Tieu hóa

LOET DA DAY - HANH TA TRANG _ • _ I O Al CU’O’NG Loet da day - hanh ta tra n g la benh bien o’ n u ’O’C ta cOng n h u tren th e g id i loet la s u pha huy m ot vung co g io i han nho lam m at lo p niem m ac da day - hanh ta trang, co the lan xuong lo p d u o i niem m ac, lo p c o th a m tri den lo p m ac va co the gay thung C o che chu yeu la m at can b ln g g iu a yeu to bao ve va yeu to gay loet T hu at n g u P eptic ulce r d ise a se (P U D ) d u o c hieu la loet da day hoac ta tra n g hoa c ca hai II chAn ooAn C h a n d o a n x a c d jn h - Lam sang: dau b un g vu n g th u o n g vi co tin h chat chu ki - Noi soi ong m em d u o n g tieu hoa tren hi£n d u o c coi la p h u o n g phap chan d oa n ch in h xac nhat, co nhieu u u diem so v o i c h u p X q u a n g da day: + M o ta h inh anh noi soi cua o loet: vi tri, so lu o n g o loet, kich th u o c , h inh dang, m au s ic , day o loet, ria o loet (niem m ac xu n g q u a n h o loet) + Sinh th ie t tim H p ylo ri: te s t urease, qua m o benh hoc + Sinh th ie t canh o lo et lam m o benh hoc neu nghi n g d ung th u , dac biet la cac tru o n g h o p loet d da day + C ac giai d oa n cua lo e t da day - hanh ta trang tren noi soi: co g iai doan sau: a G iai d o a n h o a t d o n g (a c tiv e s ta g e ): h inh trdn, ovan hoa c h in h ki di, th u o n g kich th u o c < 1cm , b d rat phu ne, phu b d i fibrin, m au h o i luc hoa c h o i vang hoac h o i tr ln g D a y co gia m ac t r ln g hoa c nhin thay m ach (diem dom den 1-2m m ) b G ia i d o a n la n h o lo e t (h e a lin g s ta g e ): b d o lo et g d len va it deu h o n , sung huye t nhieu tu ngoai vi den trun g ta m o loet, s o i to huye t phu day o loet, day o loet m au h o i c G iai d o a n lien s e o (s c a r sta g e ): d iem trln g , teo niem m ac, nep niem m ac hoi tu vao trun g tam seo Neu co cho n g ch i d jnh noi soi ong m em , co the noi soi b ln g vie n nang C h a n d o a n b ie n c h ip n g va th a i d o x u li a X u a t h u y e t d iro rig tieu h o a tren lo e t da d a y - ta tra n g - Lam sang: hoi c h u n g th ie u m au, non m au tu o i h o a c/va m au cuc, di n go phan den Tren hinh anh npi soi d u d n g tieu hoa tre n m o ta giai doan xuat huye t (the o phan loai F o rrest) C a c xet ngh iem can lam: cong th u c m au, d on g m au c o ban, noi soi d u d n g tieu hoa tre n cap c u u , - D ie u trj: tru ye n m au, djch, cac th u o c u c che b o m proton (P P I) lieu ca o d u d n g tin h m ach, noi soi d u d n g tie u hoa tre n cap c u u : cam m au qua noi soi (clip, tiem cam m au q u a noi soi, a rg o n p la sm a ) Neu dieu trj noi kh o a ket h o p ca m m au qua noi soi th a t bai ch u ye n p u th u a t H uong 484 d A n c h A n d o A n v A d i £ u t r i b En h NOi khoa b Th u n g da d a y - ta tra n g - Lam sang: dau bung d u doi, co c u n g th a n h bung - Xu- tri: + P h iu th u a t khau lo thung + C i t da day nghi n g d ung th u hoac khon g khau d u o c lo thung c R o vao cac ta n g x u n g q u a n h (du’d n g m at, ru o t non, tuy, d a i trang, ) - C h in doan: ch u p C T co uong th u o c doi quang, noi soi - D ie u tri: p h iu thuat d H e p m o n vj - C han doan: non th u c an cu, bung oc ach buoi sang, dau bung nhieu, an khong tieu - Noi soi: th a y hep m on vi hoac ta trang, m ay noi soi qua kho khan hoa c khon g the qua d u o c Trong tru d n g h o p nghi n g d ung th u hoa: can sinh thiet de lam m o benh hoc - D ie u tri: + D ieu tri khon g p h iu thuat: nong cho hep tru d n g h o p hep lanh tinh + P h iu thuat: nong th a t bai hoac ung th u III D l£ U TRj - M uc tieu cua dieu tri P U D la lam lien o loet, giam dau va ngan n g u a bien c h u n g loet bao gom loai tru cac yeu to nguy c o gay loet va dung th u o c chon g loet - N g uyen t i c dieu tri: khon g dung phoi h o p cac th u o c cung c o che, kh o n g d un g nhbm acid cung luc v d i cac th u o c khac D ie u tri noi khoa (chong loet, dieu tri trieu c h u n g ) la chu yeu H ien tai, chi phau thuSt dieu tri noi khoa m a khon g co ket qua - N eu o lo et n gh i ung th u hoa: sau th a n g noi soi sin h th ie t lai, neu o lo e t khon g d d nen dieu tn ngo khoa - T h d i gian dieu tri: - tu a n /d o t dieu trj Co the keo dai tu y th e o ke t q u a dieu trj - Kiem tra noi soi lai sau dieu trj - Sau t u in neu khon g d d tren noi soi, nen noi soi n hu om m au, sie u am noi soi N eu nghi ngo ung th u hoac ung th u nen p h iu thuat N h om th u d c khang acid (A n ta c id s ) La cac th u o c co c h u a nhom hoac calci, m a gnesi hydroxit, nho m co ta c d yn g trung hoa acid khong anh h u d n g den bai tie t djch vj cung n h u pepsin, 1-3 g id sau b u a an va di ngu N h o m lpc c h e thu th e h istam in H T h u o c u c ch e thu the H 2: hien th u d n g dung cac loai: + C im e tid in 800 m g - u o n g /tie m tin h m ach + R a nitidin 300m g - u o n g /tie m tin h m ach + F a m o tid in m g - u o n g /tie m tTnh m ach + N iza ta d in 300 m g - uong (Lieu tiem tin h m ach thong th u d n g b in g 1/2 lieu uong) U u diem cua th u o c nhom la re tien, an toan n h u n g cac th u o c kha nang u c che acid d>ch vi yeu h o n so v d i nhom PPI N h o m lpc c h § b crn i p r o to n (P ro to n P u m p In h ib ito r s - P P I) D a y la nhom th u o c u c che acid dich vi m anh nha t hien th u d n g d un g ca c nhom sau: H u o n g d A n c h An d o A n v A b i £u tri b £n h 485 N qi k h o a + O m e p z l vie n m g hoa c 40m g, ong 40m g + L a n so p zo l vie n 30m g + P a n to p zo l vie n 20m g hoa c 40m g, ong 40m g + R a b e p zo l vie n 10m g hoac 20m g, ong 20m g + E so m e p zo l vien 20m g hoac 40m g, ong 40m g N h o m b a o v e n ie m m a c da d a y - S ucrafat: bao ve te bao bao boc