Ebook Cấp cứu ngoại khoa (Tập 2): Phần 1

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Y 4

.007272

B O Y T E

CffP GUU NGOHIKHOH

TAP 2

■

(D U N G C H O B A C Si V A H O C VIEN SAU DAI H O C)

Chu bien: GS. DANG HANH OE

CD

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BO Y TE

CAP CUfU NGOAI KHOA

■

TAP 2

(DUNG CHO BAC SI VA HOC VIEN SAU DAI HOC)

MA SO: D01.Z10.W

NHA XUAT BAN GIAO DUC VIET NAM

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Chi dao bien soan:• •

VU KHOA HOC VA DAO TAO - BO Y TE

Chu bien:

GS. DANG HANH DE

T ham gia to chttc ban thao:
ThS. PHI VAN THAM 
TS. NGUYEN MANH PHA

1054 - 2010/CXB/18 - 1758/GD Ma so: 7K875Y0 - DAI

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Chu bien:

OS. DANG HANH DE

Nguvcn Pho Chu nhiem Bo mon Ngoai. TrUdng Dai hoc Y Ha Noi.
Nguyen Chu nhiem Khoa Phau thuat Tim mach - Long ngUc
13V. Viet Dilc. Chu nhiem khoa Ngoai BV. HCtu Nghi

Tham gia bien soan:

NGUYiN NGOC BICH
1

PGS.TS. Pho Tarong Bo mon Ngoai Trifdng Dai hoc Y Ha Noi. Tnidng khoa
Ngoai Benh vien Bach Mai

] TRAN NGOC BICH PGS.TS. Trirong khoa Phiu thuat Nhi BV. Vi^t Dire

jOANG HANH D$ GS. Nguyen Pho Chu nhi6m B6 mdn Ngoai. Trudng Dai hoc Y Hei N6i. Nguyfin

Chu nhiem Khoa Phau thuat Tim mach - Long ngi/c BV. Vi§t Ode. Chu nhiem
khoa Ngoai BV. HQu Nghi

! DONG VAN HE TS. Phau thuat vien Khoa Phiu thuat Than kinh BV. Viet Dire
! DITONG OAI HA

j TS. Phiu thuat vien Khoa Phau thuat Th§n kinh BV. Viet OCrc

] DUONG OL/C HUNG TS. Pho Truong khoa Phau thuat Tim mach - Long ngi/c BV. Viet DCfc

DOAN QUOC HUNG TS. Phau thuat vien Khoa Phau thuat Tim mach - Long ngi/c BV. Viet DCfc
TRAN HIEU HOC TS. Pho Truong khoa Ngoai BV. Bach Mai

j PHUNG NGOC HOA ThS. Phau thuat vien Khoa Chan thuong - Chinh hinh BV. Viet Dl/c

IkI^UDINH HUNG

I TS. Phau thuat vidn BV. Dai hoc Y H& Noi
i

PHAM o ir c HUAN PGS.TS. Pho TrUcing Bo mon Ngoai tn/dng Dai hoc Y Hci Noi, Tn/ong khoa

Phau thuat Tieu hoa BV. Viet Dire

NGUYEN XUAN HUNG PGS.TS. Truong phong Kham cap cl/U BV. Viet Di/c

HOANG LONG TS. Phau thuat vien Khoa Tiet nieu BV. Viet Due
NGUYEN VAN MAO ThS. Giam doc BV. Tim Ha Noi

TRAN BAO LONG PGS.TS. Phau thuat vien Khoa Gan - Mat. BV. Viet Due
LE HONG NHAN TS. Pho Truong khoa Phau thuat Than kinh BV. Viet OCrc

NGUYEN DUC PHUC PGS. P h iu thuat vien Khoa Chan thuong - Chinh hinh BV. Viet Difc

NGUYEN QUANG TS. Phau thuat vien Khoa Nam hoc BV. Viet B u t

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HA VANQUYET

---

---GS.TS. Truong Bo mon Ngoai Tn/dng Oai hoc Y Ha Noi. Pho Giam doc BV.
Viet OCfc

DANG HANH SON TS. Phiu thuat vien BV. Tim H& Noi

0 6 TRUONG SON TS. Phiu thuat vien Khoa phiu thuat tieu hoa BV. Viet Dire

HOANG NGOC SON TS. Phiu thuat vien Khoa phau thuat Ch£n thuong - Chinh hinh BV. Viet DC*:

