg t6c nghgn duong

ra,

s6 vdng c6n quang cdn
l4i tr€n 80% <sub>(20 vdng ) vd </sub>

nim

tflp trung d tryc

tring

tr6n phim chpp bung viro

ngay

thf

3 (hinh s)

HlnhS:\hdngv&ng Flrnh 4 : > 8O* vtrng c&n quatg r{i d*u

dtri UtnS

sOJ

rE - HUONG pAN cuANOOAN VA EIEU TRI BENH TIEU

HOA

-l3l-.ns

,ffi

1,,

ln

"#

s

:

*f,1

t..

</div>
<span class='text_page_counter'>(135)</span><div class='page_container' data-page=135>

B0Yre-uu6rl

G DAN cHAN

ooAn

va

prcu rru

nBNu

rlpu

Hoa

</div>
<span class='text_page_counter'>(136)</span><div class='page_container' data-page=136>

{

Be Y rB -

HuoNc

nAN

csaN

poRN

ve

orgu

rnl

gE. <sub>NH </sub>

<sub>rrcu uoe</sub>

'ii*r',";. ... ,i.{r

</div>
<span class='text_page_counter'>(137)</span><div class='page_container' data-page=137>

33-,a;t...:.:,

B.

II. DIEU TRI

1. Didu

tri

nQi

Gi6m clQng dpi trdng

<sub>- </sub>

IBS t6o b6n

<sub>- </sub>

T6o b6n chrlc n6ng:

dtng

c6c thu6c

kich

thfch nhu

clOng

nhu

bisalasyl,

thu6c titc

dOng

tr6n

thp

thiS

5Fil4

(Prucalopride).

2. Di6u

tri

Anismus

chich

Dysport ( Botulinum Toxin

A

<sub>) vdo co mu </sub>tryc <sub>trdng , du6i hu6ng</sub>
d6nm6y do di6n co EMG.

Di€u

tri

anismus b6ng tpp ph6n hOi sinh hgc (biofeedback) sau

khi

chfch
dys tciSt o ddi vd hiQu qu6

BOY - HU6NGEEN CHAN DOAN V r

</div>
<span class='text_page_counter'>(138)</span><div class='page_container' data-page=138>

-134-*

EOTTE=udNc

oAN cH Inl$ftil r

rmu uoe

-r

</div>
<span class='text_page_counter'>(139)</span><div class='page_container' data-page=139>

III. KET LUAN

khoing

4l%

t6o b6n c6 thi5 chAn do6n nguy6n nhdn

vdi

c6c phuong
tiQn chAn do6n :

X

quang hoat d6ng d4i trdng (Colonic tran sit <sub>Sitzmarks) , </sub>

X

quang

<sub>tryc </sub>

<sub>trlrng ho4t </sub>

<sub>tlQng (Defecography), </sub>

<sub>do </sub>

<sub>6p </sub>

<sub>lpc </sub>

<sub>vdng hflu </sub>

<sub>m6n</sub>
(Analmetry) , si6u 6m

hfu m6n

(Endo-anal-sonography), do dign ccr (EMG),

sinh

thi6t hdu mdn-truc trdng

vd

chup

cOng

huong

tt

ilQng

hqc

(MRI
defecography).

C6 th6 di6u

tri

c6c nguyEn nh6n t6o b6n

bing

thudc th6 hg mdi, thri thugt vd
phSu thu4t.

Tni

liQu

tham

khf,o

1.

Anthony Lembo <sub>, </sub>

.

Clinical

and Physiological Assessment. 14th

Annual Colorectal Disease Meeting Feb 13-25 Florida USA.

5. wexner,

steven

D. M.D.

and

al .

A

constipation

scoring

System to

Simpliff

Evaluation and Management of Constipated Patients. Drs Colon
Rectum Volume 39(6) June 1996,pp 681-685.

</div>
<span class='text_page_counter'>(140)</span><div class='page_container' data-page=140>

-136-DITU TRI

TRi

Tri

li

benh ptr6

ti6n,

dirng hang dAu trong c6c benh virng hQu m6n d6n

kh6m d khoa h6u m6n hoc. La benh kh6ng anh huong d6n sg s6ng cdn, mir ld
loai bQnh gdy kh6 chlu 6nh huong d5n chAt luqng s6ng cria bQnh nh6n.

Mgc ti6u chinh cta didu

tri

li

gi6m thi6u c6c triQu chfng gdy kh6 chiu
vd

cii

thiQn chSt lugng s6ng cho benh nhan. MOt s(5 lon bQnh nhdn c6 k6t qu6

ttit

ft!,

tuy nhi6n v6n cdn mQt s6 nh6 c6c trudng hqp c6 c6c di chimg
cfing nhu c6c bi6n chring sau di6u

tri.

Vi

vdy viQc chgn lga phuong ph6p didu

. :

<sub>-. ,.:</sub>

tn

van con duoc ban cal nnleu.

HiQn nay vdi nhiing hi6u bi6t va sinh benh hqc benh tri, c6c nhd

hiu

m6n
hgc c6ng nhfln

ld

cdc ddmrtii tinh m4ch

tri

li

tr4ng th6i sinh ly binh thuong, t4o
n6n l6p dQm

0

6ng hflu m6n, girip ki€m soiit sg

ty

cht cia

d4i tiQn8.

Tir

ph6t

hiQn ndy, quan niQm mdi vA tli6u

tri

ld c6 ging b6o t6n lop dQm ndy, do d6

c6 nhi6u thay d6i trong di6u

tri

xo

C6t khoanh ni€m m?c (Whitehead <sub>)</sub>

o

Cit

tri

ftrng biri :

.

<sub>tri </sub>

<sub>md </sub>(Milligan Morgan)

.

C6t

td

kin (Ferguson)

+

Khdu treo

tri

(anopexy)

o

Khdu treo tri v6i m6y b6m (Longo)

o

Kh6u treo

tii

bing tay (A. Hussein)

+

Khdu cQt dQng m4ch

tri

dudi huong dAn cria si€u 6m Doppler

Trong

2 h$i

nehi vd

h4u m6n

trgc

tring

trong

nem 2003

la

hQi nghi

HMTT

tpi TPHCM vd hQi nghi

HMTT

A

Cnau

hn ttul

S d Seoul, 2 tirc giit c6

bdi t6ng quan v6 didu

tri

dd tlua ra nhfln x6t vA

ty

lQ c6c phucrng ph6p diAu

tri

O nu6c

Jean Denis Stanley.M.Goldberg

</div>
<span class='text_page_counter'>(141)</span><div class='page_container' data-page=141>

-137-Di6u

trib6o

t6n 45,2yo 45%

Di6u

trivdi

dpng cp 45,5o 46%

PhAu thudt 9,3o 9%

Trong

thoi

t14i thdng

tin

qua m?ng ph6t triiSn mpnh, chring

ta

dd nhfln
duqc rat nfriAu th6ng

tin

rRI

BAo

roN,

EItu

rRI

iT

xAvt

H{.I:

Ld sg lga chgn ban cIAu trong di6u tr! tri.

1. Ch5 tIQ 5n nhidu chAt xo:

Cd nhi6u c6ng trinh nghi6n ciru (dugc x6p vdo lo4i

A

trong

bing

phdn
lopi cria y hgc chring

cf

<sub>). </sub>ChC dQ 6n nhi€u chAt xo girip phdng ngira t6o b6n vd

lim

gi6m triQu chimg cria benh tri.

Nhu

chfng

ta

ddbitit dung l6u, ngdi

hu

vd
kh6ng c6 th6i quen

tli

cAu dring gid, ldm viQc cdng

thing cta

cu

den thenh thi

A ,l <sub>' </sub> r <sub>^ </sub> 7 a N rr1 <sub>^ </sub> t

^ r I .

ld y6u t6 nguy co cao cria bQnh

tri.

Khuy0n bQnh nhan tap th€ dpc

vi

ch0 ctQ 5n

nhi0u chAt xo c6 th€ ldm gi6m triQu chimg tri.
2. Thu6c

tlng

cudmg thhnh

tinh

mqch :

Y

hgc chimg

cri

ghi

nhQn c6c thu5c tdng cudng thenh

tinh

m4ch

lim

gi6m dugc c6c triQu chimg

tri,

dugc x6p vdo lo4i B trong

bing

phdn lopi

cta

y
hgc chimg

ct,

dga tr6n nghi0n cr?u ng6u nhi€n, Srl dpng nhfrng thu6c tSng

culng thinh

tinh m4ch

niy

ld chgn lga clAu ti6n trong cli6u tri tri.

Thuiic

tga duqc vh kem b6i

t4i

ch6 :

Thudng cfugc sri dgng t<Ct frqp

vdi

thu6c t6ng cudng thdnh

tinh

mpch
nhrmg chua c6 c6ng trinh nghiOn criu ndro chimg minh hiQu

qui

vd y hqc chimg
crl c6ng nhQn

4. Thudc ch6ng t6o b6n:

Khi

di6u

tri tri

thuong cdc bdc si chri

f

den diAu

tri

cdc 16l lo4n luu thdng
ruQt nhu ti€u ch6y vd t6o b6n. Nhung c6c nhd h4u m6n hgc khuy6n c6o

khi

dUng thu6c

tri

t6o b6n n6n

dtng

thuiSc t4o kh6i phdn vd tr6nh sri dqng c6c lopi
thu(ic nhufln trdng

vi

thuiSc xO

vi

chring sE ldm

ting

triQu chimg

hi

Khi

di6u

tr!

t6o b6n ta cflng dung qu€n khuy€n bQnh nhdn

tlng

lugng nudc u5ng, gi6m
uting cbc thttc uting nhiAu kich thich nhu

ci

ph6, trd cl4m vd rugu bia. Tr6nh 5n

thyc phAm qu6

nggt

nhu chocolate, mrirt ld thgc phAm gdy t6o b6n dflc biQt vn
c6c

lopi

thuiSc u6ng

c6

tirc dUng phU gdy

t6o

b6n

nhu

kh6ng

vi6m

khong

thuiSc an thdn

...

</div>
<span class='text_page_counter'>(142)</span><div class='page_container' data-page=142></div>
<span class='text_page_counter'>(143)</span><div class='page_container' data-page=143></div>
<span class='text_page_counter'>(144)</span><div class='page_container' data-page=144></div>
<span class='text_page_counter'>(145)</span><div class='page_container' data-page=145>

-eeyrE

su6Nc

oAN cuAN

poaN

vA D

Eu rru

nENH

rrcu

Hoa

</div>
<span class='text_page_counter'>(146)</span><div class='page_container' data-page=146>

Tni

liQu tham kh6o

1. Barron

J

1963 Office ligation of hemorrhoid. Dis Colon Rectum
105:563-70.

2.BatL,

Melzer E, Koler

M

(1993) Complication of rubber band ligation
of symptomatic internal hemorrhoids. Dis Colon Rectum 36(3):287'
90.

3. Blaisdell PC (1958) Prevention of massive hemorrhage secondary to
hemorrhoidectomy. Surg Gynecol Obstet I 06 :485 -8.

4. Broader

IH,

Gunn IF, Alexander-Williams J

<sub>Q97$. </sub>

Evalution of a

bulk-forming evacuant in the management of haemorroids. Br J Surg

6t:142.

5. Charles V.Mann

(2001|

Surgical treatment

of

haemorrhoids.

i.01.,:1;;.i , .:. .: ';tr I 1,:. :.;ji,

</div>
<span class='text_page_counter'>(147)</span><div class='page_container' data-page=147>

-143-o

T6ng phdn tich m6u c6 th6 th6y tdng nhe bpch cAu vd tiriu cAu. C6 the
c6 thi6u m6u.

o

TOc clQ m6u 15ng (ESR) c6 thli

t[ng

nghi€m phan: c6y phdn c6 thd th5y

vi

khuAn ducrng ruQt, rning vd

kyi sinh

trtng,

vi

6m tfnh cli5i

vdi

Clostridium

difficile.

-

Nqi

soi dpi trang

li

x6t nghiQm lua chon oe

nem

tra t6n thuong dpi
trdng tl6nh gi6 mrlc c16 lan rQng vir mric ilQ n[ng, sinh thirit ldm giAi phSu benh

l)7 d6 chAn do6n phdn

bict

giua c6c bcnh

IBD

vd mQt s6 benh nhGm khuAn

kh6c, bpnh vi6m clpi trang c6p

tg

han ch6, vd ch6n do6n ph6n biet

VLDTTCM

v6i

b6nh Crohn. MOt s6 hinh enh

n6i

soi dflc trung cho t6n thuong clpi trang
trong b0nh

VLDTTCM

thc nhe ld : c6c chAm d6, t6 chric h4t, kh6ng th6y mpch
m6u vd dE chay m6u khi ti6p xric.

Khi

benh n{ng hon, sE thdy c6c6 loet nho, tu

chiy

m6u, vd c6c vung lo6t lan rOng, c6 thi5 thdy gihpolyp, cAu ntSi ni6m mac.

Sinh

thict

vung

t6n

thuong (bao

gio

cfing sinh

thitit

vtng

truc

trang) vd
kh6ng c6 t6n thucrng Ae tam gi6i ph6u benh ly.

-

chup

khung d4i trdng c6 barit

dtii

quang k6p thuong chi dinh trong

trulng

hqrp bQnh nhg cho phdp rl6nh gidt6nthucrng ni6m mpc dpi trang dang
hqt, mdt c6c nt5p g6p, <sub>ruQtngen lpi, ru6t </sub><sub>c6 </sub><sub>hinh 6ng, </sub><sub>c6 </sub><sub>thc th6y gi6 polyp. </sub>

<sub>c6</sub>

th6 nghi ngd ung thu n6u they khoi b6t thucrng hoflc d6u hiQu

tic

ruOt.--

Vi6n

nang nQi soi: c6 th(i sri dpng thay thtf cho

n6i

soi dai trang tuy
nhi6n chting chi cllnh n6u c6 dAu hiQu

tic

ru01.

2. ChAn do6n phfln biQt:

cAn chAn do6n phdn biet benh

vLETTCM v6i

hai nh6m benh chinh ld
b$nh tlpi trdng do nhiSm khuAn vd khOng do nhiSm khu6n. T6n c6c bEnh c6n
chAn doan phdn biQt dugc the hien & bang sau:

Bing

ch6n

do6n phan biQt bQnh vi€m lo6t

il4i

trgc

tring

ch6y m6u:
BQnh nhiSm khuAn

vi6m

tt4i trang nhi6m

khu6n

c6p (satmonella, shigella, campylobacter,
Yersinia, Escherichia

coli

0 I 5 7 : H7)

Vi€m d4i trang do amip

Vi6m tlpi trang gidm4c do Clostridium

dfficile)

BQnh vi6m tt4i trang

virut

do gi6m

mi6n

dich (cytomegalovirus,
Herpes simplex vt]'us, <sub>Neisseria gonorrhoeae, Blastocstis hominis, Chlamydia)</sub>

BQnh kh6ng nhiSm khu6n

</div>
<span class='text_page_counter'>(148)</span><div class='page_container' data-page=148>

-146-Benh Crohn

Vi6m d4i trdng do x4

tri

Vi6m d4i trturg do thii5u m6u

Vi6m d4i trang vi th6 (vi€m d4i

tring

do hQ th6ng t7o keo)

a. ChAn 6o6n

phffn

biQt bQnh

VLDTTCM

vfi

c6c bQnh

64i

trdrng nhiSm
khu6n:

MQt s6 benh

<sub>$ </sub>

nhiSm knu6n clpi trang c5p tinh hay cdn ggi

li

benh vi6m

cl?i trang cAp

ty

han- ch€ dugc the nign o b6ng 1. DC chan do6n ph6n bipt c6n

sinh thiet vung tr.uc trang

vd

c6y phan.

c6c

bQnh vi€m 1o6t ct4i trang do suy
gi6m mi6n aictr ttruong phdn biet

khi

benh chinh c6 chAn clo6n x6c dfnh nhu
AIDS, gonorrhea...

b.

ChAn do6n

phf,n

biQt bQnh

VLDTTCM v0i

cic

bQnh

64i

trirng

kh6ng
nhiSm khuAn

Benh

VLDTTCM

c6 the ph6n biQt vdi benh Crohn b6ng nhi6u chi ti6u ttr
hinh enh nQi soi ddn ktit qua gi6i ph6u benh

lf

(xem bang 3). Bonh vi6m 1o6t

cl4i

tring

do x4

tri

g6p

0

benh nhan c6 ti€n srl tti6u

tri

tia xp. BQnh vi6m clpi
trang

vi

th€ <sub>16enh </sub>hQ th6ng t4o keo) c6 hinh anh nQi soi binh thucrng nhrmg c6

hinh anh vi€m rt4i trang mpn tinh tr6n ti6u ban gi6i

phlu

benh <sub>ry.</sub>
3. ChAn tlo6n mQt sii bi5n chftng cfra bQnh

VLDTTCM:

a. Phinh

il4i

trirng

nhiSm dQc

Phinh

dai

trdng nhi6m

itac

ld

mQt bii5n chrlng hiiSm

gpp

cria benh

WDTTCM,

<sub>v6i ry </sub>

le

<

2yo.

Bi€n

chrtng ndy thudrng gap

d

benh nh6n c6

y;DTTCM

thC lan t6a toan b0 clpi

tring

(pancolitis) tuy nhi6n d6i

khi

cflng c6

th6 g{p 0 tho benh h?n chi5 hcrn.

c6

the g?p phinh tl4i trang nhi6m dQc o bat

ct

thdi

di6m

nio

cria benh nhung thudrng

gip

e giai

do4n s6m vd t'j' 19

ffi

vong

khoang ls-51yo.Bii5n chimg

niy

ki5t hgrp

v6i

thring ruQt sE d6n d6n nguy co

trl

vong cao.

b. Thring ruQt

fhring

ruQt

li

bii5n chrlng cria

VLETTCM

th6 n{ng,

ctng

khi

kh6ng

t6t

frq'p

vdi

phinh ctpi trang nhi6m dQc. Trudmg hSp thring ruQt

nly

thucrng cr

'-l

grar ooAn oau cua benh vd hay xhy ta nfrat O el4i trang sigma.

Thtng

ruQt vdo

khoang tg do d6n dtin tt} vong r5t cao.

c. Hgp tlutrng ruQt

Hgp iludrng ruot ln bi6n chimg hi6m gflp cria benh

WETTCM

vi

vay khi

"rat

nien hgp tluong ruOt thudrng phdi nghi ngd c6

urg

thu. Di6u

tri

thucrng le
c6t do4n

*&

o

benlr nhan cO

tidn

sri bQnh I6u

nim

m4c dtr sinh thi6t kh6ng
BQ Y TE . HUONG DAN CHAN DOAN VA DIEU TRI BENH TIEU HOA

-147-a

</div>
<span class='text_page_counter'>(149)</span><div class='page_container' data-page=149>

ph6t hi€n ung thu. Nrlu sinh thi6t co loan sdn nhi€u kh6 nSng c6 ung thu vd ld

chi

clinh tuyQt OOi OC

cit

*9t.

