Ebook Cấp cứu ngoại khoa (Tập 2): Phần 2

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PHAN 5

TIET NIEU

1. CON DAU QUAN THAN

■ ■

Cdn dau quan than la trieu chiing cam nhan dtfdc khi ap ltfc dtfdng tiet nieu
tren tang len gay cang gian dot ngot dai be than nieu quan do tac nghen d ben
trong hay ngoai nieu quan. Nguyen nhan gay tac thtfdng gap nhat la do soi nieu
quan dang di chuyen gay co that va viem phu ne nieu quan. Can chan doan sdm
va chi'nh xac. Dieu tri nham giai quyet cdn dau va hau qua cua hoi chtfng tac
dtfdng tiet nieu tren.

1.

T R I E U C H t r N G L A M S A N G

1.1.

Tien

suf

Ban than hoac ngtfdi trong gia dinh co tien stf dieu tri benh soi tiet nieu va cdn
dau thtfdng xuat hien sau mot chuyen di xa, sau tap the due hoac lao dong nang.

1.2.

Trieu ch iin g cd n a n g

- Benh nhan dau thanh ttfng cdn dtf doi vung that ltfng vdi ctfdng do tang len
trong vai phut den hang gid. Benh nhan thtfdng lan Ion, luon thay doi ttf the, tuy
nhien moi ttf the giam dau deu khong co hieu qua neu khong dieu tri giam dau thi
kho cat dtfdc cdn dau. Cdn dau thtfdng co htfdng lan ro ret:

- Soi 1/3 tren dau lan xuong tinh hoan cung ben.
- Soi 1/3 gitfa thtfdng dau lan xuong ho chau.
- Soi 1/3 dtfdi thtfdng lan xuong biu.

- Dau am i cang ttfc vung that ltfng khi co tf dong d nieu quan - be than.
- Cdn dau kem theo buon non va non.

- Dai mau toan bai: l't va thoang qua.

- Dai kho, di tieu nhieu lan va buot khi soi nieu quan nam sat hoac trong
thanh bang quang gay kich thich.

- Mot so trtfdng hdp gap dai it hoac vo nieu.

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1.3. Trieu chtfng thiic the

- Tham kham nhe nhang vung that ltfng, co khi sd thay than to Bung hdi
trtfdng va trong cdn dau co the thay co ctfng cd vung that ltfng va ntfa bung ben
ton thtfdng.

- Cac vung bung khac binh thtfdng, khong kham thay thoat vi ben. dui.
- Tham trtfc trang binh thtfdng, trtf khi soi n&m sat thanh bang quang.

1.4. Trieu chufng toan than

- Trong cdn dau benh nhan luon keu la, kich thich, vat va.
- Mach, huyet ap co the tang len.

- Nhiet do binh thtfdng hoac co sot nhe.

- Sot cao khi soi gay t i c nghen dtfdng bai xuat va co nhiem khuan tiet nieu.
- Soi nieu quan hai ben hoac soi than mot ben, soi nieu quan mot ben se gay
anh htfdng toan than nhanh chong: Id md, hon me do suy than, ure mau cao.

2. X E T N G H IE M SIN H H O A

2.1. X e t n g h ie m niidc tieu

- Nhieu hong cau va bach cau thoai hoa.

2.2. X e t n gh ie m m au

- Ure va creatinin mau: binh thtfdng hoac tang len.

- C o n g thtfc b a c h cau: thtfdng k h o n g tang.

3. C H A N D O A N H i N H A N H

3.1. Chup X q u a n g he tiet nieu k h o n g ch u an bi

- C h u p t h a n g h a y n g h i e n g .

- Phat hien hinh anh can quang n l m tren dtfdng di cua nieu quan co hinh thoi
hai dau htfdng len tren va xuong dtfdi. Soi co the gap d mot ben hoac hai ben meu
quan hoac di kem vdi soi than. Can ltfu y nhtfng trtfdng hdp soi khong can quang.
Trong cdn dau thtfdng gap tinh trang ruot non gian do liet ruot cd nang gay kho
khan cho viec phat hien soi.

- Phan biet soi nieu quan vdi cac hinh anh can quang doc dtfdng di nieu quan
cua hach canh cot song voi hoa (vet can quang khong dong deu, bd khong ro ret.
thudng nhieu rai rac mot ben hoac hai ben cot song) va soi tinh mach vung tieu
khung (phlebolith — vet can quang nho, tron nam sat thanh tieu k h u n g >

3.2. Sieu am b u n g

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ltfdng soi. Hinh anh can am cua soi doi khi khong ro do bi nhieu bdi hinh hdi va
phan d ruot.

- Nhu mo than day hay mong, dai be than va nieu quan co gian hay khong.
- Hinh anh bat thtfdng: ung thtf te bao chuyen tiep d be than va nieu quan (l't gap).
- Phan biet vdi cac benh cap ctfu bung khac: viem ruot thtfa, viem tui mat do
soi v.v...

Vdi hai phtfdng phap tren co the chan doan dtfdc cdn dau quan than thong thtfdng.

3.3. Chup nieu do tin h m ach (UIV)

- Chi lam ngoai cdn dau de thu thap thong tin ve nguyen nhan tac nghen (soi, u).
- Danh gia chtfc nang than: gian dai be than nieu quan, than cham bai tiet,
bai xuat.