o loet, ngan s y khuye ch tan n g u a c cua ion H + , lpc che pepsin va hap phu m uoi m at: co ta c d un g phong loet cap tin h va lam lanh loet m an tin h m a khong anh h u a n g ta i bai tiet dich vi va pepsin N en uong ti> 30 phut den 60 phut tru ’d c an - B ism uth: v u a co ta c dung bao ve niem m ac da day - ta tran g v u a co tac dung diet H pylori - M isop rostol: la d on g d in g v d i pro sta g la n d in E, co ta c d un g bao ve niem m ac da day vi lam tang bai tiet chat nha y va b ic a rb o n a t d on g th d i lam tang dong m au td i niem m ac da day - ta trang Ham lu’a n g vien 200 m cg Lieu d un g thu’d n g 0 m cg - 800m cg/ngay, uong H ien it dung tac dung phu C a c k h a n g s in h d ie t H p y lo r i -A m o x ic illin 500m g: kha n g th u o c it - M e tro n id a zo l/tin id a zo l 500m g, hien thuoc bi khang r i t nhieu, sau uong benh nhan thu’d n g m et - C la rith ro m ycin 25 m g , 500m g - B ism uth - F u razolid on: n itro fu n th u o c it dung d nu’d c ta - F lu o ro q u in o lo n e s: L e vo flo xa cin 500m g D ie u tr j n g o a i k h o a ( p h iu th u a t) C ac ch i dinh d ieu tri n go khoa hien r i t han che chi p h iu th u a t khi: - X u lt huye t tieu hoa ch a y m au da day - ta trang dieu trj noi kh o a t h lt bai, neu o loet lanh tinh: khau thung, neu o loet a c tin h p h iu th uat c i t bo da day - Thung da day - ta trang - H ep m on vj - U ng th u hoa - Ro da day - ta tra n g va o cac tang lan can P h a c d d ie t H p y o r i th e o H o i tie u h o a H o a K y (T h e o F D A c u a M y) a B is m u th - m e tr o n id a z o l - te tr a c y c lin d u n g 14 n g a y (khong d un g ch o n g u d i du’d i 18 tuoi) - P e pto b ism u th x vie n uong lln /n g a y - M e tro n id a zo l m g x vie n x lln /n g a y - T etracyclin m g x vie n x lan/ngay - P hoi h a p v d i kh a n g h ista m in H x tuan ho$ c PPI x - tuan b P h a c d o 10 n g a y h o a c 14 n g a y - PP I x vie n x la n /n g a y x 10 hoac 14 (o m e p zo l 20m g, la n z o p z o l 30m g) -A m o x ic illin 0 m g x vie n x lan/ngay - C la rith ro m y c in 0 m g x vie n x lan/ngay c P h a c d o 10 n g a y - PP I (e s o m e p z lo m g ) x vie n x lan/ng^y H i/ O n g d A n c h A n b o A n v A b i£ u t r i b £ n h N O i k h o a 486 - A m o xillin 500 m g x vie n x lan/ngay - C la rith ro m ycin 500 m g x vien x lan/ngay d P h a c 10 n g a y - PPI vie n x la n /n g a y x 10 - L e vo flo xa cin 500 m g vie n x la n/n gay x 10 -A m o x ilin 500 m g vien x la n/n gay x 10 C ac tru ’d n g ho’P khang th u d c H au het cac tru’d n g h o p loet da day - ta trang lien o lo et sau tu a n dieu tri, m ot so it o loet khong lien du’O’c xem la khan g th u o c hay loet dai d in g (refracto ry): tro n g tru’d n g h o p phai tim nguyen nhan de dieu tri C a c cau hoi d im e d at v d i benh nhan la: - C o d u p e uong dung thuoc, du lieu hay khon g? - C o d im e dung th u o c khang H 2, PPI hay khon g? - N h iem H p y lo ri hay khon g? - C o tiep tu c dung N S A ID ? - B enh nhan co dung th u o c th o a dang hay khon g? neu o loet Idn > 2cm , co the phai danh gia sau 12 tuan dieu trj - B ^n h nhan co th u o c nho m tang tie t nhu’ loet tron g hoi c h d n g Z o llin g e r - E llison - Loai tr d cac tru ’d n g ho’P loet tien ung th u 1de dieu trj sd m T h a y doi I6i son g Bo th u o c la, th u o c lao va de phong dung N S A ID s t A i l ie u t h a m k h A o S le is e n g e r& F o rd tra n ’s G a s tro in te s tin a l and L iver D isea se, 8th ed T h e o d o re M B a yle ss, A n n a M ae D iehl (2005): “A d v a n c e d T h e p y in G astroen te rology and L iv e r disease" Fifth E d ition, B.C D e cke r Inc, H a m ilton, Lon don R ich ard J S aad and: “S a lva g e T h e p y in P e rs is te n t H e lic o b a c te r p y lo ri”, A m J Gastroenterol 2006; 101: 8 ^ B erth o ld B lo ck, G u id o S c h a c h s c h a l, H a rtm u t S c h m id t, “P a th o lo g ic a l fin d in g s: S tom ach' & “P a th o lo g ic a l fin d in g s: D u odenu m ", E n d o s c o p y o f the u p p e r G I tract, T hiem e 2004, p 102-104 & p 133-135 VIEM TUY CAP I DAI C U m iG V iem cap (V T C ) la ton thu’a n g viem nhu m o tuyen cap tin h tu nhe den nang va co the gay tir vong Cf cac n u ’O’C phip o n g T a y thi khoa ng 20% benh nhan V T C co tien trien nang va so cac ca nang co 10-30% d in den tu" vong m ac du du’a c dieu trj tich cue ” V iet N am , V T C nhCmg nam gan day cung co xu h u a n g ta ng V e m a t giai phau benh co hai th e vie m tu y phu ne va viem hoai tu chay m au ii chAn An C h in d o a n x a c d jn h : d u a vao cac trieu c h u n g lam sang va can lam sang a Trieu chu’n g la m s a n g - D au bung: la trie u c h u n g hay gap (95% benh nhan V T C ), th e o nguyen nhan m a tin h chat dau bung the hien khac (th u a n g khong co tien su , nguyen nhan ro rang): + V T C soi, tin h ch a t dau dien hinh la dot ngot dau bung vung th u ’a n g vi n h u dao dam , dau lan sau lirng + V T C n gu yen nhan c h u ye n hoa, ru a u tin h chat dau thu’a n g khon g d ot ngot va khong khu tru d u doi n h u tru a n g h o p soi - Non va buon non gap tro n g 85% cac benh nhan V T C , tu y nhien benh nhan non thi trieu chu’ng dau bung van khon g th u ye n giam - T ham kham lam sang: + Toan than: ta i % b en h nhan co bieu hien nhjp tim nhanh, tu t hu ye t ap la hau qua cua giam the tich long m ach co hien tu ’a n g th o a t quan, gian m ach va chay m au + K h oang % benh nhan V T C co bieu hien sot nhe, neu benh nhan sot cao co the la m ot nhu’ng dau hieu c h i d ie m cua vie m du’a n g m at hoac vie m hoai tu + Bung tru ’a n g , an dau + N ghe tie n g soi b un g thu’a n g giam hoa c m at + C ac dau hieu khac: tra n djch m ang