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

Preventing recurrent upper gastrointestinal bleedingin patients with Helicobacter pylori infection who are taking lowdoseaspirin or naproxen.. Differences in peptic ulcer [r]

MUC LUC Trang CHUONG r: BENH Lf DA DAY TH-I/C QUAN

2 BENH TRAO NGUqC DA DAY-THIJ C QUAN 6

4.LOeT DA DAy rA rneNc l8

s xuAr rruvgr rrEU HoA Do LoET DA DAy rA rRANG

6 C}IAN DOAN VA DIEU TRI N}ilE M HELICOBACTER PYLORI

cHtIoI{G 2: BpNH r,f c.lN MAT

7 BENH GAN RrIgU

r0 xuAT HLryET rrcu HoA cAo no rANc Ap r uc rixs MACH

65

69

I1 CI{AN POAN VE XU rNi XO GAN CO HQI C}il.]^NG GAN THAN

12 crrAN poAN vA Xu rnf xo cAN CO Wmpna rrruAx o ICH

MANG BTING

13 CHAN POAN VA )(U rNi XO GAN CO HQI CHI.]^NG NAO GAN 74

14 UNG THIJ grEu rrl0 rB BAo cAN 80

ts cHAx ooAr.r ve pmu rry sAu LA GAN 86

cHrIoNG 3: Bpt\H r,f o4I TRANG

137

z: prBu TRI TRi

1.1

24 VIEM LOET DAI TRUC TRANG CHAY MAU

25 BE.NI{ CROHN

26 IACHAY KEO DAI

zT.HercHLrNG RUer rics rnlcu

cHrIor'{G 4: BENH r,f rqv

28 VIEM T.LIY CAP

29 VrEM T.rrY MAN

CHI/ONG 1: BFNH Lf DA DAY TIII,/ C QUAN

CIITNG KH6 TITU CHTIC NANG

r DAr cr.IONG

Chung kh6 ti6u ld ch4m qu5trinh ti€u h6athrlc 6n t4i d4 ddy Chtng kh6tiOu bao g6m chimg kh6 tiCu thyc thiS vd chr?ng kh6 ti6u chfc ndng Chimg kh6ti6u thlrc th6 do c5c nguy€n nh6n gdy ra: Lo6t da dny t6 trang, bQnh li trdongugc da ddy thgc quin,ung thu dA day, bQnh li dudng m4t, bQnh tUy tpng, dothu6c, bQnh lf toan thdn vi thric nn Chimg kh6 ti6u chric ning kh6ng tim th6ynguy6n nh6n thyc thi5 Ti lg chrlng kh6 ti€u chrlc n6ng cing r6t kh6c nhau theotung nu6c: lJc 6,3%o, Nhat Ban 17-23%, Ch6u du l4-27% 8}t1h kh6ng gAy

nguy hi6m tl6n tinh mang, nhung 6nh hudng t6i ch6t luong cudc s.ing, xu6t

hiQn tirng tlqt e6y lo 16ng cho ngudi bQnh.

II CHANDOAN

1 Lim sing

- Dau bpng ho{c kh6 chiu virng thugng v!

- An nhanh no, lirm cho nguoi bQnh kh6ng the 6n h6t khiii luqng thtc6n binh thudmg vdn an dugc

- Cim gi5c tliy bgng sau khi in

- N6ng rrit virng thuqng v! nhrmg thulng kh6ng lan ra sau xuong tic

2 C$n I6m sing

Giirp loai trir c6c nguy€n nhdn thr;c th6 gdy biCu hiQn chung kh6 ti€u

- NQi soi thgc quan d4 ddy: loai trir 1o6t d4 diy t|tritng, trdo nguo c dp

ddy thyc quan c6 t6n thuong tr€n nQi soi, ung thu d? dey

- Do p.H thgc qu6n: phin bipt v6i bQnh ly trio ngugc d4 day thyc quan

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

- Si6u 6m vd c6c phucrng tiQn ch6n do6n hinh 6nh girip phAn biet benh ryduong m4t vd tgy t4ng

3 ChAn do6n xic dinh

a Ti0u chuin theo Rome II

- Eau bgng holc kh6 chiu t4i vtng byng tr€n

- TriQu chrlng kh6 chiu t4i vring bgng tr6n: tric bqng, dAy chu6ng hoi,

en nhanh no vd budn n6n

BO Y TE - HUdNG DAN C HAN DOAN VA DIEU Tzu Be.Nu rr6u uoe

J

-l Circ triQu chimg kh6ng gi6m sau khi cIi tlai tiqn.

- Thdi gian xu6t hiQn tri$u chimg: tOi ttri6u 12 tuAn vd xuSt hi€n trudc

dd 12 th6ng

- Kh6ng c6 benh thuc thi5 khi nQi soi

b.Ti6u chu6n theo Rome III

- C6 I hopc nhi6u tri6u chring sau:

+ DAy bUng sau khi 6n

+ An nhanh no

* Dau vtrng thugng vi

+ N6ng r6t vtng thucrng vi

- Kh6ng c6 bQnh t6n thucrng thyc thiS: n6i soi

- Thdi gian xuAt hiQn trieu chimg: t6i thitiu 3 th6ng, xuAt hign tOl tfrieutru6c d6 6 thang

4 Phin lo4i th6 bQnh

a Ti6u chu6n theo Rome II

- The gi6ng lo6t: dau tai vDng thuqng vi li triQu chimg nOi Uat

- The r6i lo4n vQn dQng

+ OAy bUng sau khi 6n, thudrng kh6ng 16 dau, c6 thri bu6n n6n

+ An nhanh no

- ThC kh6ng ddc hiQu: c6c tri6u chimg kh6ng cti6n hinh nhu hai th6 tr6n,c6 thti c6c triQu chimg xu6t hi6n 15n lQn gita2th6.

b Ti6u chu6n theo Rome III

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

+ C6 it nhAt mQt trong hai triQu chimg:

o XuAt hign kho chiu virng thuqng vi sau khi in v6i sd luqng binhthudng, vni lan /tuAn.

o An nhanh no, n6n kh6ng 5n dugc nhi6u nhu binh thudrng, vdi lfu/tuAn

+ Circ triQu chimg k6o dii trong 3 thang vi phii xu6t hi6n trudc ch6nclo6n tOi tfrieu 6 thang

+ c6c ti6u chuAn h5 trg: dAy bgng o vr.rng tron cria 6 bgng, bu6n n6n sau5n ho{c g hoi nhi6u C6 the cirng xu6t hi€n v6i thti dau virng thuong v!

- The dauvDngthuqngvi

+ fAt c6 biriu hiQn sau:

o Eau ho6c n6ng r5t khu trfituivirng thucr,ng vi, t6i thiriu I 16n /tuAn

o Kh6ng gi6m sau khi dai tiQn hoflc trung ti6n

o Kh6ng lan ra vung ngyc hodc virng bUng kh6c

BQYTE- HU6NG oAN cTTAN DoAN DIEU TRI BE NH TIEU HOA

-2-o phai loai trir dau do c6c nguyCn nh6n nhu

trii mpt vd rtii roan vpn itQng

co Oddi

+ cdc trigu chimg k6o ddi trong 3

th6ng vd ph6i xu6t hiQn tru6c ch6ndo6n tOi ttridu 6 thang

+ cdc ti€u chu6n h6 tro: n6ng vtng

thucr,ng vi nhmg kh6ng lan ra sauxuong fc, dau c6 th6 do 5n hodc giim di khi in nhung cfing c6 th6 dau khi d6i,c6 thti xu5t frign c6 thrl dAy bpng sau Ln.

5 Ch6n dodn phAn biQt

a Chring kh6 ti6u do nguyOn nh6n thr;c th6

- Lodt da ddy t6 trang: barrg nQi soi da dny t6 trang.

- Trdo ngugc dp ddy thgc qu6n: c6m gi6c n6ng

ran dgc sau xuong fc,n6i soi c6 thti thay t6n thuong ni€m mpc thgc qu6n Do p.H thpc qu6n cha th6yc6 triro ngugc

- Ung thu dp ddy: nQi soi

- BQnh ly cluorng m$t: si0u 6m vd ciic phuong tiQn ch6n do6n hinh 6nh

- Benh ly tuy t4ng: si6u dm vd cdcphuong tien cn6n do6n nirr, anr,

b HQi chring ruQt kfch thich

chfng kh6 ti6u chric n[ng c6 th6 bitiu hiQn tri6u chring ch6ng

chdov6i hQi chring ruQt kfch thfch HQi chring ruQt kfch thfch uie, "nie, ulng ,ailoan phdn: ia l6ng ho4c t6o b6n TriQu chimg dau bpng thudng gi6m khitrung tiQn ho4c clAi tiQn.

III DIEU TRI

1 Nguy6n tic

- chri yiiu ld iriau tri triQu chrrmg, ruy theo the benh drng ro.i thu6c kh6c

nhau

- Gi6m c6ng thEng stress

- Nguoi benh can nieu ducvc benh cria

minh vd t4o ldng tin cria b6nh

-2 Di6u tri cB th6

a' c6c thu5c tfu ch6 bai tidt a xit qua bom pnoton @roton pump inhibitor _

PPr)

c6c lo*i ppl nhu: esomepraz

ore 20 mgrngiry, rabeprazore 20 mg/ngiry,pantoprazole 40 mgrngiry, raruoprazore 30 igieii, omepmzo re 20mg st

dung c6c thu6c ppl c6 kic dpng

hm giem # ffi; chimg dau trong thti crau

-3-vtrngthugngvi,d{cbietlenhtngngudixu6thientriquchimgclaukhid6i'Thdl giandtng thuiSc php thuQc vdo triQu chimg cua bQnh'

b C6c thu6c vfn dQng dudmg ti6u h6a (prokinetic)

c6c thur5c vQn dQng duong ti6u h6a co t6c dung lam nhanh qu6 trinhr6ngcuadpddyth6ngqua:t6ngtruongln:tlthat,dudi'tinglirmr6ngdpddy'

t6ng nhu dQng cira t61rdng Do do d6 .o ta, dUng tot v6i tnc aay bung sau khi

6n.

c6c thuiSc str dpng: itopride 50 mg x 3 vi6n I ngiry' mosapride 5 mg x 3

vi6n / ngay, metoclopromidelg pg * I vi6n lng?y, domperidone.l0mg x 3

vi6r:/ngiy c6cffiffi; rl ,rra Jt

"a" t6c dpng

tt'ong mong muon nhu: roito4n nhip tim v6i eT dal ra; t[ng ii6, frofu.til6; tdi vir to' m6t kinh' ti6t sira;

bi6u hien ngo4i ;;' i6r ,Lr ,ilr6 iou rt,'g riro m6u n6o vi vQv cin chu f

kh6ng dung thu5c cho nguOi diAu tti6n phuong tiQn giao th6ng vir c6c m6ymoc

c DiQt vi tnhuAn Helicobacter pylori (tLP)