Nhirng trudng hgp hpp ldnh tinh

thulng

gW (r
benh nhdn c6

VLDTTCM

th6 hopt dQng lan r6ng man tinh.

Chiy miu

nhidu

Chiy

m6u dudng rugt nhi6u cAn can thiQp ngopi khoa cdp criu

ld

m6t
bi6n chrlng

hiiim

ggp crtabenh

VLDTTCM.

e. Ung

thu

Benh nhen

mic

b6nh

VLDTTCM

c6 nguy co ung thu cao.

Mfc

clQ lan

rQng

vi

thdi

gian

mic

bcnh c6 tuong quan

v6i

nguy co ung thu.

c6c

nghicn

ct?u cho th6y nguy co ung thu o b6nh nhdn

VLETTCM

khoing

l3Yo sau20
n6m m6c bQnh vd 34Yo sau 30 ndm. Thucrng

VLDTTCM

tho han chti c6 nguy

co

th6p vn

th€

lan rQng c6 nguy

co

cao.

ung thu d

benh nhdn

VLETTCM

thulng

kh6ng ph6t tri6n

tt

polyp 6ng tuyi5n

mi

ttr c6c tO chric bi lo4n sin md tO

chric lopn s6n ndy kh6ng the phdn bi6t

vdi

td

chric l6n c4n kh6ng

bi

1o4n s6n

qua nQi soi.

Vi

vdy, khuy6n c6o benh nhdn mdc bQnh l6u hon 7-8 n6m cAn theo
ddi nQi soi clinh

k)

hdng ndm vh sinh thitit r6t nhiAu

minh

(>30 mAu sinh thitit)
rtri rdc toan bQ d4i trang. Ntiu c6 lo4n

sin

thudmg c6 chi dinh cat ruQt. N6u co

pollp mi

td chric xung quanh kh6ng c6 1o4n s6n thi c6 th6 cat polyp nQi soi.

rrr. DIEU TRI BpNH VIEM LOET

E+r

TRIrC

TRANG CHAY IAAU

Cfc

didu

tri

chung

-

MUc ti€u ctiAu

tri

ld tlti phpc hOi sric kh6e chung vd bQnh nhen

tr0

nhip s6ng nhu ngudi binh thuong.

-

C6 nhi6u lopi thu6c c6 th6 sri dpng Ae OiCu

tri

b6nh

VLDTTCM

vd dd

duy

tri

giai do?n 6n dinh benh.Mdc du c6c thu6c

niy

c6 hi€u

qui

ro rQt nhmg
cfrng c6 nhiOu t6c dpng phg.

-

Di0u

tri

c6c bi0n chung

cta

benh c6n ki5t hgp

giira

cdc bdc sy ti6u h6a

vit cdcph6u thuQt vi6n cl4i tr.uc trdng.

-

Trong diAu

tri

bQnh cfing cAn

luu

y

y6u

to

tam thAn

kinh

cria bQnh

nhen.

f6t

hqrp cti6u

tri

nQi khoa

vi

liQu ph6p t6m thAn td ytiu t6 cAn thi6t dC dpt
dugc hi€u

qui

cao.

2,

Cilc nh6m thu5c sfr dung aO OiOu

tri

bQnh

VLDTTCM

C6c nh6m thu5c, HOu lugng vd dudng dung cua cdc thu6c ndy fuy thuQc

vdo mric d0 vd giai do4n benh (xefn

btng2).

2:

Ctic nhdm thuAc

itiiu

VLDTTCM

BiQt dugc

Lidu

dtng

Thu6c chiing vi6m

5- Sulfasalazine <sub>2</sub><sub>.Vi6n </sub><sub>500mg, </sub><sub>uiing ngey </sub><sub>3-6 </sub><sub>g, chia </sub><sub>3 </sub><sub>- </sub><sub>4 </sub>

<sub>hn</sub>

BQYTE - HU6NG oAN cHAN DoAN

vA

DIEU TRI BE. NH TIEU HOA

</div>
<span class='text_page_counter'>(150)</span><div class='page_container' data-page=150>

Aminosalicylic
acid (5-ASA)

Mesalamine

Asacol

Pentasa

Balsalazide
(Colazal,Giazo)

3.Vi6n 500mg, u5ng ngey

3 g, 6

vi6n chia 3

lAn, duy

tri

3 vi6n chia 3 l6n
4.4.8 glngity

5.

glngiLy

6.Vi6n

750mg, u5ng ngey

3 vi6n

chia

3

16n

trong vdng 8 -12 tuAn

Corticosteroids

Prednisone 7.40-60mg/ngdy trong

vdng

l-2

tudn, sau d6

x. L .,

m6i tudn giam 5mg trong vdng 8

-

12 tuan.
Methylprednisol

one

8.60mg/ ngay, truydn tinh mpch, sau khi benh
thuyOn giarn chuyen sang u6ng

Budesonide Entecort EC 9.UOng 1viOn/ngdy

Hydrocortisone

10. Thpt

thrio

(100mg) mQt

hoflc

hai

lAn
lngity

Thuiic

ric ch6 miSn dich
Azathioprine

Imuran 1

1.

Vi6n ndn 50mg, u5ng lmglkglngay (t6i
da2,Smglkglngity

6-Mercaptopurine

12.

Vi6n n6n 50mg, udng

l-l,Smgkghgiry

Cyclosporine Neoral,

Sandimmune
Gengraf

13. Vi6n

nen25 mg vd 100mg, HAu dung

2-4

mgk/ngdy

chia 2ldnngey

Methothexate

14. Lq

5Omgl2m1, Ti6m bAp hopc tinh m4ch
25meftudnmOt lAn

Kh6ng sinh
Metronidazole

Flagyl

15.

Vi6n ndn 500mg, u5ng

2

glngity

chia2

lan

16. Lq

500 mgl100m1, truydn

tinh

mpch

1-2glngity

chia2ldn

Ciprofloxacin Vi0n 100 cltin 500mg

Lq

200ms./ 100m1 vd 100mg/50m1.

17.

18.

Cic

thuiic

sinh hoc

(anti-TNF-o

therapies)

Infliximab Remicade

19. Lq

l00mg, Pha

truy6n

tinh

m4ch

Sm/l<glngdy trong

2

gid,mQt li€u duy nhdt
Adalimumab Humira - Ti6m du6i da 40mg m6i tuAn

</div>
<span class='text_page_counter'>(151)</span><div class='page_container' data-page=151>

-r49-BQ Y TE. HU6NG DAN CHAN DoAN VA EIEU TRI BENH TIEU HoA

-150-a. Thu5c ch6ng vi6m S-Aminosalicylic acid (5-ASA)

Sulfasalazine vd Mesalamine duoc su dpng dti di6u

tri

bQnh

VLDTTCM

th6 nhe vir

vla

cho hiQu

qui

cai thien trieu chimg khoang 50-75% st5 Ugnfr nfran
trong vdng

4-8

tuAn. Sulfasalazine

ld

thu6c dugc

lga

chgn dC di€u

tri

b€nh

VLDTTCM

th6 nhg vd

via.

M$t

gam sulphasalazine chria khoAng 400 mg
mesalamine. Sulfasalazine dugc chi dinh

vdi

hdu 3-6glngdy trong

VLDTTCM

th6 cAp

tinh

(tfc

1,2

-

2,4 g mesalamine

/

ngdy. Tuy nhi6n c6

r1i

25% bQt)h

nhdn kh6ng dung n4p duoc sulfasalazine ho6c di ring v6i thuilc.

MQt s5 chAt O6n xu6t cira mesalamine cluo. c sir dpng nhu thu6c lya chgn

hang dAu. Nhirng thu5c

niy

c6 hdm luqng 5-ASA cao hcrn sulfasalazine,

v6i

it

tAc dUng

php

hon

ci

kJhi dung

v6i

li€u

cao. BQnh nhdn

c6 th6

dung n4p

mesalamine

voi

li6u

cao

hon

I

ngily)

vdi

c6c c6ng

thric

mdi

hon
sulfasalazine.

Hai

c6ng

thric

mdi

lir

Asacol

vir

Pentasa sE

gi6i

ph6ng

;"

mesalamine chri y6u d ruQt non. CAn

phii

theo d6i

chfc

ndng th4n

vi

men gan

kfii

dung cric thu6c ndy. G6n d6y Balsalazide cffng dugc dtng cho

VLDTTCM

th6 c6p tinh. Thu6c ndy c6 chria mesalamine (750mg balsalazide

chta267mg

mesalamine). Balsalazide

dugc

chimg

minh

c6

hiQu

qu6

h<rn

Asacol

vd
sulfasalazine qua

m6t

s5 nghiEn ciru.

Lidu

dtng

Balsalazide

ld

vi6n 750 mg

T,^

u6ng 3 viEilngay trong vdng 8 d€n 12 tuan.

Benh nhan c6 th6 h4n chli hay khu tru d tr.uc trang vd d4i trd,ng sigma c6
tne al6u

tr!

t4i ch6 qua dudng trpc trang ngdy 1 d6n 2

lan.

Benh nh6n c6 tdn

thuong

d

tryc

trang c6ch

6ng

hQu

m6n

khodrng

10 cm c6 thd sri

dpng
mesalamine dpng vi€n dan tl6t h4u m6n. Benh nhan c6 t5n thuong d doan dAu

tryc trang ho4c d4i trdng sigma c6 th6 di6u

tri

thut mesalamine. Tuy nhi6n cfing
cAn c6n nh6c

vi

d giai doan c6p tinh mQt s6 benh nhdn kh0ng

git

duqc thu5c

dE thgt ndn c6n didu

tri

bSng duong uiing tru6c cho dtin khi bQnh 6n dfnh hon.
b. Corticosteroids

Corticosteroids su dr,rng toan than hiQn dang duoc sri dung dti diCu

tri

benh

WDTTCM

th6 nhg vd

vira.

Khoang 75-90% benh nhan the nhg vd vira
c6 the diCu

tri

hiQu qu6

vdi

prednizone u5ng 40-60mg

/

ngdy. N6n trrinh sri
dgng Corticosteroids k6o ddi

vi

thti

gay ra nhidu t6c dgng phU nhu hQi

ch(mg Cushing,

trimg

c6, lodng xuong, tSng huyi5t ap, d6i th6o dudng, thorii
h6a th6n kinh, ho4i

tu

xuong... Di6u

tri

corticosteroid khoang 1-2 tu6n c6 th€
d4t dugc hiQu quA thuy€n gi6m triQu chimg, sau c16 cAn gi6m lidu

tt

tir

trong
vdng 6-8 tudn.

</div>
<span class='text_page_counter'>(152)</span><div class='page_container' data-page=152>

th6o (100mg) mQt ho{c hai lAn /ng}y. Dpn corticosteroid dugc sri dpng OC AiCu

tr!

vi€m trqc trang. Srl dpng 16u ddi lopi

thutic

dlt

t4i ch5 ndy cfing c6 th6 g6y

hQi chung Cushing, do v4y cflng n6n tranh dirng c6c thuiSc dtrng t4i ch5 co tdc

dung chuySn h6a nhanh cliS han chti dQc tinh cira thuiSc.

c. ThuSc ric ch5 miSn dich

Nh6m thu6c cl6ng dang purine nhu 6-mercaptopurine vd azathiopnne c6

vai trd quan trqng trong cti€u

tri

benh

VLDTTCM

. Ddy lA thu6c dugc lpa chQn

dC

cli6u

tri

benh

VLETTCM

th6

khang

td

hopc

phu

thuQc

dOi

vdi

Corticosteroids. Srl dUng 6-mercaptopurine d benh nhan c6 th6 benh khu tru d
tr.uc trang, d4i trang sigma

h

hqp 1)r. C6 thti thay th€

bing

methotrexate

vdi

Hdu 25mgltuan ba"g iludrng ti6m truy6n.

Trong nh6m thu()c

tc

ch6 miSn dich cdn c6 cyclosporine. Cyclosporine
c6 thiS hiru ich trong di6u

tr!

WDTTCM

th6 n{ng kh6ng ddp img

vdi

diAu

tri

corticosteroidT -10 ngdy. Cyclosporine diAu

tri vdi

1i6u 2-4melkg/neiry c6 th€

c6 higu

qui

nhanh tliSO% sO Ugntr nherl.
d.

Cic

thu6c sinh hgc

Infliximab

h

mQt kh6ng

the

don ddng

khang

TNF-

cl

trpc

tiiSp.

Infliximab

cho

hiQu qu6

ldm

sang nhanh ch6ng

b

70-80% c6c bpnh nhart

WDTTCM

phU thuQc corticosteroid hoflc ktang

tri,

ho{c th$ neng. T6c dpng
php cria

infliximab

bao gdm phan tmg

t4i

ch6 do truydn, n6n, budn ndn, mQt

m6i <sub>, mAn </sub>ct6...Tuy nhi6n hiQu qua cAn tii5p tpc dugc nghi€n cuu.

e. Didu

tri

ph6u

thu$t

chi

ctinh ec oidu

tri

ph6u

thu{t

WDTTCM

c6 thring ruQt,

chiy

m6u
n6ng, benh kh6ng ct6p ung

v6i

cli6u

tri

nQi khoa ho{c ph6t tri6n lopn s6n hoflc
ung thu.

Nhin

chung nguy co ph6t

tritin

ung

thu d

bQnh nhan

VLDTTCM

rat
cao nhung cflng chua dfi dC chi dlnh cbt Aqitrrgc hang dg phdng. Theo d6i ung

thu

bing

phuong ph6p nQi soi cffng c6 riit nhiAu hpn ch6,

vi

v4y n6n gi6i thich

k!

vdi

benh nhan ve rura neng han chii theo d6i ung thu cria nQi soi cfing nhu

lgi

ich cta ph6u thu4t trong dg phdng ung thu.

3. Khuy6n c6o tlidu

tri

cic

th6 bQnh

VLDTTCM

a. Th6

VLDTTCM

hgn ch6: &

tt6

tter, ch6, mrlc d0 nhe

vi

vira c6 thi5 diCu

tri

mesalamin (5-ASA) 500mg den <I{t hflu m6n ho4c 49 thpt th6o mQt cliSn hai tdn

mQt ngiry. Ntiu trong vdng

2

tudrt, triQu chimg l6m sang nAng [€n ho{c kh6ng

c6i

ffin

co thi5 thay thiS

b[ng

thpt hydrocortisone 100 mg

I

ngity.

N6u bQnh

nhen vdn kh6ng ct6p ung

vdi

iti€u tr!

vdi

c6c thu6c tr€n hoflc benh bi€u hien o

mric tlQ n?ng hcrn c6 tne diAu tr! bAng prednisone 40-60mg

I

ngiry,Uat

aiu

bAng

li6u cao sau d6 giarn Aan. NCu benh nhen

bi

t6i ph6t hopc khdng d6p ung

voi

c6c thu5c dA

di6; tri

tru6c ddy, cdn nghi

tdi

benh ph6t triiSn lan rQng hcrn, cAn

</div>
<span class='text_page_counter'>(153)</span><div class='page_container' data-page=153>

-151-n6i

soi dtl ch6n do6n. C6 th6 cdn nh6c di6u

tri

b6ng thu6c uc ch6 mi6n dich

trong trudng

hqp

bQnh

kh6ng d6p

img

ho4c

phg

thuQc

vdi

didu

tri
corticosteroid.

b.

Th6

VLDTTCM lan

rQng: d thti lan rQng, muc dQ nhe vd vira c6 th6 b6t

dAu di6u

tri

b6ng sulfasalazine u6ng 500mg hai t6n mQt

ngiy,

tdng dan len

v6i

li6u

3-4glngdy trong

vdng

1-2 tuAn. N6u bpnh nhan

di

rrng ho4c kh6ng dung
n4p

v6i

sulfasalazine, c5 th6 sri dqng c6c thu6c 5-ASA khiic (Asacol, 2,4 - 4,8

g/ngiry,

Pentasa 4glngiry

hoic

balsalazide 6,75glngiry).

Benh

prednisone 40-60mg

/

ngiry,

t6t

OAu

bflng

ICu

cao sau

d6

ginm

liiu

dAn

5mg/tuan trong vdng 8

-

12 tuAn. Benh nhan thi5 n4ng cAn nh4p viQn, tti6u h!
methylprednisolone 60mg/ngdy k6t hqp

v6i

b6 sung dinh du0ng. Oidu

tri

beng
thu5c ric chi5 miSn dich trong trudng hqp bQnh kh6ng d6p ung hoqc php thu6c

v6i

didu

tri

corticosteroid (xem phAn iilAu

tri

bAng thu6c irc chr5 mi6n dich).

c.

Phinh

tl4i

trirng

nhiSm tIQc:

dAy

ld

mdt

biiin

chrlng nflng

nd

cria

VLDTTCM

c6 th6 gAy trl vong, can

t6t

hqp gifra c6c phucrng ph6p di6u

tri

nQi

khoa vd phAu thu{t. Benh nhen can Oidu

tri

tai khoa hdi sric tich cuc. Can Oieu

tri

tich cr,rc:

bt

nudc

vd

diQn giAi, truydn

tinh

m4ch methylprednisolone
60mg/ngdy, khang sinh ph6 rQng

tinh

mach,

tl{t

sonde da ddy

vd

sonde

hiu

mdn. Nu6i dudng todn bQ

bing

lj

ngo4i khoa.

IV. DITU TRI

D\TPHONG

TAI

PHAT:

CO thiS Oidu

tri

dy

phdng

tdiphdt

bing

5-ASA.

O5i

vOi thri lan rQng

sulphasalazine 1g hai

len hgity,

olsalazine 500mg tttin 1g hai lAn/ ngdy, Asacol
Z,4glngiry, Pentasa 2glngiry

tl6

dugc chimg minh c6 tric dpng giam

fi

le

t6i
phrit. BQnh nhAn v6i the fr4n ch6 c6 th6 diAu

tri

bAng phuong ph6p thgt t4i ch6.

v.

TrtN

Lr/gNG

-

M6t

s6 nghi€n crlu cQng ddng cho th5y benh

VLDTTCM

c6 th€ c6

fj

l9

benh 6n dinh khodng 50o/o.

Ty

phii

c6t toan bQ d4i trang ld,24Yo trong
vdng

l0

nhm vd 30oh trong vdng 25

nim.

Tj, le bQnh nh6n v6n c6

khi

n6ng lao

dQng ld 93Yo sau 10 ndm m6c b€nh.