- Than “khong ngam thuoc” , khong bai tiet bieu hien ngtfng hoat dong tam
thdi do phan xa hoac giam chtfc nang. Khi do can dung cac bien phap chup cham
he tiet nieu sau 60 — 120 phut, hoac kich thich chtfc nang bai tiet bang tiem lasix
mdi danh gia dung dtfdc chtfc nang than.

- Chup UIV con cho thay cac di dang cua than va nieu quan.

3.4. Chup nieu q u a n - be th an ngtfdc d on g (U PR )

- Phat hien dtfdc soi nieu quan khong can quang, nhtfng soi nieu quan to day
nieu quan nam trung trtfdc cot song.

- Chan doan phan biet vdi cac trtfdng hdp tac nghen dtfdng bai xuat khong do soi.

3.5. Chup cat ldp vi tin h (CLVT)

- Chi dinh thtfc hien khi chtfa xac dinh dtfdc chan doan.

- Phat hien dtfdc soi nieu quan co do can quang it, khong phat hien dtfdc tren
phim chup Xquang thong thtfdng.

- Danh gia dtfdc chtfc nang than va phat hien cac di dang bam sinh dtfdng tiet nieu.

4.

c A c

TH E l

A

m s

A

n

G

4.1. The k h o n g co b ien chtfng

- Hay gap do soi nieu quan kich thtfdc 4 - 5mm, khong gay nhiem khuan va
khong gav tac hoan toan.

- Dien bien lam sang thtfdng thuan ldi, soi hay di chuyen xuong thap va co the
dtfdc dao thai ra ngoai sau khi dieu tri noi khoa.

4.2. The co b ien chtfng

- Soi nieu quan gay bien chtfng tai cho: viem, xd hoa va chit hep nieu quan cho
co soi. Doi khi gap thung thanh nieu quan do soi hoac vd be than — nieu quan gian

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tron soi gay tu dich ntfdc tieu sau phuc mac hoac gav viem phuc mac ntfdc tieu
(hiem gap).

- Soi nieu quan gay bien chtfng tren than: than tf ntfdc, nhiem khuan. tf mu va
co the gay nhiem khuan huyet, soc nhiem trung can chi dinh dieu tri ngoai khoa

cap ctfu.

- Soi nieu quan gay bien chtfng toan than: vo nieu do soi nieu quan hai ben,
soi tren than duv nhat hoac khi than ben doi dien mat chtfc nang. Dieu tri ngoai
khoa la rat can thiet de ctfu chtfc nang than va ctfu ti'nh mang benh nhan.

- Cdn dau dtf doi va keo dai, khong giam vdi thudc giam dau, cd the phai chi dinh
can thiep ngoai khoa.

- Soi tiet nieu tren benh nhan cd thai kem theo nhiem khuan rat nang.

5. CAC T H E L A M S A N G T H E O N G U Y E N N H A N G A Y T A C N G H E N

5.1. N guyen n han gay tac ttf ben tron g dtfdng tiet nieu tren

- Hay gap nhat la soi can quang (oxalat calci, phosphat calci) va khdng can
quang (acid uric).

- Ung thtf te bao chuyen tiep cua dtfdng bai tiet (Transitional Cell Carcinoma).
- Hep nieu quan be than do lao, giang mai.

5.2. N gu y en n h a n gay tac ttf ben ngoai dtidng tiet n ieu tren

- Hach.

- U ac ti'nh, lanh ti'nh (u xd ttf cung).
- Xd dinh, co keo sau md.

- Benh xd hoa sau phuc mac.

6. C H AN D O A N P H A N B IE T

Cdn dau quan than can dtfdc chan doan phan biet vdi:

6.1. Cac benh cap ctfu co sot

- Viem dtfdng mat, viem tui mat cap.
- Viem ruot thua cap.

- Thung o loet da day ta trang.
- Thung tui thtfa dai trang.
- U manh trang ap xe hoa.
- Viem phan phu.

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6.2. Cac benh cap ctfu khac

- Cdn dau da day.
- Viem dai trang.
- Viem tuy cap.
- Giun chui ong mat.
- Thoat vi ben, dui.

- TSc ruot do u dai trang, do ba thtfc an, sau mo.
- U nang buong trtfng xoan, chay mau.

- Chtfa ngoai ttf cung.

Chu y: Khong de sot phong dong mach chu bung.

7. DIEU TRI

7.1. Doi vdi cac the k h o n g bien chtfng

- Dung cac loai thuoc chong viem khong steroid tiem bap hoac tinh mach.

- Dung thuoc gian cd trdn: visceralgin, papaverin, nospa, spasfon v.v... Neu
dau nhieu khong thuyen giam co khi phai chi dinh dung morphin theo chi dan cua
thay thuoc.

- Soi bang quang dat ong thong nieu quan day soi len tren than va ltfu ong thong.
- Dieu tri nguyen nhan soi: tan soi ngoai cd the, tan soi noi soi nieu quan
ngtfdc dong, mo lay soi qua noi soi o bung sau phtfc mac hoac qua mo md.

7.2. Doi vdi cac the cd bien chtfng (nhiem khuan, vo nieu)

- Khang sinh: nhom cephalosporin the he thtf 2 hoac 3.
- Soi bang quang dat ong thong nieu quan.

- Dan ltfu than qua da hoac bang mo md.

- Khi benh nhan on dinh, dieu tri nguyen nhan soi: tan soi ngoai cd the, tan
soi noi soi nieu quan, mo lay soi qua noi soi o bung sau phuc mac hoac qua mo md.

