Nghiên cứu đặc điểm lâm sàng, cận lâm sàng ở bệnh nhân xơ gan có nhiễm trùng dịch màng bụng

B GIO DC V O TO B Y T TRNG I HC Y H NI ALOUNNY SISAYKEO NGHIÊN CứU ĐặC ĐIểM LÂM SàNG, CậN LÂM SàNG BệNH NHÂN XƠ GAN Có NHIễM TRùNG DịCH MàNG BụNG Chuyờn ngnh : Ni khoa Mó s : 60720140 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS TRN NGC NH H NI 2016 LI CM N Nhõn dp hon thnh lun tt nghip, tụi xin by t lũng bit n sõu sc, tụi xin chõn thnh cm n: - ng y, Ban giỏm hiu, Phũng sau i hc, B mụn Ni Trng i Hc Y H Ni - Ban Giỏm c Bnh vin Bch Mai, vin i Hc Y H Ni - Ban Ch nhim Khoa tiờu húa - Bnh vin Bch Mai, Khoa Ni tng hp Bnh vin i Hc Y H Ni - Cỏc thy cụ, bỏc s, iu dng viờn khoa tiờu húa - Bnh vin Bch Mai, khoa Ni tng hp Bnh vin i hc Y H Ni ó giỳp , to mi iu kin thun li cho tụi quỏ trỡnh hc v hon thnh lun Tụi xin by t lũng kớnh trng v bit n sõu sc nht ti: PGS.TS Trn Ngc nh, b mụn Ni tng hp, Trng khoa Ni tng hp Bnh vin i hc Y, ngi thy ó ht lũng ging dy, dỡu dt, trc tip hng dn, giỳp tụi sut quỏ trỡnh hc tp, nghiờn cu v hon thnh lun ny Tụi xin trõn trng cm n: GS.TS o Vn Long, ch tch hi ng, v cỏc thy cụ Hi ng khoa hc bo v v chm lun ó úng gúp nhiu ý kin quý bỏu cho tụi quỏ trỡnh hc v hon chnh lun tt nghip Cui cựng, tụi xin by t lũng bit n v kớnh trng sõu sc ti b m, tt c nhng ngi thõn gia ỡnh, cựng bn bố ng nghip ó ng viờn, chia s khú khn vi tụi sut quỏ trỡnh hc v quỏ trỡnh hon thnh lun Xin trõn trng cm n! H Ni, ngy 05 thỏng 12 nm 2016 ALOUNNY SISAYKEO LI CAM OAN Tụi l ALOUNNY SISAYKEO, cao hc khúa 23, trng i hc Y H Ni, chuyờn ngnh Ni khoa, xin cam oan õy l Lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Trn Ngc nh Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 05 thỏng 12 nm 2016 Ngi vit cam oan ALOUNNY SISAYKEO DANH MC VIT TT ALT: Alanin amino tranferase ALTT: p lc thm thu AST: Aspartat amino tranferase BCNTT: Bch cu a nhõn trung tớnh CRP: C-reactive protein DAAs: Direct acting antivirals DMB: Dch mng bng E.coli: Escherichia coli E.faecalis: Enterococcus faecalis HATT: Huyt ỏp tõm thu IL - 6: Interleukin IL - 8: Interleukin K Pneumoniae: Klebsiella pneumoniae LDH: Lactat dehydrogenase NO: Nitric oxide NTDMB: Nhim trựng dch mng bng SPB: Sponteneous bacterial peritonitis TNF-: Tumour necrosis factor (yu t hoi t u) XHTH: Xut huyt tiờu húa FP: Alpha fetoprotein MC LC DANH MC BNG DANH MC BIU T VN X gan l bnh thng gp nc ta v cỏc nc trờn th gii, vi t l chim hng u bnh lý v gan mt (khong 19%) [1] X gan cú rt nhiu nguyờn nhõn gõy nờn c bit l virus viờm gan B, C, D v ru ngoi cũn mt s nguyờn nhõn khỏc nh nhim khun, cỏc bnh lý chuyn húa di truyn, bnh lý ng mt, cỏc bnh t min, thuc v nhim c Theo B.S.Anand, khong gn 30-40% cỏc trng hp x gan phỏt hin c m t thi [2] T l t vong x gan cng rt cao, ti M c 100000 dõn cú 12 n 15 ngi cht v x gan [2] Vit Nam t l bnh nhõn x gan t vong ti bnh vin c tớnh khong 27,7% [3] Nhim trựng l mt nhng bin chng thng