Nguyen Chu nhiem Khoa Phau thuat Tim mach - Long ngUc 13V.. Chu nhiem khoa Ngoai BV.[r]
(1)Y
.007272 B O Y T E
CffP GUU NGOHIKHOH TAP 2■
(D U N G C H O B A C Si V A H O C VIEN SAU DAI H O C) Chu bien: GS DANG HANH OE
CD
(2)(3)BO Y TE
CAP CUfU NGOAI KHOA■
TAP 2
(DUNG CHO BAC SI VA HOC VIEN SAU DAI HOC)
MA SO: D01.Z10.W
NHA XUAT BAN GIAO DUC VIET NAM
(4)Chi dao bien soan:• •
VU KHOA HOC VA DAO TAO - BO Y TE
Chu bien:
GS DANG HANH DE
T ham gia to chttc ban thao: ThS PHI VAN THAM TS NGUYEN MANH PHA
© Ban quyen thuoc Bo Y te (Vu Khoa hoc va Dao tao)
1054 - 2010/CXB/18 - 1758/GD Ma so: 7K875Y0 - DAI
(5)Chu bien:
OS DANG HANH DE
Nguvcn Pho Chu nhiem Bo mon Ngoai TrUdng Dai hoc Y Ha Noi Nguyen Chu nhiem Khoa Phau thuat Tim mach - Long ngUc 13V Viet Dilc Chu nhiem khoa Ngoai BV HCtu Nghi
Tham gia bien soan:
NGUYiN NGOC BICH
PGS.TS Pho Tarong Bo mon Ngoai Trifdng Dai hoc Y Ha Noi Tnidng khoa Ngoai Benh vien Bach Mai
] TRAN NGOC BICH PGS.TS Trirong khoa Phiu thuat Nhi BV Vi^t Dire
T
jOANG HANH D$ GS Nguyen Pho Chu nhi6m B6 mdn Ngoai Trudng Dai hoc Y Hei N6i Nguyfin
Chu nhiem Khoa Phau thuat Tim mach - Long ngi/c BV Vi§t Ode Chu nhiem khoa Ngoai BV HQu Nghi
! DONG VAN HE TS Phau thuat vien Khoa Phiu thuat Than kinh BV Viet Dire ! DITONG OAI HA
j TS Phiu thuat vien Khoa Phau thuat Th§n kinh BV Viet OCrc
] DUONG OL/C HUNG TS Pho Truong khoa Phau thuat Tim mach - Long ngi/c BV Viet DCfc
DOAN QUOC HUNG TS Phau thuat vien Khoa Phau thuat Tim mach - Long ngi/c BV Viet DCfc TRAN HIEU HOC TS Pho Truong khoa Ngoai BV Bach Mai
j PHUNG NGOC HOA ThS Phau thuat vien Khoa Chan thuong - Chinh hinh BV Viet Dl/c
IkI^UDINH HUNG
I TS Phau thuat vidn BV Dai hoc Y H& Noi i
PHAM o ir c HUAN PGS.TS Pho TrUcing Bo mon Ngoai tn/dng Dai hoc Y Hci Noi, Tn/ong khoa
Phau thuat Tieu hoa BV Viet Dire
NGUYEN XUAN HUNG PGS.TS Truong phong Kham cap cl/U BV Viet Di/c
HOANG LONG TS Phau thuat vien Khoa Tiet nieu BV Viet Due NGUYEN VAN MAO ThS Giam doc BV Tim Ha Noi
TRAN BAO LONG PGS.TS Phau thuat vien Khoa Gan - Mat BV Viet Due LE HONG NHAN TS Pho Truong khoa Phau thuat Than kinh BV Viet OCrc
NGUYEN DUC PHUC PGS P h iu thuat vien Khoa Chan thuong - Chinh hinh BV Viet Difc
NGUYEN QUANG TS Phau thuat vien Khoa Nam hoc BV Viet B u t
(6)
HA VANQUYET
-
-GS.TS Truong Bo mon Ngoai Tn/dng Oai hoc Y Ha Noi Pho Giam doc BV Viet OCfc
DANG HANH SON TS Phiu thuat vien BV Tim H& Noi
0 TRUONG SON TS Phiu thuat vien Khoa phiu thuat tieu hoa BV Viet Dire
HOANG NGOC SON TS Phiu thuat vien Khoa phau thuat Ch£n thuong - Chinh hinh BV Viet DC*:
NGUYEN CONG TO PGS.TS Pho TrUcing Bo mon Ngoai Truong Oai hoc Y Ha Noi Pho Giam doc BV Viet OCfc
DO t r uOn g t hAnh TS Pho Tru6ng khoa Phau thuat Tiet nieu BV Viet OCfc
LE NGQC THANH PGS.TS Giam doc Trung tarn Tim mach BV E
hAk im t r u n g TS Pho Truong khoa Phau thuat Than kinh BV Viet OCfc