- Vdi nguyen nhan do u dtfdng bai tiet: cat doan nieu quan hoac cat toan bo
than nieu quan ben co u.

- V6i nguyen nhan hep nieu quan do lao: nong nieu quan qua noi soi ngtfdc
dong, cat doan hep tao hinh nieu quan.

- Vdi nguyen nhan chen ep ttf ben ngoai nieu quan: phau thuat cat u xd ttf

cung. Gd dinh giai phong nieu quan khoi to chtfc xd sau phuc mac va dtfa vao
trong o phuc mac.

Cdn dau quan than la mot cap ctfu ngoai khoa thtfdng gap do soi nieu quan
gay nen. Chan doan chu yeu dua vao sieu am va chup nieu do tinh mach khi da dd

17* CC NGQW KHOA-TC

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cdn dau. Dieu tri can lam giam cdn dau va tao dieu kien cho soi di chuyen xuong
dtfdi. Khi co vo nieu hoac nhiem khuan can dieu tri khang sinh kjp thdi va co bien
phap dan ltfu ntfdc tieu thich hdp. Dieu tri theo nguyen nhan gay tac nghen duoe
thtfc hien khi benh nhan da on dinh.

tAi l i e u t h a m k h a o

1. Doublet JD., Tchala K., Tligui M et al. In situ extracorporeal shock wave
lithotripsy for acute colic due to obstructing ureteral stones. Scand J Urol
N ephrol 1997, 31: 137.

2. Heidenreich A., Desgrandschamps F., Terrier F. Modern approach of
diagnosis and management of acute flank pain: review o f all imaging
modalities. E ur Urol 2002, 41: 351.

3. Joshi HB, Obadeyi 0 0 , Rao PN. A comparative analysis o f nephrostomy JJ
stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing
ureteric stones. B JU Int 1999, 84: 264.

4. Kravchick S., Bunkin I., Stepnov E et al. Emergency extracorporeal
shockwave lithotripsy for acute renal colic caused by upper urinary tract
stone. J Endourol 2005, 19:1.

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2. VO NIEU DO TAC NGHEN

Vo nieu do tSc nghen la hoi chiing than ngtfng bai xuat lam cho bang quang
khong co hoac co it ntfdc tieu (<200ml/24 gid). Khac vdi bi dai, vo nieu do tac nghen
la tinh trang suy than sau than do can trd d trong hay ngoai dtfdng tiet nieu tren
Nguyen nhan hay gap nhat la do soi nieu quan.

Vo nieu do tSc nghen la mot cap ctfu noi - ngoai khoa can chan doan sdm va
xtf tri kjp thdi de tranh suy than nang va cac bien chtfng toan than nguy hiem den
ti'nh mang benh nhan.

1. SINH LY B E N H

Khi bi tac nghen, ap ltfc trong he thong dtfdng tiet nieu tren tang len dot ngot.
Neu ap ltfc trong ong than tang len tren 40cm H20 thi chtfc nang loc cua cau than
ngtfng han, khi do se xuat hien cac roi loan cua suy than cap:

- U ntfdc va dien giai gay phu ne. Tang kali mau.
- Ure va creatinin mau tang. Toan chuyen hoa.
- Co the kem theo hoi chtfng nhiem trung.

2. N G U YE N N H A N G A Y T A C N G H E N

2.1. Vo nieu do soi h ay gap nhat

- 80% la soi nieu quan tren than duy nhat con hoat dong.

- 20% soi nieu quan hai ben, thtfdng gap d ddan 1/3 dtfdi nieu quan.

2.2. Nieu quan bi tac n gh en do tac n han ben tro n g

- Do mam ung thtf than, ung thtf be than - nieu quan, polyp nieu quan.
- Manh hoai ttf nhu than (hiem gap).

- Hep nieu quan do lao tiet nieu.

2.3. Nieu q u a n bi ch en ep ttf ben ngoai

- Tai 16 nieu quan do u bang quang, ung thtf tuyen tien liet xam lan.

9, 9

- 0 doan sat bang quang do ung thu co ttf cung, ung thtf buong trtfng. u xd ttf
cung, ung thtf trtfc trang va benh xd hoa sau phuc mac.

- Tai bien sau mo san phu khoa va trong tieu khung: cat, buoc that phai
nieu quan.

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3. C H A N D O A N X A C D I N H

3.1. T i e n stf

Dieu tri soi tiet nieu, phau thuat cat than, ung thu vung tieu khung, dj dang
bam sinh dudng tiet nieu, than lac cho, sau mo san phu khoa hoac phau thuat
trong tieu khung.

3.2. T r i e u c h t f n g l a m s a n g

Chan doan lam sang dUa tren 3 dau hieu cua Anvert: benh nhan khong co cam

giac buon di tieu, kham khong thay cau bang quang va dat ong thong nieu dao
khong co nUdc tieu (dudi 200ml/24h).

3.2.1. T rieu c h iin g tie t n ie u

- Vo nieu (bang quang khong co hoac co it nUdc tieu < 200ml/24 gid).
- Thieu nieu (ludng nUdc tieu < 500ml/24 gid).

- Co bieu hien cua cdn dau quan than.

- Tham trUc trang, am dao: ung thu trUc trang hoac ung thu co tu cung.
- Sau phau thuat san phia khoa hoac phau thuat trong vung tieu khung.

3.2.2. T rieu c h iin g to a n th a n : tuy theo mUc do suy than:
- Phu, non, kho thd.

- Nhip tim nhanh, tang huvet ap.
- Roi loan tri giac.