phoi hay gap ben trai, va n g da, m ang tim den sau lu ng, canh s u a n hoac khu v u c q u a n h ron chay m au tu y vao khoa ng sau ph u c m ac b C an lam s a n g - X e t n g h ie m a m y la s e h oa c lipase m au: tang > lan la co gia tri chan doan (a m yla se tra ve binh thu’a n g tru a c lipase) - C ong th u c m au: bach cau tang, h e m a to crit tang, cac yeu to vie m in te rle u k in -6 tang, C R P (C -rea ctive protein) tang va o nga y th u sau V T C - S inh hoa m au: ALT, b iliru b in tang tron g V T C soi m at, LD H tang - Roi loan d on g m au g a p a benh nhan nang 488 H i/ O n g d A n c h A n o o A n v A d i £ u tr i b £ n h - C h up bung khon g chua n bi: loai bo cac cap clpu NOi khoa ngoai khoa khac nhu- th u n g tang rong cac d iu hifcu khac co the phat hi?n n h u tran dich m ang phoi, soi - Sieu am la p h u o n g tien tot de chan doan V T C , m ire vie m tuy, cung n h u la logi tn> cac nguyen nhan dau bung khac n h u V T C soi m at - C h yp ca t lo p vi tin h (C T) hoac chup cong h u o n g tu (M R I) co gia trj ca o h o n tron g chan doan k h ic phu c d u o c yeu diem cua sieu am , dong th o i cho phep danh gia ky h o n ve ton th u o n g a cung nhir bien c h u n g cua V T C n h u la danh gia b o tuy, ton th u a n g nhu m o, m u c hoai tu , dam dich quanh B a n g D ie m B a lth a z a r d an h g ia m ipc n a n g tre n C T D ie m H oai tOr Oietn A: binh thudng Khong co hoai tir B: to khu tru hoac lantoS Hoai tOr 1/3 C: Bien (Joi cau true tuy, kem thay doi lop mo quanh Hoai tOr 1/2 D: Co m ot o dich Hoai tir > 1/2 E: Hai hoac nhieu o djch M ik f lo - E R C P (chup m at tu y n g u a c dong) tu y khong co vai tro tro n g chan doan V T C n h u n g co vai tro chan doan phan bi?t a tru a n g h a p V T C tu y phan doi (p a n cre a s d ivisu m ) ho a c benh ly c a Oddi, vd dieu tri cap c u u V T C soi, giun - Sieu am noi soi (E U S ) nha y tron g phat hien V T C soi R at it ap d un g tro n g giai doan cap c C h an d o a n x a c din h D a u bung; A m y la s e hoa c lipase m au tang gap lan b in h th u a n g ; C o ton th u a n g VTC tren C T hoac SA (trong tru a n g h a p am yla se hoa c lipase m au b in h th u a n g chan d oa n d u a vao trieu chimg dau bung dien h inh va hin h anh ton th u a n g V T C tren CT) C h an doan m u c V T C D y a vao tin h trg n g hoai tu va suy tang a Viem tu y ca p n h e : la tin h tran g V T C co roi loan c h u c nang tang nhe va t u hoi phuc b Viem tu y ca p n an g : la tin h trang V T C co kem th e o suy ta n g ho a c ton th u a n g khu tru tai (hoai tu , ap xe, hoa c nang gia tuy) B ang S IR S d u bao roi loan c h u c nang da tang hoac V T C hoai t u co > yeu to (bang 2), diem R a nson tren 3, A P A C H E -II tren (bang 3) la dau hieu s a m V T C nang B a n g C ac y e u to tien luxrng s d m viem tu y cap n a n g va ton thu’O’n g s u y tang Hdi chting dap irng viem he thong (SIRS) Suy tang theo hoi nghi Atlanta Mach > 90 chu ky/phut Soc gi3m the tich < 90mm Hg Nhip th d > 20 chu ky/phut hoac PC02 < 2mmHg Pa02 £ 60mmHg Nhiet true trang < 36°C hoac > 38°C Creatinin > m g /l sau bu dich Bach cau < 4000 hoac > 12000/m m ! Xuat huyet tieu hoa > 500 m l/24 gid H u O n g d A n c h A n o o A n v A e >i £ u t r i b E n h 489 N i khoa B a n g D ie m R an so n , G lasgow , Im rie (Im rie p h u hcyp va d e ap d u n g & nw &c ta) Tieu chuan Glasgow Tieu Chuan Ranson Imrie Khi nhap vien Trong 48 gift dau Luc m nhap vien Tuoi > 55 Tuoi > 55 Bach cau > 16000/m m Tudi > 55 Bach cau > 15000/m m Bach cau > 15G/I LDH > 350IU/I LDH > 600IU/I Dudng mau > 10m m ol/l Glucose > 11,1 m m o l/l Glucose > 10m m ol/l LDH > 600U/I AST > 250IU/I Album in < 32g/l Ure mau > 16m m ol/l Trong 48h dau Calci mau < 2m m ol/l Trong 48 gid dau Gi3m hem atocrit > 10% PO2dong mach < 60mmHg Calci mau < 2m m ol/l Ure tang > 5m g/dl Ure > 17m m ol/l Calci mau < m m o l/l Pa02 < 60mmHg Album in mau < 32g/l POj (long mach < 60mmHg Thieu hut base > 4mEq/l AST > 100U/I Tong diem: nhe: < diem, nang: 3-5 Lfdc luong dich mat > 61 Tong diem: -2 :2 % tir vong (TV); -4 :1 % TV; diem, rat nang: > diem Diem 1 5-6:40% TV; 7-8:100% TV C h in d o an p h a n biet - VOi cac tru ’a n g h g p dau bgng cap: thung tang rong (da day, hanh ta tran g), soi m at, t i c rupt, phinh tach dpng m ach chu bung, nhoi m au c a tim sau - Benh ly da day - h an h ta trang - V a i cac tru ’a n g h a p ta n g a m yla se m au: suy than, vie m tu ye n m ang tai - U tuy: lam sang b en h nhan cung co dau, tren C T co bieu hien u - D o t cap vie m tu y m an: th u ’a n g co kem theo ton th u ’a n g soi ong ho a c nhu m o C h a n d o a n n g u y e n n h a n • N guyen nhan hay gap: - Soi ong m a t chu, soi tui m at - G iun chui ong m a t chu, ong - R u a u , an nhieu dam - Tang trig ly c e rid m au - Co thai • N g uyen nhan it gap: - U -T h u o c : a za th io p rin , th ia zid , m e tronichzol - C han th u 'a n g - C u’a n g can g ia p trang - N hiem trung - B £nh ly m ach m au - B enh 11/ nhiem C h a n d o a n b ie n c h u ’n g • B ien ch u ’ng tai cho: - ty dich, hoai tu' va nhiem khua n tyy - N a ng g ia tuy: tu a n sau V TC - A p xe tgy, ro o n g tu y va o o bung H u O n g d a n c h An d o A n v A d i £ u tri b£n h 490 Noi khoa - T o n thu’O’ng m ach m au, ch a y m au • Bien ch u ’ng toan than: - S uy ho hap, suy than, tru y tim m ach - X u a t huye t tieu hoa -A D S - D o ng m au rai rac long m ach III D I^U TRI D ieu trj ch u n g - N hin an: benh nhan khon g an uong cho to i trieu c h u n g dau giam , soi bung tro lai - D a t ong th o n g ta trang, hut dich, lu u ong th o n g cho den benh nhan d o non, giam tru o n g bung - C h am soc th e o doi ch a t cac ch i so song, bao hoa oxy, neu