-

Mric

tlQ nane cria bQnh vdo

thdi

diilm ph6t hiQn ra b6nh c6 th6 ti6n
lugng ttugc ti6n tritin bQnh trong tuong lai vd

khi

n6ng

phii

cit tlai trang. M6t

s6 nghiBn cuu dya vdo cdng tt6ng cho th6y benh nhan

VLDTTCM

v6i th6 han

</div>
<span class='text_page_counter'>(154)</span><div class='page_container' data-page=154>

-1s2-ch6 khi ph6t hiQn benh c6

khi

ndng ti6n tri6n nAng 16n thanh th6 lan rQng vdi

tj'

lQ 30-50% trong vdng 10 nim.

-

Tj,

tri

vong d nh6m benh nhdn

WDTTCM

c6 cao hcrn trong c0ng
tt6ng huy kt Orrg cdn nhidu tranh cdi. MQt s6 nghidn cr?u dga viro cQng d6ng
gdn e16y cfing kh6ng chimg minh dugc tli€u

niy.

Neu t.j, 19 t'i, vong

o

nh6m

vdi

bpnh

WDTTCM.

Khoang

l}-ISYo cic

trulng

hqp vi6m ctpi trang ktr6ng the ph6n bi$t duqc 1A

VLDTTCM

hay b$nh

Crohn. Nh6m bqnh

niy

thulng

dugc gqi ld vi6m dpi tring'okh6ng x6c dinh".

3:

Chdn itodn an

WDTTCM

vd Crohn

Tni

IiQu

tham

khio

Benh Crohn
Vi6m 1o6t il4i tugc

trdng

chiy

m6u
L6m sing vd cQn l6m sang

Thuong gap (mQt

phin

ba)

Thunng e[+p @0%)

20% sd benh nhan
Thuong g4p

Kh6ng li6n quan

Thuong

t6n

thuong
c6ch qu6ng

75% sd benh nhan

Thudng

tl5n

thucrng

xuy6n thanh

20%

cdc

mdu

sinh
thi€t

Lu6n 1u6n

Li6n

tpc,

ttr tryc

tring

16n phAn tr6n

Thucrng

gi6i

han

ni6m m4c,

dudi

ni6m

mAc, trtr trudng hgp tOi

cap

Chi

li€n

quan diSn c6c

khe

tuyiSn

trong

vi6m
tl4i trang n?ng

Hi€m gap
Hi€m g?p

--. a

Hlem g?p
Hi5m gap

--. t

Hlem gap
TriQu

ch*ng

lfrm sdng

Benh c4nh hpu m6n
Dudmg rd

Apxe

Hgp tlucrng ruQt

Kiit

qu,fi nQi soi

ilgi

trdng

C6 t6n thuong trgc trdurg

Dang ti5n thuong

C6 t6n thucrng h6i trang

Kiit

qud girti phdu bQnh

DQ sdu cria vi6m nhi6m

T6n thucvng d4ng hpt

</div>
<span class='text_page_counter'>(155)</span><div class='page_container' data-page=155>

53-l.

Textbook

of

Gastroenterology Tadataka Yamada(2009). Inflammatory
bowel disease, Volume 1. 1386

-

1473

2.

Harrison Gastroenterology and

Hepatology

Dan

L.

Longo,

Anthony

Faucy (2010). In/lammatory bowel disease. 174-196

3. Schirbel,

A. And

Fiocchi,

C.J.(2010).

Inflammatory

bowel

disease:

established and evolving consideration on its etiopathogenesis and therapy.
Digestive Disease, I

l,

266-27 6.

</div>
<span class='text_page_counter'>(156)</span><div class='page_container' data-page=156>

54-fl

BpNH

CROHN

DAr

crIoI{G

Benh Crohn

li

mQt

benh

vi6m

ruQt

(xtip

vio

nh6m benh

IBD

-Inflammatory Bowel Disease) c6 thti t6n thuong iltin UAt

ty

phAn niro cria 5ng

ti6u h6a. Tuy vQy, benh thucmg hay gap o vtxlg trOi

<sub>- </sub>

manh trang kho6ng
40-s0%o,gip chi 0 vung ruQt non (vung cuOi trOi trang)

khoing

30yo, vd gap chi o

ctpi trang

ldz}%.Benh

Crohn glty raviCm

ming

ddy ciathAnh 6ng ti6u h6a c6

th6 dan cliSn dau bpng, ti6u

chiy

vd suy dinh du0ng trAm trgng.Benh d{c trung

boi

mQt sO Oac ili6m sau: kh6ng c6 t6n thucrng

tryc

trdng, t6n thuong kh6ng

1i6n tgc

thulng

xen kE tung tto4n ruQt c6 tl5n thuong vd ruQt binh thudrng. Nhin

chung

khoing

75o/o cdc trudrng hgp c6 t6n thuong ruOt non vd khoang 90% c6
t6n thuong doan cuOi nOi trang. Benh Crohn c6 th€ g?p t6n thucrng

vtng

5ng
hflu m6n

tdi

khoang mQt phdn ba vd thucrng A cdc trudrng hqp c6 t6n thucrng dai
trang. Tdn thucrng iludng ti6u h6a tr€n nhu miQng, thpc quan, d4

diy,

t6 trang

rdtit

g4pvi ntiu c6 thuong ktit hgp

v6i

c6c ttin thuong o nhfrng noi kh6c.

Benh Crohn c6 th€ c6 citct6n ggi kh6c nhau nhu vi6m trOi trang khu vyc,
t.

vlem ruer cuol, vi6m ruQt non

-

ctei trang khu

vyc,

vi6m tt4i trang th6 h4t...
Benh gflp nhiCu hon o c6c nu6c chdu

M],

Bic

Au, Anh. O Viet nam r6t

it

<sub>e[p.</sub>

Ti

19 mdc bpnh 0

My

le 5/100 000 ngudi dan

v6i

chi phi cho benh ndy khoang

1,1 ty cl6 Ia

M!

mQt n6m.

Co chiS benh sinh cria bQnh Crohn chua ilugc khane clinh rd rang. Benh

vin

thudrng dugc x6p vdo nh6m benh

ty

mi6n. ThUc tC

c6

it bAng chimg

ttt"V.t

phUc chimg minh

phin

fmg

mi6n

dich

cria ccv thi5 chiing

lai

mQt

tU

ktr6ng
nguyCn

dic

hiQu ndo c6. Tuy nhi6n cang ngdy cang c6 nhi6u b6ttg chimg cho
th5y c6

tlng

kfch hopt t6

bio T cta

mdng d6y thanh 6ng ti6u h6a trong benh
Crohn. Yi5u tO ndo gdy kich hopt ti5 bao

T

cdn chua dugc x6c clinh co th6 ld

vi

khu6n hogc cdc sin phAm chuyiSn h6a.

</div>
<span class='text_page_counter'>(157)</span><div class='page_container' data-page=157>

55-II.

CHAN EOAN BPNH CROHN

1. ChAn tlo6n xdc

tllnh

a. TriQu chring lAm

sing:

BQnh Crohn thucrngbitiu hiQn xen kE

gita

giai

do?n

brtg

ph6t

vi

giai
dopn 6n dinh. Benh nhan c6 thti c6 mQt trong c6c d6u hiQu sau:

-

Tripu chtmg hQ ti6u h6a nhu ctau qu4n bUng ttmg con

vtng

h6 chau

phii,

ti6u

chiy,

d6i

khi

tli

ngodi ra m6u. Benh nhan c6 thri di

ngoii

phdn long

tli

20 lAn mQt ngAy

d

the n?ng. C6 th6 c6 dAy bpng, m6t

r[n,

clau

vtng

h4u
m6n.

-

TriQu chimg toan thdn nhu si5t nhq, gAy srit c6n. S6t cao thuong g4p

khi c6 biOn chrlng apxe.

Cdn

luu

y

lit

cdc triQu chimg

ve

dAu hiQu

l6m

sang cria bQnh Crohn
thudng li6n quan c16n

vitri

ti5n thucrng vd thii benh.Benh nhen v6i th6 bQnh tdn
thucnrg vi€m lan t6a o ruQt non sE

c6

cdc triQu chimg k6m hdp thu ddn den gAy

srit cdn, ft bi6u hiQn dau bUng. Benh nhan

vdi

th6 benh t6n thuong xo h6a gdy
chit hgp sE c6 c6c triQu chimg cria b6n

tic

ruQt nhu dau bUng, bu6n n6n, ndn,
ddy chu6ng bUng.

Th[m

kh6m c6 thi5 thAy bpng chucmg, gd vang. Benh nhan

vdi

th€ bpnh c6 duong

rd

thii

c6 c6c bitiu hiQn cli ngodi long dQt ngQt (bi6u

hiQn rd ruQt non

<sub>- </sub>

rugt non), triQu chimg apxe trong O bpng (nhu s5t, c6 phan

img

thanh bUng khu

tru),

thii rd

+

Tim m6u An trong ph6n (FOBT)

</div>
<span class='text_page_counter'>(158)</span><div class='page_container' data-page=158>

56--

ChUp transit ru6t non c6

cin

quang (barit

ho[c

enteroclysis): c6 th6
thhy cttc t6n thucrng ruQt non nhu hinh 6nh

let

de, hinh 6nh timg do4n ruQt chit

hgp xen 15n do4n ruQt binh thudng

-

Chup cEt top

vi

tinh (CT) 6

Upng vd

tiilu

khung: girip x6c dinh c6c
biiSn chting nhu 6p xe trong

6

bpng, c6c dudng

rd

ruQt

-

bdng <sub>9umg, </sub>ruQt

-niQu quAn...

-

Ngi

soi dai

trhng:

d6,y

ldx6t

nghiQm lpa chgn Oe mem tra t6n thuong
d4i trdng vd dopn cuOi hOi trdng. MQt sO hinh enh nQi soi dpc

tnmg

cho t6n

thuong dpi trang trong benh Crohn

lir

: kh6ng c6 t6n thuong trqc treng, hinh
txth chc O loet nh6, n6ng, c6 vidn d6, c6 c6c

vtng

t6n thuonglfut ddxen kE c6c

vung ni6m mpc binh thucrng (skip lesions

-

cdc t6n thucrng c6ch qu6ng). Sinh

girip d6nh gi6 hqp <lai

trdng vd rd cl4i trdng.

-

Vi6n nang nQi soi: c5 th€ srl dpng thay thti cho nQi soi clpi trang

vi

nQi

soi ruQt non, tuy nhi6n ch6ng chi clinh n6u c6 dAu hiQu

tic

ru01.

2.

Chhn dor{n

phin

biQt:

CAn chAn do6n ph6n biet benh Crohn

v6i

hai nh6m benh chinh

h

benh
ruQt non

vtng

h6i

manh trdng

vi

c6c bQnh dpi trang. TOn c6c benh cAn chAn

do6n phAn biQt tlugc th6 hign o

bing

Bdng 1: ChAn tlo6n

phin

biQt bQnh Crohn:
Cdc bQnh O ruQt non hdi manh

tring:

Benh nhi6m khuAn

Vi6m ruQt thira c6p

Vi6m tui

thta

manh trdng
C6c bQnh vi6m vung ti6u khung
Lao h6i manh trdng

Benh vi6m ruQt do Yersinia

Benh vi6m ruQt virut do gi6m mi6n dich (cytomegalovirus)
Benh kh6ng nhi6m khuAn

Benh Celiac

Chria ngodi tri cung
Ung thu manh

tring

Vi6m m4ch m6u (bao g6m bQnh Behcet's)
Vi6m ruQt do xp tr!

U hpch hofc ung thu h4ch

</div>
<span class='text_page_counter'>(159)</span><div class='page_container' data-page=159>

-157-Vi6m d4 ddy ruQt do iii toan

Vi6m ruQt tiSt trOi trang mqn kh6ng c6 t5n thuong d4ng h4t

Cic

bpnh tl4i

trhng

Bpnh nhi6m khuAn

Vi6m

d4i Mng

nhi6m khu6n

cap

(Salmonella, Shigella,

Campylobacte)

Vi6m tl4i trdng do amip

Vi6m tl4i trang gi6 m4c do Clostridium

dfficile

Lao h6i manh trdng

BQnh vi6m ruQt do Yersinia

BQnh vi6m dai trang virut do gidm miEn dlch (cytomegalovirus)

BQnh lJr6ng nhi6m khuAn

Vi6m lo6t dpi tr.uc trang ch6y miiu
Vi€m dai trd,ng do x4 tr!

Vi€m dai trirrg do thi6u m6u

a. ChAn do6n

phin

biQt bQnh Crohn vriri cdc bQnh O ruQt non hdi-manh trirng:
BQnh nhan c6 bQnh Crohn c6 th€ phrit bQnh nhanh dQt ngQt

v6i

tripu
chimg dau bung hi5 chflu

ph6i,

stit va phan img thdnh bpng thudng Oe nnAm t6n

v6i bQnh vi6m ruQt thira c6p. ChAn do6n x6c dinh d6i khi kh6ng thti

kting

dfnh

tru

khi

md byng. C6c benh

ly

hdi manh

tring

thudng c6 tidn sri dau bpng

vi

ti6u

ch6y

tru6c

khi

c6 c6c triQu chimg c6p

tinh

n6u tr6n.

Khi

can

tU6t

ctAn
dorin phdn

bigt

gita

bQnh Crohn vd vi6m ruQt thtra c6

thti

chup

CT

6 bgng.
Trong

trulng

hqp

cAn chAn doan phdn biQt

vdi

cilc benh

khuAn lao...Trong truong hqp sd thAy

tdiii

vung hi5 chau

phii

cAn ch6n doan
phdn biQt

v6i

ung

thu

manh trlrng, ung thu phAn php,

tri

cung. N6u ti6u chAy

nhi6u kdm srit

cin

c6n phAn biet

v6i

bQnh Celiac. BQnh Behcet's thuong phdn

biQt v6i bQnh Crohn bang sg hiQn di€n

cta

c6c 6 toet O mieng vd d hQ sinh dgc.

Chin

do6n phAn bi$t bQnh Crohn

voi

mQt s5 bQnh

illi

tring

Trong mQt sti trudng hqp rat kh6 ph6n biet benh Crohn khu

tru

0

dai

trirrg

vd bQnh lo6t d4i

tryc

trang ch6y m6u. MQt sO Uenir vi6m dqi trdng do

</div>
<span class='text_page_counter'>(160)</span><div class='page_container' data-page=160>

-158-1'l

nhi6m khudn cdn chAn do6n phdn biQt

bing

cdy phdn

ho{c

huyOt thanh hqc.
Vi6m dai trang do x4

trithuong

chin

dobnbang khai th6c ti6n srl.

3. ChAn

dofn

mQt sd bi6n chring cfra bQnh

Crohn:

a. BQnh

If

li0n quan tl6n thfrng ruOt

MQt nhom benh nhan

c6

cdc t6n thuong xuyOn thanh c6 th6 d6n cti5n 6p

xe ho{c hinh thanh c6c dudmg rd. Thring ruQt

ty

do vdo trong O bpng hi6m gAp

do tr€n thgc tti lorp thanh mpc cria ruQt thuong dinh vdo circ cdutruc 16n c4n.

Ap

xe c6 th6 gpp trong hoflc

ngoii

O bpng

khoing

20%.

Ap

xe trong 6

bung g?p nhiCu hon, c6 thd

nim

trong m4c treo hoflc 0 ch5 ruQt gQp kh0c. Ap

ngoii

O bpng c6 thO g{p o sau phric m4c ho{c trong thanh bUng.

Dulng

rd

ld ktSt

qui

c0a viQc thring O loet

tludng

ruQt

Hgp tluong ruQt

li

mQt biiSn chimg thuong g4p cria benh Crohn. TriQu
chimg cli6n

hinh

ln ddu higu b6n

tic

ruQt vd thudrng c6 thri cliAu

tri

bing

nQi

khoa. Benh nhen c6 triQu chimg dau bpng

l-2

giir sau khi 5n, kdm theo chucmg
bUng. Trudmg hqrp

n{ng

hcrn c6 thiS c6 bu6n n6n vd n6n. ChAn doan

t6t

ntr6t
b6ng chpp

X

quang ruQt c6 can quang barit vdi hinh anh hgp clo4n ruQt non vd
giSn do4n ruQt tr6n ch5 hgp. Benh nhan c6 hgp duong ruQt

li

ttiOu kiqn thuan

lqi

dC ph6t tri6n qu6

mtc

c6c

vi

lJruAn chi tpi ruQt gdy ra tiOu

chiy

vi

k6m h5p

thu.

Cht

y6u giap cdc 6p xe quanh h$u m6n, vd rd hpu m6n tryc trang.
d. Thi6u du0ng do

In

u5ng

Benh Crohn c6 th€ dan ACn k6m

nu6i

du6ng do mQt sO nguy6n nhan.

Benh nhen

phii

tg han ch6

[n

uting tIC giem

bot

cic trieu chr]mg sau khi 6n nhu
dau bpng, n6n ho{c ti6u chay. Benh lan rQng ho4c c6t trOi trang d6n ctiin gi6m
h6p

thu

mutii

mpt, gi6m

vitamin

B12, k6m h6p

thu md,

d5n

il6n

thi6u c6c

vitamin hda tan trong md.

e. C6c nguy6n nhfln tiOu

chiy

khic

Trigu

chimg

ti6u

chiy d

benh Crohn kh6ng

phii

chi

do v6n cl6 vi6m
nhi6m c6p tinh

mi

cdn ld ki5t qu6 cria viQc thay eOi c6u truc cria iSng ti€u h6a.

C6t UO do?n hOi trang <100 cm thudng ddn ili5n k6m hAp thu

arit

mflt vd ph6
hong chu trinh chuy6n h6a mutSi mQt

tt

gan vdo ru01.

Axit mft

chuyi5n

vio

ruQt

</div>
<span class='text_page_counter'>(161)</span><div class='page_container' data-page=161>

gdy ti6t nudc vd diQn gi6i. C6t

h6i

trdng > 1 00cm d6n O6n k6m h5p thu axit mat

trAm trgng, vugt qu5 khd nnng t6ng hqp cira gan d6 t4o ra dugc lugng axit mflt
dy

trfi

thich hqp. HiQn tuqng niry d6n tl6n k6m h6p thu axit b6o vir ti€u chay,

h{u

qui

ld m6t nu6c vd diQn gi6i. BQnh nhdn c6 hgp ruQt vd rd tludng ruQt c6
nguy co ph6t tri6n qu5 mrlc

vi

khuAn duong ruQt, cflng ld nguy€n nh6n g6y ti6u

chAy theo co chii ph6

hty

chu trinh chuy6n h6a axit mflt tir gan viro ruQt. BQnh

nh6n c6

l5 rd

cfing

bi

ti6u

chiy

do mQt luqng 16n tiriSi tuqng trong ldng ruQt

dugc chuy6n t6t qua

tlulng

rd.
f. Ung

thu

Nguy

co

ung

thu

6

bQnh nh6n Crohn cao h<vn

d

ngudi binh

thudng

nhrmg

v6i

ty

ril

th6p. Tuy nhi6n khuy6n crio bQnh nhdn Crohn n6n ki6m tra

nQi soi d4i trang tlinh

k!

hirng ndm.