gp bnh nhõn x gan ú nhim trựng dch mng bng l bin chng nng cú th dn n cỏc t vong Nhim trựng dch mng bng c coi nh mt cỏc yu t phỏt ca hi chng gan-thn, hi chng nóo-gan, xut huyt tiờu húa mt khỏc nhim trựng dch mng bng cũn lm nng thờm trỡnh trng suy gim chc nng gan v thỳc y nhng t mt bự ca x gan Phn ln nguyờn nhõn gõy nhim trựng dch mng bng l t phỏt, khụng phỏt hin c ng vo ca vi khun a phn vi khun cú ngun gc t ng tiờu húa ca ngi bnh vi khun Gram õm, rt him gp vi khun k khớ [2], [4] Triu chng lõm sng nhiu khụng cú tớnh cht c hiu Chn oỏn xỏc nh nhim trựng dch mng bng hin da vo tiờu chun ca hip hi c trng quc t nm 2007: s lng bch cu a nhõn trung tớnh cú dch mng bng >250 TB/ml v cy tỡm thy vi khun dch mng bng [4], [5] Tuy nhiờn t l phỏt hin vi khun cú dch mng bng thng rt thp T nm 1987 trờn th gii ó cú nhiu ci 10 tin v phng phỏp cy dch mng bng, c bit l phng phỏp cy dch mng bng vo chai cy mỏu, cho t l phỏt hin vi khun cao hn v thi gian t cy cho n vi khun mc ngn hn Nu bnh nhõn x gan b nhim trựng dch mng bng c phỏt hin v iu tri kp thi, bnh nhõn hon ton cú th qua t nhim trựng dch mng bng mc dự t l tỏi phỏt sau ú khỏ cao v tiờn lng xa khụng tt Theo Moore KP chn oỏn sm v iu tr thớch hp t l t vong nhim trựng dch mng bng trc õy l 90% ó gim xung cũn 20% [6] Cỏc nghiờn cu v bin chng nhim khun dch mng bng bnh nhõn x gan ó c cp n ti Vit Nam, nhiờn cũn ớt tỏc gi nghiờn cu v ny Vỡ vy chỳng tụi tin hnh nghiờn cu ti: Nghiờn cu c im lõm sng, cn lõm sng bnh nhõn x gan cú nhim trựng dch mng bng nhm hai mc tiờu sau: c dim lõm sng bnh nhõn x gan cú nhim trựng dch mng bng c im cn lõm sng bnh nhõn x gan cú nhim trựng dch mng bng 65 nng v sc khỏng ca bnh nhõn x gan cng yu, theo nhiu tỏc gi - Bilirubin mỏu tng trờn 500 àmol/l thỡ him cú bnh nhõn no sng sút Bờn cnh protein mỏu thp, bilirulin ton phn mỏu cao, xut huyt tiờu húa cng l iu kin thun li cho NTDMB XHTH gp 31% bnh nhõn nghiờn cu, õy l biu hin u tiờn khin bnh nhõn phi vo vin Kt qu ny ca chỳng tụi cao hn ca tỏc gi Nguyn Th Chi XHTH bnh nhõn x gan ch yu l gión tnh mch thc qun ngoi cú th gión tnh mch phỡnh v, gim cỏc yu t ụng mỏu, bnh d dy xung huyt Theo ý kin ca nhiu tỏc gi, bnh nhõn x gan cú bin chng XHTH thng kốm theo cỏc bin chng khỏc nh hi chng nóo gan, NTDMB Khi bnh nhõn b XHTH, mỏu chy t thc qun hay d dy b ng lũng rut v c vi khun rut phõn hy thnh NH3 v tng tỏi hp thu NH3 vo mỏu lm tng thờm mc NH3 mỏu (õy l ng to NH3 ngoi sinh), t ú lm xut hin hi chng nóo gan, cú nhiu gi thuyt v c ch bnh sinh hi chng nóo gan nhng cho n c ch tng NH3 l ch yu, vỡ vy bnh nhõn x gan cú XHTH chỳng ta thng dựng Duphalac (Lactulose) iu tr tng o thi phõn v mỏu ng lũng rut t ú giỳp phũng nga hi chng nóo gan [9] Ngoi XHTH cng l iu kin thun li cho NTDMB, XHTH lm tng hin tng qỳa phỏt vi khun rut hn na li lm tng tớnh thm thnh rut phự n cỏc t bo ni mụ ng tiờu húa, hai iu ny úng vai trũ quan trng c ch bnh sinh ca NTDMB Trong thc