NGUYEN CONG TO PGS.TS. Pho TrUcing Bo mon Ngoai Truong Oai hoc Y Ha Noi. Pho Giam doc
BV. Viet OCfc

DO t r uOn g t hAnh TS. Pho Tru6ng khoa Phau thuat Tiet nieu BV. Viet OCfc

LE NGQC THANH PGS.TS. Giam doc Trung tarn Tim mach BV. E

hAk im t r u n g TS. Pho Truong khoa Phau thuat Than kinh BV. Viet OCfc

TRINH VAN TUAN TS. Phau thuat vien Khoa Cap cCiu Tieu hoa BV. Viet OCfc

DOAN THANH TUNG PGS.TS. Trudng khoa Phau thuat Gan - Mat. BV. Viet OCfc

NGUYEN HOU UOC PGS.TS. Pho Truong Bo mon Ngoai Truong Oai hoc Y Ha Noi. Pho Truong
khoa Tim mach - Long ngUc BV. Viet OCfc

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L d l GICJl THIEU

Dao tao nguon nhan lUc can bo chat ltfdng cao la mot trong nhOng moi quan
tarn hang dau cua nganh Y te. Song song vdi viec dau tu cO sd vat chat cho cac cO
s6 dao tao, Bo Y te chu trong tang cUOng cac phUOng tien day va hoc, trong do viec
bien soan tai lieu day-hoc dac biet Uu tien.

Sach Cap cufu ngoai khoa dUOc bien soan nh&m phuc vu cho viec dao tao sau
dai hoc cua trUOng Dai hoc Y Ha Noi, nhUng cung la tai lieu tot de tham khao cho
viec dao tao dai hoc va cho cac bac si ngoai khoa. Sach dUOc bien soan v6i phUdng
cham: Kien thiic c0 ban, he thong; noi dung chinh xac, khoa hoc, cap nhat cac tien
bo khoa hoc, ky thuat hien dai va thuc tien Viet Nam.

Cuon sach nay dUOc bien soan boi cac nha giao, cac nha khoa hoc giau kinh
nghiem trong linh vUc Ngoai khoa. Sach da dUOc Hoi dong chuyen mon thanh lap
theo quyet dinh so: 1683/QD-BYT ngay 20 thang 5 nam 2010 cua Bo Y te tham
dinh. Sach dUdc ban hanh lam tai lieu sU dung chinh thiic phuc vu dao tao dai hoc

va sau dai hoc cua nganh Y te trong giai doan hien nay, dong thdi cung se la tai
lieu hu!u ich cho cac bac si tham khao hang ngay.

P3o Y te xin chan thanh cam dn GS. Nguyen BUu Trieu, Chu tich Hoi dong tham
djnh, GS. Do Diic Van va GS. Ha Van Quyet Uy vien phan bien va cac uy vien Hoi

dong da doc, dong gop nhieu y kien quy bau de cuon sach dUOc hoan thien.

Chung toi m on g nhan dUOc y kien dong gop cua dong nghiep va cac doc gia de

sach dUdc h oan chinh hOn cho nhutng lan xuat ban tiep sau.

VU KHOA HOC VA DAO TAO - BO Y TE

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L O l

n o i

d a u

Cap ciiu ngoai khoa luon la mot van de thdi sU khong nhutng cua cac phau
thuat vien ma con cua tat ca nhu!ng ai lam cong tac lam sang.

Trong the ky trUdc Nha xuat ban Y hoc da xuat ban cuon Cap cvfu Ngoai 
khoa, nhUng trai qua nhieu nam vdi nhiing tien bo nhanh chong cua y hoc noi
chung cung nhu sU phat trien cua nganh Ngoai khoa noi rieng, cuon sach do
khong con cap nhat niia.

Chung toi bien soan lai lan nay nham trU6c het phuc vu cho cong tac dao tao
(dai hoc va sau dai hoc trong cac trUdng Dai hoc Y) va sau do la cac dong nghiep d
cac tuyen y te trong ca nUdc. NhOng ngUdi tham gia bien soan deu la cac can bo
giang day trong Bo mon Ngoai trUdng Dai hoc Y Ha Noi vdi nhieu nam giang day
va p h iu thuat tai cac benh vien 16n (Viet Diic, Bach Mai, Saint Paul), thuoc dung
chuyen khoa cua minh. Vi the chung toi hy vong cuon sach se dap ling dUdc yeu
cau cua cac dong nghiep.