O nhfing ngudi bi chrmg kh6 ti6u chirc ning n6u co nhi6m {l:.tt1

khi diet H.P co tfr? tam giam cac triQu chring kh6 ti6u chrlc n+ng cv 8-10% s6

trudng hgP

d ThaY AOi tOi s6ng vlr thric In

T6ngcu}ngv4nclQngth6lyc,tranhc5ctresslimgi6m,Ai:Yfoc6ctri6u

chimg kho ti6u "lif nang.MOt si5 thirc 6n nhu

cvt vir gia vi cay nhi6u cflng ldmtdng citctriQu chimg ctra bQnh'

e Thu6c chdng trflm cimvi chiing lo 6u

c6c thu5c ch6ng tram c6m vd ch6ng lo 61t c6 t6c dung lirm giim c6c

triQu chimg i"

-4-Tii liQu tham kh6o

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

L Clinical trial: prolonged beneficial effect of Helicobacter pylori eradication

on dyspepsia consultations - the Bristol Helicobacter Project AlimentPharmacol Ther 2010 Aug; 32(3): 394-400

2 Mahadeva S, Goh KL Epidemiology of firnctional dyspepsia: a

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

3 Miwa H, Ghoshal UC, Fock KM, Gonlachanvit S, Gwee KA, Ang

TL, Chang FY, Hongo M, Hou X, Kachintorn (J, Ke M, Lai KH, Lee KJ, Lu

CL, Mahadeva S, Miura S, Park H, Rhee PL, Sugano K, Vilaichone RK, Wong

BC, Bak YT Asian consensus report on functional dyspepsia -I Gastroenterol

-5-BPNH TRAO NGIJqC DA DAY-THITC QUAN

r D{.r cr/oNG:

BQnh trdo ngugc dp ddy - thgc quAn (BTNDD-TQ) le mQt bQnh kh6 ph6bi6n d c6c nudc Au-M! vdi t6n su5t ttr 10 - 20% de$ s6 d c6c nu6c chAu A,

tAn suSt c6 khuynh hu6ng gia ting trong nhfrng nbm gAy d6y vi dao dQng tt 5

- l5% Ri€ng d nudc ta, benh ndy chi mdi dugc ltru y tir hon mQt thflp ni€n trd

lai vdi t! lQ dugc Chi nhan khoang 15-16% trong m6t vdi nghi6n cfu MQttrong nhfrng nguyOn nhdn ldm cho BTNDD-TQ chua dugc quan tdm dring mr?c

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

dugc tAm so6t k!, trong khi cric triQu chrlng kh6c thi r6t d6 bi lAm 15n vdthudng tlugc qui cho c6c bQnh kh6c nhu vi6m lodt d4 diry - t6 tri'ng, vi6mthanh quin, vi6m mffi xoang

Thinh thoAng trong ngiry c6 th6 xu6t hiQn trdo ngugc d4 diry-thyc qu6nsau 6n, kh6ng kdm theo bAt k! trieu chimg gi, dugc xem ld hi€n tuqng sinh lf

binh thudng Ngugc l4i, theo HQi ngfi d6ng thu{n Montreal nim 2006,

BTNDD-TQ dugc dinh nghia l2r khi hipn tuqng trio ngugc dich vi tu da ddyl6n thyc qu6n x6y ra thudng xuy0n hon vd gl,y ra c6c triQu chring kh6 chiu

vdy'hoflc bi6n chung cho b€nh nh6n

II ChAn tlo6n:

1 ChAn tlo6n x6c tlinh:

a TriQu chirng lAm sirng:

- TriQu chirng ldm sang ditin hhh ld o n6ng vi tr6 Nu6t nghgn cfing ldtrigu chimg thulng g4p trong khodmg l/3 trutrng hqp

+ O n6ng: ld cim giric n6ng r6t d sau xuong uc lan tr) thugng vi di l€nc6, c6 khi lan d6n rung ha hgng ho4c l€n t6n mang tai Trulng hqp diian hinh'chimg o n6ng xuAt hiQn sau bta 6n vi do tu thiS ciri g4p ngudi v6 phia tru6cho{c nim rgta CitctriQu chimg tr€n tlng khi uting ruqu, An c6c thuc 6n chua

; 'X

cay, nhi6u gia vi vd ddu md

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

thulng xiy ra khi thay d6i tu th6 ho4c do gdng sfc Dich trd thudng kh6ng mti

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

+ Nuiit nghgn: li cim giitc nghgn thrlc 6n hay thuc u6ng ngay sau khinu6t Can phin biQt v6i nu6t nghgn do nguy6n nh6n h6u hqng ld thuc 6n kh6ng

di5n tlugc vuqg hA hgng md trdo ngugc l6n mfii hoqc vdo khi quin vd thudngkdm theo sac Tru6c mQt b€nh nhan bi nu6t nghgn, dt r6t nhg ho4c thoang qu4cflng phii c6nh gi6c v6i ung thu thyc quin d6 tAm sorit ho4c lo4i trir nguy€nnh6n kh6c

BQ Y TE HUdNG DAN CHAN DOAN VA DIEU TRI BEJH TI6u uoa

-6 Circ tri6u chring it gdp: cbm giirc cuc nghgn (globus), r?a nudc bgt

^ A, - ' .\

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

- Cdc triQu chimg ngoei thyc quin: dau nggc kh6ng do tim, triQu chring1i6n quan hO hap (ho mpn tinh, khd khd, con hen ph6 quin), triQu chring 1i6n

quan bqnh tai mfii hgng (khan giQng, vi6m tai gita, mdn rdng, dilngmiQng, clau

hgng, vi6m xoang, vi6m hAu hgng, h6i miQng )

b TriQu chring c$n I6m sing:

* NQi soi tiOu hoi tr6n

- Dugc chi clinh khi c6 c5c dAu hi6u b6o clQng c6c bi6n chimg hoflc c6c bQnh ly 6c tinh nhu nu6t kh6, nu6t dau, spt c6n, xuAt huytit hay thi6u m6u; ho{c

de tAm so6t nhirng benh nhdn c6 nguy co cao bi bi6n chftng, hay c6c triQuchimg kh6ng di6n hinh Cric bQnh nhdn khdng d6p ung v6i di0u tr! chu6n bingc6c thu6c ric chti titit acid hay ph6i dtng thu5c kdo ddi cfrng cAn dugc nQi soi

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

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

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

-3 Thgc quin Barrett (Barrett's esophagus): khi c6 sp dlch chuy6n 16n

tr6n cria phan ti6p gi6p bitiu md trU- 16t tdng (squamocolumnar

junction) ctrng sp hiQn diQn cria hiQn tugng chuytin sAn ruQt

(intestinal metaplasia)

- Phan lopi Los Angeles (LA) d6nh gi6 mrlc rtQ npng cria vi6m thpc

qudrn qua n6i soi:

+ DO A: c6 mQt ho4c nhi6u vtit xudc cy ni6m mac thpc qu6n nhmg < 5

mm vi kh6ng lan rQng qua giira hai n6p ni6m mpc

+ EO B: c6 mQt hoflc nhi6u viSt xudc ni6m mac ddi > 5 mm nhmgkh6ng lan rQng qua gifia hai niip ni6m mac

+ EO C: c6 nhi6u v6t xu6c lan rQng qua nhi6u ni5p ni€m mpc nhrmg chi

<75oh chu vi thuc qudn.

-7-+ Dd D: c6 nhidu v6t xudc ni6m m4c lan rQng, chiiSm it nhdt 75 Yo cfit

thlrc quan hit5m gip nhrmg l4i c6 nhuoc di6m ld kh6ng chinh x6c do bi 6nhhu&ng c0a khAu kinh 6ng do vd cu dQng hd hAp.

.! Do pH thrp quin 24 giitz dugc xem ld ti6u chudn vang d6 chAn do6nx6c rllnh Phucrng ph6p ndy girip xric dlnh trio ngugc d4 diry - thr;c quan d bQnh

nh6n c6 triQu chung kdo ddi nhrmg kh6ng c6 bing chimg cria t6n thucrng vi6m,

d6c biQt td htri thAt bai vdi di6u tri khang ti6t acid'

c Ti6u chu6n chAn tlo6n:

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

bi€t ld trigu chring di6n hinh nhu g n6ng vh tr6 CAn dua viro ldi m6 tA ctabgnh nhdn ae pnainipn triQu chung vi thu$t ngfr "g n6ng" c6 th6 lam benh nhankh6ng hii5u d6 khai benh

- N6u nghi ngd BTNDD-TQ, cO *rC el6u tri thrl b6ng thutic irc cht! bomproton fidu.tuAn epf test) trong 2 tuan d6 tlanh gi6 d6p rlng di6u tri'

- NQi soi ti€u h6a tr€n kh6ng dugc khuytin c6o thyc hiQn thulng qui khi

c6 trieu chimg trdo nguqc di6n hinh'

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

<ti6u tr!thri hoflc c6 c6c d6u hiQu b6o dQng bi6n chung hay bQnh 6c tinh, c6n Ouqc ti(in hdnh c6c phuong tiQn c4n l6m sdng kh6c tl5 x6c dlnh chan Ooan'

- C6c d6u hiQu b6o dQng:

+ Nu6tnghgnn4ngd6n

+ Nu5t dau

+ Chan 5n, spt c6n (kh6ng chir Y)

+ Thi6u m6u (m6i xuAt hiQn)

+ NOn ra m6u/ dai tiQn Phdn den

+ Su dgng thu6c ktang vi€m kh6ng steroid k6o ddi

+ Ti6n srl gia dinh bi ung thu d4 ddy/ung thu thyc quirn

2 ChAn tlo6n phAn biQt:

TriQu chimg cta BTNDD-TQ c6 th6 tuong tU c6c bQnh ly t4i thqc quan

vd ngodi thpc quan nhu:

- Co thit tim vi.

- Trii thtra Zer*er.

sO v TE HU6NG DAN CHAN DOANvaoIEU TR] BE.NH TIEU HOA

-8 Ung thu thuc quan

- Rr5i 1o4n v6n dQng thuc quiin

- Vi6m thgc quin do nguyCn nhdn khric (nhi6m khuAn, thu6c, tia x4)

- Li6t nhe d4 ddy

- S6i m4t

- Vi6m lo6t d4 diy

- Kh6 ti6u chuc n6ng

- Dau th6t ngr,rc.