t nghiờn cu ca chỳng tụi thy cú nhng trng hp bnh nhõn mi vo vin iu tr XHTH cha cú c trng hoc c trng mc ớt nhng sau ú c trng tng lờn rt nhanh v xut hin nhim trựng dch mng bng, ngc li nhim khun cng l iu kin thun li cho XHTH tỏi phỏt Do vy XHTH, bnh nhõn cn iu tr kp thi cỏc bin phỏp cm 66 mỏu cng nh iu tr d phũng cỏc bin chng nh hi chng nóo gan v NTDMB 67 KT LUN Qua nghiờn cu 42 bnh nhõn x gan cú nhim trựng dch mng bng chựng tụi nhn thy: c im lõm sng bnh nhõn x gan cú nhim trựng dch mng bng: - Cỏc triu chng lõm sng gi ý NTDMB nh St: 76,2%; au hay cng tc - bng: 71,4%; a lng: 47,6% Vng mt vng da: 78,6%; Hi chng nóo gan: 28,6%; Xut huyt tiờu húa: 31%; c trng va v nhiu: 92,9% c im cn lõm sng bnh nhõn x gan cú nhim trựng dch mng bng - Ri lon chc nng gan: 83,3% l x gan Child Pugh C, ú PT 50%: - 81%; Albumin 35 àmol/l: 88,1% V chc nng thn v in gii : creatinine 130àmol/l: 23,8%; Natri mỏu - 10G/l: 64,3%; Procalcitonin - >10ng/ml: 18,2% 28/42 BN (66,7%) cú s lng BCNTT DMB > 1000 t bo/àl S - lng BCNTT trung bỡnh DMB l 55717475 t bo/àl Nguyờn nhõn nhim khun DMB qua cy DMB khụng cao 5/42 BN (11,9%) cy cú vi khun ú 3/5 bnh nhõn cy vi khun Gram õm bao gm: E Coli(2/5), Klebsiella Pneumoniea (1/5), v 2/5 bnh nhõn cy vi khun Gram dng nh: Streptococcus Gordonii v Enterococcus.spp TI LIU THAM KHO Nguyn Khỏnh Trch, Phm Th Thu H (2000) X gan, Bnh hc ni II, Nh xut bn Y hc, Tr 180-189 Anand BS (1999) Cirrohosis of liver Western Journal Medicine, Vol 171, 110-115 Nguyn Xuõn Huyờn (2000) X gan, Bỏch khoa th bnh hc, III, Nh xut bn t in bỏch khoa,Tr 549-552 Gines Pere, Andres Cardenas,Arroyo Vicente,and Rode Juan (2004) Management of cirrhosis and ascite, NEJM, Vol 350 number 16,p:1646-1654 Navarro Victor J (1999) Spontaneous bacterial peritonitis, Current treatment optiún in gastroenterology Vol 2,P: 457-462 Moore KP and Aithal GP(2006) Guidelines on the management of ascites in cirrohosis, Gut; 55,P:1-12 o Vn Long (2012) X gan, Bnh hc Ni khoa, Nh xut bn Y hc, Tr.9-16 Hewish Paul(2006) Cirrhosis, Patient UK, WWW.patient.co.uk Blei Andres T,Cordoba Juan(2001) Hepatic encephalopathy, The American Journal of gastroenterology, Vol 96 No 7, 968-1976 10 Krige JEJ, Beckingham IJ (2001) Portal hypertension-2 Ascite, encephalopathy, and other condition, BMJ, Vol 322, P:416-418 11 Morre Kevin,Wilkinson Stephen and Williams Roger (2003) Ascites and renal dysfunction in liver disease, Hepatology and billiary, Vol Chapter 51, P:1346-1371 12 o Vn Long (2002) iu tr x gan, iu tr hc ni khoa, Nh xut bn y hc,Tr: 151-153 13 Gunnarsdottir SteingerdurAnna et al (2003) Small intestinal motility disturbances and bacterial overgrowth in patient with liver cirrhosis and portal hypertension, American Journal of Gastroenterogy, Vol 98 No 6, P:1362-1370 14 Runyon BA (1986) Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis Gastroenterology; 91:1343 15 Titú L, Rimola A, Ginốs