Noi dung cuon sach chi thu gon trong nhOng cap cCfu ngoai khoa thong
thUdng, rat hy vong trong tUdng lai co the bien soan cuon Ngoai khoa toan tap 
(Textbook of Surgery), mot cong trinh 16n doi hoi sU tham gia cua nhieu ngUdi,
trong nhieu chuyen nganh khac nhau. Sach dUdc bien soan thanh 2 tap:

- Tap 1 gom cac chuyen khoa: Than kinh, Long ngUc va Tim mach, Nhi.
- Tap 2 gom cac chuyen khoa: Tieu hoa, Tiet nieu, Chan thUdng.

Du da rat co gang nhUng van khong the tranh dUdc nhutng thieu sot do nhting
tien bo khong ngting va nhanh chong trong nganh Y noi chung, viec cap nhat kien
thiic khong the bat kjp.

Chung toi xin chan thanh cam dn ong Phi Van Tham, chuyen vien cao cap Vu
Khoa hoc va Dao tao Bo Y te da khuyen khich va tao moi dieu kien thuan ldi de
cuon sach dude xuat ban. Cam dn ba Nguyen Thi Thanh Binh, Thu ky Bo mon
Ngoai da gop phan bien soan cuon sach.

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MUC LUC

Ldi gidi thieu... 3

Ldi noi d a u ... 5
P han 4. TIEU HOA

1. Thung thiic q u a n ... 13

(Pham Dtic Huan)

2. Thung o loet da day - ta trang... 24

(Ha Van Quyet)

3. Chay mau do loet da day - ta trang... 32

(Ha Van Quyet)

4. Hep mon v i...41

(Ha Van Quyet)

5. Chan doan va dieu tri chan thUdng ta trang... 48

(Trinh Van Tuan)

6. Chan doan va dieu tri chan thUdng t u y ... 58

(Trinh Van Tuan)

7. Tac ruot... 69

(Pham Dite Huan)

8. Thoat vi n g h e t ... 79

(Ha Van Quyet)

9. Xoan r u o t ... 88

(Nguyen Ngoc Bich)

10. Chan thUdng bung va vet thUdng bung... 98

(Ha Van Quyet)

11. Viem ruot thvfa...108

(Pham Di'/c Huan)

12. Viem tui thu'a Meckel...119

(N guyen N goc Bich)

13. Viem phuc mac va cac o ap xe trong o b u n g ... 125

(N guyen N goc Bich)

14. Thoat vi co h o a n h ... 136

(N guyen N goc Bich)

15. Chay mau trong o bung khong do chan thUdng...143

(Nguyen N goc Bich)

16. Vet thUdng hau mon - true t r a n g... 151

(Ha Van Quyet)

17. Ap xe gan do a m ip ...156

(Tran Hieu Hoc)

18. Chan thu'dng va vet thUdng gan... 164

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19. Soi mat va bien chting cap ciiu ... 173

(Doan Thanh Tung)

20. Viem tui mat... 183

(Doan Thanh Tung)

21. Viem tuy c a p ... 189

(Tran Hieu Hoc)

22. Chay mau do ap ltfc tinh mach ciia...202

(Tran Hieu Hoc)

23. NhCfng cap ctiu thUdng gap vung hau mon trtfc trang...216

(Nguyen Xuan Hung)

24. Bong thiic quan... 230

(Do Tritctng Scfn)

25. Chay mau dUdng m a t ... 238

(Do Trii'dng Scfn)

Phan 5. TIET NIEU

1. Cdn dau quan than... 253

(Hoang Long)

2. Vo nieu do tac nghen... 259

(Hoang Long)

3. Dai m a u ... 264

(Hoang Long)

4. Bi dai c a p ... 268

(Hoang Long)

5. Soi ket nieu d a o ... 271

(Hoang Long)

6. Chan thUdng than...273

(Hoang Long)

7. Chan thifdng va vet thtfdng nieu q u a n ... 287

(Hoang Long)

8. Chan thUdng bang quang...293

(Do Triibng Thanh)

9. Chan thUdng nieu d a o ... 299

(Do Triibng Thanh)

10. Chan thtfdng vung b iu ... 310

(Hoang Long)