co cac dau hieu n u a c tieu it roi loan huyet dong, giam bao hoa oxy m au chuye n d a n vi dieu tri tic h c u c - N uoi d u a n g qua d u a n g tin h m ach: benh nhan d u a c tru ye n qua d u a n g tin h m ach de dam bao flu n u a c , dien giai va nang lu a n g (cac dung dich m uoi, d u a n g , cac acid am in, ) Toe truyen dich th u o c vao tin h tran g benh nhan, neu benh nhan co bieu hien tu t ap thi tru y e n toe nhanh den dam bao d u a c huye t dong on dinh, tri toe truye n -5 0 m l/g ia D a t ong th o n g ta trang cho thirc £n xuon g ruot non cho ket qua khon g kem nuoi d u a n g d u a n g tTnh m ach - G iam dau: dung cac th u o c giam dau th e o d u a n g tTnh m ach s u dung th e o cu n g bac tu paracetamol doi v a i cac tru a n g h a p dau nhe va v u a , v a i cac tru a n g h a p d un g cac th u o c g iam dau thong thuang khon g d a thi co th e dung m orphine - Kiem soat cac roi loan ch uye n hoa: kiem soat chat d u a n g m au g iup s a m cai th ie n trieu chung lam sang, cung n h u han che cac bien c h u n g cua V T C , calci huye t g ia m la m o t tro n g yeu to lam nang benh nhien phai bu calci tu tu , tang trig lyce rid co the la hau qua h oa c n g u ye n nhan cua VTC nen dinh lu a n g lai va dieu chinh V T C on dinh, tru a n g h a p trig lyce rid ta n g q u a cao co the tien hanh lpc huye t tu a n g - K hang sinh: tron g tru a n g h a p V T C nhe khong co chi djnh d un g khan g sinh, nhien cac ca V T C nang dac biet la tru a n g h a p V T C hoai tu co ngu y c a nhiem kh u a n phoi, d u a n g nieu thi co chi dinh khan g sinh nen chpn cac khang sinh tham nhap vao to c h u c tu y to t n h u m etronidazo l, quinolon, ce p h a lo sp o rin the he 3, im ip enem - C a c thuoc: giam tie t acid dich vi - CT, M RI hoa c E U S xac djnh nguyen nhan soi m at, cac bien c h u n g tai ch o de co the tien hanh lam E R C P giai qu ye t n gu yen nhan gay V T C cap cu u D idu trj viem tu y c i p nang (tai d a n vj dieu trj tich c u c : IC U ) - B enh nhan co bieu hien: giam oxy m au, tu t huyet ap khon g d a p u n g v a i truye n d ic h , suy than (cre a tin in m au > 17 m m o l/l) benh nhan can d u a c ch u ye n den ICU - M ot so dau hieu co the ngu y c a dien bien nang can ch uye n ICU: b e o phi BM I > 30 vo nieu lucmg n u a c tieu < m l/g ia , nhjp tim nhanh > 120ck/phut, co dau hieu ve b en h nao, ta n g lieu thuoc giam Sau - T ICU co the ho tra nhieu p h u a n g dien: ho tra tim m ach, ho hap, tieu hoa, ngoai khoa Boi phu dich m u c toi u u, th e o doi pha t hien s a m bien doi dau hieu suy tang N ang huye t ap; suy ho hap: dat noi quan, th a m ay; suy than: loc m au - P hau thuat: ch i dinh a benh nhan V T C hoai tu co nhiem khua n, p u th u a t nen d u a c chi dmh sam V T C hoai tu co nghi n g a nhiem khuan nhien ti le t u v o n g cao H u O n g d A n c h A n o o A n v A d i£ u tr i b £ n h N O i k h o a 491 D ie u trj viem tu y c i p hoai tip nhiem khuan - C h p c hut o hoai t u d u a i h u a n g dan sieu am hoac CT: lay benh pha m nhuom G ram va nuoi cay Sau co ket q u a xac dinh c h ic chan o hoai tu- nhiem khua n d ieu tri khan g sinh: + G m (-): ca rb ip e n e m , flu o ro q u in o lo n + m etronidazo l, ce p h a lo sp o rin + m etronidazo l + G m (+): v a n co m ycin dieu tri khang sinh dai tuan - X u tri o h oa i tu nh ie m khuan: phau th u a t lay o hoai tu + dan lu u hoa c dat dan lu u o hoai tu qua da d u a i h u a n g dan sie u am , CT D ieu trj v ie m tu y c i p co o hoai t u vo k h u in - T h a i diem 2-3 tu a n dau - C a c bien phap p h iu th u a t, dan lu u qua da, dan lu u qua noi soi, neu tru a n g h o p co ong tu y can phau th u a t hoa c qua noi soi can thiep D ieu trj th e o n g u y e n nhan D inh h u a n g d u g c n g u ye n nhan vie m cap giup cho bac sT co m ot pha c dieu tri dung va phong tranh d u g c tai phat - V T C soi, giun ong m a t chu: E R C P tien hanh s a m m a c a O ddi, lay soi, phau thuat neu ER C P that bai - T ru a n g h g p nghi n g a V T C giun chui ong m at chu ch o benh nhan ta y giun dua s a m b in g thuoc Fugacar, Z en tel, t A i l ie u t h a m k h A o D avid C, W h itc o m b (2006) “A cu te p a n c re a titis ” V o lum e 354; 214 -2 P e te B a n k s , M a rtin L, F reem an et al (2006) “P ctice g u id e lin e in a cu te p a n c re a titis ” A m J g a stro e n te ro lo g y; 101: 237 -2 0 Tad ata ka Y a m a d a et al (2009) “Textbook o f g a stro e n te ro lo g y" A c u te pa n cre a titis V olum e 2; 1761-1810 VIEM TUY MAN TINH • • I O Al C U m iG V iem tu y m an tin h la tin h tran g c h u c nang tu y bi suy giam keo dai ton th u ’a n g nhu m d hay ong II chAn An Lam san g D a u bung vung thu’a n g vi lan sau lu n g la trieu chu’ng thu’a n g gap D a u a cac mi>c dp Thiromg dau nhieu, dau tang len an vay phan nao lam benh nhan s o kho n g d a m an nhieu lam benh canh suy kiet nang len R oi loan tieu hoa thu’a n g gap: phan long co vang m a , so lu’a n g nhieu Suy kiet g iy sut can nhanh giai d oa n m uon co the xuat hien phu chi, tran dich cac m ang d o hoi chu’ng kem hap thu D au hieu xam lan de day vao ta tran g va cac tang lan can dan den cac trie u ch u ’ng: non va buon non, hoi chu-ng tang ap ly c tin h m ach ci>a, vang da t i c m at C an lam san g T ham cht>c nang tu y ngoai tie t bi roi loan, m ot so tru’a n g h o p co ca roi loan c h u c nSng npi tiet Xet nghiem danh gia tin h tra n g dinh du’a n g ; protid huyet th a n h thu’a n g giam , d a c biet album in huyet Phan m a: lu p n g m a tro n g phan chiem > 10% tron g lu p n g phan D o lu p n g n ita tron g phan Lam ngh iem phap p a n creo zym in X e t ngh iem calci m au th u ’a n g giam Bilan m a m au th u ’a n g bien loan tang ch o le ste