P, et al (1988) Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors Hepatology; 8:27 16 Rimola A, Bory F, Teres J, et al (1985) Oral, nonabsorbable antibiotics prevent infection in cirrhotics with gastrointestinal hemorrhage Hepatology; 5:463 17 Conn Ho (1964) Spontaneous peritonitis and bacteremia in Laennecs chhosis caused by enteric organisms A relatively common but rarely recognized syndrome Ann Intern Med; 60:568 18 Gines Pere and Ortega Rolando (2005) Spontaneous bacterial peritonitis treatment and prophylaxis, Patient UK, WWW patient.co.uk 19 Runyon BA, Montano AA, Akriviadis EA, et al (1992) The serum ascites albumin gradient is superior to the exudatetransudate concept in the differential diagnosis of ascites Ann Intern Med; 117:215220 20 Rimola A, Gracia-Tsao G, Navasa M, et al (2000) Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document International Ascites Club J Hepatol; 32:142153 21 Runyon BA (2004) Practice Guidelines Committee, American Association for the Study of Liver Diseases (AASLD) Management of adult patients with ascites due to cirrhosis Hepatology; 39:841855 22 Moore KP, Wong F, Ginốs P, et al (2003) The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club Hepatology; 38: 258266 23 Bodadilla Miriam, Sifuentes Jose (1989) Improved method for bacteriological diagnosis of sponteneuos bacterial peritonitis, Journal of clinical microbiology, Vol 27 No 10, P: 2145-2147 24 Bird, G., et al (1992) "Activation of the classical complement pathway in spontaneous bacterial peritonitis." 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Journal of Postgraduate Medical Institute (PeshawarPakistan)18.4 (2011) 60 Butani RC, Shaffer RT, Szyjkowski RD, Weeks BE, Speights LG, Kadakia SC Use of Multistixđ leukocyte esterase dipstick testing for ascitic fluid infection [abstract] Gastroenterology.2000;118(Suppl):1089 61 Nguyn Th Tuyt (2006) Nghiờn cu c im lõm sng, cn lõm sng v bc u kho sỏt mt s yu t nguy c hi chng gan thn bnh nhõn x gan Lun bỏc s chuyờn khoa cp II, i hc Y H Ni 62 Exp Clin Transplant (2015) Factors affecting Mortality and Morbidity of patients with cirrhosis hospitalized for spontaneous bacterial peritonitis 13 suppl 3:131-6(ISSN:2146-8427) 63 Guevara Monica and Terra Carlos(2006) albumin administration in patients with cirrhosis and infection unrelated to spontaneous bacterial peritonitis clinical Trials, www.ClinicalTrails.gov 64 Barclay Laurine (2003) advances in spontaneous bacterial peritonitis Mescape medical News, www.Mescape.com 65 Hong Trng Thng, Nguyn Th Kiu Sng (2008), Ri lon natri, kali mỏu bnh nhõn x gan, gan mt Vit Nam,(5).24-31 66 El-Gendy NA, Tawfeek NA, Saleh RA, Radwan EE, Ahmad EE, Mohammed RA Diagnosis of spontaneous bacterial peritonitis Egypt J Intern Med 2014;26:53-9 67 Jino Thomas, Sunil Kumar Kandiyil, Varghese Thomas Serum Creactive protein: A simple noninvasive