3 ChAn do6n nguy6n nhAn:

Khi CTDTQ hoat dQng kh6ng ttit sc dE dan dt5n BTNDD-Te C6c ytiu tii6nh huong A6n ri5i 1o4n ho4r dQng cria CTDTe vi co ch6 bao v€ ch6ng triongugc c6 the do (1) Su thu din thoring qua cria CTDTe xiy ra thudng xuy6n

vd kdo ddi hon, (2) Tho6t vl hoanh, (3) Ri5i loan vfln rtQng thuc qu6n, (4) ciamti6t nu6c bot vd (5) Ctrc tec nhen hm gi6m 6p lgc CTDTe nhu c6c thu5c kichthich thu th6 p, iic chi5 thu thd o , thu5c a5l ruuing cholinergic, thu5c gi6n co

theophylline ); c6c chAt cafein, ruqu, thu6c H, chocolate, hay bta 6n nhi6um0

Cric ytiu t6 khric g6p phAn hm teng hiQn tugng trdo ngugc, bao g6m:

- C6 thai (c6c nQi ti6t til ttral nghdn ldm gidm 6p luc cria CTDTe)

- Nhu dQng ruQt kh6ng hiQu qu6

- Xo cirng bi

- Cham ldm triSng da dny

- Tu th6: tu thti nim, crii g{p ngudi

- Bdophi

- Didu tritiQt tru H.pylori

4 Ch6n do6n bi5n chrirng:

Can tuu y ld kh6ng c6 su song hdnh gifia triQu chtmg l6m sang vd t6nthuong thpc th6 cria c6c biiin chrmg: Dau nhidu nhrmg chua ch6c d6 c6 t6nthuong vi€m thyc quan n4ng; ngugc l4i vi6m thyc quan n{ng c6 th€ di6n tit5n

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

Bit5n chring thudng xiy ra nh6t h vi6m thlrc qu6n do triro nguoc v6i c6c

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

Thgc quan Barrett ld biiin chung quan trQng cria BTNDD-Te, hi6n diQn

0 8 -15% b6nh nh6n D6y ld tinh trang ni€m m4c thgc quan bi thay thi5 dan bdini6m m4c d4 day v6i nguy co ung thu h6a (adenocarcinoma) do4n ni6m m4c b!chuy6n san.

BQYTE - HU6NG DAN CHAN DOAN VA DIEU TRI BENH TIEU HOA

-9-BQ Y TE - HU6NG DAN CHAN DOAN VA D IEU TRI BE.NH TIEU HOA -

10-Lo6t thgc qu6n c6 th6 g6y xu6t huy6t

Ngoiri ra, c6 th6 c6 c6c bi6n chimg nhu vi6m thanh qu6n, vi6m xoang,vi6m mfli hgng, vi6m phOi ao hit do trdo ngugc, hen ph6 quan xiry ra vho band6m, mdn r6ng

III DITU TRI

1 Mgc ti6u di6u trl

- KiiSm so6t trieu chung d6 cii thiQn ch6t luqng sting

- Lem lanh vi6m thgc quan (n6u c6)

- Ngin ngtra bgnh t6i ph6t ho[c cric bi6n chimg

2 Di6u tTiBTNDD-TQ bao gdm ttng bufc:

a Thay O6i tii sSng: c6 th6 c6 lqi d nhi6u bgnh nhan BTNDD-TQ nhung dugc

kh"#" c6o n6n k6t hqP vdi thudc:

- Giam c6n (n6u thta cAn)

- Chia thdnh nhi6u bta 5n nho, sau khi 6n khdng ndn nbm ngay it nhdt sau 2-3 gid

- Gi6m an chAt b6o, chocolate, cilc thitc u5ng nhu cafe, nudc 6p chua,

coca-cola vil ruou

- N6ng dAu cao 10-15 cm so vdi m{t giucrng

- Ngmg thu5c 16.

- Tr6nh mflc qudn rlo chft (nit ngyc, nlt lmg)'

- Trlnh c6c thutic nhu llc chil calci, theophylline, an thAn,

anticholinergics vi lirm tlng trao ngugc'

b NQi khoa:

- Ni5u benh nhen bi triro ngugc nhq hay trung binh: c6 th6 dtrng thuOc

trung hod acid dich vi - antacid (sau nn hay khi.di ngn) vd thu5c rtc chtl thy th6H2 (H2RA) crich khoang hay phdng ngla khi cdn thi€t'

- Lieu chuAn H2RA cO tne lu* gi6m triQu chring d5n 600/o vir d6u hiQu

liurh vi6m 1o6t thgc qu6n tren nQi soi khoimg 5o% a benh nhan suy th?n phii

didu chinh [Au

- Nhtng ca nh9 c6 th€ dung cric thu5c lim ting truong lyc CTDTQ nhuMetoclopramide, Domperidone; tuy nhi6n kh6ng khuy6n c6o ding lAu dii vi c6th€ c6 nhidu t6c dgng Phg.

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

so vdi placebo vd I-DRA [6u chuAn trong viQc gi6m tripu chimg cflng nhu ldmDnh vtSi thuong tr€n nQi soi Thdi gian dieu tri ln 8 tuan e5i vOi STNDD-TQ c6vi6m thlrc quun ua 4 tuan d6i v6i NERD Iftdi <IAu dung PPI 1 lAr/ngdy tru6c6n sring 30 phrit Li6u cao nhu Omeprazole 2040 mglngiry x 2ldn tru6c 6n

s6ng vir t5i hay c6c ho4t ch6t tuong ducrng dugc chi tlinh cho nhirng trudng

hgp nflng vd c6c triQu chimg k6o dii ViQc sr] dpng l6u dii PPI tucrng ilOi an

toan vd higu qud trong vigc duy tri phdng ngira tili ph6t trong c5c trudrng hgpvi6m thgc quan, Barrett thpc quan vi triQu chimg nang Tuy nhi6n, cdc dti liQu

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

thucrng Oan truyAn tim, gdy tlng nguy co nhi6m Clostridium difficile vi ldmt6ng nguy co gdy xucrng chQu hay lo6ng xuong o phU nt mdn kinh

- Di6u tri' duy tri: sau giai clo4n di€u tri ttin cdng aOi vOi r*rftng benhnhan bi tiliph6t sau ngLmg thu6c ho{c c6 biiln chimg vi6m thgc quan hay thpcquin Barrett Di0u tri duy tri s€ thay tl6i tuy tung benh nhen, mpc ti6u ln ki6m

so6t triQu chimg vlr ngdn ngta bi6n chung.Benh nhan co thiS phOi hqrp sri dgngantacid v6i thay AOi tOi si5ng hay giam H€u PPI xuiing liCu thAp nh6t md v5ncdn hiQu qui hopc dung thu6c khi c6 triQu chimg (diQu tri theo y6u cAu).

Lidiu lugng cic thuiic khing ti6t acid

BQnh trho nguqc DD-TQ

Famotidineu

a: chinh liiu khi suy thQn

c NgoSi khoa:

C6c phuong ph6p diAu hi ngo4i khoa dugc chi ctinh hong c6c trudmg hqp:

- DiAu tri nQi khoa k6o ddi vi ting li6u cao nhrmg cii thiQn rdt it.

- Benh nhan kh6ng tuen tht diAu tri vd mong mu6n phdu thu4t

rv Ktr LUaN

Benh TNDD-TQ ld mQt benh m4n tinh, ngey cang xu6t hiQn thucrng hcrn dc6c nudc chdu A vi c6 khuynh hudng t6ng tdn su6t & ViQt Nam Benh kh6ngchi 6nh huong itdn ch6t lugng cuQc s5ng do c6c triQu chung mi cdn c6 th6 gdyc6c bilin chimg neng nhu 1o6t thpc quan, hgp thpc quan vi h6a ung thu ViQcchan doan vd tli6u tri cAn dugc xem x6t, cdn nhic ky d6 dat k6t qu6 ttit nh6t vOi

Cimetidineu 400 mg ngey 4 len

800 mg ngay 2 AnRanitidineu 150-300 mg ngdy 2 hnhay 4 lAn

20- 40 mg ngiy 21rdn

Nizatidineu 150 mg ngay 2 hnOmeprazole 20- 40 mg mdi ngay hay ngdy 21dnEsomeprazole 20 - 40 mg m6i ngey hay ngiy 2ldnLansoprazole 15 - 30 mg m5i ngey hay ngdy 2\6rnRabeprazole 10 - 20 mg mdi ngey hay ngiy 2ldnPantoprazole 20 - 40 mg m6i ngey hay ngdy zl.drn

B0 y re - su6NG DAN cHAN DoAN vA DrEu rRI BEIIH TrEU H6A

-11-I

chi phi hqp ly nh6t, cffng nhu tr6nh b6 s6t nhirng bi{ln chrrng nguy hi6m nhuh6a ung thu.

Tii liQu tham kh6o

l DeVault KR, Castell DO Updated guidelines for the diagnosis andtreatment of gastroesophageal reflux disease Am J Gastroenterol Jan

4 Philip O Katz MD, Lauren B Gerson MD MSc and Marcelo F' Vela

MD Diagnosis and management of gastroesophageal reflux disease llzl

J Gastroenterol.F eb 2013; 1 08(1 ): 308-328'

r.DArcuoNc

Vi6m d4 ddy (gastritis) ld tinh h4ng vi6m cria ni6m mac d4 diry, v6i d4c

tnmg ld sg thdm nhQp c6c t6 bdo vi6m (bpch cAu da nhAn, bach cAu lympho,tuong bdo ).Do d6, chAn do6n vi6m d4 ddy chi dugc x6c dlnh chic chin khic6 k6t qu6 m6 b€nh hqc d4 ddy.

Tr6n thuc tti l6m sdng, thu{t ngfi "vi6m d4 diy" thudng dugc su dgng

ptrO UiCn nhrmg l4i kh6ng chinh x6c khi tt6 c{p d6n tri€u chimg goi f r6i lo4ncria dudng ti€u h6a trdn (vi dp: dau thuqng vi li€n quan bfla 6n, n6ng riit vtrngthugng vi, dAy bqng sau dn hoic 6n nhanh no ) N6u benh nhan c6 ciic triQu

chrmg k0 tr6n chua dugc thim dd b6ng c6c x6t nghiQm chan dorln, thu6t ngt sridqng chinh x6c trong truong hqp ndy lir chring kh6 ti€u chua duoc thdm dd(uninvestigated dyspepsia) Trong trudng hqrp bQnh nh6n v6i c6c triQu chimg

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

gqi I vi€m d4 diy nhung kh6ng c6 ki5t qu6 m6 bQnh hgc d4 ddry, thudt ngt sri

dgng trong trudng hqp ndy ld r6i lo4n ti6u h6a chric ndng (functionaldyspepsia)

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

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

ddy ldm ting nguy co ung thu d4 diy.