III. DIIU

TRI

BENH CROHN

l.

C6c tlidu

trl

chung

-

MUc ti6u di6u

tr!

ld d6 phpc

hdi

srlc kh6e chung vd bQnh nhdn trd v6
nhip s6ng nhu ngudi binh

y

y6u

t5

tam

than

kinh

cta

bQnh

nhan. K6t hqp di6u

tri

nQi khoa vd liQu ph6p t6m thAn ld yt5u

tti

cAn thi6t de dat
tlugc hiQu

qui

cao.

Cic

nh6m thuSc sfr dgng.16 di6u

tri

bQnh Crohn

C6c nh6m thu5c,

[Au

lugng

vi

tluong dung

cta

c6c thu5c ndy tuy thuQc

vio

mrlc dQ vd giai do4n bQnh (xem bang 2).

Bfin 2:

Cdc nhdm thuiic

diln

iliiu

tr

Crohn

BiQt dugc Lidu

dtng

Thu5c

Thu5c ch6ng vi6m

5-Aminosalicylic
acid (5-ASA)

Sulfasalazine

Mesalamine

Asacol

Pentasa

20. Vi6n

500mg, u6ng ngdy 1 -2

g,

chia 3 - 4

ldn,

c6 th6 teng

l}ntbi4glngiry

21.

Vi€n 500mg, uting ngdy 3 g, 6 vi€n chia 3

':

l6n,

duy

tri

3 vi6n chia 3 l6n

22.

4.8 glngiry

23.

4elneiry
Corticosteroids

</div>
<span class='text_page_counter'>(162)</span><div class='page_container' data-page=162>

-160-Prednisone

24.

40-60mglngdy trong vong

l-2fidn,

sau d6

i. ), ., \ <sub>^</sub>

m6i tu6n

giim

5mg trong vdng 8

*

12 tudn.
Methylprednisol

one

25.

60mgl ngiry,

truy6n

tinh

m4ch, sau khi
b€nh thuyCn gi6m chuy6n sang u5ng

Budesonide Entecort EC

26.

U6ng

I

viCn/ngdy
Thu6c rlc ch6 miSn dich

Azathioprine

Imuran

27.

Vi6n n6n 50mg, u5ng lmgkelngdy (tdi da
2,5mflkglngay

6-Mercaptopurine

28.

Vi6n n6n 50mg, u5ng 1- l,Smg/kg lngiry
Cyclosporine Neoral,

Sandimmune
Gengraf

29. Vi6n

n6n

25 mg

vd

100mg, 1i6u dirng

2,Smglk/ngey

(c6 th6

tSng

1i6u

16n

a.Smelkglngdy) chia 2 ldn ngdy

Methothexate

30. L9

50mg l2ml,

Ti6m

bAp hoAc

tinh

m4ch
2lmgltttdnmQt lAn

Khfng

sinh
Metronidazole

Flagyl

31.

Vi6n n6n 500mg, ui5ng

2

glngily chia 2 16n

32. Lq

500

mg/100m1, truyAn

tinh

m4ch

1-2glngily chia 2 lAn

Ciprofloxacin Vi6n 100 diSn 500mg

Lq

200mgl100ml vd 100mg/50m1.

33.
34.
C6c

thuiic

sinh hgc

(anti-TNF-a

therapies)

Infliximab Remicade

35. L9

100mg,

Pha

truyAn

tinh

mpch
Smkglngdy trong

2

gitt, mQt [Au duy nhdt
Adalimumab Humira - Ti6m dudi da 40mg mdi tuAn

a. ThuSc ch6ng vi6m S-Aminosalicylic acid (5-ASA)

Sulfasalazine dugc sr} dgng OC eidu

tri

benh Crohn th6 nhg

vi

vira tr6n

50 ndm nay.

Thinh

phAn cria thu5c gdm

5-ASe

ket hgp

vdi

sulfapyridine.

5-ASA

rlugc cho td c6 hiQu

qui

cliAu

tri

tiit

nhat cria thu6c vdr dugc gi6i ph6ng tai

cl4i trang.

Vi

vfly sutfasalazine c6 hiQu qu6 di6u

tri

d the bQnh clAi trang vn

hOi-manh

trang.

BOi vOi benh Crohn ttr6 O ruQt non, sulfasalazine kh6ng c6 tdc

dUng. T6c dpng phg cria thuiSc ld bu6n ndn, n6n, ilau clAu, nOi man ngua, siSt va
mQt s6 t6c dgng phU

it

gflp hon nhu thi6u m6u, tan m6u, vi6m tgy c6p, xo h6a

phOi.... Benh nhan dung 16u ddi sulfasalazine c6n uting th6m folate lmglngity.

</div>
<span class='text_page_counter'>(163)</span><div class='page_container' data-page=163>

-161-Mesalamine dang nguy€n b6n ban dAu tlugc h6p thr,r

d

duong ti€u h6a

tr6n. Mesalamine

gi6i

phSng ch4m sau niry dugc h5p thp

t4i

h6ng trdng, h6i
trdng vd d4i trang

vi

v@y dugc

dtng

dti tti6u

tri

bdnh Crohn th6 ruQt non vd d4i
trdng. Mesalamine cfrng tlugc su dgng d d4ng vi6n d4t h4u m6n vd thu6c thqt
th6o

vi

vdy c6 hiQu qua d6 Ci6u

tri

th0 benh d tlo4n thAp tl4i trdng, truc treng,

: ,^

gan nau mon.
b. Corticosteroids

Corticosteroids hiQn dang tlugc sri dpng di5 didu

tri

bQnh Crohn thr,l vtra
vd n{ng. PhAn lon bQnh nhan the

vta

c6 th6 di€u

tri

hi€u

qui

thuy€n gi6m bgnh

vdi

prednisone

iluong

u6ng. BQnh nhan thC

n[ng

c6n nhdp viOn

vd

truy€n
methylprenisolone tinh mach. Sau

khi

cl4t <tugc hi€u

qu4

bgnh 6n dinh c6 th6
chuyiSn sang dirlu

trl

bing

tlucrng u6ng.

Li€u

srl

dyng xem bang

1 d

tr€n.
Corticosteroids c6 th6 g6y ra nhiAu t6c dpng php nhu hQi chimg Cushing, trung
c6, lodng xuong, tang huyiit 6p, drii thrio

dulng,

thorii h6a thAn kinh, ho4i tri
xuong...

Gin

ddy, nh6m thu5c Corticosteroids didu

tri

t6c dpng

tpi

ch6, kh6ng
chuyen h6a qua gan c6 th6 han ch6 c6c tric dgng toan th6n. Nh6m thu6c ndy

bao

g6m

tixocortol

pivalate,

fluticasone

propionate,

beclomethasone

dipropionate vd budesonide. Budesonide dang vi6n ut5ng giAi ph6ng

ch{m

6
do4n

cuiii

frOi trang c6 tric dgng

t6t

nhu

dtng

prednisolone toirn then d benh
nhAn Crohn

giai

tto4n c6p vd c6 th6 ginm tdn su6t tfui phdt bQnh. Budesonide
g6y nhi6m dQc Corticosteroids it nh6t.

c. Thudc ric chii miSn

dich

Nh6m thu6c dOng dang purine nhu 6-mercaptopurine v?r azathioprine c6

vai trd

quan trong trong di6u

tr!

bQnh Crohn. E6y ld thu6c dugc lya chqn d6

ndy

li

chfm

dat tlugc hiQu quA diAu tri, trung binh ld 3 thring. D6
d4t hiQu

qui

tiii

da c6 th6 phdi didu tr! k6o ddi 6-9 thring. Benh nhen cAn dusc

gi6i

thich vO dQc

tinh

cta

nh6m thu6c ndy trong d6 c6 t6c dgng

rlc

ch6 triy,
vi6m tgy, vi€m gan vd nhi6m khuAn.

Trong

nh6m

thu5c

ric

chti

miSn

dich cdn

c6

cyclosporine vir
methotrexate. C6c thu nghiQm thu5c ngdu nhi6n c6 OtSi ctrung dE kh6ng chring
minh dusc t6c dgng cria cyclosporine trong giai tto4n c5p cria bQnh Crohn. Hon
nira cyclosporin c6 th€ g6y nhiSm ttQc thfln vd than kinh. Cyclosporine c6 th6

hfiu

ich

trong di6u

tri

c6c

dulng

rd,

tuy

nhi6n

ty

6i

ph6t cao sau ngtmg

thur5c. Di€u

tri

methotrexate tinh m4ch cho hiQu

qui

thuy6n ginm bQnh vd giai

rto4n

6n

dinh

vd

c6 th6

giem

<sub>li€u </sub>

hopc ngtmg tran

Oieu

tri

duy

tri

</div>
<span class='text_page_counter'>(164)</span><div class='page_container' data-page=164>

-162-B0 YTE -

HafNc

oAN

c

HAN ooAN vA otEu rRI BENH TIEU HOA -

163-Corticosteroid. Methotrexate c6 hiQu qud hay kh6ng dti di6u

tri

dudng rd trong

bQnh Crohn cdn dang ti6p tgc nghi€n cr?u trong c6c thr! nghigm 16m sdng'

d. Kh6ng sinh

Metronidazole tluoc su dgng rQng r6i t16 di€u

t4

benh Crohn, tuy nhi€n

hiQu qud cdn h4n ch6. Ciprofloxacin cfing dugc diAu

tri

c6 hiQu qud thuy6n

gidm

bQnh

d

th€

nhe

vd

vta.

Cfing

c6

th€ k6t hqp

ciprofloxacin

vd
metronidazole.

e. C6c thu5c sinh hgc

Cric cy'tokine,

TNF- o

ld c6c y6u

t6

quan trQng trong phAn rmg vi6m d

bQnh Crohn.

Vi vfy

cric thu6c sinh hqc nh6m kh6ng TNF- o c6 vai trd tlac bi€t
trong di6u

tri

benh Crohn th6 vira vd n{ng.

Infliximab

li

mQt khring th6 don
ddng khrimg TNF- o

tryc tilip,

cho hiQu qu6 l6m si'ng nhanh ch6ng

d

70-80%
cric bQnh nhdn phU thu6c corticosteroid hodc kh6mg

tri.

Drip rmg l6m sirng c6

thd d4t dugc

giai

doqn 6n ttinh khoang 48% b19nh nh6n. T6c dgng php cya
infliximab

tuo

g6rn phan ring t4i ch6 do truydn, n6n, budn n6n, mgt m6i , mAn

tt6...Infliximab c6 th€ su dune di5 diAu

tri

benh Crohn c6 dudmg rd.
3. Nudi du0ng:

Ch6 dO an b6 sung hqp

ly

d6ng vai

trd

quan trqng trong di6u

tri

bQnh

Crohn.

Mac

dt

c6 hiQn tugng thric 5n ld mQt ngu6n

di

nguy€n, kh6ng c6

bing

chimg ch6c ch6n

ring

1o{ trir

hay

h*n

ch6 ch6 d0 5n c6 vai trd trong tti6u

tri

UO tang duong tinh m4ch chi thgc hiQn khi c6 rd l<rn

ho&

tic

ruOt'

4. Gi6o dgc, girip dO theo nh6m,

tim

thAn [Qu

phip

Benh nhan n€n

trrffi

c6c y6u t5 stress, trrinh cing thdng tnan

m*r

va tn0
lpc. NOn thudng xuy€n thu giem, tAp thd vd tdp th6 dqc d6u dan'

B€nh nhan c6n tim hi€u

k!

v€ bQnh cria minh

Nh6m h6 trg c6 thti cung c6p th6m th6ng

tin

v6 bQnh, c6c phuong ph6p
di€u

tri

mdi ddng

thdi

hO trq vd tinh then, chia s6 kinh nghiQm tl6

trii

qua'

ffram

v5n

y

ki6n

cta

c6c nhd tAm

li

holc

brlc

s!

tAm th6n c6

thii

girip

</div>
<span class='text_page_counter'>(165)</span><div class='page_container' data-page=165>

5. Dii)u

tri

bi5n chfrng

a. BQnh

lf

li6n quan d6n thfrng ruQt

Benh nhdn c6 6p xe cAn dugc chgc hrit d5n luu qua da hopc ph6u thudt.

Khi

c6 nghi ngd 5p xe cAn dugc chup cht lop

vi

tinh vd dirng kh6ng sinh ph6
rQng.EOi khi cAn d6n luu

6

6pxe du6i hucmg d6n cria si6u Am hoflc CT.

C6c dudrng

rd

c6 triQu chimg

rd

rQt phAn lcrn ph6i di6u

tri

bing

ph6u
thupt. Nhirne dudng rd kh6ng

giy

triQu chimg vd c5c h4u

qui

vA chuy6n h6a c6

thti kh6ng cAn phAi diAu

tri.

Trong mQt s6 trudng hqrp rd rugt

<sub>- </sub>

b*g

quang, rd
ruQt ra da,

rd

ruQt-ruQt

vdi

c6c tripu chimg mric clQ vtra c6 th6 cAn nhEc gifia
di6u

tri

nQi khoa vd ngopi khoa.

Di6u

tri

nQi khoa benh Crohn thudng k6o ddi

vd

c6 hiQu

qui

ttSt chi
khodng mQt phAn ba sti benh nhdn, do v4y quyet dinh diAu

tri

nQi khoa hay
ngo4i khoa php thuQc vdo triQu chtmg l6m siurg

vi

lga chgn cria bQnh nhan.

b.Hep

tludng

ruQt

Benh nhdn c6 dAu hiqu ban t6c ruQt do hgp

clulng

ruQt thucrng c6 th6
di€u

tri

b6ng nQi khoa

vdi klit

quA

ttit

trong vdng 2-3 ngiry (ntrin 5n, hrit dich
qua sonde d4 ddy,

bt

nu6c, diQn gini). Benh nhen khdng il6p rmg

v6i

cliAu

tri

nQi khoa b6o t6n vn bQnh nhan

tic

ruQt hoan toan c6p tinh

phii

cliAu

tri

bing

phSu thu4t: c6t <lo4n rugt

bi

hgp vd n5i lpi,

hoic

ld tpo hinh ch5 hgp gi6ng nhu
tpo hinh l5 m6n vi.

c. BQnh

ving

quanh

trqc

trdrng

Di6u

tri

c6c benh

ly

quanh h4u mdn

tryc

tring

ddi

h6i

sp ktit hgrp chflt
chE cria b6c

s!

chuyCn khoa ti6u h6a vd c6c b6c

s!

ph6u thuflt.

Dulng

ro

dugc

d6n

tuu

c6 th6 dugc

d6ng

lpi

vdi

tli€u

tri

ktit hqp ddi

ngay bing

metronidaz o\e, azathioprine hopc 6-mercaptopurine. BQnh

nfng

hon cAn ph6i
dugc di6u

tri bing

infliximab truy€n tinh mpch vd kdo ddi di€u

tri

rtc chi5 mi6n
dich. C6c 6 6p xe cpnh tryc trang cAn dugc ph6u thu4t d6n luu.

d. C6c nguy6n nhffn ti6u

chiy

kh6c

C6c bQnh nhen tiOu

chiy

do ph6t tri6n qu6 mrlc

vi

khuAn chi trong ruQt

c6 th6 di6u

tri

bing

khang sinh ph6 rQng nhu metronidazole, augmentin .. Benh
nh6n

bi

cat dopn ruQt c6 ti6u

chiy

c6 th€ sri dyng cholestyramine 49 hai hoflc
ba

6n

mQt

ngiy.

BQnh nhdn

di

ngoii

ra md cAn c6 ctri5 Aq 6n hpn chiS md b6
sung th6m triglyceride chuSi vtla di5 co th6 hdp thu nhanh kh6ng cAn mut5i m4t.

rv.

TrtN

LTIQNG

VA

PHONG BeNH

^.4 .:. I 1 ^ a A t A, J r nr I 1, r ^ r I ^

-

Ti€n tri€n cria benh Crohn rdt da dang. Phan lon benh nhan co cuQc

si5ng cl4t y6u cAu

vdi

timg giai do4n ti6n triiSn cria bQnh. Khoang 10-20% bQnh

nhdn c6

giai

doan 6n dinh k6o

dii.

Trong c6 titin

trinh

cria bQnh, khoang
60-7T%bflnhnhen cAn ph6i phSu thuat.

\

</div>
<span class='text_page_counter'>(166)</span><div class='page_container' data-page=166>

-164--

Tji

le

ffi

vong cua bQnh Crohn dE giAm xu5ng trong vdng

vdi

chpc
ndmnay vi

xti

ly t}thon

cdc bii5n chring.

-

Kh6ng c6 thu5c niro dugc chimg minh

c6

tirc dUng phdng ngira t6i
ph6t bQnh.

Tii

liQu tham kh6o

1.

Sands,

BE. And

Siegel, C.A.(2010).Crohn's disease,

in

Sleisenger and

Fordtran's

Gastrointestinal

and

Liver

disease:

pathophy s iolo

gt/

Diagno s is / Management, 9th edn.pp 19 4l -t97 3 .

2. Schirbel,

A. And

Fiocchi,

C.J.(2010).

Inflammatory

bowel

disease:

established and evolving consideration on its etiopathogenesis and therapy.
Digestive Disease, I

l,

266-27 6.

3. Textbook

of

Gastroenterology Tadataka Yarnada(2009). Inflammatory
bowel disease, Volume 1. 1386

-

1473.

</div>
<span class='text_page_counter'>(167)</span><div class='page_container' data-page=167>

65-ia cnAv xno

oAr

DAr

crIoNG

Dinh

nghia ia ch6y :

ia

chhy ld tinh tr4ng di ti6u phAn l6ng hon

2lUngity

th5u: Khi

trong ldng ruQt hiQn diQn mQt lugng

l6n

c6c

chSt c6 tinh thAm th6u cao nhung khdng du<rc h6p thu ( thui5c tAy x6, c6c thuilc
chua magne sulfate...). Ndng dQ th6m th6u cao trong ldng ruQt sE gdy ra sy di

chuy6n Na* vd nudc viro trong ldng ruQt. ia chdy thAm th6u sE ngrmg nilu bQnh

nh6n nhin tl6i.

2.ia

chity do

ting

ti6t: Mgt

s6 t6c nhAn nhu dQc

t5 cta

trgc khuAn t6 c6

kh6 nang g6,y t1ng tii5t dich vd diQn gi6i t4i ruQt.