marker for the diagnosis and treatment response assessment in spontaneous bacterial peritonitis Journal of Clinical and Experimental Hepatology, Vol 3, Issue 1, S90 Published in issue: March 2013 68 Garcia Nelson Jr, Sanyal Arun J(2001) Minimizing ascites, Postgraduate Medicine,Vol 109 No 2, P: 91-103 69 Gomez-Jimenez J et al (1993) Randomizes trial comparing ceftriaxone with cefonicid for treatment of spontaneous bacterial peritonitis in cirrhotic patients, Antimicrobal agents and chemotherapy, P: 1587-1592 70 Bhuva M, Ganger D, Jensen D Spontaneous bacterial peritonitis: an update on evaluation, management, and prevention Am J Med 1994; 97: 16975 71 Kerr DNS, Pearson DT, Read AE Infection of ascitic fluid in patients with hepatic cirrhosis Gut 1963; 4: 3948 72 Schwabl, Philipp, et al "Risk factors for development of spontaneous bacterial peritonitis and subsequent mortality in cirrhotic patients with ascites." Liver International 35.9 (2015): 2121-2128 73 Phan Th Thu Anh (2002) Sinh lý bnh chc nng gan, Sinh lý bnh hc, Nh xut bn y hc, Tr:372-391 74 Nguyn Th Võn Hng (2012) Bnh gan ru Bnh ni khoa 2, nh xut bn y hc, 79-86 PH LC BNH N MU Hnh chớnh: H tờn: Mó bnh ỏn: Tui: Gii: Ngy vo vin: Ngy vin: Lý vo vin: Tỡnh trng vin: Chuyờn mụn: 2.1 Bnh s: 2.2 Tin s: Cú Khụng Nghin ru Viờm gan Bnh khỏc Ung thuc nam 2.3 Lõm sng Triu chng Mt mi Hong m a lng St au bng XH di da Mc c trng: Cú S ln ớt Hi chng nóo gan (giai on): Huyt ỏp: M: Marker virus: HBsAg Triu chng XHTH Phự Lỏch to Gan to Thiu mỏu Lit rut Va Anti HcV Cú Nhiu ụng mỏu c bn: Nc tiu 10 thụng s: 2.4 Cn lõm sng: 2.4.1 Xột nghim mỏu T l prothrombin Hng cu Hemoglobin Bch cu Bch cu NTT Tiu cu Ure Creatinin Glucose Billirubin TP Billirubin TT Billirubin GT Protein Albumin Natri Kali Clo AST ALT GGT LDH FP CRP Procalcitonin 2.4.2 Xột nghim dch: Mu sc Albumin Protid LDH Rivalta Hng cu Bch cu Bch cu NTT Cy dch mng bng Tờn vi khun Nc tiu (V= Cy mỏu Tờn vi khun Tờn vi khun ) Bch cu Na+ Hụng cu K+ Nitrit C1- Protein Ure Cy Creatinin Dng tớnh m tớnh 2.4.3 Chn oỏn hỡnh nh: XQ phi: Siờu õm bng Gan Lỏch Tnh mch ca Ni soi d dy tỏ trng TMTQ TM phỡnh v Khỏc Chn oỏn xỏc nh: x gan Child Pugh A B C Bin chng Nhim trựng dch mng bng Bin chng gan thn Bin chng nóo gan Bin chng xut huyt tiờu húa Bin chng nhim khun ... hành nghiên cứu đề tài: Nghiên cứu đặc điểm lâm sàng, cận lâm sàng bệnh nhân xơ gan có nhiễm trùng dịch màng bụng nhằm hai mục tiêu sau: Đặc diểm lâm sàng bệnh nhân xơ gan có nhiễm trùng dịch màng. .. dân có 12 đến 15 người chết xơ gan [2] Ở Việt Nam tỷ lệ bệnh nhân xơ gan tử vong bệnh viện ước tính khoảng 27,7% [3] Nhiễm trùng biến chứng thường gặp bệnh nhân xơ gan nhiễm trùng dịch màng bụng. .. nhiễm trùng dịch màng bụng Đặc điểm cận lâm sàng bệnh nhân xơ gan có nhiễm trùng dịch màng bụng 11 CHƯƠNG TỔNG QUAN 1.1 Những vấn đề chung xơ gan Những phản ứng gan trước tác nhân xâm phạm khác