ro l va trig lyce rid A m yla se va lip a se th u ’a n g b inh thu’a n g it tang D u ’a n g m au tang, H b A c tang th u ’a n g kem v a i tieu du’a n g typ C han doan hin h anh: - C h y p b yn g khong chua n bj tim hinh anh can quang vung - S ieu am va c h y p c i t la p vi tin h xac djnh h inh thai co nho, nhu m o tu y khon g dong nhat, ong hep hay gian, nhieu not ca lci hoa tuy, nang gia - S ieu am noi soi: xac djnh h inh thai nhu m o thu’a n g khon g deu co cac ton th u ’a n g o hoai tir 6ng hep gian xen ke nhau, b a m ap m o khong deu - C h up M RI xac djnh ton th u ’a n g nhu m d va ong C h an d o an n g u yen nhan - Rupu - S au vie m tu y cap - Soi - T yy phan doi - Roi loan ch u ye n hoa th ie u hut a1 a ntitrypsin - S uy dinh du’O’ng - B enh nha y n t - C at doan da day - V ie m ty y m an tin h t y m ien H u 0 ng/m l va hinh anh HC C d ien h in h tre n ch u p C LV T thi tu a n g doi c h ic c h in N eu A F P tang it hoac hinh anh tren C LVT khong dien h in h th i can lam them cac p h u a n g phap chan d oa n hinh anh khac n h u M RI, X ac djnh u gan tre n gan x a hay gan lanh - K hoang 70% ung thu* gan pha t trien tren gan xo C h d c nang gan, vi tri, kich thu’d c khoi u la n hd ng yeu to ch in h de lu a ch o n phu’o n g phap dieu tri va tien lu a n g V i vay, can xac dinh m d c x o gan d bpnh nhan HC C - C han doan gan xo : + Lam sang: gan c d n g chac, b d du’d i sac Hoi c h d n g tang ap lu c tin h m ach c d a va hoi c h d n g suy te bao gan (xem bai “ X o g a n ’’) + X e t nghiem : a lb u m in m au giam , bilirubin m au tang, tieu cau giam TT le pro th ro m b in giam + Sieu am bung: h in h thai gan th a y doi, tang ap lu c tin h m ach cd a + Noi soi tieu hoa tren: g ian tTnh m ach th irc quan, tTnh m ach p h in h vj, m o sa iq u e than vj - C han doan giai d o a n x o gan: s d dung bang diem C h ild - Pugh C h an d o a n phan biet a A p x e g an : th ird n g gan to va dau, co diem dau choi, co hoi c h d n g nhiem trung C hoc hut o giam am co mu b U n g th ir g a n thip p h a t: th u d n g th d p h a t sau ung th u ong tie u hoa, ung th u phe quan va ung th u vu, T h u d n g xuat hien tre n gan lanh K hong co trieu c h d n g cua viem gan m an C o trieu c h d n g cua c o quan dich sieu am th u d n g co nhieu khoi tro n g gan co hinh anh “ m it tra u ” trung tam tang am xu n g q u a n h co vien giam am A F P khong tang c U g a n la n h tin h n h ir c a c tan g sa n n o t v u n g (fo c a l n o d u la r h y p e rp la s ia ), adenom , u m au tro n g g a n : th u d n g tre n nen gan b inh th u d n g Khong co cac trieu c h d n g c o nang va th u c the C hup CLVT va M RI khon g co d a c diem cua HCC T rong tru d n g h o p nghi n g d u m au tron g gan, chup S P E C T gan v d i 99mTc gan hong cau tu than co gia trj chan doan xac d jnh u m ach m au gan co kich th u d c > 1,5cm d C a c u g a n k h d n g p h a i b ieu m o te bao gan : ung th u bieu m o te bao d u d n g m at, u te bao Kuffer, sarcom te bao Kuffer, sa rco m x o soi, sarcom m d, osa rco m c o tro n , D e phan biet can djn h lu o n g aF P va sinh th ie t gan hoac te bao hpc g iup chan doan xac dinh IV D ^ U TRj C a c p h u ’o n g p h a p dieu trj a D ie u trj n g o a i k h o a - P hau th u a t c i t gan: c i t nhan ung th u , c i t gan han che, c i t phan thuy, m ot th u y gan C h i dinh: + K hoi u nho < 5cm p u th u a t u u tien cho khoi u < 3cm tre n gan lanh, dac biet d gan trai + C h d c nang gan tot: tre n gan lanh hoac x o gan d giai d oa n C h ild -p u g h A H uong 556 d A n c h A n d o An v A d i £u tri b£ n h N O i k h o a + C h u a co di can - P hau th u a t t h lt d on g m ach gan: chi dir]h cho n h u n g tru d n g h g p ch a y m au v d nhan ung thir Trong ung th u gan nhieu khoi thi ket qua rat-Jian che - P hau th u a t g he p gan: H C C tren nen vie m gan m an tinh b Tiem c o n tu y e t d o i (P E I), a c id a ce tic vao k h o i u - C h i dinh: khoi u nho < 5cm , dac biet khoi < 3cm a benh nhan khon g th e phau thuat - Tien hanh tie m tu y e t doi vao khoi giOa khoi u d u a i h u a n g d in cu a sieu am L u a n g so lan tiem th u d c va o k ic h th u a c khoi u - L u a n g m oi lan tiem th u a n g tu 2-10m l Tong lu a n g d u a c tin h th e o cong th u c: V ( m l) = /3 x t t (Y + )3 Trong 50 tuoi + T a o bon m o i x u a t hien + S ut can + T hieu m au + C h a y m au qua hau m on - Tre em : hau het ta o bon co tin h chat c h u c nang c h u khon g phai la ton th u o n g th u c the Khi dieu tri that bai, tao bon lau dai th a n h dau hieu nguy c o cao H irsch u sp ru n g la benh th u o n g gap o tre em Tao bon o tre em co th e ket h o p v o i cac nguyen nhan dac biet n h u tap di ve sinh c u o n g b uc, bo m e can thiep qua nhieu va c h u n g s o toilet X e t n g h iem C hup khun g dai tra n g va noi soi dai tran g loai tru ta c nghen: gian dai tran g, dai tran g sigm a dai Test danh gia c h u c nang dai trang: van dong tru e trang D ie n c o , toe van chuye n phan Sinh th ie t niem m ac tru e trang T h a i gian nhu d on g dai trang: ch a t danh dau C hup tru e tran g ran: g o c ong hau m on va bong tru e tran g < 90°, n g u o i b in h th u o n g goc ong hau m on va bong tru e tra n g v u o n g goc M ot so xe t n g h ie m m au: calci, dien giai do, F T4 va TS H C h up C T tieu khung C h up M RI tie u kh u n g loai tr u ngu yen nhan tao bon u, long ruot, t i c ruot, sa sinh due Tom lai: - C an ch a n d o a n hai lo n g u ye n nhan ta o bon: ta o bon th u c th e a dai tra n g va n go dai tran g (u dai tran g, u nao, m a n g n a o ) lai la ta o bon th u phat, ta o bon trie u c h u n g ; ta o bon khon g ton th u a n g th u c th e (h o i c h u n g ruot kich th ic h ch a t x