II NGIIYTN NHAN

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

da ddy ph6 bit5n ld 1L pylori vit vi6m dp ddy h6a hgc (cdn dugc ggi ln bQnh da

ddy - gastropathy do trong trudmg hqp ndy hinh 6nh m6 bQnh hqc d4 ddythulng thAm nhflp rdt it circ tti bio vi6m)

- Vi€m d4 ddy do H pylori ld d4ng quan trgng nh6t vi H pylori ldnguy€n nhdn chinh dan A6n lodt d4 diy -t6 trang, cric tinh tr4ng vi6m vir t6nthuong titin ung thu d? day (teo ni6m m4c, di sdn ru6t, lo4n sin ruOt) vd tidmnlng d6n d6n ung thu d? dey Tuy vgy, do m6i tuong t6c phrlc t4p gita 3 y6u tO

vd A6c Oi6m cta chring H pylori sinh bQnh, dac di€m di truy6n cria ngudi bi

nhi€m vd cric y6u td m6i truong (ch6 d0 5n u6ng), chi c6 khodng 15% nguoivi€m d4 ddy do H pylori trong sutit thdi gian s5ng c6 thra bi lo6t da diy - tritrdng vi kho6ng 1% ph6t triiln thanh ung thu d4 ddy

- Vi6m d4 ddy h6a hgc x6y ra khi c6 sr,r tiiip xric cria ni6m m4c d4 diry

vdi dich mAt (sau ph6u thu4t c6t tan phan da ddy ho{c trong c6c hQi chtmg rtii

1o4n v{n tlQng d4 de/; bQnh nh6n sr} dgng aspirin, thu6c khring vi6m kh6ng

BQ Y TE HUdNG oAN cuAN ooAN v ADIEU TRI BE}IH TIEU HOA

-13-steroid vir ruou bia Tuy nhiOn hAu h€t c6c trudng hqp vi6m d4 ddy h6a hqckh6ng gdy triQu chimg vd kh6ng gdy tinh treng teo ni€m m4c d4 diy do d6 cog6y ung thu da day thAP.

- C6c trudng hqp bQnh nhan bi ddng thdi hai t6c dQng cta nhi6m H'

pylori vd vi6m d4 diy h6a hqc c6 nguy co bi t6n t!,*g n4ng n€ hon' Vi6m teoioan b0 d4 ddy ld yi5u ti5 nguy co chinh y6u tlua d6n ung thu d4 ddy

B 1.N 6n nhin vi6m d

III PHAN LOAI

1 Vi6m dg dny c6p: c6c t6n thuong xu6t truy5t vd vi6m trqt x?ry ra ngay sau

khi ni6m m4c dp ddy tii5p xirc v6i c6c ttQc chAt Gnr{ng vi€m kh6ng steroid,

rugu bia, axit mSt ) hoic khi c6 tinh tr4ng gi6m tu6i m6u d de ddy (ch6nthuong, b6ng, h4 than nhiet, nhi€m khu6n huy6t, h6a tri toan thdn ho4c x4 tri ungthu )

2 Vi6m d9 dny m4n (ph6n lopi Sydney cii ti6n)

- Vi€m d4 diy kh6ng teo ni6m m4c (cdn gqi ld vi€m da ddy ffp B): do

H pylori vi mQt s6 t6c nh6n kh6c

- Vi€m teo ni6m m4c d4 diry: bao gOm d4ng vi6m teo d4 ddy da 0 (cdngqi li vi6m da ddy fjp B ho4c fip AB do H pylori), vd vi6m teo d4 diy tgmiSn (cdn ggi ld vi6m da ddY ffP A)

a) Nhi6m trtrng

- Vitrung: H pylori,lao, c6c chtngMycobacteriumY'hhc

- Si6u vi: CMV, HerPes

- N6m: Candida, Histoplasma, Phycomycosis

- Kf sinh trung: giun dfr4 giun luon, Cryptosporidiumb) T6c nh6n h6a hsc (vi6m da daY {P C)

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

- Rugu

- Dfch m4t

- Cocainec) Tia x4

d) Qua trung gian mi6n d!ch: Tg miSn (typ A), H pylori, v6 cdn

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

BQ Y TE HU6NG DAN cHAN ooAN ve oGu rru sE.NH TIEU HOA

-14 Circ dqng vi6m d4 ddy d4c biQt: h6a hoc (dich m{t, khdng vi6m kh6ngsteroid ,.,), vi6m d4 ddy lympho bdo, vidm d4 dity d4ng u h4t, vi6m dq dily c6tbng b4ch cAu 6i toan, vi6m d4 ddy do nhiSm trung (vi trung, si€u vi, h-i sinh

- ChAn tlorin x6c rllnh vi€m d4 diy dya tr€n m6 bQnh hgc: tr6n thuc t6, hAu h6t ld benh nhdn c6 tri6u chimg ti6u h6a tr6n (dau thuqng vi, o hoi g chua,

n6ng r6t thuong vl, dAy bUng hodc kh6 chlu thuqng vi sau dn ) c6 chi rlinh

n6i soi da ddy vd dugc quyct dinh thuc hi6n sintr thi6t da ddy qua nQi soi khi c6lodt da ddy - tri trang hoic nghi ngd c6 t6n thucrng tidn ung thu ho{c ung thud4 ddy trdn nQi soi

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

+ 5 miu theo khuy6n c6o cta h6 th6ng Sydney c6i ti6n (2 m6u vung

hang vi, 2 m6u vtrng th6n vi d 2 phia bd cong nh6 vd bd cong lon, 1 m6u J vtng g6c bd cong nh6) 5 m6u sinh ttritit ndy n6n d€ vdo 5 19 ri6ng ghi rd vi tri

sinh thiiit d6 grii drinh gi6 m6 bQnh hqc Tuy nhi6n 6p a,.rng vao thuc t6

ia-sdng kh6 do phric t4p, gd,hn4ng chi phi cho benh nhan vd qu6 t6i cho c6c tlon

vi nQi soi vd gi6i ph6u b6nh.

+ Nghi6n criu trong nu6c cho thAy sinh thi6t 3 m6u doc phia bd congnh6 (d vung gifta thAn vi, gifa hang vi vd rung g6c bd cong nh6) c6 thii d,igirip x6c dinh rlugc cric trudng hqp c6 t6n thuong ti6n ung thu C6c m6u ndyn€n dugc grli trong hai l9 ri6ng (1 l9 chria m6u sinh thi6t vung th6n vi, lg cdnl4i chria m6u vung hang v! vd vtng g6c bd cong nh6)

2 Xric ilinh nguy6n nhin vir t6n thuong tidn ung thu d4 diy

a Xr{c tlinh nguyOn nh6n: tr€n m6 b6nh hoc thu}ng c6 th6 x6c tlinh dugcnhi6m /r pylori, dbi khi c6 thri xic dinh duoc ctic nguy€n nhdn kh6ng thudngg[p nhu: vi€m dp ddy c6 tnng b4ch cAu rii toan, u h4t

b X:ic tlinh cic t6n thuong tidn ung thu dg diy (vi0m teo niGm m4c dgdiry, di sin ruQt, Io4n srln): Nguy co ti6n tri6n thinh ung thu d4 ddy hang nAm

ld 0,1% d benh nhan b! vi6m teo ni6m m4c d4 diry,0,25%o khi c6 di sin ruQt,

0,6%kltt c6 lo4n san d6 thSp vit6yokhic6 lopn s6n tt6 cao.

1 Nguy0n t6c tli6u tri

- Di6u tri nguydn nh6n (ntiu x6c dinh tluoc)

B0 Y rE - HTJdNG DAN CHAN DOAN]/ADIEU TRI BE'NH TIEU HOA -

l5 Didu tri triQu chimg

2 DiBu tri cB th5

a Dilu tri nguy0n nhin:

- Di€u tri tiet tni H pylori: girip cii thiQn tinh tr4ng vi6m m4n tinh virvi6m teo ni6m mac Tuy nhi€n n6u tru6c khi didu tri de c6 di san ruQt ho{c loqns6n o d4 ddy thi c6c t6n ttruong niy thulng kh6ng phvc h6i dugc vd v6n phditheo ddi nguy co ung thu dp dey otii vOi c6c.tru'dng hqp kh6 chua tiQt truthanh c6nj viQc di€u t| bnng Rebamipide (thu5c c6 t6c dgng kh6ng vi€m t4ini6m m4c d4 ddy vd kich thich tao Prostaglandin nqi sinh) cho thdy c6 kiit quacai thien vd lim chdm tiiin trinh vi€m d4 dly, c6 ttt6 gt"p ich trong khi cho dgi

mQt phuong ph6p di6u tri tiet tru H pylori hiQu qui hon'

- Vi€m d4 ddy do t6c nhdn h6a hgc: Ngmg sri dgng c6c t6c nh6n h6ahgc gdy viOm d4 ddy niSu c6 th6 tluqc (ruqu bia, khring vi6m khdng steroid'aspirin .)

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

- Vi6m d4 day do bQnh Crohn ho{c vi€m d4 ddy ting lympho bdo kh6ngphai do H pylori ttugc diAu tri vdi c6c thu6c uc ch6 bom proton'

b Di6u tri triQu chrtng: Tu<rng tq bdi kh6 tiOu chfc ning

VI THEO DOI

ViQc theo d6i chi tlugc theo d6i 0 nh6m c6c bQnh nh6n vi€m d4 diy c6

tinh trang hoflc tdn thuong tidn ung thu dA ddy nhim mqc dich ph6t lriQn ung

thu da day khi cdn A giai tloan sdm HiQn chua c6 khuyiin crio th5ng nh5t

"t,r,g Urorrg aan cta ff6i NQi soi Tieu h6a Ch6u Au vd HOi Gi6i

- Vi6m dp ddy m4n teo mrlc dQ nhg / trung binh; hopc c6 di s6n ruQt chi

0 vung hang vi: Kh6ng c6n theo d6i

- Vi€m d4 diry m4n teo hof,c c6 di san ruQt d ca than v! vd hang vi: CAn

theo d6i vd d6nh gi6 l4i m6i 3 nam.

- C6 lo4n san vd quan s6t dugc t6n thuong khu tni (c6 1o4n san) tr6n nQi

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

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

- C6 loan sin tlQ cao nhrmg kh6ng th6y t6n thuong khu tru tr6n n6i soi:theo ddi vd danh gi6 l4i ngay l4p trlc, vd sau d6 6 - 12 thing.