TRINH VAN TUAN TS Phau thuat vien Khoa Cap cCiu Tieu hoa BV Viet OCfc
DOAN THANH TUNG PGS.TS Trudng khoa Phau thuat Gan - Mat BV Viet OCfc
NGUYEN HOU UOC PGS.TS Pho Truong Bo mon Ngoai Truong Oai hoc Y Ha Noi Pho Truong khoa Tim mach - Long ngUc BV Viet OCfc
(7)L d l GICJl THIEU
Dao tao nguon nhan lUc can bo chat ltfdng cao la mot nhOng moi quan tarn hang dau cua nganh Y te Song song vdi viec dau tu cO sd vat chat cho cac cO s6 dao tao, Bo Y te chu tang cUOng cac phUOng tien day va hoc, viec bien soan tai lieu day-hoc dac biet Uu tien
Sach Cap cufu ngoai khoa dUOc bien soan nh&m phuc vu cho viec dao tao sau dai hoc cua trUOng Dai hoc Y Ha Noi, nhUng cung la tai lieu tot de tham khao cho viec dao tao dai hoc va cho cac bac si ngoai khoa Sach dUOc bien soan v6i phUdng cham: Kien thiic c0 ban, he thong; noi dung chinh xac, khoa hoc, cap nhat cac tien bo khoa hoc, ky thuat hien dai va thuc tien Viet Nam
Cuon sach dUOc bien soan boi cac nha giao, cac nha khoa hoc giau kinh nghiem linh vUc Ngoai khoa Sach da dUOc Hoi dong chuyen mon lap theo quyet dinh so: 1683/QD-BYT 20 thang nam 2010 cua Bo Y te tham dinh Sach dUdc ban hanh lam tai lieu sU dung chinh thiic phuc vu dao tao dai hoc
va sau dai hoc cua nganh Y te giai doan hien nay, dong thdi cung se la tai lieu hu!u ich cho cac bac si tham khao hang
P3o Y te xin chan cam dn GS Nguyen BUu Trieu, Chu tich Hoi dong tham djnh, GS Do Diic Van va GS Ha Van Quyet Uy vien phan bien va cac uy vien Hoi
dong da doc, dong gop nhieu y kien quy bau de cuon sach dUOc hoan thien
Chung toi m on g nhan dUOc y kien dong gop cua dong nghiep va cac doc gia de
sach dUdc h oan chinh hOn cho nhutng lan xuat ban tiep sau
VU KHOA HOC VA DAO TAO - BO Y TE
(8)(9)L O ln o i d a u
Cap ciiu ngoai khoa luon la mot van de thdi sU khong nhutng cua cac phau thuat vien ma cua tat ca nhu!ng lam cong tac lam sang
Trong the ky trUdc Nha xuat ban Y hoc da xuat ban cuon Cap cvfu Ngoai khoa, nhUng trai qua nhieu nam vdi nhiing tien bo nhanh chong cua y hoc noi chung cung nhu sU phat trien cua nganh Ngoai khoa noi rieng, cuon sach khong cap nhat niia
Chung toi bien soan lai lan nham trU6c het phuc vu cho cong tac dao tao (dai hoc va sau dai hoc cac trUdng Dai hoc Y) va sau la cac dong nghiep d cac tuyen y te ca nUdc NhOng ngUdi tham gia bien soan deu la cac can bo giang day Bo mon Ngoai trUdng Dai hoc Y Ha Noi vdi nhieu nam giang day va p h iu thuat tai cac benh vien 16n (Viet Diic, Bach Mai, Saint Paul), thuoc dung chuyen khoa cua minh Vi the chung toi hy vong cuon sach se dap ling dUdc yeu cau cua cac dong nghiep
Noi dung cuon sach chi thu gon nhOng cap cCfu ngoai khoa thong thUdng, rat hy vong tUdng lai co the bien soan cuon Ngoai khoa toan tap (Textbook of Surgery), mot cong trinh 16n doi hoi sU tham gia cua nhieu ngUdi, nhieu chuyen nganh khac Sach dUdc bien soan tap:
- Tap gom cac chuyen khoa: Than kinh, Long ngUc va Tim mach, Nhi - Tap gom cac chuyen khoa: Tieu hoa, Tiet nieu, Chan thUdng
Du da rat co gang nhUng van khong the tranh dUdc nhutng thieu sot nhting tien bo khong ngting va nhanh chong nganh Y noi chung, viec cap nhat kien thiic khong the bat kjp
Chung toi xin chan cam dn ong Phi Van Tham, chuyen vien cao cap Vu Khoa hoc va Dao tao Bo Y te da khuyen khich va tao moi dieu kien thuan ldi de cuon sach dude xuat ban Cam dn ba Nguyen Thi Thanh Binh, Thu ky Bo mon Ngoai da gop phan bien soan cuon sach
(10)(11)MUC LUC
Ldi gidi thieu 3
Ldi noi d a u P han TIEU HOA
1 Thung thiic q u a n 13
(Pham Dtic Huan)
2 Thung o loet da day - ta trang 24
(Ha Van Quyet)
3 Chay mau loet da day - ta trang 32
(Ha Van Quyet)
4 Hep mon v i 41
(Ha Van Quyet)
5 Chan doan va dieu tri chan thUdng ta trang 48
(Trinh Van Tuan)
6 Chan doan va dieu tri chan thUdng t u y 58
(Trinh Van Tuan)
7 Tac ruot 69
(Pham Dite Huan)
8 Thoat vi n g h e t 79
(Ha Van Quyet)
9 Xoan r u o t 88
(Nguyen Ngoc Bich)
10 Chan thUdng bung va vet thUdng bung 98
(Ha Van Quyet)
11 Viem ruot thvfa 108
(Pham Di'/c Huan)
12 Viem tui thu'a Meckel 119
(N guyen N goc Bich)
13 Viem phuc mac va cac o ap xe o b u n g 125
(N guyen N goc Bich)
14 Thoat vi co h o a n h 136
(N guyen N goc Bich)
15 Chay mau o bung khong chan thUdng 143
(Nguyen N goc Bich)
16 Vet thUdng hau mon - true t r a n g 151
(Ha Van Quyet)
17 Ap xe gan a m ip 156
(Tran Hieu Hoc)
18 Chan thu'dng va vet thUdng gan 164
(12)19 Soi mat va bien chting cap ciiu 173
(Doan Thanh Tung)
20 Viem tui mat 183
(Doan Thanh Tung)
21 Viem c a p 189
(Tran Hieu Hoc)
22 Chay mau ap ltfc tinh mach ciia 202
(Tran Hieu Hoc)
23 NhCfng cap ctiu thUdng gap vung hau mon trtfc trang 216
(Nguyen Xuan Hung)
24 Bong thiic quan 230
(Do Tritctng Scfn)
25 Chay mau dUdng m a t 238
(Do Trii'dng Scfn)
Phan TIET NIEU
1 Cdn dau quan than 253
(Hoang Long)
2 Vo nieu tac 259
(Hoang Long)
3 Dai m a u 264
(Hoang Long)
4 Bi dai c a p 268
(Hoang Long)
5 Soi ket nieu d a o 271
(Hoang Long)
6 Chan thUdng than 273
(Hoang Long)
7 Chan thifdng va vet thtfdng nieu q u a n 287
(Hoang Long)
8 Chan thUdng bang quang 293
(Do Triibng Thanh)
9 Chan thUdng nieu d a o 299
(Do Triibng Thanh)
10 Chan thtfdng vung b iu 310
(Hoang Long)
11 Ctfdng dau difdng vat keo dai (Priapism) 313
(Nguyen Quang)
12 Vet thtfdng dUdng v a t 320
(Nguyen Quang)
13 Vd vat hang 327
(Nguyen Quang)
14 Xoan tinh h o a n 332
(Nguyen Quang)
(13)15 Lf mu than 338
(N guyen Quang)
16 Ap xo quanh th a n 346
(N guyen Quang)
1 Ap xe va nhot t h a n 353
(N guyen Quang)
18 Viem tuven tien liet cap tfnh 362
(N guyen Quang)
19 Hoai thu cd quan sinh due: benh Fournier 367
(N guyen Quang)
Phan CHAN THl/ONG
1 Vet thUdng phan m em 373
(Phung Ngoc Hoa)
2 Gay xUdng d tie c m 378
(Nguyen Diic Phuc -Phung Ngoc H o d ) Gay xUdng h d 383
(Phung Ngoc H od ) Gay xUdng co bien chiing than kinh 394