11. Ctfdng dau difdng vat keo dai (Priapism)... 313

(Nguyen Quang)

12. Vet thtfdng dUdng v a t ... 320

(Nguyen Quang)

13. Vd vat hang... 327

(Nguyen Quang)

14. Xoan tinh h o a n ...332

(Nguyen Quang)

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15. Lf mu than...338

(N guyen Quang)

16. Ap xo quanh th a n ... 346

(N guyen Quang)

1 7. Ap xe va nhot t h a n ... 353

(N guyen Quang)

18. Viem tuven tien liet cap tfnh... 362

(N guyen Quang)

19. Hoai thu cd quan sinh due: benh Fournier... 367

(N guyen Quang)

Phan 6. CHAN THl/ONG

1. Vet thUdng phan m em ...373

(Phung Ngoc Hoa)

2. Gay xUdng d tie c m ... 378

(Nguyen Diic Phuc -Phung Ngoc H o d )...
3. Gay xUdng h d... 383

(Phung Ngoc H od )...
4. Gay xUdng co bien chiing than kinh...394

(Nguyen Ditc Phuc - Phung Ngoc Hod)

5. Gay xUdng co bien cluing mach m a u... 401

(Nguyen Diic Phuc - Phung Ngoc Hod)

6. Hoi cluing chen ep khoang... 406

(Phim g N goc Hod)

7. PhAu thuat cat cut c h i...414

(Phung N goc Hod)

8. Vet thUdng k h d p...425

(P him g N goc Hod)

9. Viem xu'dng...429

(Phung N goc Hod)

10. Hoai thu sinh hdi...436

(P hung N goc Hod)

11. Dai cUdng ve bong...440

(P hung N goc Hod)

12. Dai ciidng ve U xUdng... 447

(P hung N goc Hod)

13. Trat khdp v a i ...454

(Ph ung N goc Hod)

14. Trat khdp khuyu... 460

(Phung N goc Hod)

15. Trat khdp hang...467

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16. Gav than xUdng canh l a v ...478

(Phung Ngoc Hod)

17. Gay tren loi cku xUdng canh tay d tre e m...482

(H oang N goc Sctn)

18. Gay hai xUdng cang tay ... 494

(Phung Ngoc Hod)

19. Gay dau dudi xUdng quay ngUdi ldn... 502

(H oang N goc Scfn)

20. Vet thUdng ban t a y...513

(Phung N goc Hod)

21. Nhiem Lrung ban ta y ... 522

(Phung Ngoc Hod)

22. Gay xUdng c h a u ... 532

(Phung N goc Hod)

23. Gav co xUdng d u i ...543

(Phung Ngoc Hod)

24. Gav khoi mau chuyen xUdng d u i...550

(Phung Ngoc Hod)

25. Gay than xUdng dui ... 555

(Phung N goc Hod)

26. Gav d&u dudi xUdng dui... 563

•(Phung Ngoc Hod)

27. Gay hai xUdng cang c h a n...568

(Phung N goc Hod)

28. (-lay xUdng co ch a n ... 577

(Phung Ngoc Hod)

29. Cac ton thuong phan mem vung co c h a n ... 582

(Phung N goc Hod)

30. Gav mam ch a y...588

(Phung N goc Hod)

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PHAN 4

TIEU HOA

1. THONG THUCQUAN

Thung thiic quan la tap hdp cac ton thiidng tat ca cac 16p cua thanh thiic quan
lam thong long thiic quan v6i ben ngoai do cac nguyen nhan khac nhau nhii vet
thufdng, chan thiidng va thung thiic quan tii phat hoac do thay thuoc gay ra. Du do
nguyen nhan nao thi thung thiic quan cung co nhieu diem chung la benh canh lam
sang giong nhau, deu co nguy cd viem trung that, nguyen tac va cac phiidng phap
dieu tri giong nhau.

Thung thiic quan la mot ton thiidng it gap trong ngoai khoa nhUng lai la ton
thiidng thung co tien liidng nang nhat trong cac loai ton thUdng thung rua tieu hoa
vi chan doan thiidng muon, dieu tri kho khan va ty le ty vong rat cao (20 — 30%)
mac du hoi siic va dieu tri phau thuat da co nhieu tien bo.