Khi

dlch ti6t

tti

ruot vuqt qu6

khA n6ng ttii h6p thu

cta

ruQt non vd dai trirrg sE d6n d6n ia chity. Do su bdi titit

cta

ruQt ld mQt qu6

trinh

li€n tuc, ia chdLy sE khdng ngimg m4c

di

bQnh nh6n
nhin d6i. Phdn thuong nhidu nudc, kh6ng c6 nhAy m6u hay mri trong ph6n.

ia

ch6y do vi€m: Tinh tr4ng vi€m lodt ldm gi6m chric ndng hAp thu vd
ti6u h6a cria ni6m m4c binh thudng. Tai

ving

ni6m m4c bi t6n thuong c6 hiQn

tuqng bdi

titit

ch6t nhAy, m6u

<sub>, </sub>

mi,

protein vdo ldng ruQt. Kh6

ning

h6p thu

nudc, ch6t

diQn

<sub>ei6i vir </sub>

c6c ch6t hda

tan

cfrng

bi

ri5i

loan.

Ngoii

ra,

prostaglandine do hiQn tuong vi6m cdn ldm tdng titit vdr tdng nhu tlQng ruQt g6p
,:. . <sub>,,a ^ </sub> <sub>"</sub>

phAn vdo co ch6 gdy ia chdy.

ia

chiry do

riii

lo4n vqn tlQng rudt:

Ting

nhu dQng ruQt non

lim

gi6m
thdi gian ti6p xric gifia cdc chhttiOu h6a vdi b€ m+t ruQt h5p thu. MOt luqng lon
dich d6n d4i trang, vuqt qu6 khd n6ng hAp thu cria d4i trdng sE gdy hgu qu6 ld ia
chtty.

Edy ld

co ch6 chinh gdy

ia

ch6y trong hQi chung ruQt kich thich. M4t
kh6c,

tinh

tr4ng gi6m nhu dQng ruQt non

lai

tao tli6u kiQn cho c6c

vi

khuAn
sting t4i tl4i trang tdng sinh o rudt non cfrng dE ddn di5n r6i loqn ti€u h6a.

II. NGITYtN NHAN:

MQt sii nguy6n nhfln gffy ia ch6y k6o ddri:

-

Nhi6m trirng: lao, amip, nhi6m Giardia

-

Benh vi6m ruQt m4n: vi6m lodt d4i trang vd bQnh Crohn

</div>
<span class='text_page_counter'>(168)</span><div class='page_container' data-page=168>

-166--

HQi chung k6m hAP thu

+

Bdnh

ly

d4 ddy, sau

cit

ru6t

+

vi

khuAn tang sinh qu6 mric d ruQt non c6 th6

g[p

trong cric bQnh

nhu d6i th6o duong, xo cimg bi...

+

Thi6u men disaccharidase, thi6u men lactase

-

Benh

ly

nQi

ti6t:

cudng gi6p,

drli

th6o dudng, suy thuqng

th?n'
carcinoid, ung thu tuydn gi6p d4ng tuy, u t6ng ti6t hormon cria tqy, u ti6t VIP (
vasoactive intestinal polypeptide)' gastrinoma

-

U budu: u tuy6n nhanh, ung thu d4i trdurg

-

Thu5c vir c6c ch6t nhu4n trudng

-

Hoi chung ruQt kich thich
TII.

CHANEOAN

Lim

sirng

Ngo4i

tru

mQt

sii

t6c nh6n

dic

biqt nhu lao

ruQt,

vi6m

d4i trang do

urrrip...,iu

s6 truong hqp ia chAy k6o dai thudng

it

li6n quan d6n nguy6n nhAn

;te.;;c

,a

.Aniuq.

tham

io k!

ludng d6 loei

tru

cric bQnh

Iv

thvc the'
H6i benh sri vir khrim benh

ky

luong, krit hqp

v6i

circ x6t ngtriem thudng quy

c6th6ginpd6nhgi6tinhtr4ngnu6c-diQngi6ivddinhdudngctabenh.nh6n'

aOng

tioi

"lrg

gqi

i

d6n

co.t6

gay ia

chiy

tt

d6 c6 dinh hu6ng dd nghl

th€m c6c c{n l6m sang h6 trg chAn do6n nguy6n nhdn bqnh
H6i benh su c6 th6 girip x6c dlnh t6n thuon

g

gity

ia

chity:

-

tuOi

lJrdi <sub>Ph6t </sub>bQnh:

+

tu6i

thanh-thitiu ni6n: thudng do c6c

r6i

loan chrlc

n[ng,

lao ruQt,

vi6m dpi

trirrg

do

nhi6m

trung,

bQnh

vi€m lo6t d4i-tryc

trirng

hoac bQnh
Crohn...

6n, thuong do hQi chung
ru6t kich thich, benh Crohn ho[c viem 1o6t d4i-tryc trang

</div>
<span class='text_page_counter'>(169)</span><div class='page_container' data-page=169>

-B€nh su cdn c6 th6 girip x6c dinh tdn thuong

nim d

ru6t non hay dai
trdng: N6u

r6i

lo4n ld

tt

ruQt non: phAn thudng nhidu nudc, l6ng b6ng ho{c c6

vring m6, c6 th6 c6 nhirng ph6n thric 6n chua dugc ti6u h6a h6t; c6 th6 kdm rlau

d

quanh r5n ho4c mQt phAn

tu

bgng du6i bdn

phii

ho4c dau qudn bUng timg
con.

N6u

bQnh

l!

xu6t ph6t

d

dai

trang xu5ng ho4c

truc

trdng: bQnh nh6n

thudng di ti6u s6 luong ph6n it ho4c c6 ch6t nhAy; phAn thuong x6p, n6t, thinh
thoang c6 l6n m6u vd ch6t nhAy; thucrng

di

kdm

cim

gi6c m6t rdn

ho[c

lit

nhit;

n6u c6 dau,

thulng

li

dau

li€n tuc

d

bpng du6i, virng chdu hay

ving

xucrng

ctng;

khi

xi

gifa

tri6u chimg cria bQnh nh6n

v6i

sg ti€u
h6a sfta, hay citc s6n phAm kh6c

tri

sfta, ho4c c6c sin phAm thric u5ng En ki6ng
c6 chria sorbitol...

Kh6m lAm sdng: c6 th6 ph6t hiQn nhi6u d6u hiQu goi

j

diin nguy€n nhdn

gdy

iachhy,

bao gdm bu6u tuy6n gi6p, vi€m kh6p, benh then kinh ngo4i bi6n,
am th6i

vtng

bung, 6p-xe quanh hAu m6n, rd ti6u h6a vd u tryc tring...

2. C$n lAm sirng

X6t

nghiQm

phAn:

ld xdt nghiQm quan trgng nh6t trong drinh gi6 b€nh nh6n

ia chdy k6o ddi. Cdn soi ph6n

tuoi

d6 xem c6 sp hiQn di6n cria mri (b4ch cAu),

Vi

khu6n

hoic

kf

sinh

tring

hiQn diQn trong m6u ph6n tuoi, tt6i khi c6

cA bdo trl hoec thii nang

cta

kf

sinh trung. C6y ph6n girip x6c dlnh tric nh6n ld

vi

khu6n. MOt sti trudng hqp d4c biet, c6 rh6 tim doc t6 A ve B cria Clostridium

difficile

trong ph6n...

</div>
<span class='text_page_counter'>(170)</span><div class='page_container' data-page=170>

-l68-b.

C0ng

thric

miu:

c6 th€ phri,t hiQn thi€u m6u, t6ng b4ch cAu da nhAn trung

tinh

(nhi€m

trung)

ho4c tdng bpch cAu

6i

toan

(u,

di

une, nhi6m

lci

sinh

tring...)

c. Sinh h6a: danh giri tinh trang diQn giAi, gi6m albumin m6u'/gi6m protein m6u
(suy dinh du0ng, bQnh ruQt m4n gAy m6t protein) ho4c d6i th6o dudng...

d. NQi soi

trqc

trhng,

tlqi

trirng

chiu

hOng

ho{c

nQi soi

toin

tl4i

tring

tluoc chi tllnh tny theo d6nh gi6 t6n thuong d doan ndo

cta

d4i trang, c6 the
girip ph6t hiQn u, polyp vA vi6m nhiSm o ruQt.

X

quang

tl4i trhng

c6n quang: c6 th6 girip xric dlnh

vi tri

tdn thuong vir
mrlc dQ bQnh

f. X6t nghiQm kh6c:

-

TSH, FT4: d6nh gi6 chric ndng tuy6n girip

-

C6c x6t nghiQm chuy6n biQt khric: dinh lugng m0 trong

ph?ntrong72

gid, danh gi6 khn

ning

dung n4p lactose, dfnh luqng gastrin trong m6u, do thoi

lian

v4n chuyen d ruQt non, mQt s5 x6t nghiQm tt6nh gi6 trpng k6m h6p thu, sg

ting

sinh qu6 mric cta

vi

khuAn, bAt

thulng

hormon...

3. Ch6n tlo6n xric

ilinh:

Di

ti6u phdn l6ng hon 2 ldnlngity

v6i

lugng ph6n lon hon 200glngdy,
trong thdi gian k6o

dii

tr0n 4 tuAn, dugc gqi ld ia chAy kdo ddi.

4. ChAn rlo6n ph6n biQt:

CAn

<sub>itran </sub>

biQi ia ch6y kdo

dii

v6i

hai tinh tr4ng

r5i

lo4n

di

cAu thuong

g[p

ld gi6 ia

chiy

vir ia kh6ng

tq

chir.

Ci

hai tinh tr4ng r6i lo4n niiy d6u c6 tAn
su6t tuong duong

v6i

chiy

k6o

dii,

do tI6 cAn luu

i

loai trt) tru6c mQt benh
nh6n d6n kh6m vdi than phidn ia ch6y k6o ddi.

Hdi

bgnh srl vir kh6m ldm sang

k!

ludng c6 th6 ginp phdn biQt v6i tinh tr4ng ia chiy thflt sq

-

Gid ia

chiy:

di cAu nhidu lan, nhung m6i lAn

tli

chi dugc chrit

it

phdn,
di kdm v6i triQu chimg bu5t m6t.

-

ia

khdng tU

cht:

benh nhan kh6ng kir3m so6t duoc

tinh

trang tho6t
ph6n

4. ChAn tlor{n bi5n chring:

-

R5i

loan nudc-tliCn

gi6i: M6t

nudc, suy

thin

c6p'

r6i

lo4n diQn gi6i
nhu toan chuy6n h6a, h4 kali m6u

-

Suy dinh dudng, sgt c6n, thitiu m6u thi6u s6t, thiiiu nhimg vitamin tan
trong md nhu A,D,E, K trong ti6u PhAn md

BO Y TE. HUdNG DAN CHAN DOAN VA DI

Eurrue

ENH TIEU HOA -

169-6

</div>
<span class='text_page_counter'>(171)</span><div class='page_container' data-page=171>

-

Suy gi6m tam

thoi

chric n6ng ni6m mpc dudng tiOu h6a nhu kdm h6p
thu lactose thu ph6t sau vi€m d4

diy

ru6t c6p.

rv.

Ertu

TRI

1. Nguy6n t6c tlidu

tri:

Ei6u

tri ia

chity k6o ddi cdn dua vdo didu

tr!

nguyOn nh6n vd theo co ch6

sinh bQnh. Thinh tho6ng,

khi

kh6ng th6 ch6n tlo6n clugc nguy€n nh6n, ngudi ta

c6 th6 tli€u

tr!

theo kinh nghiQm bao g6m ctr5 O6 an ki6ng (lactose, gluten vd

acid

b6o

ctru6i

aai;,

cung c6p

men

tuy ctng v6i

thu6c

tc

chti

histamin,
cholestyramin, vd khriLng sinh.

Khi

th6t bai, c6 th6 su dqng cric d6n xu6t opiate

d€

lim

gi6m tri€u chring.
2.

Diiu

tr!

cu th6:

a. D6nh gi6

tinh

tr4ng

thi5u nu6.c,

r6i

loqn tliQn gi6i vh thi5u

vitamin

-

chiy

k6o
ddi c6

th€

do c6 cilc ytiu t5 tnOi ph6t nhu thric dn, thu6c ho6c u.

Khi

loai b6

c6c ytiu t6 ndy c6 th6 larn cho ia

chiy

trit

thtc.

. -

iachAy do acid mflt: di€u

tri

theo kinh nghiem bang cholesty.amine c6
th6 girip ch6n do6n vd di6u tri. LiCu dtng thuong ld 49 x 3 lan/ngdy

-

Kh6ng dung n4p lactose:

trirh

circ san ph6m stra

vta gifp

ch6n do6n

vira didu

tri.

-

86

sung men

tuy:

c6 th€ c6 hi0u qu6

d

nhirng trudng hqp ti6u ph6n
md.

-

Ting

sinh qu6 muc

vi

khu6n

d

ruQt non: thuong l6m sang il6p rmg
nhanh v6i kh6ng sinh t6c dgng tai ru6t.

c.

Cdc

thu6c

ch5ng

ia

chiy

dAn

xu6t morphin:

thu&ng an todn

d

nhirng
trudng hqrp

ia

chity tir nhg dtin trung binh.

</div>
<span class='text_page_counter'>(172)</span><div class='page_container' data-page=172>

-170-I

-

Loperamide

(

Imodium)

2

t6i 4mg

x

4

lar/ngny ho?c 4mg, sau d6 2
mg m5i tAnii6u phdn long, c16n khi ctat li6u

ttii

ld

16mg.

-

Diphenoxylate vir atropin

e:

4mg x 4 l,€rnlngity'

d. Octreotide:

c6 th6 dugc sri dung trong ia

chiy

tAng tii5t cl6 gi6m sO lucr,ng
phdn.

Khing

sinh:

c6 th6 xem

xdt

tli6u

tri

theo

kinh

nghiQm n6u bQnh nhdn c6
nguy

,,

Li6n chimg cria mdt nudc hay bitin chimg toan thdn, trong c6c

trulng

hqrp nghi ngo

,gry6n

nhdn nhi6m

tring,

ho4c niiu tAn su6t

ia

chtty nhi6m

trtng

trong tQng Cl6ng kh6 cao. C6 th6 sri dpng metronidazole hoflc fluoroquinolone'

Tni

tiQu tham kh6o

l.

eu6ch Trgng Dric,

Biri

Hiru

Hodng (2009),

ia

long vd T6o b6n, Tri€u
chilmg hqc n4i khoa,Nhd xuAt ben

Y

hpc,

tr.

139-143'

2. Canan Avunduk (2008), Diarrhea,

Manual

of

Gastroenterologt,

Diagnosis and Therapy, Lippincott

williams

wilkin,

pp 182-194.

3.

Hongha Susan

T. Vu

(2012), Diarrhea, Gastroenterolog,t subspecialty
Consult, Lippincott Williams

Wilkin,

pp 20-32'

</div>
<span class='text_page_counter'>(173)</span><div class='page_container' data-page=173>

-171-Hor

cHfNc

RUer

ricn ruicn

+

BCnh ndy thudng g6ry cdc <sub>tri6u chimg k6o ddi: t6i ph6t tung dqr, tri6u</sub>

chrlng b€nh da d4ng vd li6n quan d6n

bta

dn, anh hucrng dtin cuQc s6ng hang
ngdy vd c6ng vi6c

cta

nhidu benh nhan. TriQu chrlng cria b6nh c6 th6 khdi ph6r

sau m6t tlqt nhiSm

trtng

ruQt n4ng, khdi ph6t sau mQt bitin c6 vA tinh than goi

stress.

-

HCRKT duqc phan chia thdnh hai nh6m theo ti6u chuAn Rome

III

gidi

30% d€n 50%o c6c trudng hgrp

+

M9t

s5 luu y: BQnh nh6n c6 thi5 thay d6i

gita

c6c nh6m

-

Dich tE

^

+

Kh6 th6ng kO mQt c6c chinh x6c vd t1i tC HCRKT do ttmg vung quAn

th6 vd

lya

chon ti6u chuAn khric nhau

vi

dg ch6u 6u vd B6c my

ti

tO-lSn,

Thuy cti€n 13,5%.

+

Ti/

HCRKT

d

c6c nu6c ch6u ri thrli binh ducmg

Bic

kinh 0,g2%,
H6ng kdng 6,6%, Singapo re 6,6yo, Diti loan

2l%

II. CH6NDoAN

BOYTE . <sub>HU6NG </sub><sub>DAN </sub><sub>CHAN DOAN </sub><sub>VA </sub><sub>D</sub><sub>IEU </sub><sub>Tzu </sub>

</div>
<span class='text_page_counter'>(174)</span><div class='page_container' data-page=174>

-t72-I

1. Khai

thic

tidn sfr

Kh6mmotbenhnhanHCRKTkh6ngchixemx6tc6ctripuchrlngd6u

tien bQnh nh6n den kh6m md cdn

tim

c6c y6u t5 khdi phrit li€n quan 0 hQ ti€u

h6a cfrng nhu

ngoii

hQ ti€u h6a. Ngoiri ra cdn ph6i d6nh gi6 vir

tim

c6c tri€u
chimg b6o dQng.