(Nguyen Ditc Phuc - Phung Ngoc Hod)
5 Gay xUdng co bien cluing mach m a u 401
(Nguyen Diic Phuc - Phung Ngoc Hod)
6 Hoi cluing chen ep khoang 406
(Phim g N goc Hod)
7 PhAu thuat cat cut c h i 414
(Phung N goc Hod)
8 Vet thUdng k h d p 425
(P him g N goc Hod)
9 Viem xu'dng 429
(Phung N goc Hod)
10 Hoai thu sinh hdi 436
(P N goc Hod)
11 Dai cUdng ve bong 440
(P N goc Hod)
12 Dai ciidng ve U xUdng 447
(P N goc Hod)
13 Trat khdp v a i 454
(Ph ung N goc Hod)
14 Trat khdp khuyu 460
(Phung N goc Hod)
15 Trat khdp hang 467
(14)16. Gav than xUdng canh l a v 478
(Phung Ngoc Hod)
17 Gay tren loi cku xUdng canh tay d tre e m 482
(H oang N goc Sctn)
18 Gay hai xUdng cang tay 494
(Phung Ngoc Hod)
19. Gay dau dudi xUdng quay ngUdi ldn 502
(H oang N goc Scfn)
20 Vet thUdng ban t a y 513
(Phung N goc Hod)
21 Nhiem Lrung ban ta y 522
(Phung Ngoc Hod)
22 Gay xUdng c h a u 532
(Phung N goc Hod)
23 Gav co xUdng d u i 543
(Phung Ngoc Hod)
24 Gav khoi mau chuyen xUdng d u i 550
(Phung Ngoc Hod)
25 Gay than xUdng dui 555
(Phung N goc Hod)
26 Gav d&u dudi xUdng dui 563
•(Phung Ngoc Hod)
27 Gay hai xUdng cang c h a n 568
(Phung N goc Hod)
28 (-lay xUdng co ch a n 577
(Phung Ngoc Hod)
29 Cac ton thuong phan mem vung co c h a n 582
(Phung N goc Hod)
30 Gav mam ch a y 588
(Phung N goc Hod)
(15)PHAN 4
TIEU HOA
1 THONG THUCQUAN
Thung thiic quan la tap hdp cac ton thiidng tat ca cac 16p cua thiic quan lam thong long thiic quan v6i ben ngoai cac nguyen nhan khac nhii vet thufdng, chan thiidng va thung thiic quan tii phat hoac thay thuoc gay Du nguyen nhan nao thi thung thiic quan cung co nhieu diem chung la benh canh lam sang giong nhau, deu co nguy cd viem trung that, nguyen tac va cac phiidng phap dieu tri giong
Thung thiic quan la mot ton thiidng it gap ngoai khoa nhUng lai la ton thiidng thung co tien liidng nang nhat cac loai ton thUdng thung rua tieu hoa vi chan doan thiidng muon, dieu tri kho khan va ty le ty vong rat cao (20 — 30%) mac du hoi siic va dieu tri phau thuat da co nhieu tien bo
1 N G U Y E N N H A N
Co rat nhieu nguyen nhan gay thung thiic quan v6i cac cd che gay thung khac nhii la vet thiidng, chan thiidng tii ngoai vao (vet hiidng bach khi, hoa khi, tai bien phau thuat), hoac tCf (noi soi, di vat), hoac la vd thiic quan tii phat tang ap liic dot ngot long lam xe rach thiic quan hoac la cac benh ly thiic quan (ung thii thiic quan)
1.1 T h u n g thiic q u a n tai bien cua phau th u a t, th u th u a t
1.1.1 Tai bien cua noi soi
Thung thiic quan noi soi la nguyen nhan thiidng gap nhat, chiem tren 50% tat ca cac nguyen nhan gay thung thiic quan Ty le thung thiic quan noi soi chan doan lidc tinh khdang 0,13 - 0,4% Trong noi soi chan doan, thung thiic quan co the gap co thoat vi hoanh, dung ong soi ciing, dat ong soi mo m lm , khong kiem soat bang mat Trong noi soi dieu tri, nong thiic quan dieu tri cac nguyen nhan hep d thiic quan (seo hep thiic quan sau bong, dieu tri co that tarn vi ) la nguyen nhan gay thung thiic quan hay gap nhat, sau la cac tai bien cac dieu tri tam thdi hep thiic quan ung thii (dat nong thiic quan, laser), tiem xd cam mau