1. N G U Y E N N H A N

Co rat nhieu nguyen nhan gay thung thiic quan v6i cac cd che gay thung khac
nhau nhii la do vet thiidng, chan thiidng tii ngoai vao (vet hiidng do bach khi, hoa
khi, tai bien phau thuat), hoac tCf trong ra (noi soi, di vat), hoac la vd thiic quan tii
phat do tang ap liic dot ngot trong long lam xe rach thiic quan hoac la do cac benh
ly thiic quan (ung thii thiic quan).

1.1. T h u n g thiic q u a n do tai bien cua phau th u a t, th u th u a t

1.1.1. Tai bien cua noi soi

Thung thiic quan do noi soi la nguyen nhan thiidng gap nhat, chiem tren 50%
trong tat ca cac nguyen nhan gay thung thiic quan. Ty le thung thiic quan trong
noi soi chan doan lidc tinh khdang 0,13 - 0,4%. Trong noi soi chan doan, thung
thiic quan co the gap khi co thoat vi hoanh, dung ong soi ciing, dat ong soi mo
m lm , khong kiem soat bang mat. Trong noi soi dieu tri, nong thiic quan dieu tri
cac nguyen nhan hep d thiic quan (seo hep thiic quan sau bong, dieu tri co that
tarn vi...) la nguyen nhan gay thung thiic quan hay gap nhat, sau do la cac tai bien
trong cac dieu tri tam thdi hep thiic quan do ung thii (dat nong thiic quan, laser),
tiem xd cam mau.

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1.1.2. Tai bien phau thuat

Cac phau thuat 6 vung co. nguc va bung tren deu co the gay ra vet thuong
thuc quan do cat phai thiic quan. do cac ton thudng cua tang lan can xam lan vao
thanh thuc quan hoac cac dung cu phau thuat dat tai cho ty de vao thUc quan lau
ngav gay thung. Cac phau thuat d vung co co the lam thung thiic quan la cat
tuyen giap do ung thu. hoac tuven giap qua to. cac nep, vit cot song co ty de vao
thuc quan. md khi quan khong dung ky thuat. Cac phau thuat d long ngiic nhu cat
phoi. soi trung that co the gay ton thiidng thuc quan ngitc. 0 bung, cac phau thuat
co the gay thung thuc quan la md cd thiic quan ngoai m em mac (phau thuat

Hellerv). cat than than kinh X. cac phau thuat dieu tri thoat vi hoanh.

1.1.3. Cac nguyen nhan khac

Tai bien cua dat bong Blakemore, bong Linton de cam mau trong chay mau do
tang ap luc tinh mach ciia thanh thiic quan rat de ton thudng do thieu mau. ty ep keo
dai cua bong. Thung thuc quan do ong noi khi quan va thd may keo dai rat it gap.
1.2. V et thifdng va ch an thiidng thiic quan

Vet thiidng thuc quan do bach khi va hoa khi it gap d co, vet thudng thiic quan
thudng phoi hdp vdi cac vet thudng mach mau ldn vung co hoac khi phe quan vdi
bieu hien lam sang la chay mau ldn hoac tran khi ldn diidi da co hoac trung that.

Vd thuc quan do chan thiidng bung hoac chan thiiOng ngiic kin rat hiem gap
va chu yen thay d nhung benh nhan da chan thuong. Sii tang ap liic dot ngot trong
lon£ thuc quan thudng gay vd thuc quan ngUc. 0 doan 1/3 tren thuc quan. dUdng
vd d mat tru'dc va thudng kem theo vd phan mang khi quan. Mot so trUdng hdp vd
thiic quan do hut vao ong hdi co ap luc cao. duong vd thiic quan thudng rat ldn.
1.3. Vd thufc quan tii phat

Vd thuc quan tu phat la vd thuc quan sau non manh va nhieu, bao gom hoi

chung Boerhaave, hoi chiing Mallory - Weiss va mau tu tu phat thanh thuc quan

Hoi chiing Boerhaave dude dinh nghia la ton thuong vd hoan toan cac ldp cua thiic
quan ngue khong do chan thudng. Cd che vd thuc quan la do non manh gay tang
ap hie dot ngot trong long thuc quan trong khi cd nhan hau dong kin. Trong cac
trudng hop vd thuc quan tu phat. thudng thay co cac ton thudng thiic quan. than
kinh phoi hop nhu viem thuc quan. tang trudng luc cd that diidi cua thiic quan. tui
thua thuc quan nguc v v... Hoi chung Mallory - Weiss co cd che chan thudng tucr.g
tu nhu' hoi chung Boerhaave. nhung ton thudng la rach doc m em mac tam vi. lop
eO khong bi ton thudng.