3.3. X e t n g h i e m s i n h h o a . Bat dau nguy hiem neu:

- Creatinin huyet tudng > 150mmol/l, ure mau > 17mmol/l, kali mau > 6mmol/l,
du tru kiem > 15mmol/1, pH mau < 7,25, bach cau trong mau tang.

•y •» x

3.4. C h a n d o a n h i n h a nh (rat quan trong)

3.4.1. C h u p p h im h e tie t n ie u k h o n g c h u a n bi

- Bong than to, soi can quang he tiet nieu: vi tri, so ludng, kich thudc.

3.4.2. S ieu dm r a t c o g id tri

- Danh gia bong than to, xac dinh do day nhu mo than.
- MUc do gian cua dai be than va nieu quan.

- Phat hien soi it hoac khong can quang tren phim Xquang thong thudng.
- Khdi u trong bang quang. u trong tieu khung.

3.4.3. C h u p n ie u d o tin h m a c h (UIV neu khong co chong chi dinh):
- Chup phim thi sdm va muon (sau 12 gid).

- Phat hien nguyen nhan va vi tri tdc nghen.

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3.4.4. Soi bdng quang vd chup nieu quan ngitOc dong (UPR)

- Phat hien soi ft hoac khong can quang khong thay ro tren phim chup he tiet nieu.
- Xac dinh ton thtfdng chit hep va ro nieu quan sau phau thuat san phu khoa.

3.4.5. Chup cdt lap vi tinh

- Chup phim co tiem thuoc can quang hoac khong tuy theo mtfc do suy than.
- Chu y tranh chup phim Xquang khi benh nhan co thai trong 3 thang dau.
- Phat hien nhtfng vi tri soi nieu quan it hoac khong can quang khong thay
dtfdc tren phim chup Xquang thong thtfdng.

- Xac dinh chi'nh xac nguyen nhan gay nen va vi tri tac nghen, danh gia chtfc
nang than va phat hien dtfdc cac di tat bam sinh cua than va dtfdng tiet nieu di kem.

4. CHAN D O A N P H A N B IE T

4.1. Vo nieu do suy th a n trtfdc than (suy than chtfc nang)

- Soc do mat mau, nhiem khuan.
- Mat ntfdc ngoai te bao.

- TSc dong mach than.

4.2. Vo nieu do suy th a n tai than• ** • • •

- Viem ong than ke (hau san).

- Ngo doc (sot ret ac tinh, mat ca tr^m).

4.3. Vo nieu do tac n gh en sau than

- Soi tiet nieu.

- Ung thtf tuyen tien liet, co tii cung, buong trtfng.

- Ton thtfdng nieu quan sau phau thuat san phu khoa va trong vung tieu Khung.

5. TIEN LLfdN G P H U T H U O C V A O CAC Y E U TO

5.1. N guyen n h a n gay tac

- Tien ltfdng xau neu nguyen nhan tac nghen la ung thtf.

- Thuan loi neu nguyen nhan do soi nieu quan chtfa gay bien chtfng. Co khi soi

nieu quan mot ben cung gay vo nieu hoan toan. Day la mot cap ctfu khong tri hoan.

5.2. Thdi gian d en d ieu tri

- Neu den cham sau khi vo nieu 48 gid, benh nhan se gap cac roi loan dien giai
kali mau tang, phu phoi cap, nguy cd nhiem trung tang.

- Can phat hien sdm vo nieu trong giai doan thieu nieu (ntfdc tieu dtfdi 500ml/24h).
Ty le song phu thuoc vao thdi gian phat hien.

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5.3. Chtfc nang than va tinh tran g toan than

- Suy than do soi nieu quan co 2 miic do:
- Suy than co kha nang hoi phuc.

- Suy than khong con kha nang hoi phuc (vo nieu qua 7 ngay).

- Cao huvet ap do soi nieu quan co the la bieu hien cua suv than man hoac do
soi gay tSc nghen dan den thieu mau nhu mo than.

5.4. C hien th u at xtf tri va kha nang dieu tri cua c d sd (hoi siic cap ciiu,
than nhan tao)

6. D IEU TRI

6.1. Giai p h o n g tac nghen la Uu tien hang dau. Hien nay co nhieu bien phap:
- D in ltfu than qua da dtfdi htfdng dan cua sieu am hay bang phau thuat.
- Dtfa ong thong nieu quan vtfdt qua vien soi va dat ong thong JJ.

- Lay soi nieu quan bang phau thuat hay tan soi qua noi soi nieu quan.

- Dtfa nieu quan ra da.

- Neu ton thtfdng nieu quan do phau thuat: noi phuc hoi ltfu thong nieu quan
va dan ltfu than qua da hay dat ong thong JJ.

6.2. Dieu tri cac bien chtfng cua suy than cap va n h ie m k h u an

- Hoi stfc tich ctfc va neu can chi dinh chay than nhan tao khi xuat hien cac veu
to nguy cd: creatinin mau > 800mmol/l. ure mau > 45mmol/l, kali mau > 6mmol/l.
pH mau < 7,15.

- Dieu tri khang sinh tot nhat theo ket qua khang sinh do neu benh nhan sot
cao, ret run, bach cau tang cao do den muon hoac co nhiem khuan ttf trtfdc.

- Sau khi giai quyet nguyen nhan tac nghen hoac dan ltfu than can theo doi va
dieu tri de phong cac bien chtfng sau can thiep: da nieu, roi loan dien giai. dac biet
la mat kali.