-

Benh nhdn dau bqng hay kh6 chiu d bpng

+

Thdi gian dau

+

Tinh chAt dau c6ch nhQt ho4c dau 1i6n tgc

+

Vi

tri

dau mQt s5 Uentr nh6n dau c6 di€m r5 rQt, m$t sO

lgnn

diih

bi HCRKT mflc

di

ngudi ta chua bi6t 16 co ch6 tuy
nhi6n tidn su gia dinh cfing anh hucrng

tdi

khi

ning bi benh'

-

D6nh gia vd tAm lY

+

C6c yiiu til t6m

lf

kh6ng ph6i

li

nguy€n nhdn cfing nhu khdi ph6t bQnh

ly

HCRKT tuy nhi€n c6c y6u t5 tem

li

cfrng tl6ng vai trd lirm kdo ddi

thdi

gian

b!

dau bgng, anh hudng dtin mrlc dQ ttau, 6nh huong d6n

chi phi

y

t6, anh
huong d6n ch6t lugng cuQc s6ng benh nhan.

benh

lI

co quan nQi t4ng nhu bQnh ly tiCu h6a' chring nghi ngd bQnh

t{t'

2. Kh6m

trqc trirng

Cric triQu chimg tlucrc c6i thi6n sau khi bQnh nh6n di ngodi

o

Li6n quan diln thay d6i s6 lan di ngodi

o

Thay dOi k*ru6n phdn

-

Cbc dirc diiim c6 th6 girip ich trong chAn dori'n HCRKT

+

C6c trigu chimg k6o ddi trdn 6 thring

+

Stress ldm

ting

c6c tri6u chung cria bQnh

' -.:

+

TiCn su c6 c6c bi€u hien triQu chrmg kh6ng

gi6i

thich ducyc nguyCn

XuAt hiQn cric triQu chung m6i sau diOu

tri

+

Cec x6t nghiQm c6ng thrlc m6u, sinh h6a m6u, chuc nEng tuy6n gi6p'
test phdn tim h6ng cAu, trimg lcf sinh trung,

kf

sinh

rung

III. CH6NDOANPHANBIET

a. BQnh Celiac sprue: triQu chimg chinh

ld

chiy

m4n tinh, ch4m

l6n'

mQt

m6i, tuy nhi6n benh ndy

it

gflp 0 nudc ta,

vtng

dich tE c6 bQnh luu hdnh cao

(chau 6u khoang 1%), benh nhan

bi

celiac

sprue kh6ng c6

bitiu

hiQn triQu
chimg diiin hinh, c6

tte

Uieu hiQn HCRKT d4ng

tio

b6n'

b. BQnh k6m dung ngP lactose

TriQu

.tri,ng

AAy bpng, chu6ng

hoi ia

l6ng li6n

quan d6n 6n c6c s6n

phAm chc bi6n

tt

sta

..

ngnn

<sub>$ </sub>

viOm

lo6t

tlli

trhng (vi6m lo6t

tl4i

trirng

ch6y m6u

vi

bQnh

Crohn)

Chi

y

dich

t6 luu

hanh b€nh kh6c nhau

giira

c6c

vtng'

TriQu chimg
chinh gdm: ia l6ng t6n t4i tren 2 tuan, di

ngoii

ra m6u, c6 bi6u hien vi6m, srit

cin,

t6n thuong quanh

hiu

m6n, s6t

d. BQnh

I

ung

thu

il4i

trgc

tring

-

Benh nhan lcrn tu6i xuAt hiQn triQu chtmg ldn dAu ti€n

-

ia phAn c6 m6u, srit c6n kh6ng 16 nguy€n nhdn, dau ki6u

tic

nghEn n6u

t6n thuong dai trang

tr6i,

thi6u m6u hoflc thi6u

sit

ntiu t6n thucrng d4i trang

phii

ia

ch6y do lcf sinh

trirng

vi

khuAn nhu ly amip, do

Giardia

ruQt

C6c bi6u hiQn chinh, ia chdy mang

tinh

ctr6t c6p tinh, x6t nghiQm phdn
ho[c sinh thi6t te

fang

f. BQnh

I

vi6m

trii thita

Thulng

tlau b6n

tr6i,

s6t, c6

cirn

gi6c cimg

d

h4 su&n b6n

tr6i,

chdn
dorin qua nQi soi

g. L4c nQi m4c tfr cung

</div>
<span class='text_page_counter'>(177)</span><div class='page_container' data-page=177>

-r'75--

Dau theo chu ki. vDng bung dudi

-

Budng tning to ho6c c6 nang phi d4i c6 tri cung khi thdm kh6m
h. BGnh

lf

vi6m nhi6m

ving

khung

chiu

ti6u khung

N6u c6 k6t frqp c6c triQu chung tAng kich thu6c bgng, chu6ng br,rng, trigu
chimg tii5t niQu g6p

tli

43% b€nh nh6n ung thu 6 bsng, chi6m 8%1r€n tO.,g ,6
benh nhan

Iv.

ErAU

TRi BeNIr NHAN

ncnxr

1. MUc ti6u

tliiiu

tri

MUc ti6u

cta

didu

tr!

bQnh nh6n c6 HCRKT ld di6u

tri

tri6u chimg

vi

v6y
kh6ng c6 nguydn

tic

chung, kh6ng c6 m6t phuong ph6p don nn6t

naot6

Oidu

tribenh

HCRKT

2. Di6u

tri

trq

Loai b6 cdc y6u t6 khoi ph6t v6i HCRKT nhu ch6 dQ

in,

stress, y6u t,5 tam

li

-

Yiiu t6

tam

l),

giiu

ch6t xo, An

<sub>{fng </sub>

btra, cung c6p tfii dich, hoat dQng th6 lyc hqp l),

3. Thu5c ilidu

tri

triQu chring
a. Cdc thu6c

giim

tlau:

</div>
<span class='text_page_counter'>(178)</span><div class='page_container' data-page=178>

-176--

Thu6c paracetamol clugc uu ti€n lqa chon hon nh6m NSAIDs

vi

crlc

t6c dgng cta nh6m thu6c ndy n€n dudng ti6u h6a. Kh6ng n6n dtng thu6c nh6m
Opiat vi c6 th€ gdy nghiQn

-

C6c thu5c chOng co thAt hien nay c6 rAt nhi6u lo4i tr6n thi trudng

+

Dicyclomine 20 mg u6ng 416nlngdy

*

Hyoscamine 0,125-0,25 mg crt 4

gid/lin

-

Thu6c trdm

cim

ba vdng:

+

Amitryptiline,

khdi

dAu 10 mg/ngdy,

c6 th6 li6u

tir

10-75mgingdy,

ding

vdo hic di

ngt.

+

Desipramine, li0u khdi

diu

10 mglngiy, cO thri fieu

fi

10-75mg/ngdy,
dirng vdo hic di

tr6n 6 thring, mir kh6ng c6 d6p ung

v6i

di6u

tr!

cric thu5c ch6ng ia

ch6y th6ng thudng. Tuy nhi€n thu6c ndy c6 th0 gdy vi€m d4i trang thi6u m6u
d. Didu

tri

c6c bi6u hi$n

ttiy

thu

c6 tric dqng chting dAy

hoi

d

benh nhan
HCRKT.

e. C6c phucrng ph6p tlidu

trl

kh6c (tlidu

tritim

lf).

TIfN

TRITN HCRKT

+

Hitiu tluqc bQnh

ly

+

Gi6o duc benh nhdn vA benh l), HCRKT

+

Tao nidm tin benh nhan khi chfa b6nh

VI. THEO

-

Dot

-

C6 thay OOi trieu chung nhi6u.

Tni

[Qu

tham

kh6o

1. Worid

Gastroenterology Organisation

Global

Guideline(2009). Irritable
bowel syndrome: a global perspective.

2.

Brar,dt, L.J.,Chey, W.D.,Foxx-Orenstein,

A.E.,et

a1(2009).

An

evidence-based systematic review

in

the management

if

irritable bowel syndrome.
American Joumal of Gastroenterology, 104, S1-S35.

3.

Drossman

DA

et

al(2002).

AGA

technical

review

on

irritable

bowel
syndrome.Gastroenterology 123 :2108.

4.

Ford

AC

et a(2009). Efficacy

of

5-HT3 antagonists and 5-HT4 agonistsin

irritable bowel

syndrome: systematic

review and

metaanalysis.Am J

Gastroenterol 104:1831.

5. Gershon

MD,

Jack

J(2007).

The

serotonin signaling

system: From

basicunderstanding

to

drug

development

for

functional

GI
disorders.Gastroenterology 132:397 .

</div>
<span class='text_page_counter'>(180)</span><div class='page_container' data-page=180>

-178-cHI/oNG

BPNH

Lf

TUY

VTTM

TUY

CAP

DAr

cr-roNc

Vi6m

tpy

c5p hay hoai

tu

tuy6n tgy c6p ld tinh tr4ng vi€m dQt ngQt cria
tuyiin tgy.

N6

c6 th€ g6y nhirng bitin chimg n4ng vd

ty

hi

vong cao m4t dft

dugc di,)u

tri.

Trong khi vi6m

t,y

cAp nhq thuong dugc di'iu tr! thirnh c6ng

v6i

nhftng phuong ph6p

kinh

di6n nhu nhfn 6n u6ng hoirn toirn

vir

bir dich tinh
m4ch

tich

cqc, nhirng trudng hgp nang

l4i

cAn ph6i nhap vien

vio

khoa H6i
Srlc c6p ct?u

holc

ngiy

"akhoa

ngo4i d€

xri

lf

nhfrng bi5n chimg n4ng n6

cia

bQnh.

Theo Atlanta 2012, vi€m tpy c6p c6 th6 cluoc chia thdnh 2 loai : vi6m tpy

pht

nri m6 k6 vd vi6m tpy ho4i tu.

ViOm tlry

phir

ni

k0:

Chiiim da sO, Ugntr nh6n viOm

tgy

c5p c6 tqy
l6n lan t6a do vi€m phtr n6. TrOn chpp

cit

tE

vi

tinh c6 c6n quang nhu m6 tgy
c6 t6ng dm d6ng nn6t va tO chrlc m0 quanh tgy thudng c6 nhirng bi6n d6i vi6m

cta

d6i sgi nhg. Cfrng c6 th€ c6

it

dlch quanh tqy. TriQu chung I6m sirng

cta

vi6m tgy

pht

nd t6 chrlc kE thudng nhq

vi

hdi phgc nhanh trong tuAn dAu'

ViAm

di€m
Mayo-Robson 6n dau, 6n dau

vtng

dAu tuy-6ng mat

cht.

+

D5u hiQu Korte (dau, Od kfrring

vtng

diiu tqy' d

ving

thuqng

vi,6'7cm

tr€n r5n <sub>).</sub>

+

D6u hiQu Kamenchik (dau khi t4o rip lqc tr6n m6m mfri)'

b. Nhfrng d6u hiQu

it

ph6 bi5n

vi

vd

lipase huyrit thanh, k6t hqp

vdi

clau

bqng dfr dQi thuong tlua ra chAn ttorln ban dAu cira vi6m

tpy

c6p. Tuy nhi6n,
chfng kh6ng c6 vai trd ti6n luqng mric dQ

ning

cria b€nh.

-

Lipase huy6t thanh tang

til

4 rliin 8 gid ke tu khi khdi phrlt triQu chimg

vi

binh thudng sau 7

dlin

14 ngity sau didu tri. Nhin chung, lipase huytit thanh
tlugc cho ld nhay c6m vir

ttic

hiQu hon amylase huyiit thanh trong chAn do6n

vi€m tuy c6p

-

Amylase huytSt thanh c6 the binh thudng (trong 10%

trulng

hqp) d
nhirng

trulng

hgrp vi6m tgy c6p c6 tdng triglyceride m5u.

-

Nhirng nguy€n nh6n g6y t5ng amylase trong huy6t thanh bao g6m

bQnh tuyiin nudc bot (amylase nudc bot cao), t6c ru6t, nhdi milu, vi€m tui mflt,
lo6t sAu.

-

N6u n6ng dQ lipase khoang

2,5

dln

hn

v6i

Amylase, n6

li

mQt

chi di6m

cta

vi6m tpy c6p do rugu.

-

Giam Calcium huy6t thanh.

-

Dudng niQu.

c. ChAn do6n hinh

inh

-

Si6u 6m bqng;

+

gi6

tri

tuorrg d6i h4n ch6, girip ph6t hi6n s6i tui

c6p. Nhirng th6m dd khric bao g6m chgp

X

quang
bung c6 d0 nhay k6m vd khdng khuy6n c6o sri dgng. cAn chri

j

li

chAn do6n
hinh anh trong 12

gid

tliu

thudng kh6ng chinh x6c bdi

vi

t6n thuong vi€m

vi

hoai tu

thulng

xu6t hi6n 16 sau 48 gid.

</div>
<span class='text_page_counter'>(182)</span><div class='page_container' data-page=182>

-180-BQ Y TE. HUdNG DAN CHAN DOAN V

ForEu

rzu BENH rm,u

soa

tE

vi

tinh dugc khuytin c6o nhu cdng

cu dinh

gi6

tri

ho6n

trong ciic tinh hu6ng sau :

o

Thay d6i trong tinh tr4ng cAp tinh.

o

X6c dfnh d6p ung di6u

tri

sau phAu

thuft

hay

tht

thuft

X-quang can
thiQp.

o

Tru6c khi cho xu6t vipn d b€nh nhAn vi6m tpy c6p n4ng.

+

Chup c6t top

vi

tinh bung kh6ng n6n thUc hiQn

trulc

12 gid ngdy ddu

ti6n khdi ph6t trieu chimg nhu chgp c6t lop vi tinh s6m

(<

12 gid) c6 thti c6 k6t

qu6 kh6ng r5 rdng hay binh

thulng.

+

DAu hiQu

cta

chgp cdt lop

vi

tinh c6 th€ dugc ph6n thirnh c6c loai sau

dary:

o

Trong nhu md

tgy:

lan t6a hay khu trir,

pht

nA' bqt khi, nang gid tpy
hay 6p xe. . .

o

Quanh tgy hay ngodi

tpy -

tyy

kh6ng d6u, th6m nhi6m md quanh
tuy,

pht

n0 sau phric m4c, dich trong kho6ng kh6ng b0n than tnii.

o

Gi6i

han tai ch5 - DAu hieu m6 1i6n k5t Gerota (Ddy l€n m6 li€n ktit
vi6m Gerota, c6 thri nhin th6y dugc ), c6 trudng tuy, dich mang ph6i (nhin thSy
tr6n

mit cit

khoang mirng phOi;, nhu dQng ruQt...

-

Hinh 6nh cQng huong

tti

+

Trong khi chpp cat

tE

vi

tinh ttugc xem ld ti6u chuAn vang trong ch6n
elo6n hinh dnh cria vi€m

tqy

c6p, cQng huong ttr

trd

thanh c6ng cg c6 gi6

tri

ngdy cdng tang hong kh6o s6t tuy6n tgy, dec bipt dlch tgy vdr mdnh t6 chrlc ho4i
trl. CQng hu<rng ttr cffng dugc chi dinh d6i v6i benh nh6n d! ung v6i c6n quang,
c6 d0 nhay cao hon Orii vOi xuat huyilt, bi5n chimg m4ch m6u, chimg gi6 phinh
m4ch vir huy6t khtii tinh m4ch.

+

M6t

tiQn ich cria cQng hu&ng

tt

ln ung dpng

cta

n6 ld chgp mat tpy

cQng huong

tt.

Chgp mat tuy cQng hu0ng tu cung cAp nhirng th6ng tin hiru ich
li6n quan diin nguyCn nh6n vi6m tpy c6p nhu sy hiQn diQn

cta

s6i m4t nh6 vd
b6t thudng ducrng m@t.

Nhilng

thrl nghiQm l6m

sing

cho th6y

ring

chpp

m{t

tgy cQng

fr""rg

ti,

c6 th6 ld phuong tiQn chAn doan hiQu qu6 trong vi6m tuy c6p

v6i

bQnh nguy€n m6t nhu chpp mQt

qy

ngugc ddng, nhrmg

v6i igi

ich

it

xdm

</div>
<span class='text_page_counter'>(183)</span><div class='page_container' data-page=183>

B0Y16-HUl

dNc oAN cHAn ooAN

va

DIEu rRI BENH rrEu

uoa

-182--

Si6u 6m

ndi

soi (EUS): girip danh gi6 chinh x6c t6n thucrng

tuy,

s6i
nhd ting m4t

cht,

tdn thuong vtrng b6ng Vater...

3. Ti6u chuAn chAn tlo6n:

Ti6u chu6n ch6n doan

cfp

nh4t vd ttugc ch6p nhfln rQng

rii

nhAt hiQn nay

li

ti6u chuAn

Atlanta2Ol2:

ChAn doan vi€m tgy c6p ddi h6i 2 trong 3 d[c diiim sau

(1) Dau bpng kdo ddi hong vi6m tUy c6p (khdi ph6t cAp tinh clau virng
thugng

vi

dt

dQi, dai ding thuong lan ra sau lrmg.

(2) Tang fipase huy6t thanh (ho[c amylase huyiit thanh; it nh6t tren 3 lAn

gidi h4n tr6n binh

thulng.

(3) Nhfrng d6u hiQu d4c trtmg cria vi6m tgy cAp trdn chup

cit

top

vi

tint

,

:,.:

c6 cd.n quang vd it phO bi€n hon ld cQng hudng tri hay si€u 6m bpng.

N6u dau bgng c6 khd n6ng cao

li

vi6m

tgy

c6p nhrmg sy

ting

lipase
hodc amylase m6u

it

hon

3

lan

gi6i

han tr6n binh thudng c6 thi5 le do bQnh

nh6n d6n vign mu6n, c6n

phii

c6 chAn do6n hinh

inh

dii x6c dinh viQc chAn

dorln. N6u ch6n ttorln vi€m

tuy

c6p c6 thi5 dga

vio

l6m sdng

+

t6ng n6ng d0

erlzyrne tgy huy6t thanh,

thulng

kh6ng c6n chpp

cit

l6p

vi

tinh c6 c6n quang
trong phdng c6p cfiu hay hic m6i nh6p vi6n.

4. ChAn tlo6n mtfrc iIQ

Trong dq tlorin

ti6n

lugng, c6 mQt

sii

chi sO Oiem dd dugc sri dr,rng du
do6n vd sg s5ng cdn. Hai h€ thi5ng di6m d6nh giri mric d0 nang thudng dirng ld

chi

s6 Ranson vd APACF{E

<sub>II. </sub>

HAu htit c6c nghi€n criu cho thAy

ring

chi s6

APACHE c6 th6 le chinh x6c hon, trong d6

APACIIE

ll

24

giit duo. c sri dpng
nhiriu hcyn APACHE

II48

gid.

a. Di6m Ranson

Dlc

thir

cta

Ranson ld ti6n luqng

cht

yiiu dua vdo l6m sing dri ti6n do6n

mtc

d0 n6ng cta vi€m tr,ry cAp.

-

Khi

m6i nhflp viQn:

-

:.

+

I uol > 55.

+

BachcAu>

16.000/mm3.

+

Dulng

m6u

> l0

mmoVl.

+

LDH

> 350 U/L.

+

AST(SGOT)>250UL.

-

Lric 48 gid :

+

Gi6m hematocrit

> ljyo.

+

T6ng ure m6u

>

l,8mmol/I.

+

Carxi

miu<2

mmol/I.

</div>
<span class='text_page_counter'>(184)</span><div class='page_container' data-page=184>

+

Gi6m HCO3->

4mEqll.

+

dlch ti dgng > 6 lit.

Di6m Ranson

>

8, ho4i tu tpy dring kti suy co quan

(it

nnilt nolo ho4i tri
tuyiin ghi nh{n trOn chpp

cit

lop

vi

tinh). N6u diiSm > 3, vi€m tuy c6p c6 kh6
ndng n4ng. Nliu dirim < 3 vi6m tuy cAp kh6ng npng.

Ho[c

<

1.90 mmoVl (< 8.0 mgldl-) hay albumin huy6t
thanh, 33

gll

( < 3,2 <sub>e/dL).</sub>

c. Di5m

Balthazar

Eugc ph6t tri6n

vio

nhirng n6m dAu 1990 bdi Emil

I

Balthazat

vi

cQng

sy, chi sti mirc dd n4ng chgp c6t

tE

,i

tinh

(CTSI)

li

mQt hp thi5ng ph6n lo4i
duoc su dr,rng d€ x6c dlnh mrlc tlQ nqng cta vi6m tqy c6p.