1.4. Tilling thiic quan do di vat

Nguyen nhan thuong gap nhat ia do nuot phai xuong. Vi tri thung tb.v.zr.z :

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nhCtng ncfi hep cua thuc quan, dac biet la d thiic quan ngiic. Chieu dai xUdng va
hinh dang manh cua xUdng la you to' nguy cd quan trong nhat gay mSc lai d thiic
quan va gay thung. Thung thiic quan co the do manh xUdng bi mac lai va choc
thung thanh thuc quan, cung co the do thu thuat lay xUdng qua noi soi gay thung.
Can het siic chu y tim dau hieu thung thiic quan trUdc, trong va sau soi thiic quan
lay xUdng mdc.

1.5. M ot so n g u y e n n h a n k hac

- Thung cac khoi u cua thiic quan hoac cac khoi u cua trung that, u phoi vd
vao thiic quan.

- Cac ton thUdng viem lao, hoi chiing suy giam mien dich mac phai.
- Uong phai cac chat an mon (acid, kiem manh).

2. SIN H B E N H H O C

TrCf cac cd che thung thiic quan do tai bien cua phau thuat, noi soi, cd che cua
vd thiic quan tii phat la do tang ap liic dot ngot trong long thiic quan do non hoac
nac manh khi cd che' that tren cua thiic quan dong kin. Vd hoac thung thiic quan
lam long thiic quan thong vdi cac khoang te bao d phi'a tren la khoang sau hau,
sau thiic quan co va phia dudi la khoang te bao cua trung that sau. Hdi nuot vao,
tham chi la do bdm hdi khi bdm thiic quan lam tach cac khoang te bao long leo,
gay ra hien tUdng tran khi du6i da co va tran khi dudi trung that. Nude bot, thiic
an chay vao cac khoang te bao nhanh chong dan tdi tinh trang viem trung that
nhiem khuan nang. Viem trung that nhiem khuan thudng xuat hien sau thung 12
gid. Dich acid cua da day tran vao trung that trong cac trUdng hdp vd thiic quan
thap, trao ngUdc dich da day len thiic quan vao trung that co the lam nang them
tinh trang nhiem khuan trung that. Viem trung that con gay ra phan ling tang
tiet cua khi phe quan, nhiem trung phoi. NgUdc lai, nhiem trung phoi bi nang
them do vd thiic quan thong vdi mang phoi hoac thii phat do cac o ap xe trung that
vd vao mang phoi gav nen.

Dien bien tii nhien cua qua trinh viem trung that la rat nang do nhiem trung,
nhiem doc va do cac bien chiing ho hap nang. Nguy cd nay co the nhe hdn trong
cac trung that da xd hoa nhu trong cac trUdng hdp viem thiic quan trao ngUdc hoac
sau cac viem chit hep thiic quan, sau bong thiic quan.

3. G IA I P H A U B E N H

- Thung thiic quan do thu thuat noi soi: ton thudng thung thiic quan thudng
la cac lo thung nho, bd sac nhon, dai, cheo tii tren xuong, lo trong va lo ngoai lech
nhau hoac la ton thuong xe rach thanh thiic quan tUdng ling vdi cho thanh thiic
quan benh ly.

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- Vd thiic quan do chan thiidng: thiidng gap d 1/3 tren cua thiic quan ngiic do
cac chan thiidng manh vao long ngiic. Ton thUdng d thiic quan kern theo ton
thiidng mang sau cua khi phe quan va cac tang trong long ngiic.

- Vet thudng thiic quan: it gap va it khi la ton thUdng thiic quan ddn doc d co,
vet thiidng thiic quan thiidng kern theo ton thudng cac mach mau ldn d co va khi
quan nen trieu chiing lam sang thudng bi che lap bdi hoi chiing chay mau hoSc
kho thd.