o , th ie u K ) goi la ta o bon tie n phat, tao bon c h u c nan g - V e vj tri ta o bon: ta o bon phan, phan bj u dpng lau o tru e trang III D I^ U TR| D ie u trj ta o bon la d ieu trj trieu c h u n g T ru o n g h o p tim d u o c n g u ye n n n phai giai qu ye t nguyen nhan ta o bon (khoi u, sa tru e tran g, suy gi£p, tang calci m au, ) H an ch e d un g th u o c nhuan tran g keo dai m& nen d u n g n g lt q u a ng D o i can phai dieu trj keo dai va y m u c tieu dau tien tron g dieu trj la thay doi each so n g lau dai m a i co the g iup th a y doi cau true phan va so lan dai tien C h e an n hieu ch a t xo , nhieu hoa qua, uong nhieu n u o c T h a y doi th o i q u e n sin h hoat: di cau va o dung g ia T a p th e due, n an g va n dong • C a c nho m th u o c d ieu trj ta o bon: 562 H uong d An ch An oo An v A d i £u tri b £n h N oi k h o a - N huan tran g ta n g ta o khoi lu a n g phan: psyllium , p o lyca rb o p h il, m e th ylce llu lo se C h i dung khong co the tang khau phan chat x a tron g b u a an T ac dung g iu n u a c lai lam tcing khoi lu a n g p h in Thuoc co the gay day h a i va tru a n g bung n h u n g kha an toan dung lau dai C h u y d u y nhat la can cung cap n u a c day du - N hom boi tra n : dau - N huan tra n g kich th ich : ta c dung b in g cach kich th ic h tru e tie p v a o he th o n g than kinh dai trang T ac dung th u a n g xay tro n g vong - gia, vien dat ta c d un g nha nh h a n - phut D ung keo dai nhom khon g nen vi co ngu y c a ung th u + T ac dong tre n be m at: ducu sat, acid m at + Dan xuat d ip h e n y lm e th a n : phe n o lp h ta le in , bisacodyl, p ic o su lfa t m uoi - R icin o le ic acid: + A n th q u in o n : S ena, ca sca sagrada, aloe, rhubard - N huan tran g th a m thau: m uoi m agnesi va ph o sp h a t - g /n g a y ta c d un g nhanh co nguy ca tieu chay, d u a n g la ctu lo se 20 - 40g/ngay, S o rbito l 10 - 20g/ngay, p o lye th yle n g lyco l T a c dung g iu n u a c lai th e o c a che th a m thau - G lyce rin dat hau m on: + Ion m agnesi, dong, ca lci giup tang c u a n g van dong ong tieu hoa: P a n a n g in vien/ngay • K huyen cao dung th u o c nhuan trang: - D ung ngat q ua ng khon g nen dung keo dai - N hom th u o c nhuan tra n g kich th ich nen han che vi nguy c a g a y benh dai tran g den - N en dung luan p hien cac th u o c nhuan trang C hu y: can phan biet ta o bon nguyen phat, ta o bon tan T a o bon n g u ye n p h £ t dieu tri tao bon b in g th u o c co th e co ta c dung T a o bon tan th u a n g gap a n g u a i gia, n im lau, roi loan van dong san ch3u dieu tri noi khoa it hieu q u a doi can chi dinh ngoai khoa IV k £t lu a n Ket qua dieu trj ta o bon r i t han che C a c giai phap hien d an g ap d u n g nen dung luan phien tranh c&c bien c h u n g G iai p p dieu tri h u a hen nhieu th a n h cong la nho m th u o c u c che chon Iq c receptor 5H T4 Ket qua dieu tri th a n h cong n h it la lieu phap ta m ly va g iup b en h nhan th a y doi thoi quen sinh hoat, che an th a y doi so lu g n g nhieu len va tang lu g n g c h it x a tro n g khau p h in an t A i l ie u t h a m k h A o M a rk F e ld m a n et all "G a stro in te s tin a l a n d liv e r d ie a se - P a th o lo g y/d ia g n o sis/m a n a g e m e n f S a u d e rs E lsevier, 8th edition C H a s le tt et all “D a v is o n - m e d e cin e in te rn e P rin c ip e s e t p tiq u e , 19 erne edition" Malome LAO MANGBUNG i d a i c ir a N G Lao m ang bung la b en h lao ngoai phoi th u o n g gap Lao m ang bung th u ’d n g lao th u phat sau lao phan phu hay lao tieu hoa ii ch An o o An Lam san g Sot: th u o n g sot ve chieu, co th e sot cao 39°C - 40°C hoa c sot nhe tu 37,5°C - 38°C , sot keo dai A n uong kem , chan an, day bung, kho tieu M et m oi, gay sut • K ham lam sang: - K ham bung p h a t hien co co tru o n g , khong co tuan hoan bang he, khon g co gan to, lach to Co tru o n g m u c dp v u a , it co tru o n g nhieu, co tru o n g tu Lao the ba dau: hoa: b un g co tru d n g it hay nhieu D oi gap co tru d n g khu tru K ham bung co the thay n h u n g m ang ch ac, m em xen ke khap bung C o the ta o th a n h cac m ang c h ic ld n de nham v d i khoi u bgng Lao the x o hoa: to c h u c x o pha t trien nhieu k h ip bung: lam sang co dau hieu ban t i c ruot bung c h u o n g dau, cang c u n g kho kham , trun g tien d u o c thi d d dau N ang co the co dau hieu t i c ruot dau bung, tru d n g h o i, bi tru n g dai tien - K ham cac bo phan kh a c de tim ton th u o n g lao phoi hop: co the co hach to, co the co tran dich m ang phoi, co the co tra n d ich m ang tim , co tru d n g h o p bi day m ang ngoai tim , lao ruot co roi loan phan npi soi thay ton th u o n g lao d m anh trang, hoi trang C an lam san g - Soi o bung va sinh th ie t la p h u o n g phap chan doan quye t dinh H inh anh soi bung: ph u c m ac th a n h va tang vie m sung hu ye t C a c hat nho m au t r in g nga tren phuc m ac th£nh, m a c noi va th a n h m ac cua rupt C o th e thay cac s o i vie m fib rin d in h n h u to nhen, d inh cac quai ruot hay m a c noi v d i phu c m ac bung - Sinh th ie t m ang b un g va o cac ton th u o n g dang hat tren p hu c m ac va m ac noi tim b in g c h u n g nang lao tren m o benh hpc N ang lao dien h inh gom vung: g iu a la c h it hoai t u ba dau vi k h u in lao, tiep theo la Idp te bao ban lien, te bao lym ph o va te bao khon g lo L a n g h a n s , Idp n go cung la to c h u c xo M anh sinh th ie t d u o c lam phan u n g P C R tim vi khua n lao nuoi cay m anh sinh th ie t d m oi tru d n g truye n th o n g L o e v in s te in h oa c neu co dieu kien nuoi c ly MGIT - C h u p phoi co th e t h iy h inh anh ton th u o n g lao, ton th u o n g d inh phoi, tra n dich m ang phoi - C