6-Tni [Qu tham kh6o

1 Rugge M, Graham D In Talley N (ed) Practical gastroenterology and

Hepatology: Esophagus and stomach Gastritis l" edition 2010: Wiley

-Blackwell 345 - 52 Singapore

2 Washington M, Richard M Peek Jr Gastritis and gastropathy In Yamada T.Textbook of gastroenterolog 2009 Wiley - Blackwell 5th edition 1005 -

1025 Singapore

3 Lee E, Feldman M Gastritis and gastropathies (eds) Feldman M, Friedman

L, Brandt L Sleisenger and Fordtrans's Gastroenterology and liver disease.

gO Y TE - HU6NG DAN CHAN DOAN VA EIEU TRI BE.NH TIEu uoa

-17-LofT DA oAv rA rnANc

r DAr cr/oNc

Lo6t d4 diy tri trang ld tinh trpg ni6m m4c bi tdn thuong bii m4t vuotqu6 lop co ni6m do tric tlQng crla dich v! d4 ddy D6y ld mQt b€nh d6 duqc bi6tttr l6u vd kh6 ph6 bii5n tr6n thi5 gi6i ctng nhu 0 ViQt Nam M[c dt tld c6 nhtingtilin b0 lcrn trong chAn do6n vd tlidu tr!, n6 v6n ld mQt v6n dri suc kh6e l6n bdisii luqng benh nhan nhi6u, tinh chAt c0a benh le m4n tinh vd dE trii ph6t, chiphi tli6u tr! cao vi c6 thti giy mQt s6 biiin chung

II NGIITTN NHAN

+ U bai tiiit gastrin - (Gastrinoma giy hQi chimg Zollinger - Ellison)

+ TSng hoat dQng cta t6 bdo G O hang vi

+ Chiiiu x4

+ Crohn, sarcoidosis

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

sdng cho th6y c6 3 nguy€n nh6n chinh:

BO Y TE - HUdNG DAN CHAN DOAN VA DIEU TR] BE.NH TIEU H OA

-18-Lo6t do Helicobacter Pylori: ld nguy€n nhdn cht y6u gAy lodt d4 ddy t6tring, vi6m d4 ddy c6p vd man, ung thu d4 ddy.

Tf lQ nhi6m chung cta ngudi ViQt Nam khodng 70% vit ngudi ta th6ychi 7 - 2o/o s5 ngudi bi nhiem IIP bi lodt d4 ddy t6 trdng

C6c khring vi6m, gi6m tlau NSAID, vir Aspirin: hiQn ld mQt trongnhirng nh6m thu5c dtng hiit srlc ph6 bit5n BQnh nhAn su dpng c6c thu6c niry c6th6 bi 6 1o6t c6p tinh vi thulng ld nhi6u 6.

Lo6t do stress: thudng giq tt cdc benh nhan nim c6p criu nhu: thd m6y,b6ng, chAn thuong sg n6o, nhi6m trung huy6t, vi6m tpy c6p, suy gan, suy

thfln vdi t'i le tir 50 - 100% Nhrng bQnh nh6n nhu vfy c6 ff lQ xu6t huytittieu h6a dai th6 dao dQng ttr lO -20% vd nhtng bi6n chimg ndy ldm n4ng th€m

bQnh chinh, ldm ting th0m tf lQ trl vong

rrr rRrFu cHirNc LAM SANG vA cAN r-,Avr sAxc

1 TriQu chirng lim sirng

Dau bqng cht ytiu d vtng thugng vi ld tripu chimg c6 th6 n6i ld hangdinh cria b€nh ndy Dau c6 th6 tr) mrlc dQ kh6 chfu, 6m i d6n dii dOi Ttry thuQc

vdo v! tri 6 lo6t, tinh ch6t dau c6 th6 c6 it nhi€u kh6c biQt:

- Lodt hanh ta trdng thulng xu6t hi€n hic tl6i ho4c sau bfia in2 - 3 giit,

dau trQi 16n vd d6m, 1n vdo hoic sri dgng cric thu6c trung hda acid thi <td dau

nhanh

- Lo6t d4 ddy: tuy vi tri 6 loet me v! tri vd hu0ng lan cria tinh ch6t dau

c6 th6 kh6c nhau Thulng dau sau 6n trong khoang vdi chgc phrft dr5n vdi gid'D6p tmg vdi bira in vir thu5c trung hda acid ctng kdm hon so v6i lo6t hanh t6trdng

Dau c6 thC am i, k6o dii ho4c thdnh con nhtmg c6 tinh chu k) vi thanhtirng dqt Vi vfly, khai th6c vC ti€n su c ua circ dgt dau trudc il6 r6t cO gia tri A5i

vdi chAn tloan

C6 th6 c6 c6c triQu chrlng: buiin n6n, n6n, ch6n dn, cim gi6c n6ng r6t,ddy bUng, sgt c6n, g chua.

Kh6m bsng: thudng kh6ng thAy gi tlec biQt, d6i khi c6 th6 th6y bvngtrudng ho4c co cimg nhg.

2 Cin l6m sing

a NQi soi d4 dny t6 trhng: clugc coi ld phuong phrip c6 gi6 tri nh6t trong chAn

clo6n x6c dinh lo6t Ngoi,i ra, nQi soi cdn cung cAp c6c th6ng tin: vi tri, s5

lugng, kich thu6c, tinh ch6t 6 1o6t: c6p hay m4n tinh, n6ng - s6u, bd d€u hoackh6ng d6u, tt6y s4ch hay c6 ch6t ho4i tri vd c6c t6n thuong kdm theo nhu vi6m,trqt

b Test x6c tlinh HP: c6 nhidu phuong ph6p: 2 phuong phrip hay sri dpng nhAt

BQ Y TE HU6NG DAN CHAN DOAN VA DIEU Tzu BENH TIEU H OA -

19 Ure test ld,rn trong qua trinh nQi soi

- Test thd C13,Cl4

IV CHANDOAN

1 ChAn do6n xic tlinh

- Dga vdo triQu chfng 16m sang

- NQi soi vd phuong phrip quytit dinh chAn doan

2 Chdn tlo6n phAn biQt

- Chung ch4m ti€u gi6ng lo6t: triQu chimg khri gi6ng vdi lodt d4 ddy t6trang nhrmg nQi soi kh6ng th6y c6 t6n thuong

- Trio ngugc d4 ddy thpc quin: lo6t da ddy t6 trdng tinh cnAt n6i U4t tatlau thugng vi, lan ra xung quanh ho4c phia sau Triro ngugc - tinh ch6t dienhinh ld c6m gi6c n6ng r6t ving thuqng vi, sau xuong uc, lan l6n ngyc, miQng -

> N6i soi r6t cO giat4 trong chdn do6n ph6n biQt.

- Ngodi ra, c6 th6 nhim: vi6m da ddy c6p vir m4n, ung thu da ddy, s6i

trii m{t, vi€m tgy m4n

V BItN CHLNG

- Xu6t huylit tieu h6a tr6n: ld bi6n chung thulng gpp nh5t

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

- Ung thu h6a: hay g4p 0 cric O toet UO cong nh6, m6n vi ho{c tidn mdnvi.

- Hep m6n vi: thunng g4p vdi c5c 6 lo6t hanh t6 trang

vr DrturRI

1 C6c thuSc tlidu t{

a Cic thu5c trung hda acid dlch vi (Antacid)

C6 nhi6u lo4i khric nhau, tru di6m ln pH dlch vi <lugc ndng l€n nhanh Dovqy, ctng gi6m dau nhanh PhAn lon, trong stl ndy niiu uOng thulic tiling c6chcdn c6 t6c dpng b6o vQ ti5 bdo Nhu-o c di6m chung ld: t6c dgng ngan, phni dungnhi6u lan trong ngdy (thuong ld 7 lan), dung 16u kh6ng c6 lgi Hi€n it tlugc sudgng tlon tlQc trong di€u t4 lodt d4 ddy t6 trang

Antacid: dung 1i6u nh6 u6ng ngay sau bta 5n vir c6ch bfa 6n 2 - 3 gidctng vdi I li6u tru6c khi tli ngri C6c thu5c thuong hay dung: Gastropulgite,Maalox, Phosphalugel, c6c mu5i magnesi (hydroxyd, carbonate)

b Thu6c rirc ch5 II2: gdm 4 thu5c th6ng thulng: Cimetidin, Ranitidin,Nizatidin vd Famotidin

- Thu6c tranh ch6p vdi Histamin dAn tli5n uc ch6 thg the H2 d t6 bAo

thanh d4 ddy

- Thu6c ldm gi6m ca bei ti6t dich vi co ban vd dlch vi kich thich: gi6m

90%biliti6t dich vi co ban, 50 -70% bei ti6t dich vi 24h )tlu di6m: tlic dung

-20-nhanh, pH tangrilt 16 sau 1 gid vd it4t t5c dgng t6i da ngay tir ngiy dAu ti6n,ki6m so6t dich viban d€m r6t t6t.

truoc Dua an cnleu

d Sucralfat: c6 t6c dgng khang acid, h5p thu pepsin vd dich m6t, teng bdi tiiitdich nhdy vi cacbonate, tdng t6ng hqp Prostaglandin nQi sinh, ting tudi m6uni6m m4c da ddy, girip hOi phuc lop bi6u m6 bA mat Thu6c: Sucralfate: 1g x 3

lAn/ ngdy

e Cic Anticholinergic: do t6c dgng ytiu n6n it dugc dtng

f Prostaglandin: Misoprostol ld mQt Prostaglandin El - hi€n nay it dugc dtng

aC Oieu trl lo6t

g Crlc thu6c kh6ng IIP: c6 nhi€u 1o4i hiQn nay hay duoc dirng:

- Bismusth: t6c dgng tryc tii5p l6n vi khuAn ldm vi khudn bf ly giii n6nldm giAm mit dQ vi khuAn trong d4 diry.

- C6c khring sinh: thudng tlugc dr)ng lir: Amoxicillin, Tetraxyclin,Metronidazol, Tinidazol, Clarithromycin, Fluoroquinolone vd Rifabutin.

2 Cic biQn ph6p tli6u tq k5t hqp k'hnc

- Ch.i dO 5n u6ng vir sinh ho4t O mQt s5 benh nhdn chii d0 5n c6 li6nquan kh6 16 di5n tinh tr4ng cta bQnh Cric thrlc 6n c6 lgi v6i ngudi 1o6t d4 diy

-21-+ Nhtrng Od an glau c6c ch6t ch6ng oxy h6a nhu rau quii: qud anh ctdo,

khoai t6y, rau xanh

+ Thric 5n gidu vitamin B vd calci: qud h4nh nhdn, ddu, cric loai 16 c6miru xanh tlflm, rong bi6n

+ Ciic loai dO an chria nhi6u cellulo min nhu gao lut, brinh mi tlen

+ Thit tr6ng, c6, dflu ndnh vd c6c lo{ protein c6 ngudn g6c thgc vft

+ C6 th6 b6 sung ttmg dqt probiotic vi vitamin C

+ C6c lo4i thpc phAm c6 khi ndng ric cht5 bai tiiit acid da diy nhu nudcbhp ciri, chu6i KhAc vdi ttinh ki6n cta nhi6u ngudi chutSi te 1o4i qu6 c6 lgi v6ibenh nhan 1o6t d4 ddy t6 trang

- Ngudi lo6t hanh t6 trang n6n tr6nh crlc lo4i thyc phrim lam t6ng themtinh trang b€nh nhu:

+ D6 r6n: c6, thit rrln, cric 1o4i thit d6, thlt md, socol4 rugu, dudng vichring ldm gi6m truong lgc co th6t thyc quin du6i