6.3. D ieu tri n gu y e n nhan sau khi da giai q u y et x o n g vo nieu

- Dieu tri soi bkng cac phu'dng phap noi khoa (soi do acid uric) va ngoai khoa
(tan soi ngoai cd the, tan soi qua noi soi nieu quan, tan soi va lay soi qua da>

- Ung thu' bang quang: cat bang quang toan bo. tao hinh bang quang

- Ung thu tuyen tien liet giai doan di can: dua hai nieu quan ra ngoai da. cat
tinh hoan va dieu tri hormon Uc che androgen.

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- Xd hoa sau phuc mac: giai phong nieu quan doan hep va dua vao trong phuc
mac, dieu tri tiep bang thuoc chong viem nhom steroid: cortisol.

Vo nieu do tac nghen thtfdng gap do soi nieu quan va la mot cap ctfu noi
ngoai khoa can dtfdc chan doan va xtf tri kip thdi. Giai quyet tinh trang tac
nghen dtfdng tiet nieu song song vdi hoi stfc noi khoa tich ctfc trtfdc, trong va sau
dieu tri ngoai khoa. Sau giai doan dieu tri cap ctfu, can chu y giai quyet cac
nguyen nhan gay tac nghen.

TAI LIEU T H A M K H A O

1. Chistale SV., Scott—Barrett S., Ho ET et al. The management of ureteric
obstruction secondary to malignant pelvic disease. Clin Radiol 2002, 57: 1118.
2. Chung SY., Stein RJ., Landsitte ID et al. 15—year experience with the

management of extrinsic ureteral obstruction with indwelling ureteral stents.

J Urol 2004, 172: 592.

3. Donat SM., Russo P. Ureteral decompression in advanced nonurologic
malignancies. A nn Surg Oncol 1996, 3: 393.

4. Park DS., Park JH., Lee YT. Percutaneous nephrostomy versus indwelling
ureteral stents in patients with bilateral nongenitourinary malignant extrinsic
obstruction. J E ndourol 2002, 16: 153.

5. Shokeir AA., Shoma AM., Mosbah A et al. Noncontrast computed tomography
in obstructive anuria: a prospective study. Urology 2002, 59: 861.

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3. OAI MAU

Dai mau dai the la tinh trang ntfdc tieu co mau do vdi so ltfdng hong cau nhieu

hdn 5000/ml. Phan biet vdi dai mau vi the, ntfdc tieu khong co mau do khi nhin bang
m;it thtfdng nhtfng co so ltfdng hong cau cao hdn binh thtfdng tren 5 hong cau/1
trtfdng dem.

CAn phan biet dai mau vdi:

- Chay mau nieu dao hoac ntfdc tieu lan mau khi hanh kinh d ntf.

- Ntf6c tieu khong co hong cau ma chi co sac to' mat, hemoglobin, myoglobin.
- Ntfdc tieu co mau s&c do dung thuoc nhtf phenothiazin, rifampicin hay cua
thtfc an nhtf cu cai.

1. TR IE U CHLTNG L A M S A N G

1.1. Tien siY

- Hut thuoc la, dieu tri thuoc chong dong mau.

- Benh nhan mac benh than: soi than, than da nang, lao than.

- Benh nhan da dtfdc chan doan u bang quang, phi dai hoac ung thtf tuyen
tien liet.

- Chan thtfdng vung bung, that ltfng hoac tang sinh mon, vd xtfdng chau do tai
nan giao thong, lao dong.

1.2. Thdi d iem x u a t h ien dai m au

- Dai mau khi bat dau di tieu thtfdng do ton thtfdng d co bang quang va nieu dao.
- Dai mau cuoi khi di tieu la do ton thtfdng tai bang quang: u hoac soi bang quang.

- Dai mau toan bai do nguyen nhan tren than: u than, u dtfdng bai tiet, lao
than hoac do u bang quang gay chay mau nang. Thtfdng bieu hien dai mau dai the
co mau cuc.

Dai mau thtfdng di kem dai kho, dai dat, dai buo't. Doi khi co cdn dau quan
than do mau cuc gay tac nghen dtfdng bai tiet.

1.3. K h am thvfc the

- Trong trtfdng hdp dai mau nang do chan thtfdng than do IV - V. u than vd,
chay mau sau mo benh than, tuyen tien liet, benh nhan co tinh trang soc mat
mau: nhdt nhat, va mo hoi, mach nhanh, huyet ap tut, kham thav khoi tu mau ldn
sau phiic mac hoac co cau bang quang cang to dtfdi ron. Can thiet phai xtf tri cap
ctfu ngay.

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kiem tra vung dtfdi ron co the thay cau bang quang hoac sd thay khoi u. Kham biu
phat hien gian tinh mach tinh trong u than co huyet khoi tinh mach than hoac
tinh mach chu dtfdi. Nghe o bung de phat hien tieng thoi trong cac bat thtfdng
mach mau cua than. Cuoi cung, tham trtfc trang danh gia tinh trang tuyen tien
liet va vung co bang quang.

2. X E T N G H IE M SIN H H O A

Xet nghiem: hong cau, huyet sac to, hematocrit danh gia mtfc do mat mau.
Xet nghiem: ure mau, creatinin mau, cong thtfc bach cau, dong mau toan bo.
Xet nghiem te bao, vi khuan trong ntfdc tieu, tinh the, tru nieu, protein nieu.
Tim te bao ung thtf than, ung thtf bang quang, nam trong ntfdc tieu.