o ng th u c m au: b a ch c iu tang, chu yeu tang dong lym ph o, toe m au lin g tang H u O n g dA n c h A n o o A n vA biCu t r i bEnh 564 NOi khoa - X et nghiem dich co tru’d n g (khi co tran d|ch m ang phoi can xe t n g h ie m ca dich m ang phoi): dich cac m ang la dich tiet, pro te in tro n g dich tren 25g/l - C o the tim th a y vi khua n lao dich co tru’d n g : b ln g phan d n g PC R - P han d n g M a n to u x (+) Tuy nhien, neu M antoux am tin h thi van khon g du’a c loai trd benh lao Phan d n g it gia tri chan d oa n lao d n g u d i Idn - X e t n gh iem danh gia to a n tran g benh nhan: protid m au, a lbum in, cre a tin in , tra n sa m in a se C han doan xac dinh b ln g : P C R du’a n g tin h v d i vi khua n lao, m o benh hpc tim t h iy nang lao nuoi c ly co vi k h u ln III D ltU TR| P h an loai th u d c a C ac th u o c d ie u tri la o du’O’c c h ia la m n h o m : N hom 1: th u o c uong: iso nia zid, rifam picin, eth a m - butol, pyra zin a m id N hom 2: th u o c tiem : ka n a m ycin , am ika cin, ca p reom ycin, stre p to m icin N hom 3: flu o ro q u in o lo n : le vo flo xa ccin , m oxiflo xacin, ofloxa cin N hom 4: thuoc uong diet k h u in : paraam in osalicylic acid, cycloserin, ferizid on, ethionam id, protionamid N hom 5: cac th u o c c in can n h ic co the lu a chon dieu tri vi khua n la o khan g th u o c clofazinin, linezolid, a m o xilin /cla vu lin ic, im ip enem , th io a ce ta zo n , c la rith ro m ycin , iso n ia zid lieu cao 16-20m g/kg C ach phan loai khac: th u o c dieu tri lao d u o c chia lam nho m th u o c die t k h u in va th u o c kim khuan N hom th u o c d ie t khuan: strep tom ycin, isoniazid, pyra zin a m id , le vo flo xa cin , kana m ycin N hom th u o c kim k h u ln : rifam p icin, etham butol B a n g C a c n h d m th u o c th u ’d’n g d u n g Hang lan/tuan Lieu mg/kg khoang cach lieu Lieu toi da/ngay Lieu mg/kg Ueu toi da/ngay (4 -6 ) 300 (8-12) 900 Rifampicin R 0(8-12) 600 10(8-12) 600 Pyrazinamid Z 25 (20-30) - 35 (30-40) - Ethambutol E 15(15-20) - (2 -3 ) - Streptomycin S 15(12-18) - 5(12-18) 1000 Isoniazid H C ach d u n g th u d c B enh nhan lao m d i pha t hien dieu tri lin dau: H R ZE t i n cong th a n g , sau tri tiep b ln g HR thang H o ac H R Z E thang, sau tri thang HE T h e o doi dieu trj: cac th u o c dieu trj lao co nhieu bien c h d n g va y ch i nen chi djnh co b ln g c h d n g nhiem lao Lao khan g thuoc, lao tai phat: th d i gian dieu tri keo dai th a n g C o th e lu a chgn cac nhdm thu6c dieu trj lao kha n g thuoc a Is o n ia z id : th u o c die t khuan T h u o c co ta c dung diet kh u a n tot, co th e d un g keo dai C h o n g ch i djnh hau nhu' khon g co T a c dung phu: vie m gan d m at, dau bung, m et, n g d a , bong da ban ta y va ban chan H u o n g dAn ch A n d o A n vA oiEu t r i bEnh N O i k h o a 565 b R ifa m p ic in : th u o c kim khuan C h o n g ch i dinh m an cam thuoc T a c dung phu: soc, suy than cap, viem gan nhiem doc, n u ’O’C tieu do, hoi chu’ng gia cum c P ira z in a m id : tac dung diet vi khuan lao chi nen ch i dinh tron g thang dau C hong ch i djnh: m ln cam v o i thuoc, benh gan tien trien nha t la th e vang da i> m at, dai porphyrin T ac dung phu: dau bung, m ay day, dau kh o p , dau co Khi xuat hien cac dau hieu cua ta c dung phu va chon g c h i djnh can th e o doi sat, nhat la xuat hien cac dau hieu nhu1vang da, dai Neu tien trien trien nang can d u n g thuoc N eu nhe co the giam lieu thuoc xuong ng a y/tu a n hoa c giam v o i lieu 500 -750m g/ngay d E th a m b u to l: th u o c co kha nang kim khuan, th u o c co nhieu doc tin h nhat la v o i than va m it C hong ch i d jn h /ta c dung phu: m in cam v o i thuoc, roi loan thj lu c Than tron g dung cho phu n u co thai, dac biet tron g thang dau khon g nen chi djnh vi rat kho kiem soat doc tinh Khi dung can kham m it, thj ly c tru o c dieu trj C an tin h th a n h th a i cre a tin in D o thai cre a tin in < m l/p h u t la co suy than neu xu h u o n g tang len dieu trj hay d o th a n h thai creatinin < 30 m l/p h u t co th e th a y doi dung lieu ngay/tuan Neu van tang len nen d u n g th u o c N eu co cac lu a chon khac khong nen chi djnh o benh nhan suy than e S tr e p to m ic in : th u o c co ta c dung diet khuan: C hong ch i d jn h /ta c dung phg: m an cam , diec, dau co , co thai C an kham th in h lu c ch o benh nhan tru o c dieu tri H an che lieu dung ch o b en h nhan > 60 tuoi nen giam lieu 10m g/kg/ngay B enh nhan < 50kg lieu 500-750m g/ngay T ru o n g h o p n hiem lao xay o benh nhan H IV (+): dieu trj n h u ph a c dieu trj lao tien trien, dieu trj cung co keo dai - th a n g G iai doan A ID S dieu trj d u phong th e m c o trim o xa zo l n h im d u phong nhiem P n e u m o cystis phoi h o p v o i th u o c diet virus ART D ie u trj b i§ n c h u n g - T ic ruot: p h iu th u a t g o d in h , c i t cac doan ruot hoai tu - Lao tien trien cac ta n g khac lao phoi, lao hach, lao cac m ang khac dieu trj n h u phac dieu trj lao - thang - Lao m ang tim co bien c h u n g day d in h m ang tim (P ick) m o boc tach m a n g tim - Lao ruot: ket h o p nh o m q u in o lo n uong neu ton th u o n g nhieu - V iem gan n hiem dpc th u o c co the nhieu loai th u o c hay m ot loai th uoc T im kiem loai thuoc gay doc v o i gan b ln g ch a n d oa n loai tru C o the th a y doi pha c dieu trj C a c pha c co the ap dung: + H R thang + H R S E thang, sau th a n g tiep HR + R Z E - thang + H E S th a n g tie p th e o 10 th a n g HE V iem gan nh ie m d o c nhieu loai th u o c dieu trj lao co th e ap dung ph a c 18-24 thang: strep tom ycin, e th a m butpl, flu o ro q u in o lo n D ie u trj ket h o p : lao m a n g bung can b o m h o i dac biet oxy vao m