- Thung thiic quan tii phat: ton thUdng la nhiing dUdng vd doc, thudng nam d bd
trai cua thanh thiic quan ngiic, tren cd hoanh. Kich thudc cua dUdng vd tii 3 - 4cm,
doi khi tdi 10cm. Dudng vd thudng lam rach tat ca cac ldp cua thanh thiic quan,
doi khi la dudng vd khong hoan toan, khong ton thudng het cac ldp cua thanh thiic
quan, sau do do cac nhiem trung tai cho gay hoai tii hoan toan thanh thiic quan.
Mot diem can liiu y la ton thiidng niem mac bao gid cung rong hdn ldp cd nen can
phai md rong ldp cd trudc khi khau vet thudng de tranh bd sot dudng vd dudi niem
mac. Ngoai ra, co the gap cac ton thudng phoi hdp da co tti trudc nhu viem thiic
quan, tui thiia thiic quan, co that tarn vi v.v...

- Thung thiic quan do di vat: thudng gap nhat la do nuot phai xUdng. Chieu
dai xUdng va hinh dang sac nhon, goc canh ciia manh xUdng la yeu to” nguy cd
quan trong nhat gay mac lai va gay thiing. Thung thiic quan co the do manh
xUdng choc thiing thanh thiic quan, cung co the do thu thuat lay xUdng qua noi soi
gay thiing. Do vay, ton thudng thiing co the nho nhUng co khi rat phiic tap.

- Vi tri ciia lo thiing: vi tri cua lo thiing co the d moi vi tri cua thiic quan.
Tuv nhien trong thiing thiic quan tii phat, vi tri lo thiing thudng gap nhat la
thiic quan 1/3 dudi, bd trai cua thiic quan, trong khi vet thudng thiic quan va di
vat thiic quan lai hay gap d doan thiic quan co. Vi tri thung thiic quan hay gap
nhat trong cac thii thuat noi soi la thiic quan ngiic va thiic quan co, ngay dudi

mieng thiic quan. Thiing thiic quan do chan thudng thudng gap d thiic quan
ngiic 1/3 tren.

4. T R IE U CHLfNG V A C H A N D O A N

Chan doan thiing thiic quan thudng kho va muon vi cac trieu chiing dac trUng
thudng it gap hoac xuat hien muon. Trong chan thUdng va vet thudng thiic quan.
cac trieu chiing thudng bi che lap bdi benh canh cua da chan thudng hoac hoi chiing
chav mau, kho thd do ton thudng cac mach mau ldn hoac ton thudng khi phe quan.

Thiing thiic quan thudng dUdc phat hien va chan doan trong cac hoan canh sau:
- Trong khi lam noi soi vdi gay te tai cho, benh nhan thay dau dot ngot du doi.
dac biet la xuat hien sau mot cii dong bat thudng hoac sau khi benh nhan nac
manh. Khi noi soi thiic quan vdi gav me toan than, khong thay diidc dau hieu dau
nhung khi rut ong noi soi tii tii va kiem soat bang mat co the phat hien dtfdc ton
thudng thiic quan.

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- Khi nuot phai di vat, benh nhan thay dau dot ngot, khu tru, lien tuc d mot vung.
- Vd thuc quan tii phat dUdc nghi den khi benh nhan co dau ngiic, kho thd dot
ngot, tran khi dudi da co sau non hoac nac manh.

- Cac trUdng hdp chan thUdng hoac vet thudng thuc quan thudng phat hien muon
hoac phat hien khi mo de xii ly cac ton thUdng phoi hdp d co va trong long ngUc.

4.1. T rieu chufng lam san g

- Dau: dau la trieu chiing chinh, dau dO doi va lien tuc. Dau sau xUdng lie
hoac tren ron trong cac trUdng hdp thung thUc quan tii phat, dau cao d vung co doi
vdi thung thuc quan co. Dau tang khi nuot nen benh nhan khong dam nuot va
thUdng phai nho nUdc bot.

- Kho thd: rat thudng gap nhat la trong cac thung thiic quan ngiic vao mang
phoi. Kho thd kem theo dau, co the kem theo thay doi giong noi.

- Tinh trang soc co the xuat hien rat sdm vdi cac dau hieu mach nhanh, nho
va huyet ap tut.

- Non ra mau la dau hieu co gia tri nhung rat it gap.

- Tran khi dudi da vung co xuat hien sdm: co phong to len, sd thay mem va co
dau hieu lep bep cua khi dudi da.