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

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

3 Di6u tri crl th6

a Lo6t do H.pylori: thudng ph6i hqp thu6c ch6ng lodt ve kh6ng sinh Vi ti l€

kh6ng Clarithromycine t4i ViQt Nam >20% vi vfly di€u tri diet H.P ph6i dung

14 ngdy bAng mQt trong ba phric tt6: ba khring sinh ho{c ph6c dd 4 thu6c c6Bismuth ho6c phdc AO t6 ti.5p srla d6i

- Phric d6 lya chgn dAu ti6n: thu6c rlc ch6 bom proton (PPf vd 3 khdngsinh:

- Phric o6 t6 ti6p sria d6i:

+ 7 ngiry dAu: PPI + Amoxicillin 500mg x 2 vi6n x 2\dn/ngity

- Trong truong hqp H.P v6n khang thu5c c6 th€ dtng ph6c d6 thay thii

sau: dtng 14 ngdy

+ PPI

* Levofloxacin 500mgx 1vi6nx 1 lAn/ngdy

+ Amoxicillin 500mg x 2 vi6n x 2ldn/rrgily

- Trudng hgp cric phric dd tr6n kh6ng hiQu qu6 cin nu6i c6y vi khuAn virldm kh6ng sinh dtl

b Lo6t do nguyGn nhin kh6c

- Lo6t do NSAID, AINS vd dg phdng: t6t nfr6t ldr sr? dgng thu6c irc ch6

bom proton

- Lo6t do stress: thu6c irc ch6 bom proton

Tiri liQu tham kh6o

1 Chan FK et al(2001) Preventing recurrent upper gastrointestinalbleedingin patients with Helicobacter pylori infection who are takinglowdoseaspirin or naproxen N Engl J Med 344 - 967

2 Chan FK, Leung WK(2002) Peptic-ulcer disease Lancet,360 - 933

3 Leong RW(2009) Differences in peptic ulcer between the East and

theWest Gastroenterol Clin North Am 38 - 363.

4 Napolitanol(2009) Refractory peptic ulcer disease GastroenterolClinNorth Am 38 -267.

5 Textbook of Gastroenterology Tadataka Yamada(2009) Peptic ulcerdisease, Volume 1 936 - 982

6 P Malfertheiner, F Megraud, C O'Morain, F Bazzoli, E El-Omar, DGraham, R Hunt, T Rokkas, N Vakil,E J Kuipers, The EuropeanHelicobacter Study Group (EHSG).Current concepts in the management

of Helicobacter pylori infection: the Maastricht fV Consensus Report.Gut2012;61:646-664

BO Y TE - HU6NG DAN CHAN EOAN VA DIEU TRI BENH TIEU HOA

-23-XUAT HUYTT TITU HOA Do LOET DA DAY TA TRANG

I DA,r ct/oNc

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

- Ngo4i khoa, chi6m khoang hon 50% s6 trudng hqp XHTH tr6n Ti lg tri vongdao ttQng tt 3 - 14o/o HAu hiSt nhirng trudng hqp tu vong xiry ra 6 benh nhanl6n tu6i, thulng c6 bQnh n4ng kdm theo hoflc xu6t truyit trii ph6t Thu6c giirmttau ch6ng vi€m kh6ng steroid (NSAIDs) ho[c aspirin ld mQt trong nhirngnguy€n nh6n hang tlAu gny XHTH d ngudi tru6c d6 dE c6 lodt da diy t6 trirngho[c trudc tl6 chua c6 Stress ld nguy6n nhdn g6y XHTH d bQnh nh6n nangdang di6u tr! tai bqnh viqn

cnay mau nnleu

- M4ch nhanh, huytit rip c6 th6 tgt vd c6 thii c6 d6u hiQu sOc do m6tm6u Da xanh, ni6m mac nhot C6 th6 c6 cdc bi€u hiQn cta m6t m6u c6p tinh:

- Dtng thut5c gi6m dau ch5ng vi€m kh6ng steroid ho[c aspirin

- Trong thuc t6 khoang 15 -20o/o benh nhan )GITH do lo6t d4 ddy t6

, :

trdng md kh6ng c5 ti€n sri lo6t d4 ddy t6 trdng ho{c dau vtrng thuong vi khi bi)GITH.

- Thim khrim l6m sdng kh6ng c6 bitiu hi6n tri€u chung bQnh ly gan mQt

nhu: vdng da, c6 trufng, l6ch to, tuan hoan bang hQ, pht chdn.

b C$n l6m sirng

- H6ng cAu giim, huyiit shc t6 ginm, hematocrit gi6m

- NQi soi x6c dinh chAn dorin.

2 ChAn tlo6n mric tIQ xu6t huy6t vt nguy co chiy miu tdi ph6t

- D6nh gi6 dya tr6n c6c d6u hiQu gi6m th6 tich m6u (xem bdi )GJTHtr0n do tdng 6p lyc tinh m4ch crla)

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

Dich hft da ddy Mdu phdn T1i 16 tri vong (%)Kh6ng c6 mriu D6, n6u, tlen 10

Miu cd phd NAu hoic tlen i0BOY -HUi G DAN CHAN Do DI TRI BENH TIEU HOA

Ia Mrlu phun thimh tia

D6nh gi6 nguy co chiy mriu t6i phdt vir tri vong dpa vdo l6m sang vdhinh anh nQi soi: thuong su dr,rng thang tlilim Rockall Tty di6u kiQn c6 thti sridpng thang di6m l6m sdng tlon thuAn ho4c thang diiim Rockall tliy til) c6 pht5i

hqp gita l6m sang vd nQi soi

Than ili6m Rockatt

BQnh di kdmThitiu m6u co tim, suy tim, c6c bQnh

3

DirSm so

Ung thu dudng ti6u h6a tr6n 2

BQ Y TE HU6NG DAN CHAN DoAN vA DIEU TRI BENH TIEU HoA

-25-DAu hi6u chAy m6u tr€n n6i soi

O lodt tt6y s4ch, ch6m den phAng t4i 6

M6u d dulng ti6u h6a tr6n, dang chdym6u, c6 di6m m4ch, cuc m6u d6ng 2Thang tlirim Rockall tliy dri tir 0-11, thang di6m IAm sdng tir 0-7 Ni5u

di6m s5 thang di6m Rockall rlAy tfii S 2,hoQc tli6m s6 Rockall l6m sang beng 0(kh6ng) thi ti€n luqng nguy co chiy m6u t6i ph6t vd ti lQ tri vong thAp.

D6nh gi6 nguy co chiy mriu trii phdLt dya tr6n mQt s6 chi s5 ldm sang vdx6t nghiQm: nguoi ta thudng su dung thang didm Blatchford

Than ili6m Btatch

Thang ditim Blatchford tluo c tinh ti, O-23 tlirim, di6m s5 cing cao thinguy co ch6y m6u t6iphitt cang lon

C6c chi si5 danh gia Di6mHuyiit 6p tdm thu (mmHg)

1

3

<90Ure m6u (mmol/l)6,5-7,9

3 Chin tlo6n phAn biQt

C6c xu6t huyrit ti6u h6a caoL'hilc do:

- Xu6t huytit ti6u h6a do ting 6p lqc tinh m4ch cua: XHTH thubngn[ng, ti6u sri 6 th6 c6 )G{TH nhidu Dn, ctic bi6u hiQn bQnh li cta teng 6p lyctinh m4ch cua nhu: vdng da, c6 tru6ng, tuAn hoan bang hQ.

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

- R6ch t6m vi ch6y m6u (hQi chimg Mallory - Weiss)

- Chdy mriu dulng m4t

- Di d4ng m4ch

- Polyp thgc qutn, d4 ddy ch6y m6u

- K thyc quan, lo6t thyc qu6n

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

soi

l Nguy0n tic: h6i sric tich cgc, nQi soi cAm m6u vii di6u tri li6n 6 lo6t

2 Didu tri cB th6

Ngay khi bQnh nhAn vdo viQn cdn drinh gi6 tinh tr4ng huytit dQng

- ttOi sric tich cgc ngay tri dAu

- X6t nghiQm c6ng thuc m6u, tli6n gidi, ure, d6ng m6u, x6t nghiQm chricning gan th4n, nh6m m6u vir diQn t6m d6.

- NQi soi d4 ddy tri trirng dC chAn dorin x6c dlnh vd cAm m6u

- Dirng thu5c giAm titit acid

- Di6u tr! li6n O loet vir ch6ng t6i phrit

a, Hdi srirc

- ru thti bQnh nh6n dAu th5p

- E6m b6o dudng thd: duy tri kh6 nEng v$n chuy6n oxy miiu cho bQnh

nh6n (BN) (tIAc biQt d6i vdi BN c6 tu6i va/holc c6 kdm benh l), tim mach): chothd oxy qua x6ng mfii 3-6 Vphrit Niiu c6 nguy co trdo ngugc vio dudng h6 hAp

ho[c c6 suy h6 h5p can OAt nQi khi quin

- IJu ti6n hdng diu trong h6i srlc ld bt l4i kh6i luqng tuAn hoan d6 6ndlnh huy6t dQng.

- tdt ca BN ph6i dugc d4t tludng truydn tinh m4ch O BN c6 rt5i loqntruy5t OEng, ttflt 2 ttuong truydn tinh m4ch l&n ( kich thu6c 16-18c) ho4c dfltcatheter tinh mpch trung tAm n6u kh6ng th6 dAt duqc duong truydn tinh m4chngoai bi6n

+ Phii chri ), nhen bi6t c6c benh di kdm e6 aldu tri thich hgp, nh6t ldngudi gid hay kdm theo cric bQnh vd tim m4c11 hd h6p, th{n vd m4ch n5o.