Chi s5 mric d0 nang chpp

cit

lorp

vi

tinh c6

ttii

da 10 di6m vir ldr t6ng cria

nhfrn dir3m lo Balthazar vir di6m 1o

tli

Di6m hoai

tft

Di6m
Bi6u hiQn

tr6n

chgp

cit

1,5.p

"i

tinh

Lopi Balthazar

0 di6m
Loai

A

Binh thudng tr6n chup

clt

lop

vi

tinh

1 tli6m
Lan rQng khu tru hohc lan t6a cua tuy6n tgy

Lopi C e6t thuong tuy6n tpy vd vi€m quanh

tyy

3 di€m
Tg dich trong mQt dia di6m duy nh6t

Loai D

4 di6m

bgt khi trong ho4c li6n kC vdi tuyiln tpy

Lo4i E

Khdng ho4i

trl

0 di6m
0-30% hoai

tt

2 di€m

BO Y TE - HU6NG DAN CHAN DOAN

va

orEu

rry

aENH TIEU HOA

-183-Lo4i B

2 di6m

Tp dich hai hay nhi€u hon c6c

vi tri

/

hoic

Di6m

</div>
<span class='text_page_counter'>(185)</span><div class='page_container' data-page=185>

30 ddn 50% hoai

tri

4 di6m
TrCn 50% hoAi tu 6 di6m

Chi s6 mric d0

ning

chup c6t lop

vi

tinh dang thti hiQn mric dQ

ning

crla

vi6m

tpy

c6p duoc chi ra

bdi

m6t s6 nghiEn cuu cung c6p ttrinh girl chinh x6c
hon APACHE

II,

Ranson, n6ng dQ CRP. Tuy nhi6n mQt

vdi

nghiOn ciru cho

thAy

ring

chi s6 mric d0

nine

chyp

cit

lop

vi

tinh

kh6ng li€n quan mdt thi6t

ti6n

lugng nh6p viQn

d

b€nh nhdn hoai

tri

tuytin

tpy,

cfing kh6ng ph6i ld mQt

y6u t6 dg b6o chinh xdc

cinmric

dQ npng vi€m tgy c6p.

d. Ti6u

chuin

Glasgow

Ti6u chu6n Glasgow ld c6 giri

trl

cho cd hai vi6m tqy c6p do s6i mdt vir
do rugu, trong

khi

t16 diiSm Ranson chi cho vi€m

tpy

c6p do rugu. Nriu di6m

cia

bdnh nhdn 3 hay hon n6 cho th6y vi€m tpy n{ng vd bQnh nh6n n€n ilugc
chuy6n dtin

tlon

vi

tliAu

/L

-

C-Canxi4mmollL

-

R - Chric nlng th4n, Ur€> 16 mmol /

L

-

E - Enzymes: LDH> 600iu / L,

ASD

200iu /

L

-

A

Albumin<32g/L

(huy6t thanfr;

-

S - <ludng: ttuong huy6t> 10 mmol /

L

5 Nguy6n

nhin

-

Ch6n thuong bgng.

-

Nhtng

6 lodt sau.

-

Benh ric tinh.

-

Thu5c

:

lqi

ti6u

(Thiazide, <sub>furosemide...), tetracycline, sulfonamide,</sub>
estrogen...

</div>
<span class='text_page_counter'>(186)</span><div class='page_container' data-page=186>

-184--

Nhi6m

trung

:

quai

bf,

vi6m

gan

Suydaphttang

-

D6ng m6u rAi r6c nQi m4ch

-

Giam Calci m6u

-

1 Didu

tri

nQi khoa
a. Gi6m tlau

Trudng hSp nhe cO

th6

dirng Acetaminophen, nqng

hon

c6

thiS dung
Tramadol.

Ban dAu ngudi ta nghi

ring

thu6c gidm <lau kh6ng n6n cho Morphine bdi

vi

c6

tht

gdy co thht co vdng Oddi vd ldm

n{ng

th6m dau,

vi

th6 thu6c
thudng dugc lya chgn lir Meperidine.

Tuy

nhi6n, do

thitiu

hiQu qu6 vd nguy

co

d6c ctra meperidine, nhirng
nghiCn criu gdn ddy hon d6 cho th6y morphine le thutic gi6m dau ttugc lga
chgn. Meperidine c6 th6 vdn duo. c sri dpng bdi mQt s5 b6c sy trong trudng hqp
nh6 khi md Morphine c6 ch5ng chi d!nh.

b. Nhin nn

</div>
<span class='text_page_counter'>(187)</span><div class='page_container' data-page=187>

-185-Kh6ng

cho b€nh nhAn En duong mi€ng dti

tuy

tlugc

nghi

ngoi

trong
trudng hqp vi6m tuy c6p thti ndng

hoic

vira.

Cung c6p dlch qua dudng

tinh

m4ch, dy phdng m6t nu6c vd gidm dau

cho b€nh nh6n. Khi tuy6n

<sub>{ry </sub>

ttuoc kich thich

titit

enzyme bdi sy hiQn di6n cria

thric 6n trong da ddy, kh6ng c6 thuc an th6ng qua hQ th6ng cho phdp tuy nghi
ngoi. X6p

xi

20Yo bQnh nh6n c6 t6i ph6t dau trong qu6 trinh

bi

vi6m

tqy

c6p.

Xdp

xi

7 5%

tii

ph6t xity ra trong 48 gid cta nudi dudng <sub>bAng </sub>duong mi6ng.

Ti

le t6i

ph6t sau

khi

l4i

dudng miQng c6 th6 dugc gi6m

bdi

nu6i
du0ng tludng h5ng trang.

c. Cung c6p dinh dudng

GAn d6y, c6 sg thay tl6i trong quan niQm diAu

tr!

vC dinh dudng. Trudc
kia ngudi ta khuy5n c6o nu6i du6ng hodn todn bing duong TM.

HiQn nay, n6n cho 6n sdm

bing

dAt sonde xu6ng h6ng trdng: 6ng nu6i

[a

ttuoc d4t vao sau tlo4n

thri

3

ct:atd trang. Thuan

lgi

cta

nudi nn

bing

duong
ruQt ld sinh

lj

h<rr,

ngin

ngira teo ni6m mac ru6t

vi

cric bi6n chring khric

cta

nu6i 6n ngodi

dulng

ti6u h6a nhu nhi6m n6m.

B6t

lgi

crla nu6i En qua sonde mfri ld ldm

ting

nguy co vi6m xoang (d4c

biQt ntSu ilng luu lai hon hai tudn)
d. Kh6ng sinh

Vai trd cta khang sinh cdn tranh c6i.

Kh6ng sinh kh6ng cAn thi6t trong c6c trudng hgp vi6m tqy c6p nhg.

C6 th6 su dung Imipenem trong trudng hqp CT-scan cho th6y

ty

lQ hoai

tu tr€n 30% tuy.

MOt s(i ktAng sinh kh6c c6 thd dtng nhu Cephalosporine, <sub>Quinolone....</sub>
2 Di6u

tri

nQi soi

ChUp mflt tuy nguoc ddng qua nQi soi (ERCP), ginp ch6n do6n vd lo4i b6

c6c nguy€n nhdn do s6i dudng mQt, giun chui duong m4t,

Chi dinh ERCP s6m, trong24-72 gid dAu didu

tr!

nguy€n nhdn s6i, giun
dudng m4t girip gi6m biiln chring vd

tf

lQ tri vong.

Bi6n chung c6 th6

glp:

chdy m6u ho{c vi6m tpy c6p sau ERCP.
3. Phdu

thuflt

-

K!

thuflt: c6t m6 ho4i tu: d6n luu, mO n0...

</div>
<span class='text_page_counter'>(188)</span><div class='page_container' data-page=188>

-186-t

vrtvr

rUY

MAN

DAr

cUcnc

Vi6m tpy mpn

(V.T.M.)

ld mQt bQnh ly mpn tinh cria tuytin tpy ngopi ti6t,
bqnh nguy€n thudng ld do ruou nOn bQnh ngay cdng gia tdng.

Khi

triQu chimg
l6m sdng dd 16 rdng thi viQc chAn do6n thudng kh6ng kh6;

nhmg

khi tpy m6i
t6n thucrng mQt phAn hoflc cdn

it

chAn do6n rAt t<hO

khin

chri ytiu dpa

vio

c4n

ldm sdng. Vi6m

tpy

mpn c6 th6 bi6u hiQn

dudi

mQt hQi chrlng bQnh h6p thu.
Nguy0n nhdn vi6m tpy m4n cfing tucrng tp nhu vi0m tgy cAp

li

do rugu, do s6i,

do thu5c,

xo

nang tuytin tpy.

Khi

tUy

bi

ph6 hriy >$Oyo <sub>mdi </sub>bi6u hiQn suy tgy
hopc cti iachtty mO ho{c cli ia phdn s6ng.

6

circ nu6c phucmg Tdy chtr ytiu

li

ruou

d

ngudi l6n

chii5m

tt

60-90%

trulng

hcr.

p, vlr trd

li

bpnh nang xo

tuy6n

tr;y

(cystis fibrosis);

6

ctrc nudc suy

dinh

du0ng

ld

do thii5u
protdine-calori dua d5n xo tgy. O Viet Nam

ngoii

nguy6n nhdn do rugu cdn do nguy6n

, A ' I t <sub>'.</sub>

nhdn vi6m

tpy

cdp tdi phitt nhi6u 16n do soi vir giun dfia chui

vlo

dudrng mpt
tpy.

Ti

suAt th6 & Ph5p \d,4,71100.000 d6n, s6 ca

m6i

mit

hdng

nim

tr6n th6

gi6i

cho ddn

6ng

ld

7,71100.000 ddn

vd

php

nt

ld

1,2/100.000 ddn.

Ti

NamAIfr ld 411.

II.

PHAN

LOAI

Trong phan lopi cria Marseille- Rome d6 dlnh nghia viOm tpy c6p ld :"TOn
thuong vi6m m4n tinh cria tuy6n tpy mang tinh ch5t ph5 hriy phAn nhu m6 ngo4i

titlt

kdm

xo

h6a; vd sau ph6 hriy tu6n phdn nQi ti6t

".

Ngudi ta chia ra ldm hai
lopi:

1. Vi6m tpy do

tic

nghEn: mang

tinh

ch6t ddn d6u 5ng tpy tr6n ch6

tic

xtty ratrudc vi6m nhu trong ung thu d6u tpy, vi6m

xo

co Oddi, u b6ng Vater,
xo hgp 6ng tpy nguy6n phdt.

2. Vi6m tgy m4n calci h6a:

thulng

<sub>efip </sub>0

din

6ng tr6 thudng ld do rugu,
c6 thucrng tdn gi6i phdu

itic

Trulng

ph6i Cambridge (Sarner 1984) chia ldm 3 th6 :

</div>
<span class='text_page_counter'>(189)</span><div class='page_container' data-page=189>

87-+

The nhg: chpp

tpy

qua nQi soi nguoc ddng c6 th6 6ng

tpy

cdn binh
thuong (< 3 nh6nh b6n b6t thucrng).

+

The vtra: c6 tr6n 3 nh6nh b€n bdt thudng.

+

ThC n{ng:

ngoii

c6c thuong t6n tr6n cdn thdy cdc kystes, s6i calci h6a

\ lr , A

vd nghEn c6c 6ng tpy.
ITI.

GIAI

PHAU BENH

1. D4i th6:

Lric dAu tr;y cdn binh thuong. Giai dopn sau tpy thucmg l6tn chic, cutii cirng
ld xo teo, cimg;l,rhi cat

<sub>By </sub>

c6 mdu tr'ing x6m, m6t ranh gi6i

gita

c6c thtry, 6rg tUy
ddn kh6ng cl0u do soi nghEn vh xo 6ng tUy. Cutii ctng 6rg tUy c6 hinh c6i m0 nrit
chai, kh6ng d,5u, c6 nhirng doan bi nrit l4i bang chet proteine trong su6t hoic calci

hou

cdc ting nh6nh cfing bi ddn c6 th€ c6 dpng k6n; d6i khi c6c k6n ndy vd

vio

bqng hoac

bi

6p-xe h6a. Xo tqy va mO chung quanh tUy c6 th0 lam xo hgp dQng

m4ch, tinh mpch, b4ch mpch duong mpt

vi

d6i khi c6 ting ti6u hoa.

Soi

tyy

c6 thiS trong su5t, mdm hopc calci h6a clucrng kinh c6 th6

tt

vai
mm d6n hdng cm c6 hinh d6ng kh6ng d€u.

Trong giai do4n dAu t6n thucrng .5p

*tt

v6i

t6n thucrng m?n n6n c6

th0 di

tt

pht

tpy d6n xuSt huy6t vd ho4i tri.

2. Vi

thO:

^i,. ' 1, - t '

Tdt c6 c6c nang tuy6n cl6u

bitdn

thuong cdn c6c d6o Langerhans chi

bitdn

thucrng vdo giai do4n cutii . Cttc t6n thuong trong mQt thdi gian sE dugc t6i tao

kh6ng clAu, df hgrp. Cflng vpy mQt sii nang tuytin bi t6n thuong b6n cqnh chc nang
tuy6n cdn binh thucrng. Ni6m m4c cria c6c 5ng tuytin bi teo dAn, d6n ra vd chria

cdc chdtkrit tria pr6t6ine, c6c 5ng tuy6n mang hinh th6i cria cdnh cdy kh6. Hi6m

hcrn

li

ni€m mpc 6ng tuyen

biphi

d4i ho4c d! san lorp malpighi ho4c c6c tuytin titit,
doi

khi

c6 hinh

arn-toit; .ar

io

chric 1i6n

tet

pnaitri6n chung quanh 6ng tuytSn

gdy ra

xo

he.p

lim

tic

nghEn timg phdn hay

toin

bQ 5ng tuy5n, 6 tr6n ch5

tic

nghEn nhu m6 bf teo

lqi

gdy raxo b6n ngoiri r6i bCn trong titiu thuy.

rv.

BpNH

NGUYTN

Do

nrgu:

thudng

g{p

o chdu

Au,

chdu

M!,

Trung Phi, mQt phAn chdu A.
Chri ytiu g?p (,

din

6ng >gToh <sub>trudng </sub>hgp,

tutii

trung binh ld 40. C6 sy tuong
quan tuyr5n

tinh

giira tAn su6t v6m

tuy

cdp do

ruqu vir

mric dQ u6ng ruou.
Tuy nhi6n dQc tfnh

cfa

rugu cdn

tty

thuQc tO

tinh

mAn

cim

cria ttrng ngudi,
c6 th6 cdn do

tinh

di truy6n

c6

trudc. Thdi gian utSng rugu cfing quan trong,

trung

binh

17 ndm & tldn 6ng, 11 n6m

6

phU

n8

vi

lugng

rugu trung binh
m5i ngdy le >100 g.

Chc yi,;n

t6

ve

5n u6ng cfing

inh

hucrng nhiAu cl6n bQnh nhu:

An

qu6
nhi6u protides ldm gia tdng nguy co

mic

benh, 5n qu6

it

hopc qu6 nhi6u lipide

</div>
<span class='text_page_counter'>(190)</span><div class='page_container' data-page=190>

88-cing

vfly. Trong khi d6 dn md 1i6u trung binh 80-100 mg/ngiy thi nguy co m6c
Ugntr tnap nh6t. Thu6c 16

ctng

ldm gia

ting

nguy co m6c bQnh.

z.

ffr6 tfri6,

ni6n &

ving

nhiQt t15ri: xhy ra 0

ci

hai gi6i,

tu6i

trung binh ld
12,5 ndm, d ddy bQnh nh6n hoirn

toin

kh6ng u6ng ruou nhtmg suy du0ng quri
n{ng vd k6o ddi benh thucrng g4p d midn nam

An

dQ, Tich lan, Nigeria, Zaire,

Ba-tdy.

S. Cutrng ph6

gi6p:

tit

cd cdc thti cuong ph6 gi6p ldnh ho{c 6c tinh d6u c6 th6

gdy ra vi6m tUy mAn calci h6a. Trong 3/4 trudng hgp lir do addnome cria ruy6n
ph6 gi6p. Tu6i trung binh, diSn ti6n 16m sirng cfing tuong tu nhu vi6m tqy m?n
calci h6a do ruou.

4. Do

di

truydn:

tu6i khdi dAu thuong <15 tu6i, hoi uu th6 0 nam

gi6i'

BQnh

xdy ra c6 th6 do khuy6t tflt cria nhi6m s6c th6 mang tinh trQi'

fn6 tiiim

gip:

b6nh xAy ra trong Utii

canl

cria bQnh

nhiy

nhot d ngudi l6n

ho[c d ngudi ghdp thfln.

v.

BpNH srNH 56r

ruY

Nghi6n

cfu

vdi hinh th6i si6u c6u trric cria c6c t6 bdo nang tuy6n vd 6ng
da cho th6y tho4t ti€n chua c6 thuong t6n nhrmg

di

c6 sy ngrmg k6t prot6in
trong c6c 5ng tuyr5n, sau d6 ld sp k6t

tta

cria carbonate calcium qua nhi6u n6m
de t+o thanh s6i th4t sg md c6u t4o

chi

y6u ld calci.

T6t

cit clc thti ddu c6 sq
chuytin d4ng

tt

k6t

tta

protein qua cali, tuong

tp

nhu s6i thQn vir ti6n trinh

viOm vd xo h6a cfing nhu trong xo gan.

Trong

tlidu kiQn sinh

<sub>$: </sub>

Mac dir c6u t4o cria dich ttty ld thich hqp cho

I

sg
k6t tua

cia

prot€in vd calci (dich tUy

di

dugc b6o hda calci). Nhung nhd ddng
chdy

ty

do cria dich tgy

vi

sg c6n

bing

gifra sg ti6t nudc diQn gi6i vd c6c men
tuy dE hen chri nguy co k6t tria prot6in; sy k6t tria calci cluo. c kiilm so6t bdi 3 co

chti kh6c nhau trong tuy6n tgy.

-

Lithostathine d6 dugc phdn lQp trong co chdt

cta

s6i tuy, n6 tlugc ti6t
ra du6i 4 dpng phdn t&. E6y

ld

1 glycoprot6in c6 vai trd ric ch6 sg t4o nhAn vd
phrit tri6n cria ciic tinh thii carbonate calcium.

-

Citrate: ddy

ld

ch6t chelate

cta

calcium tlugc c6c t6 bdo nang tuyiSn

ti6t ra, n6 cO

ai*r

mQt phdn calci trong dich tuy girip ng6n chln li€n k6t

v6i

cric

ion bicarbonate.

-

Ni€m m4c 5rrg tuy6n cfrng c6 vai

trd

chi

dQng trong viQc t6i h6p thu
bicarbonate bdng c6ch ti6t ra ion H+ trong

thdi

ki

ti6u h6a; pH h4 sE ldrn gia
tdng chi s6 hda tan cta calci.