a n g bung g iup han che lao t iin trien C o th e dung co rtic o id lieu t h lp de chon g d in h n h lt la v o i th e x o d inh D ie u trj ta n g c u o n g to a n tran g: bu dinh d u o n g , vita m in T ru y e n d jch g iai d oa n b en h nhan khong an d u o c 566 H U O N G D A N C H A N O O A N V A D l f U TRI B f N H NOl KHOA Theo doi dieu trj T heo doi hieu qua dieu tri: th e o doi cac dau hieu lam sang sot, m et m oi, ngon m ieng can nang dau hieu tai bung (khong dich, het dau) C ong thipc m au: so lu’o n g bach cau giam , toe m au lin g giam , lu’o n g dich co tru ’a n g giam IV PHONG BENH Khai bao ngu’o i m ac benh v a i tru n g ta m dieu tri lao C ach li benh nhan dang b| benh lao co kha nang lay nhiem , deo khau tran g tiep xuc v a i n g ira i xung quanh tAi lieu tham khAo W orld health o rg a n iza tio n "T reatm e nt o f tu b e rcu lo sis guideline s, F o u rth edition, 2010" Fedja A Rochling, R ow en K Z etfenm an "M anagem ent o f ascite, D m g s" Auckland: Sep 2009, Voi 69.lss13, pag 1739, 22p h o ic h l Tn g g a n t h A n • • Hoi c h d n g gan than (h e p a tic renal syntro m e - H R S) la tin h tran g suy than c h d c nang xay chu yeu benh nhan x o gan co tru 'd n g co suy gan rat nang, ngoai co the gap d suy gan cap hoac viem gan ru o u T in h trang suy g ia m c h d c nang than la hau qua cua su* roi loan c h d c nang tuan hoan va hoat dong qua m u’c cua he th a n kin h g iao cam va he re n in -an gio ten sin M ac du la ton th u ’o n g than c h d c nSng, hoi chu’ng gan th a n (H C G T ) lai co tien lu’o n g rat toi va dieu tri hieu qua nhat la ghep gan I CHAN DO AN XAC DIN H (th e o tieu chuan chan doan cua C au lac bo co tru ’d n g q uo c te) - H R S thu’d n g xay d benh nhan x o gan co co tru ’dng - N ong cre a tin in h u ye t th a n h > 133m cm ol/l (1 ,5m g/dl) - Khong giam nong c re a tin in huyet (giam du 'd i m d c 3 m cm o l/l) sau it nhat dieu trj bang d d n g th u o c lo i tie u va boi phu the tich tuan hoan b ln g album in, lieu kh uye n cao album in la g/kg can n a n g/n gay cho td i toi da 100g/ngay - Khong co tin h tra n g soc - Trong th d i g ian gan day ho a c hien tai khong s d dung cac th u o c doc v d i than - Khong co benh ly nhu m o than (bieu hien protein nieu > 0,5g/ngay, dai m au vi the (> 50 hong cau tren vi tru’d n g ) va h oa c co bat thu’d n g than tren sieu am ) II phAn LOAI HOI CHO'NG gan than - H C G T co typ H C G T typ dac tru n g b d i tin h tran g suy than tien trien nha nh, n g h ia la tang gap doi nong dg cre a tin in hu ye t th a n h ban dau len m d c tre n 2 m cm o l/l tro n g vo n g tuan H C G T typ c6 the xuat hien tu phat, nhu’ng th u ’d n g sau cac yeu to th u c day, dac biet la nhiem trun g dich co tru’d ng H C G T typ d a c tru ’ng b d i tin h trang suy than tien trien d m d c tru n g b in h , nong creatinin huyet td 133 - 2 m cm o l/l, th u d n g tien trien t y pha t nhu'ng cung co the xu a t hien sau cac yeu to thuc day H C G T typ dien h in h th u ’d n g kem co tru’d n g dai dang - Tien lu’o n g cua H C G T typ la rat nang Tien lu’o n g song cua b en h nhan H C G T typ thu’d n g n g ln hon benh nhan x o gan khon g co suy than nhu’ng to t h o n H C G T typ ill chAn An p h A n b ie t Do khon g co x e t n g h ie m dac hieu chan doan H C G T va benh nhan x o gan tien trien co the suy than c£c n g u ye n n n kh a c (suy than tru ’d c than giam th e tic h tu a n hoan, hoai t d ong than cap, ton thu’o n g th a n th u o c ho a c vie m cau than), de chan doan H C G T la phai loai trd du’o c suy than th d phat giam th e tic h tu a n hoan va benh ly tai than S u y th a n d o b e n h ly ta i th a n B enh nhan x o g a n cu n g co the kem th e o benh ly tai th a n gay suy than T rong tru 'd n g h o p nay, xet 568 H uong d An chAn d o An v A d i Eu t r i b En h NOi khoa nghiem nu’O’C tieu se co protein nieu, hong cau nieu, tru nieu S ieu am th a n se th a y cac bieu hien cua suy than m an n h u kich th u d c than teo nho, nhu m o tang am m at ranh g id i tu y vo S u y th a n c a p tru ’d c th a n - T in h tran g suy th a n cap m at dich qua du’O’ng tieu hoa (non hoa c ia chay), m at dich qua d ud ng tie t nieu dung lo i tieu qua m u’c phai du’O’c lu’u y Neu suy than thi> pha t giam the tic h tuan hoan c h u c nang than se cai th ie n nhanh chon g sau bu du the tic h tu a n hoan va giai qu ye t d irg e yeu t6 th u c day tin h tran g giam the tic h tuan hoan - S oc la tin h tran g th u o n g gap d benh nhan x o gan va co the gay suy th a n cap tru o c than, neu khong dieu tri tich c u e thi co th e dan den hoai tu ong than cap M ac du giam the tic h tu a n hoan xuat huyet tieu hoa th u o n g de nhan ra, soc nhiem khuan co the kho pha t hien vi trieu c h u n g nhiem trung d mot s6 benh nhan x o gan lai rat m o nhat H o n n u a tin h tran g giam huye t ap d on g m ach lai co the nham la benh gan tien trien M ot so benh nhan, vo nieu (do soc nhiem kh u a n ) lai la trie u c h u n g dau tien cua tinh trang nhiem trung, vi the co the bj chan doan nham HCGT T in h tran g suy th a n o’ n h u n g benh nhan n^y co the cai th ie n sau d un g khan g sinh hoac co th e tien trie n th a n h H C G T th u c su, ke ca nhiem trung d u o c khon g che H o a i ti> o n g th a n c a p N goai tin h tran g soc keo dai khong phuc hoi dan den hoai tu ong th a n cap, benh nhan x o gan co nguy c o tien trien suy than nang dung cac th u o c n h u cac th u o c giam dau ch o n g viem khong steroid, th u o c khan g sinh nho m a m in o g lyco sid B a n g C h a n d o a n p h a n b ie t c a c tin h tra n g s u y th a n O’ b e n h n h a n x o ’ g a n c o tru x m g Hdi chang gan than Suy than trtfdc than Hoai tiirong than cap 1 > 30