3. CHAN D O A N H iN H A N H

Dong vai tro quan trong de biet r6 nguyen nhan va mtfc do ton thtfdng

- Sieu am dtfdc stf dung dau tien de phat hien cac ton thtfOng tren than: chan
thtfdng, soi, nang than va cac ton thtfdng d bang quang va co bang quang: u bang
quang, soi bang quang, u tuyen tien liet.

- Chup nieu do tinh mach phat hien soi than, lao than, u bang quang va danh gia
dtfdc chtfc nang than ttfng ben.

- Soi bang quang phat hien cac ton thtfdng cua bang quang gay chay mau va
chup nieu quan be than ngtfdc dong phat hien ton thtfdng cua dtfdng bai tiet: u
dtfdng bai xuat, soi than nieu quan.

- Chup cat ldp vi tinh can thiet de xac dinh ro nguyen nhan va mtfc do ton thtfdng.
- Chup dong mach than phat hien cac bat thtfdng mach mau trong nhu mo than:
thong dong - tinh mach than, gia phinh dong mach than, u cd md mach than.

4. CHAN D O A N N G U Y E N N H A N

* *>

4.1. N guyen n h a n de ch a n doan

- Sau chan thtfdng: chan thtfdng than, vd bang quang trong, ngoai phuc mac,
chan thtfdng nieu dao trtfdc do nga dap tang sinh mon va chan thtfdng nieu dao sau
(di kem vd xtf dng chau).

- Sau phau thuat benh ly d than, u bang quang, phi dai tuyen tien liet, dac biet
khi co nhiem khuan, nhiem nam.

4.2. N gu y en n h a n th eo tuoi benh nhan

- Tre em: Ung thtf nguyen bao than (u Wilms), u cd trdn bang quang.
Soi than tren di dang bam sinh he tiet nieu.

Soi bang quang.

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- Thanh thieu men: chan thtfdng than, bang quang, nieu dao, soi than.

- Ngtfdi ldn: soi than, ung thtf than, ung thtf bang quang, chan thtfdng tiet nieu.
- Ngtfdi gia: phi dai tuyen tien liet, ung thtf tuyen tien liet, ung thtf than, ung
thtf bang quang.

4.3. N guyen nhan it gap

- Cac benh co roi loan dong mau: benh tfa chay mau, benh bach cau, suy tuy.
- Bat thtfdng ve mach mau trong than: thong dong - tinh mach than, gia phinh
dong mach than.

- Dai dtfdng chap do benh giun chi di kem vdi dai mau.

- Lac noi mac ttf cung trong bang quang va nieu dao d ntf. Dai mau trung vdi
ky hanh kinh.

- Nhiem trung tiet nieu, viem bang quang hay gap d ntf.
- Benh san bang quang (Bilharziose) hay gap d chau Phi.

5. TH A I D O X t f TR I

Nguyen tac:

- Hoi stfc cap ctfu, boi phu mau.

- Bdm riia bang quang lay mau cuc khi co cau bang quang.
- Cam mau va giai quyet nguyen nhan gay chay mau.
- Chu y bao ton chtfc nang than.

5.1. C han thtfdng th a n n an g do IV - V

Chi dinh can thiep cap ctfu khi chan thtfdng nang dtft cuong than, huyet dong
khong on dinh hoac kem theo cac ton thtfdng khac trong o bung co chi dinh mo.
Can thiep s6m lam tang kha nang bao ton than: khau cam mau nhu mo than, cat
ban phan than, khau phuc hoi mach mau va dtfdng bai tiet. Hien nay, khi tinh
trang huyet dong on dinh, co the thtfc hien chup mach va nut chon loc mach ton
thtfdng gay chay mau. Can thiep nay dem lai ket qua tot dac biet trong chay mau
do vet thtfdng than hoac sau phau thuat than.

5.2. C hay m au n a n g do u b a n g q u a n g

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5.3. C hay m au do di d a n g don g - tinh m ach than

Thtfdng chain doan dtfa tren chup dong mach than ket hdp dieu tri bang nut
mach than chon loc nhanh dong mach cap mau cho khoi di dang.

5.4. Dai m au k em th eo dtfdng chap do giun chi

Hien nay, benh ly nay hiem gap. Co the bdm dung dich co chtfa 0,1% - 0,5%
Nitrat bac vao ben be than co thoat dtfdng chap va mau.

Dai mau rat hay gap trong cap ctfu noi va ngoai khoa. Chan doan thtfdng

khong kho trtf mot so trtfdng hdp dac biet. Dieu tri dai mau nang can hoi stfc cap
ctfu va co bien phap xtf tri thich hdp ve ngoai khoa va Xquang can thiep.

t A i l i e u t h a m k h a o

1. Ganatra AM., Loughlin KR. The management of malignant ureteral obstruction
treated with ureteral stents. J Urol 2005, 174: 2125

2. Kristjansson A., Pedersen J (1993), Management of blunt renal trauma, The
Bristish Journal o f U rology, 72, pp. 692 — 696.

3. Mansi M.K., Alkhudair W.K (1997), Conservative management with percutaneous
intervention of major blunt renal injuries, The American Journal o f Emergency
Medicine, Vol. 15, No. 7, pp. 633 — 637.

4. Margenthaler J.A., Weber T.R., Keller M.S (2002), Blunt Renal Trauma in
Children: Experience with Conservative Management at a Pediatric Trauma
Center, The J ou rn a l o f Traum a Injury, Infection and C ritical Care. 52, pp.
9 2 8 - 9 3 2 .