- sdi phu thti tich:

BO Y TE HU6NG DAN CHAN DoAN VA EIEU TRI BENH TIEU HoA

-27-+ BOi phu the tich dugc b6t dAu truy€n tinh m4ch dich mu6i ding truong

20 ml/kg O da s6 benh nhan truydn 1-2L dfch NaCl 0,9o/o sE di€u chinh dugcthe tich dich bi m6t

+ N6u sau khi tti truyAn dlch ding truong tdi t6ng li€u 50m1,&g md benhnhdn v6n cdn d5u hiQu s6c cAn truydn dich keo (500-1000m1) d6 bao aam th6tich trong ldng m4ch

+ Plasma tu<ri tl6ng l4nh truydn cho bQnh nhen bi )GITH md c6 tinhtr4ng r6i lo4n d6ng m6u Truydn ti€u cAu cho bQnh nhAn ttang bi )GITH md s6

b Di6u tri cAm m6u biing nQi soi 6ng m6m

Kh6ng nh6t thi6t phai thuc hi€n nQi soi ngay khi benh nhdn viro viQn

nhrmg cin tirin hanh nQi soi sdm trorg 24 gid ddu dC chdn clo6n x6c dinh vddi€u tri nQi soi cim m6u n6u c6 chi d!nh CAm mriu trong24 gid dAu girip giAm,u6t try& trii phdt, Ciam ty lQ ph6u thuQt Trong trutrng hqp t4i bQnh viQn

kh6ng c6 khir nlng nQi soi md benh nhen n4ng, ntiu di€u kiQn cho ph6p thichuy6n tdi benh viQn tuy6n trdn tl6 tit5n hdnh cim m6u qua nQi soi Trudng hqpkh6ng th6 chuytin benh nhan, sau khi h6i sric tich cuc mir huy6t dQng v5nkh6ng 6n dinh thi hQi chAn v6i b6c s! ngo4i khoa dti ph6u thu4t

Mgc tlich cria cim mriu qua nQi soi:

).,

- Girip c6m mriu nhanh

- Gi6m nhu cAu truydn m6u

- NgEn ngtra ciic bitin chring do shock m6t m6u

C6c phuong ph6p nQi soi cAm miu:

- Ti€m cAm milu: bing adrenalin l/10.000, c6n tuyQt d6i, nudc muiii rru

trusng Titin hdnh ti6m 4 g6c cta 6 lodt vd ti6m vdo d6y 6 lo6t

- Dtrng nhiet: dtng dAu dd don cyc ho{c dAu dd da cyc, argon plasma '

- Cam miiu co hgc: dtng kgp clip c6 t6c dgng t6t trong trudng ho p dangchiy m6u ttr c6c mpch m6u l6n

Ngiry nay c6c bdc s! nQi soi kh6ng cdn su dgng ti6m cAm m6u clon

thudn vi hiQu qu6 th6p Niiu c6 diAu kiQn n6n phiSi frqp ti6m cdm m6u vdi c6c

BO Y TE - HU6NG DAN CHAN DOAN VA DIEU TRI BE.NH TIEU HOA

-28-phuong phrip cAm m6u kh6c, dic biqt trong trutmg hqp m6u dang ch6y tr) ttQng

m4ch sE ldm giAm ry le fi vong cfing nhu khA ndng ph6i can thipp blng ph6uthu4t

Benh nhan v6n c6 nguy co cao ch6y m6u t6i ph6t khi hinh 6nh nQi soidang chdy m6u hopc nhin thAy di6m mpch t?i 6 lodt (Forrest d0 IA,IB hoic

IIA) phdi ti6n hdnh cAm m6u nQi soi

Benh nhen v6n c6 nguy co chiy m6u trii ph6t khi hinh anh nQi soi c6 cpcmriu d6ng b6m dinh t4i 6 1o6t ( Forrest dO IIB) cAn chn nhic viQc ph6 b6 cgcmriu d6ng Chi ti6n hdnh d6i vdi b6c si nQi soi c6 kinh nghiQm di€u tri cAm

m6u vd c6 trang thi6t bi t6t Sau d6 tiiSn hnnh cA m6u nQi soi n6u d6y O loetdang ch6y mriu hopc nhin thAy di6m m4ch

BQnh nhAn it c6 nguy co ch6y m6u t6i ph6t: tren hinh enh nQi soi 6 lo6tdity c6 cln tlen hopc d6y s4ch (Forrest d0 IIC hoac III) Kh6ng c6n ti6n hanh

l.

cam mau qua ngl sol.

OOi vOl trudng hgrp cAm m6u qua nQi soi thanh c6ng mi sau d6 kh6ng c6 d6u hiQu ch6y m6u tii phdtkh6ng cAn thi6t phei ti6n hanh nQi soi 14i Dn hai chiv6i mlrc dfch tlanh giit chiry m6u trli ph6t.

Trutlng hqp kh6ng cAm tluqc m6u qua nQi soi hoic chiy mdu t6i phit:

- Truong hqp di6u tri cAm m6u qua nQi soi 16n tIAu kh6ng thd rh c6ng,can nQi ch6n vdi brlc s! ngo4i khoa d6 xem x6t khd ndng phSu thu4t N6u c6

di€u ki€n thi hQi ch6n vdi b6c s! diQn quang can thiQp OC ti6n hanh nrit m4ch

- Trulng hqp ch6y mhttiti ph6t sau khi dE nQi soi cAm m6u lin mQt,

tirin hanh nQi soi l6n hai d6 cAm m6u, n6u r6n ti.5p tpc ch6y m6u cAn ti6p qc

hQi ch6n vdi b6c s! ngo4i khoa dti ph6u thudt hoic n6u c6 didu kiQn v6i bric s!

diQn quang can thiQp d6 ti6n hanh nrit m4ch

Theo d6i chiy m6u l4i ho{c tiSp t}c ch6y mriu:

- N6n ra m6u: sau khi ttd nQi soi cAm m5u.

- D6u higu thi6u m6u n6o: kich thich, vflt v6

- Mpch nhanh l6n li d5u hiQu sdm, huyi5t 6p tut khi de m6t mriu nhiAr

- Tr6n nQi soi: c6 d6u hiQu cho th5y nguy co chdy m6u tiri phfut cao nhuForrest IA,IB, IlA, IIB

- llb gi6mtr6n20glngiry

- NCu nghi ngd dang chdy m6u, d{t sonde d4 ddy, ntiu c6 th6y mriu d6tuoi rut sonde ngay

3 Thu6c

C6c thu6c ric ch6 bom proton dudng tinh m4ch lidu cao tluoc chring minh

ln ldm gidm ch6y mriu t6i phrit vir giAm ti IQ phdi phlu thu4t:

BO Y TE Hu6Nc DAN CHAN DOAN VA DIEU Tzu BENH TIEU HoA

-29 Li€u dirng: 80mg ti6m tinh mach chAm, sau tt6 8mg/ gid truy6n li6ntuc trong 72 gid sau d6 chuy6n sang deng u6ng v6i li6u 40 mg/ngdy tOl ttrieu

28 ngdy tiiip theo (esomeprazol, pantoprazol, omeprazol)

- Oiii vOl Rabeprazol, dtrng 1i6u 40mg ti6m tinh mach ch6m + 4mglgiittruydn li6n tuc trong 72 gid sau d6 chuy6n sang tludng u6ng Hdu 40m glngity t6i

thi€u 28 ngdy ti6p theo

- Trudng hqp kh6ng c6 thu5c ding dudng tinh m4ch, c6 thii sri dUng

thu5c vi€n e6p 2 -: tan tieu ti€u chu6n trong 72 gid dAu Sau tI6 dtng ti6p I€u

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

4 Didu tri ngo4i khoa: khi su dgng c6c phuong ph6p cAm m6u ndi soi vi

thutic thAt bai c6 thii xem xdt di€u tri ngo4i khoa ho4c nrit m4ch

5 N6u cr6 HP ph6i tiet trt sau khi XHTH tle 6n dinh

BOYTE-HUdNG DAN CHAN DOAN VA EIEU TRI BENH TI6U HoA

-30-Sa tI6 xfr tri XHTH do lo6t hirnh trfl tr]rng

NOn m6u/ia phin den

Cim m6u thAt b?i

Nrit mpch hoflc ph6u thu6t

Th6t bai

Didu tri nQi soi cim m6u DiAu tri PPI tinh m4ch liAu cao

Cim m6u thinh c6ng

DiQt H.pylori LAp

cam

nQl sol m6u

-31-Tii liQu tham kh6o

1 Barkun AN, Bardou M, Kuipers EJet al(2010) Intemational consensus

recommendations on the management of patients with nonvariceal uppergastrointestinal bleeding Ann Intern Med;l 52:101-13

2 Jensen DM, Ahlbom H, Eklund S et al(2010) Rebleeding risk for oozingpeptic ulcer bleeding (PLIB) in a large intemational study

- a reassessment

based upon a multivariate analysis Gastrointest Endosc;71:A8117

3 Jensen DM, Machicado GA(2005) Endoscopic hemostasis of ulcerhemorrhage with injection, thermal, or combination methods Tech

Gastrointest Endosc;7 :124-3 l.

4 Sung J, Chan F, Lau J et al(2003) The effect of endoscopic therapy inpatients receiving omeprazole for bleeding ulcers with nonbleeding visiblevessels or adherent clots: a randomized comparison Ann Intern Med;139:

BQYTE HU6NG DAN CHAN EoAN vA oreu rRr BENH TIEU HOA -3

Z-cHAN DoAN vA ottu rry NnrfnnarzICoBACTERPYLoRr

r D4.r cLroNG

Nhi6m khuan Helicobacter pylori (Hp) ld mQt trong nhfrng nhi6m khu6n

ptrO titin nhAt 0 ngudi, chi6m tr6n 50% d6n- s6 thi5 gi6i' D6y ld nguy6n nhAn

thuong C4p Cay vi€m d4 ddy m4n (VDDM), lo6t d4 ddv - tri trang (DD-TT) vdune thu Ja Ouy rufOO) Nghi6n ctu trong nudc cfing cho th6y nguy co bt lo6t

pd - ff 'o nluoi nhi6m np cao ghp 27,816n so v6i ngudi kh6ng nhi6m Hp'Tuy vfy, nfri6- ffp kh6ng phdi ludn lu6n d6ng nghia v6i mic c6c benh ldm

sdng n4ng, nguy co ph6t triiSn thanh 1o6t DD-TT chi vio khoing 15% vi nguy

co UTDD khoang 1% O ViCt Nam, ty 1€ nhiem Hp d6nh gi6 dga tr6n x6tnghiQm huy6t thanh hoc theo c6c nghi6n ciru rii r6c vio khoing 56Yo - 75,2o/o;

ty lQ Hp (+) trong vi6m d4 ddy m4n ld 53 - 72,8%; trong 1o6t DD-TT lit 87,2

-89,5olo vd trong UTDD ld 50 - 60%

II CHANDOAN

1 C6c trutmg hqp tluo;c chi ilinh lirm x6t nghiQm chAn tlo6n nhiSm IIp:

- Do ph6n 16n c6c trulng hqp nhi6m Hp kh6ng gdy c6c bQnh c6nh ldm

sirng, viQc x6i nghiQm tarn so6t rQng rdi cho toirn th6 cQng d0ng hiQn kh6ng phirhs,p v6i tinh hinh hien tai Kh6ng n6n chi dinh ldm x6t nghi€m chAn doan

nhi6m Hp mQt c6ch thudng qui khi ki6m tra sfc kh6e dinh ki'

- X6t nghiQm chAn tlo6n nhi6m Hp n€n ilugc chi dinh trong c6c trudnghqp sau:

+ Chimg kh6 ti6u

+ Tidn sri 1o6t DD-TT

+ sau ph6u thuat d6 dicu tri UTDD

+ C6 hinh anh vi6m DD - TT, Io6t DD - TT tr€n nQi soi

+ C6 cha mg ho{c anh ch! em ruQt biUTDD

+ Can diAu td ldu dii v6i c6c thu6c thuQc nh6m khang vi€m kh6ngsteroid

+ CAn tli€u trf aspirin 16u dai d ngudi c6 c6c yiSu tti nguy co cao bi lo6t

vd bi6n ch(mg do lo6t DD - TT (> 60 tu6i, ti6n sir lodt d4 ddy - t6 trang, sridqng d6ng thdi thu6c khring d6ng, corticoid ho{c c6 kdm bQnh lf ph6i hqpnanc)

+ B€nh triro nguoc dp dny - thyc quan can ei6u tri duy tri k6o dai bing

nh6m thu5c fc ch6 bcrm proton

+ thi6u m6u thiiiu sit kh6ng gi6i thich elucr c nguy6n nh6n

+ Ban xu6t huytit gidm ti6u ciu v6 cdn

BQ Y TE - HU6NG DAN C HAN EoAN VADI2,iru EE.NH TIEU HOA

-33-+ Benh nhdn mong mu6n dusc di6u tri (sau khi di dugc thAy thu6c tuv6n)

2, Cicphuong ph6p x6t nghipm ch6n tlo6n nhi6m Hp

- C6c x6t nghiQm ch6n do6n Hp bao gdm:

+ Nh6m x6t nghipm xdm I6n (c6n nOi soi dp ddy): urease nhanh, m6b€nh hoc, nu6i c5y, PCR

+ Nh6m xdt nghiQm kh6ng x6m l5n: x6t nghiQm huy6t thanh hoc, xdtnghiQm hoi thd, x6t nghiQm tim khang nguy6n trong phAn.