- Trong trifdng hdp thung thuc quan co, benh nhan cam thay rat dau khi
ngu'di thay thuoc cam vao sun giap va lac nhe sang hai ben. Trong cac ton thudng
thiic quan bung, co dau hieu co ciing hoac phan ling thanh bung vung tren ron.

- Trong trUdng hdp thung thiic quan 1/3 tren kem theo co rach mang sau cua
khi quan, benh nhan co dau hieu ho, sac khi nuot do dudng vd lam thong thiic
quan vdi khi quan.

Khi thay co sii phoi hdp cua ba trieu chiing (dau khi nuot, kho thd va tran khi
dudi da co), can nghi tdi ton thudng thung thiic quan va phai ngiing cho an qua

T O •» x

nneng. Lam ngay cac tham kham can lam sang de khang dinh chan doan va dieu
tri sdm.

Neu khong dude chan doan va dieu tri sdm, sau vai gid se dan tdi tinh trang
viem trung that nhiem khuan rat nang. Benh nhan sot cao 39 - 40°C, ve mat hoc

hac, tang tiet ddm dai, kho thd, tim tai.

4.2. T rieu chvfng can la m sang

4.2.1. Chup X q u a n g long nguc

Chup ngiic thang, nghieng, lay ca vung co thudng thaj^T^iBTiJga^h tran khi
dudi da vung co. Hinh anh tran khi trung that co tii 75 - '80%- cac trufeng hdp, co
khi thay hinh anh hdi hinh chuf V tren cd hoanh (dau hieu Nacle - Rjeo). Neu de
muon, co the thay dau hieu trung that gian rong do tu dich, ap xe trung that, tran

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dich va tran khi' mang phoi do thung vao mang phoi hoSc la tran dich do phan ling
cua mang phoi. Tren phim chup nghieng vung co co the’ th&'v dau hieu hdi sau thiic
quan (dau hieu Minigerode) khoang sau thiic quan rong ra, day thiic quan va khi
quan ra tnidc.

4.2.2. Chup bung khong chuan bi

Chup bung khong chuan bi co the thav hdi tii do trong o bung (dau hieu hem
hdi dudi hoanh tren phim chup diing) hoac co the thay co hdi sau phuc mac trong
cac trifdng hdp thung thiic quan bung sau phuc mac.

4.2.3. Chup can quang thuc quan

Chup thiic quan vdi thuoc can quang hoa tan trong nude co the xac dinh dUdc
80% cac trUdng hdp thung thiic quan, ngoai ra con giup xac dinh vi tri ton thUdng
va ben thanh thuc quan bi ton thudng de chon dUdng mo phu hdp. Tren phim chup
thiic quan can quang, thung thuc quan diidc kh&ng dinh khi co cac hinh anh sau:

- Hinh khac d thuc quan trong trUdng hdp ton thudng m6i chi co d thanh thiic quan.

- Hinh dam thuoc can quang tren cd hoanh trai trong trUdng hdp vd thiic quan
tii phat.

- Dudng ro thuoc can quang ra ngoai thiic quan vao trung that, mang phoi
trong cac ton thudng lam thung hoan toan thanh thiic quan ngiic hoac co thap.

4.2.4. Choc mang phoi

Trong cac trUdng hdp co tran dich mang phoi, choc mang phoi thay dich mang
phoi co mau xanh nhat cua dich da day. Xet nghiem dich co pH < 6. Dich choc
mang phoi co mau xanh sau khi cho benh nhan uong xanh methylen chiing to la co
thong thudng gitia ong tieu hoa va mang phoi.

4.2.5. Chup cat ldp vi tinh

Dau hieu thung thiic quan tren phim chup c&t ldp vi tinh co uong thuoc can
quang dang nUdc la hinh anh ro thuoc can quang ra ngoai thiic quan vao trung
that dau hieu tran khi trung that va to chiic phan mem d co. Dau hieu tran khi
trung that va to chiic phan mem thay rat ro tren phim chup cat ldp. Ap xe trung
that the hien difdi dang o djch cd hdi d giiia. Chup cdt ldp co hai ldi l'ch can ban la
chan doan va danh gia chinh xac. toan dien cac o nhiem khuan, ap xe trung that
trong cac trudng hop thung muon, giup lua chon dudng d i n luu o ap xe qua da.

Hdn nut a, chup cat ldp la phitong tien tot nhat de chan doan ton thudng tu
mau thanh thuc quan.

4.2.6. Noi soi .

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