5. Shekarriz B., Shekarriz H., Upadhyay J et al. Outcome of palliative urinary
diversion in the treatment o f advanced malignancies. Cancer 1999, 85: 998

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4. BI OAI CAP

Bi dai cap la tinh trang benh nhan rat buon di tieu nhung khong the chu dong
cho ntfdc tieu thoat ra khoi bang quang, gay dau ddn. Khac vdi vo nieu, bi dai bieu
hien cd cau bang quang cang to.

C&n phan biet bi dai cap vdi:

- Bi dai man tinh, thtfdng gap d ngtfdi gia cd phi dai lanh ti'nh tuyen tien liet.
Khi bang quang qua day thi ntfdc tieu ttf tran ra va khong gay dau.

- Bi dai khong hoan toan khi benh nhan van di tieu binh thtfdng nhtfng ltfdng
ntfdc tieu ton dtf cdn tren 100ml.

1. CH AN D O A N X A C D IN H

1.1. Tien stf

- Phat hien va dieu tri sdi tiet nieu

- Cd rdi loan tieu tien: dai khd, dai nhieu lan.

. - Chan thtfdng vung khung chau va bo phan sinh due.
- Mo’ benh ly tiet nieu, san phu khoa, dai trtfc trang.

1.2. Trieu chtfng lam san g

- Toan than: benh nhan kich thich, keu la. Kiem tra mach, huyet ap, nhiet do.
- Kham thay ngay cau bang quang cang to dtfdi ron, go due va dau.

- Kham nieu dao: phat hien hep mieng sao, sdi ket nieu dao.

- Tham trtfc trang: phat hien phi dai tuyen tien liet hoac u tuyen tien liet.

ty

- 0 phu ntf, kham am dao de xac dinh sa ttf cung, u xd ttf cung, u nieu dao.

- Kham than kinh: danh gia phan xa cd that hau mon va phan xa hanh hang
d nam.

1.3. X e t n g h ie m sin h h oa

- Ure mau va creatinin mau binh thtfdng hoac tang.
- Cong thtfc bach cau.

- Dinh ltfdng PSA mau binh thtfdng hoac tang tren 4ng/ml.

1.4. C han d oan h in h anh

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- Sieu am: bang quang cang day niidc tieu, thay hinh anh phi dai tuyen tien
liet. u bang quang va danh gia mtfc do gian cua dtfdng tiet nieu tren.

1.5. T ham do nieu dao b an g on g th o n g m em

- Danh gia hep nieu dao trtfdc hay nieu dao sau.
- Phat hien xd ctfng co bang quang.

2. CHAN D O AN N G U Y E N N H A N

2.1. Cac benh tuyen tien liet

- Ngtfdi cao tuoi:

+ Phi dai lanh tinh tuyen tien liet: roi loan tieu tien, th&m trtfc trang.

+ Ung thtf tuyen tien liet: roi loan tieu tien, xet nghiem PSA tang, tham trtfc trang.
- Ngtfdi tre: viem tuyen tien liet, ap xe tuyen tien liet.

2.2. Cac benh of b a n g q u a n g

- Xd ctfng co bang quang nguyen phat hay mac phai sau mo.
- U vung co bang quang gay tac nghen.

2.3. Cac benh of nieu dao

- Soi ket nieu dao.

- Hep mieng sao, hep nieu dao trtfdc, hep nieu dao sau.
- U nieu dao d ntf va nam.

- Van nieu dao sau d tre nam.

3. CHAN D O A N P H A N B IE T

- Bi dai man tinh.

- Bi dai khong hoan toan.
- Bi dai do phan xa sau mo.

- Bi dai do nguyen nhan than kinh.

4. DIEU TR I

4.1. D at on g th o n g n ieu dao th eo n gu yen tac

- Vo trung, nhe nhang, dung ky thuat vdi ong thong mem 18Fr hay ong thong
Tieman tuy theo benh ly.

- Chu y cho ntfdc tieu chay ra ttf ttf, tranh gay chay mau d niem mac bang
quang do ntfdc tieu thoat ra qua nhanh.

- Chong chi dinh: viem tuyen tien liet, dtft nieu dao, viem mu bang quang.

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4.2. Choc dan ltfu b a n g q u a n g qua da h oac dSn ltfu b a n g q u a n g tren
xtfdng m u

- Chi dinh thtfc hien khi khong dat dtfdc ong thong nieu dao hoac co chong chi
dinh dat o’ng thong nieu dao.

- Chong chi dinh choc dan ltfu bang quang qua da neu do u bang quang vi se
gay chay mau va lan rong ung thtf.

4.3. Trtfdng hdp dac biet

- Soi ket nieu dao: bom day soi vao bang quang va tan soi noi soi. Xeu khong
day dtfdc vao bang quang, phai rach nieu dao d phfa tren, lay soi va khau vtfi nhieu
ldp de tranh ro nieu dao.

- Ap xe tuyen tien liet: dan ltfu bang quang va choc hut mu qua tang sinh mon.
Trong moi trtfdng hdp, sau khi dan ltfu ntfdc tieu can chuan bi tot benh nhan
de giai quyet nguyen nhan gay bf dai.

t

A

i l i e u t h a m k h a o

1. Choong S, Emberton M (2000), Acute urinary retention. BJU Int, 85:186.
2. Fitzpatrick JM, Kirby RS (2006), Management of acute urinary retention.