- ci6 tri cia c6c x6t nghiQm chAn dorin Hp

+ X6t nghiQm urease nhanh vi x6t nghiQm hoi thd lit 2 xdt nghiQm chinhxlct'th(x

+ X6t nghiQm huylit thanh hgc k6m chinh xric nhSt ve kh6ng n6n luachgn n6u c6 nhfrng phuong phrip chdn doan Hp kh6c X6t nghiQm tim khringnguydn trong ph6n cdn cen th€m c6c nghiEn criu trong nu6c d6 drinh gi6

t Xdt nghiCm mO bQnh hoc, nu6i c6y, PCR: it phO bitin, m6t thdi gianchd do tI6 chtr yiiu chi dirng trong ciic trulng hAp cAn phOi hgp ttrffi gi6 m6b€nh hqc (x6t nghiQm mO bgnh hgc), x6c dinh dA khrlng khring sinh khi th6t baidi6u tri itnhetz hn (nu6i cdy) vitxdc dlnh chtng Hp trong nghiCn cuu (PCR)

3 Chgn lga phuong ph6p x6t nghiQm chAn do6n Hp

- Tru6c khi ldm circ xdt nghiQm chan dorin Hp (ngo4i tru x6t nghiCmhuy6t thanh hgc), cAn dung srl dqng khang sinh (kC ci khang sinh sri dqngkh6ng ph6i vdi mqc dich ti€t tru Hp) vi Bismuth I 4 tu6n; c6c thu6c thu6cnh6m thu5c ric chil bom proton vir khring thU th6 H2 > 2 tuan tinh tir li6u dung

,( .

cuol cung,

- ViQc chgn lua phuong ph6p ch6n doan Hp, ngoiri c6Lc v6n dd nhu lo4ix6t nghiQm chAn do6n Hp sin c6 tai ch6, gi6 thanh x6t nghiQm cdn bdn phirthudc vdo c6c yiiu t5:

+ C6c triQu chimg brio dQng bqnh nguy hi6m

+ Tidn su <tE c6 len diAu td tiQt tru Hp

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

chAn dorin x6m 6n (chi <t!nh nQi soi d4 ddy) nhim d6ng thoi denh giii nQi soi +

mO bQnh hpc d6 1o4i tnr c6c benh l), nguy hi6m C6c d6u hiQu b6o dQng baogom:

+ Bi6u hiQn nghi ngO xu6t huyiit tiCu h6a tr6n

+ N6n k6o ddi ho4c n6n ra thirc in cff

B0 Y rE - HUdNG DAN cHAN DOAN vA DIE U TRI BE.NH TIEU HOA

-34-+ KhOi u virng bgng tr6n

+ Trieu chung kh6 ti6u m6i khdi phrit d tu6i > 40

+ Tri6u chung kh6 ti€u khdng d6p ung ho4c t6i ph6t sau di6u tri tht2

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

th6 chi dinh *lt ,ghig huyi5t thanh hgc nhrmg cAn th4n trqng khi phdn tich kOt

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

tinh thi v6n c6 khd ndng 6m tinh gi6 cao Kh6ng chi tlinh x6t nghiQm huy€tthanh hgc ntiu bQnh nh6n dE c6 tii:n sir tiQt tru Hp do k6t qun v6n cdn duongtinh mQt thdi gian ddi ngay cd sau khi tiQt tru thanh cdng'

TII EIIU TRI

L Mgc ti6u & nguy6n tic tlilu tri

Nguy6n t6c diAu tri tiet tru Hp ln ph6i hqp mQt thuiSc khring ti6t acid d4

ddy mpnh l6t hqp vdi ttr hai lo4i khang sinh trd 16n C6c thu6c khang titit acid,goai ta dQng tr.uc tiilp ldm gi6m mQt dQ cria Hp cdn c6 vai trd girin ti6p quantrgng ld,rn gi6m sy tho6i gi6ng vd tEng tinh th6m cta c6c khring sinh cht lUc d6

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

ti5t la dat duqc ti lQ tiet tru thanh c6ng t5i thi6u Z 80%

BQ Y T6 - HU6NG DAN CHAN DOAN VA D IEU Tzu BENH TI6U HOA

-35-2 TGn vir [6u cira cric thuiic th d tro trir H

3 T0n ui ufc cta c6c h6c ttd tli6u t

4 Chgn tga ph6c tld tlidu tri

- Ph6c d6 dAu tay (b€nh nhdn chua timg duqc di6u tri tiet tru Hp): C6th6 su dqng ph6c d6 ntii tii5p, phric tlO 4 thu6c c6 Bismuth ho4c phric OO + ttrui5c

kh6ng c6 Bismuth

- Ph6c dd thir 2 (dA th6t bai di6u tri tiQt trir 1 lAn): Sri dgng phric tl6 4thu6c c6 Bismuth n6u trudc ct6 chua di€u tri vdi ph6c dd ndy Trong trudnghqp dd su dqng 4 thu6c chria Bismuth ldm ph6c dd dAu tay nhung that bqi thisri dlrng phric dd 3 thu5c chria Levofloxacine

- Ph6c d6 cuu crinh (da th6t b4i sau didu tri ti€t tnr 2 l6n): CAn nu6i c6y

vd ldm khring sinh dd d6 x6c dinh kh6ng sinh diAu tri thich h-o,p.

Trudc bta 6n chinh 30 - 60 phritThoi tli€m

su dgng

Ngay sau bila 5n

Ghi chi: A: Amoxicilline, B: Bismuth, C: Clarithromycine, L: Levofloxacin,M: Metronidazole , Te: Tetracycline, Ti: Tinidazole,

TGn ph6c tlii Thli gian

(ngiv) Cich sfr dgng

Ph6c dd 3 thu6c c6 Levofloxacin 10 PPI+A+L

l0 5 ngiy PPI + A, sau tl6

5ngdyPPI+C+Ti

Ph6c tI6 4 thu6c kh6ng c6 Bismuth l0 PPI+A+C+M/Ti

Ph6c dO 4 thu6c c6 Bismuth t4 PPI+M+Te+B

B0 t iE - HU'dNc rAN CnAN SoAN vA oteu rnisENH rr6u HoA

-36-Ph6c tI6 nOl ti6p

- Kh6ng dung 14i khring sinh di sri dgng trong ph6c Ad eidu tri bi th6tb4i tru6c d6, dac biet la Clarithromycine (ngo4i tru Amoxicilline) vi ti lQ khangthu5c thri ph6t r6t cao.

- Khuy€n benh nhan t4m ngtmg hrit thu(ic 16 vd kh6ng u6ng rugu biatrong thdi gian diAu tri tiet tru Hp vi c6 th6 ldm ginm hiQu qui thdnh c6ng criaph6c d6.

- CAn ldm x6t nghiQm ki6m tra hiQu qui tiQt tru cho tat ca benh nhdn ddduqc di6u tri diQt trir tru6c d6.

- N6n thpc hipn nQi soi trong trulng hqp can Aa*r gi6 l4i t6n thuongtr6n nQi soi vd / ho4c m6 benh hqc nhu lodt da ddy - tblringvd dd c6 c6c t6nthuong tidn ung thu d4 diy (vi6m dp diry m4n teo, di sirn ruQt d d4 ddy, 1o4n

sdn da ddy) Lodt d4 ddy sau tli6u tri can Aann gi6 lai blng nQi soi + sinh thititd€ loai trir ciic trudng hqp UTDD dpng lo6t Tiet tru Hp thanh cOng girip ldmgi6m nhrmg kh6ng ngin ngira tlugc hodn todn nguy co LrfDD d c6c bQnh nh6nnhiSm Hp ct6 c6 c6c t6n thuong tidn ung thu d? dey trudc didu tri Do d6, c6c

benh nhen ndy v6n cen dugc nQi soi d4 ddy d0 theo ddi titin triiln nhim phrithien UTDD d giai do4n sdm Thdi khoang dC dinh ki' nQi soi d4 ddy + sinhthii5t dinh k! cdn dugc nghi€n cuu th6m

- Trong c6c trulng hqp kh6c cO th6 ki6m tra hiQu qud tiQt trir bing x6tnghiQm kh6ng xdm l5n X6t nghiQm hoi th0 ( l3C vn 14C) tluoc khuytin c6o

hong trulng hqp ndy do c6 gi6 tri tuong duong v6i x6t nghiQm Urease nhanh

v DUPHONG

Cho diin nay v6n chua c6 v8c xin phdng ngua nhi6m Hp ViQc phdng nguat6i nhiSm hiQn t4i cht yi5u h rfia tay k! tru6c khi [n, 5n c6c thrlc 6n duo c ctruAn bidring ti6u chu6n vQ sinh thpc ph6m vd uting nudc tt c6c ngu6n nudc s4ch, an

toin.

Tiri liQu tham khfro

-1 Hunt R, Xiao S, Megraud F et al (2010) Helicobacter pylori indeveloping countries: World Gastroenterologt Organisation GlobalGuidelines

2 Malfertlreiner P., Megraud F., O'Morain C A., et al (2012)

"Management of Helicobacter pylori infection the Maastricht IV/

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

3 Fock KM, Katelaris P, Sugano K, et al (2009) "Second Asia-PacificConsensus Guidelines for Helicobacter pylori infection." J

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

eO v TE - HU.dNG DAN CHAN DOAN VA DIEU TRI BE.NH TIEU HOA