Trong

tlidu kiQn bQnh

tf

Trong vi€m tuy m?n calci h6a c6 hai hiQn tuong co b6'n sau ddy

di

ph6i
hqp vdi nhau d6 gdy ra co ctr6 Ue*r sinh cta n6 :

</div>
<span class='text_page_counter'>(191)</span><div class='page_container' data-page=191>

189--

M6t

su ket tria bat thuong

cta

prot€in. C6c ktit

tta

cia

prot€in trong

giai

ilo4n

dAu cria b€nh,

n6 tlugc

cAu tao

cht

y6u

du6i

d4ng

thty

phdn vd
kh6ng hda tan cria lithostathine

vin

cdn chua hodn todn bi6t rd.

-

Sy k6t tua b6t thudng cria bicarbonate calci.

Euoc

ldm dE

bdi

su c6

mit cta

cbc

tta

prot6in,

n6 t6c

d6ng

nhu

ch6t tao nhAn

vd

do

su ha th6p
lithostathine trong dich tgy dE dugc thAy vdo giai dopn dAu

cta

benh b6t lu?n
do nguydn nh6n gi. Di6u ndy cho th6y c6 th6 do y6u t6 O truydn c6 sEn ct6 t4o
tidn dA cho vi€m tqy m4n.

Ngoii

2 y6u t6 chinh k6 h6n cdn do su kic dQng cria c6c yilu t6 ngo4i lai sau :

-

Rugu: li€n quan d€n>90% trudng h-o.p vi€m

tyy

man calci h6a. MOt
luqng nh6 rugu dugc

tuy

chuy€n h6a dd

lim

gia t5.ng su ti6u thu

ning

lugng

cia

tuyiin vd su

6ng

dgng lipid trong nhu m6 tuy nh6t ld qua trung gian cria su
tdng

ti€t

protdin

vi

do

su ha

cia

citrate mir

ruou

ttd ldm d6 cho sU k6t

tia

prot6in-ca1ci. MQt

sq

gia

tlng

trucrng

lpc

choline ai5i vOi ruou cfrng nhu su
nh4y

cim

cia

tuy O6i vOi kich thich hormon, dE gi6i thich cho su t6c tl6ng

cta

rugu 16n su ti6t prot6in.

-

Su gia tdng calci m6u m4n tinh: d4c biQt

li

trong cudng ph6 gi6p tr4ng

d6 tao didu kiQn thuen

loi

cho su tpo s6i. O ch6 ngudi ta th6y mQt sy gia

ting

ti

calci/bicarbonate ph6i hqp

v6i

su t6ng ti6t protdin.

-

Cutii

cr)ng ld tAm quan trong cira gi6i ph6u de ldm dE cho sq

ting

ktit
tua cria prot€in-calci: hgp i5ng tpy dE ldm ri trQ

vd

giatdng d6 qu6nh cria dich,

sr,r ph6

hty

cria ni€m m4c 6ng ruy6n khi ti6p xrhc

vdi

cric prot6in k5t tna dd gdy

n6n su ph6ng thich calci vdo

n6i

bdo, tli€u ndy cfrng

lim

gia t6ng sg k6t tua
calci.

VI. LAM

SANG

-

Dau: tlau ttmg dcrt, v6 sau tlau kdo ddi vd li€n tuc cucrng dQ mpnh. Dau
ki6u qu4n ho4c n4ng tric. Benh nh6n vi€m tqy men c6 th6 bieu hien nhfrng dqt
c6p nhu trong vi€m

tyy

cdp nhung phdn lon c6 th€ tlau 6m

i

li6n tuc ho4c ng6t
quan c6 hic trQi tran t6n

nhmg

dOi

khi

lpi

kh6ng tlau.

Kinh

diiin ld dau vtrng
thuqng v! hoflc ha suon tr6i lan ra sau ltmg, dau s6u vd dau thudng gia tdng sau

khi

6n; d6i

khi

dau

6

g6c 114 tr€n b6n

phii

ho4c b€n tr6i nhung d6i khi

l4i

dau

sdu mo hd trong 6 bpng ho4c tlau d phia sau lung, dau gia t6ng khi u6ng rugu
hoflc 6n nhiOu

diu

md ngodi dau cdn kdm cdrm gi6c ch4m ti6u. Dau gi6m khi

ngOi g4p minh ra phia trudc ggi

li

tu thti giam dau ki6u cd sring. Dau kdo ddi

, .: .. ,,4

nhi6u gid d6n viri

ngiy

sau tI6 c6ch do4n mQt vdi ngdy ho4c cd thrimg.

-

Stt

c6n: hic dAu srit cdn theo ttqt dau hl5t dau l€n c6n trd l4i, vti sau khi
k6m h6p thu srit cdn ngdy cdng gia

tlng

vd giai doqn sau ld suy kiQt.

</div>
<span class='text_page_counter'>(192)</span><div class='page_container' data-page=192>

-190--

Rt5i lo4n bdi ph6n: thuong ld di

chiy,

d4c bi€t ld di chdy md 1dm ph6n
b6ng I6n c6 vring md vd Id ntrO thOng ti€u hrit thric 6n nhu hpt c<rm, sgi thit, 16

rau ggi 1d phdn s5ng;

tt

d6 gdy ra hQi chimg kdm h6p thu.

Dlc

biQt ld k6m h6p

thu lipide, protide, c6c vitamin hda tan trong dAu, c6c y6u ti5

vi

lugng trir s6t vd
cu6i ctrng g6y phir, thi6u m6u,

rtli

1o4n sac

t6

da vir ldm t6c c6 mdru hung d6

nh6t lir d tr6 em.

-

Vang da: thuong

di

kdm

v6i

dgt dau, vdng da thudng nhp vdr thoang

qua <10 ngdy. Ni5u vang da n4ng vdL k6o ddi cAn nghi tltin kgt s6i hay nang lon

0 dAu tpy chdn dp viio dudng mflt.

-

Diii

dudng: khoang 1/3 benh nhAn

vi6m

tqy

c6

r6i

lo4n dung n4p

dudng m6u,

l/3

benh nhdn c6 d6i duong thflt sq hic ndy bQnh nh6n cdn c6 ctic
triQu chimg cria bQnh v6ng m4c, benh than vd bQnh than kinh do tt6i duong.
Nguy

co

g6'y ddi dudng trong vi6m tuy m4r,

lit

l2Yo sau 5 n6m vd 24Yo sau 70

nim

vir 36oh sau 15 ndm.

-

Khrim

t4i

ch5 thudng nghdo

nin

kh6ng tuong

ximg v6i

bQnh canh

toirn thAn c6 thd chi c6 di€m tlau

vtng

tpy hi0m

khi

khAm th6y mang do nang
tgy lon ho4c c6 b6ng.

vrr.

xfT

NGHTEM

1. Amylase m6u vir lipase m6u: thudng chi cao gAp 2-3 lan binh thudng trong
dqt ti6n tri6n vi€m, ngoii dqt ti6n triiin c6 th6 binh thuong n€n kh6ng

tllt

hiQu. Su

ting

lipase m6u nh?y vd dflc hiQu hon Amylase m6u trong vi6m tuy man.

Bilirubin

miu

vir phosphatase

kilm

m6u: c6 th6 gia t6ng trong trudng hqp
c6 ngh6n tluong mQt.

3. C6c x6t nghiQm

thlm

dd chric

ning

tuy6n

tgy:

th6ng

ti

trdng sau khi kich
thich bang secr6tin vd choldcystokinine (CCK) ho4c ceruldine cho thAy c6 suy ti6t
dlch

tqy:

Gi6m bicarbonate vd t5ng calci trong 90% truong hqp.

Dinh

luqng
trypsin m6u thuong giiun. nt5i loan ndy c6 thlS duo. c tlidu chinh sau

khi

su dUng

men tuy. Test pancreolauryl: dC tham dd sg ti6u ho6 lipide sau

khi

dn co ch6t

Dilaureate de fluoresceine ttugc c6t doqn boi men cholesterol ester hydrolase. Sau

d6 dinh luqng fluoresceine hong m6u vir trong nu6c ti6u. DQ rt\Ay

tt

62-92%.
4.

X6t

nghiQm

tludng

m6u bdng nghiQm ph6p tSng dudng mriu hoflc dudng
m6u khi d6i. DC ttanh gi6 tuy nQi ti6t.

5. X6t nghiQm

thim

dd k6m h6p

thu:

beng tim c6c thanh phAn lipide, protide,
vd glucide trong ph6n;

v6i

lipid b6ng

bta

6n chu6n c6 chria 50 g lipide 3 ngdy

li€n ti€p binh

thuong

<5

g.

Ho[c bing

test Schilling bSng c6ch

ti€m

1000

microgam

P12;2

giit sau cho u6ng 0,5 microgam

Bl2

c6

gbn ddng

vl

ph6ng x4
cobalt, sau d6 dinh lugng

Bl2

ph6ng x4 hong nu6c tiilu. Binh thuong 15-40%,
hong trudng hqp kdm hAp thu <So/o.Hoic beng nghiQm ph6p

D

<sub>- </sub>

xylose; bing

</div>
<span class='text_page_counter'>(193)</span><div class='page_container' data-page=193>

-c6ch cho ui5ng 25 g ducrng D-xylose hic bpng clSi (cfay ld lo4i ducmg chi dugc h6p

thu o do4n dAu ru6t non) rOi Ainfr lugmg D-xylose m6u sau

2

gitl vd D-xylose ni€u

sau 5gid. Binh thuong D- xylose niQu >5 g vd D- xylose m6u >250 mgll.
6. Do

cfc

ch6t chi tli6m sinh hgc

trong

men

tgy:

-

Lactoferine

tlng

cl6y ld nghiQm ph6p kh6 cl6c hipu.

-

Einh

luqng lithostathine ld mQt x6t nghiQm dang dugc thgc hign mang
nhi6u hria hgn.

ntr6i ttru

tni

&uv),
nang

gii

Si€u
nhu mO vi.l5ng

fuy

BQY HU] GD DOAN VA D TRI BENH T H

rI

</div>
<span class='text_page_counter'>(194)</span><div class='page_container' data-page=194>

VI[.

BIfN

CHLTNG

1. Nang gif,

tgy:

c6 th6

xiy

ra,do,h,9a1,f96au
t8c ngh€n Ong tpy do soi vi0m xo

trit

hgp 6ng

vi€m tpy cdp

ngoii

ra cdn do sq
tgy trong khi c5c nang tuYtin vdn

BQ Y TE - HUONG DAN cnaN DoAN

v

A DIEU TRIBE. NH TIEU HOA -r
93-, il ':.

't,lt".

</div>
<span class='text_page_counter'>(195)</span><div class='page_container' data-page=195>

cdn ho?t dQng. Lric dAu ld c6c nang nh6 vd sau

ngiy

cdng lon c6 th6 vO vdo
trong 6 bgng. C6c nang ndy c6 th6 bQi nhi6m 6p xe h6a. Ngodi ra c6c nang l6n

, ., ,l , . I

c6 thd chdn dp vdo 6ng mflt

cht

gdy vang da, viro tinh m4ch l6ch gdy titng itp
luc cua timg phAn vn l6ch lon,

chiy

m6u trong nang do dn mdn viro mach m6u
ho6c rd vdo t4ng r6ng ki5 cAn; v0 hoqc rd vdo 6 bung g6,y rabing, hi6m

khi

c6
th6 rd vdo mirng tim, trung th6t.

2..

T6n

thuong

gan

vir

iluimg

mit:

gan nhi6m md thudng g?p,

xo

gan thay
d6i tuy theo tric giA tu 2,3-18,5yo. Xo gan <sub>mflt thu </sub>ph6t hitim g[p.

Xo

doqn 6ng m4t chri trong tuy dd dugc Caroli phrit hiQn 1953 vd d6t t6n
ld xo dudng

mft

type

I

gdy ra vang m6t.

3. T6n thucrng dg dny t6

trhng:

g6y ra varices d4 ddy do ting iry lr,rc cria ttmg
phAn. Lodt d4 ddy tri

tring2-

15Yo,hgp

ving

hang-m6n vi-hirrh t6 trdng ld mQt

bi6n chung it g6p.

4. Chny m6u ti6u h6a:

-

Do tdng rip

lyc

cria tung phan hopc phiii hqp v6i thuydn t6c tinh m4ch
kich - crla do xo quanh tpy ho{c do nang chdn 6p, ph6t hi6n

bing

si6u 6m

-

Chdy m6u 5ng tuy: ddy ld mQt bi6n chrlng hir5m do nang 6n mdn mach
m6u vdr O6 ttrOng vdo 6ng tpy. Ch6n dorin r5t kh6 cAn nhd d6n nQi soi th6y m6u
chity ra

tir

6ng

tuy.

Chup nhu6m m4ch m6u th6n tqng- mAc treo

li

m6t x6t
nghiCm r5t a4c rupu.

-

T6n thuong mach m6u: vi€m d6ng mach chi dudi

thuong

g[p

<sub>e%),</sub>

nhmg

nhdi miiu co tim khdng gia t5ng.

ytiu

t6 nguyEn nh6n c6 th,i ia ao tang
urique m6u, do thu5c 16 vd cl6i

dulng.

5. Hogi tr?

m6'durli

vi

xuong kh6p: cric ntit tr4 Ui t6i phrit thu<mg ld d 2 ch6n

(h6i chung Weber-Christian) c6 th6 bi6n m6t ho6c rd ra ngoAi ch6t dang dAu.

6. Ung

thu

h6a: c6

thA24%

IX. CHANDOAN

f.

ChAn do6n x6c

tlinh:

chfr y6u dya vdo tidn sri u5ng ruqu, suy dinh du0ng
vdi nhirng dgt vi€m tpy c6p. L6m sang v6i dau

vtng

tpy k6o ddi cing ggi y cho
ch6n doan khi c6 hQi chring di chdy m4n vd kdm h6p thu.

ChAn doiin x6c dinh cAn dua viro xdt nghiQm sinh h6a

v6i

suy tuy ngo4i
ti6t va

*rAt

li

chqp phim bqng kh6ng sria so4n c6 hinh anh s6i tgy hodc si6u
6m, chgp cEt lorp

ti

trgng c6 hinh 6nh tuy teo nh6, t6ng 6m ho4c h6n hqp, i5ng

qy

dan vd nh6t la hinh anh s6i tuy.
2. ChAn do6n ph6n biQt :

Dqt

tdi

phrit

cfra vi6m

tgy

c6p: bQnh canh l6m sang gAn gi6ng nhau d d6y
thudng ld do s6i, amylase m6u

thulng

cao hon cAn dua viro si6u 6m c6 hinh
6nh s6i 0 b6ng Vater vd co Oddi.

</div>
<span class='text_page_counter'>(196)</span><div class='page_container' data-page=196>

-194-!

b. Ung

thu

tuy

: thudng x6y ra 0 ngudi gid. O tlAy dau

thulng

6m i vd li€n tpc
hon kdm ving da ngity

cing

gia

ting

dei

tien

phdn bqc mdu. Kh6m c6 th6 sd
thAy mdng vung dAu tpy vd gan trii mQt lon do ri m4t'

ChAn dori'n x6c dlnh cAn dga

vio

ghi hinh

bing

si6u Am, CT' ho[c chup dudng
mat tuy ngugc ddng c6 th€ k6t hqp

vdi

chqc hrit, sinh thitit t6 bdo hgc' O dey
si€u 6m vd CT cho hinh anh

th6i

tang si6u 6m vd hOn hqp.

c. Lo6t d4 dhy trl trhng nhAt l2r lodt xo chai 6 lo6t s6u dinh ho4c thring vdo tpy.

O tl6y cAn h6i

ki

con ttau lodt vd nh6t Dr dqa viro nQi soi d4 dAy t6 trang.

d. Ccrn tlau

thit

bgng do

thi6u

mfu

m?c

treo:

thuong g4p d ngudi gid >60
tu6i cffng thudng dau sau khi 6n. O

d6y

thuong kdm theo tnng huy6t iip

vi

xo
vfra m4ch m6u, n6u n4ng

thulng

kdm liQt ruQt ho{c

tli

cAu ra m6u. ChAn doan

cAn dga vdo chup nhuQm dQng mach mac treo qua cath6ter.

e. HQi chr?ng k6m h6p

thu

do c6c nguyEn nhdn kh6c nhu: trong bQnh Crohn,
lymphoma ruQt nguy€n ph6,t, bQnh coeliac.

x.

Drnu

rRI

thu

cdn dtrng 30.000 don

vi

Lipase 3.000 don

vi

protease, 10.000

tllv!

Amylase. C6c thu6c thuong dirng
Eurobiol, Cr6on, Alipase, Festale, Pancreozyme li6u 2-3 viOn/ngdy cho tru6c

bta

5n.

Trong truong hqp di chdy mo di) khring di€u

tri

cdn khdo s6t dQ toan dich
tqy. N6u tAng toan cAn ph6i hqp th6m thuiic khring tit5t vd tmng hda toan. Men

':

tqy cfrng phin niro lirm giirm dau.

c. Di6u

tri

chdng dau thuong ld cAn thitit nhAt ld trong thti dau nhi6u, th6ng
thuong ld srl dgng c6c thu6c

giim

dau nhu aspirine, paracdtamol, codein vir
nhidu hic can dtng d6n c6c d6n xu6t cta morphin.

C6c thu6c khang men d6t va it hiQu qu6, N6u

tn

vdo g6y dau nhidu c6 th€
nudi bang duong ngoiri miQng. Niiu do s6i kgt cAn cho thu5c ch6ng co

thit

co tron
ho[c l6y s6i nhtmg thuong kh6 thgc hiQn

vi

s6i

nim

rii

r6c trong nhu m6. Trong

mQt vdi trudng hgp cdn phong t6 thAn t<infr bang Xylocaine dung dich 1%.

d. Di6u

tri

tl6i

tlutmg:

n6u c6 tdng duong m6u thyc sU >11,1mmol/1. Trong
mQt vdi truong hqp girlm insulin qu6 nhi€u c6 thiS dirng insulin liOu trung binh

</div>
<span class='text_page_counter'>(197)</span><div class='page_container' data-page=197>

-195-20-30

tllvi

/m5i ngay theo ph6t d6 2 nhanh

+

1 ch$m

vio

bu6i t6i. Uoac

2

chQm

hoflc3nhanhlchpm.

e. Ditlu

tri

tan s6i:

thulng

dung h6n hqp Citrat-natri +

Kali

HAu 20-30 grlngiry

bi6t

duoc

li

foncitril

3-6

g6ilngity, c6 thiS lirm

tan

soi mQt phAn trong 40o/o

trulng

hgrp, nhung di6u

tri

ndy r6t ttin k6m.

hgp qu6 tiltmQt c6 th6 dpt 6ng nQi gi6.

vd t6 tring...

</div>