BJU Int, 97: 16.

3. Gulmi FA., Felsen D., Vaughan ED Jr. Pathophysiology of lower tract obstruction.
In.Walsh PC et al (eds) Campbell’s urology, 8th edn. Saunders, Philadelphia
2002, pp 411.

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5. SOI KET NIEU DAO

■ ■ ■

Soi ket nieu dao phan ldn tu: bang quang va dtfdng tiet nieu tren di chuyen
xudng va dtfng d nieu dao gay dau ddn, dai khd va bi dai. Sdi ket nieu dao thtfdng
gap d nam gidi, 1/3 nam d nieu dao sau va 2/3 nam d nieu dao trtfdc vdi nhtfng vi tri
xoang tuyen tien liet, nieu dao hanh goc dtfdng vat va ho' thuyen nieu dao. Thanh
phan hoa hoc hay gap nhat la sdi oxalate calci xu xi, cd nhieu gai va kha ran.

Trong mot so trtfdng hdp, sdi dtfdc hinh thanh tai chd tren mot doan hep cua
nieu dao hoac trong tui thtfa nieu dao d goc dtfdng vat cd ttf trtfdc. Sdi loai nay
thtfdng la sdi phosphate calci va amoni magie phosphate (struvit) cd mau trang nga,
de vd.

1. CH AN D O A N

1.1. Tien stf

- Dieu tri sdi than hoac da dai ra sdi mot vai lan.

- Dieu tri hep nieu dao hoac cd bieu hien dai khd ttf trtfdc.

1.2. Trieu chtfng la m san g thtfdng de ch an doan

- Hay gap cac trieu chtfng bao trtfdc: khd dai, dai buot, dai tac va dai ra mau

dau bai.

- Benh nhan thay dau vung nieu dao tang sinh mon, dai khd va tac dai mot
cach dot ngot, cd khi bi dai hoan toan. Benh nhan co ran dai chi ra vai giot ntfdc
tieu mau dd.

- Kem theo la cdn dau quan vung bung dtfdi ron do bi dai hoan toan.

- Neu sdi nam trong tui thtfa nieu dao thi thtfdng gap trieu chtfng viem nhiem:
dai due, viem nieu dao.

- Tham kham cd the thay chd sdi nam phong len d gan lo sao, d nieu dao goc
dtfdng vat hay vung biu tang sinh mon.

- Neu sdi nam d nieu dao sau khi tham dd bang que nong kim loai se thay dau
hieu cham sdi.

1.3. Trieu chtfng can la m sang

- Chup Xquang he tiet nieu lay qua khdp mu de chan doan nhtfng trtfdng hdp
khd phat hien nhtf soi trong hep nieu dao, soi trong tui thtfa meu dao co lo thong nhd.

- Chup Xquang toan bo he tiet nieu de phat hien soi tiet nieu ket hdp d tren
than, nieu quan va trong bang quang.

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2. D IEU TRI

2.1. T uyet doi tranh dun g kim phau thuat gap soi ra ngoai qua nieu dao

vi thudng khong co ket qua va chac chan se lam ton thtfdng niem mac nieu dao. gay

hep nieu dao.

2.2. Phau th u at cap ctfu khi soi ket nieu dao gay bi dai

- Neu soi d ho thuyen hay ngay gan lo sao thi nen rach rong lo sao ve phia 6
gid, lay soi trtfc tiep va khau phuc hoi lai lo sao.

- Neu soi ket d nieu dao goc dtfdng vat hay vtfng biu thi nen dung ap ltfc nude
day soi vao trong bang quang, sau do dung may tan soi qua noi soi ngudc dong
hoac mo md bang quang lav soi.

- Doi vdi soi hinh thanh do nguyen nhan tai cho (hep, ro, di vat. ttfi thtfa), soi
thtfdng bi ket lau ngay hoac co chit hep nieu dao d phia trtfdc thi co the rach nieu
dao lay soi. De tranh ro nieu dao, nen rach nieu dao d phia tren (12 gid) sau khi
boc tach nieu dao ra khoi vat hang, lay soi va xoay nieu dao 90 do, sau do khau lai
nieu dao va dat vao vi tri cu (phtfdng phap Monseur).

2.3. Sau khi lay soi ket nieu dao can giai q u y et n g u y e n nhan

- Soi tren than va nieu quan: tan soi ngoai cd the hay tan soi noi soi nieu quan.
- Soi bang quang: giai quyet hep co bang quang, dieu tri u phi dai tuyen tien liet.
- Dieu tri hep nieu dao: cat trong nieu dao, tao hinh nieu dao.

Chan doan soi ket nieu dao khong kho nhtfng can tim bien phap lay soi ket nieu
dao dam bao an toan nhat va khong lam ton thtfdng nieu dao. Sau khi lay soi nieu
dao, can dieu tri nguyen nhan d than, nieu quan, bang quang hay d ngay nieu dao.

TAI L IE U T H A M K H A O

1. Emberton M, Anson K (1999), Acute urinary retention in men: an age old

problem. BMJ, 318: 921

2. Morey AF, Hernandez J, M cAm nch JW (1999), Reconstructive surgery for
trauma of the lower urinary tract. Urol Clm North Am, 26: 49.

3. Segura JW., Preminger GM., Assimos DG et al. Ureteral stones clinical
guidelines panel summary report on the management o f ureteral calculi. The
American Urological Association. J Urol 1997, 158: 1915.

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