(16)1.1.2 Tai bien phau thuat
Cac phau thuat vung co nguc va bung tren deu co the gay vet thuong thuc quan cat phai thiic quan cac ton thudng cua tang lan can xam lan vao thuc quan hoac cac dung cu phau thuat dat tai cho ty de vao thUc quan lau ngav gay thung Cac phau thuat d vung co co the lam thung thiic quan la cat tuyen giap ung thu hoac tuven giap qua to cac nep, vit cot song co ty de vao thuc quan md quan khong dung ky thuat Cac phau thuat d long ngiic nhu cat phoi soi trung that co the gay ton thiidng thuc quan ngitc bung, cac phau thuat co the gay thung thuc quan la md cd thiic quan ngoai m em mac (phau thuat
Hellerv) cat than than kinh X cac phau thuat dieu tri thoat vi hoanh
1.1.3 Cac nguyen nhan khac
Tai bien cua dat bong Blakemore, bong Linton de cam mau chay mau tang ap luc tinh mach ciia thiic quan rat de ton thudng thieu mau ty ep keo dai cua bong Thung thuc quan ong noi quan va thd may keo dai rat it gap 1.2 V et thifdng va ch an thiidng thiic quan
Vet thiidng thuc quan bach va hoa it gap d co, vet thudng thiic quan thudng phoi hdp vdi cac vet thudng mach mau ldn vung co hoac phe quan vdi bieu hien lam sang la chay mau ldn hoac tran ldn diidi da co hoac trung that
Vd thuc quan chan thiidng bung hoac chan thiiOng ngiic kin rat hiem gap va chu yen thay d nhung benh nhan da chan thuong Sii tang ap liic dot ngot lon£ thuc quan thudng gay vd thuc quan ngUc doan 1/3 tren thuc quan dUdng vd d mat tru'dc va thudng kem theo vd phan mang quan Mot so trUdng hdp vd thiic quan hut vao ong hdi co ap luc cao duong vd thiic quan thudng rat ldn 1.3 Vd thufc quan tii phat
Vd thuc quan tu phat la vd thuc quan sau non manh va nhieu, bao gom hoi chung Boerhaave, hoi chiing Mallory - Weiss va mau tu tu phat thuc quan
Hoi chiing Boerhaave dude dinh nghia la ton thuong vd hoan toan cac ldp cua thiic quan ngue khong chan thudng Cd che vd thuc quan la non manh gay tang ap hie dot ngot long thuc quan cd nhan hau dong kin Trong cac trudng hop vd thuc quan tu phat thudng thay co cac ton thudng thiic quan than kinh phoi hop nhu viem thuc quan tang trudng luc cd that diidi cua thiic quan tui thua thuc quan nguc v v Hoi chung Mallory - Weiss co cd che chan thudng tucr.g tu nhu' hoi chung Boerhaave nhung ton thudng la rach doc m em mac tam vi lop eO khong bi ton thudng
1.4 Tilling thiic quan di vat
Nguyen nhan thuong gap nhat ia nuot phai xuong Vi tri thung tb.v.zr.z :
(17)nhCtng ncfi hep cua thuc quan, dac biet la d thiic quan ngiic Chieu dai xUdng va hinh dang manh cua xUdng la you to' nguy cd quan nhat gay mSc lai d thiic quan va gay thung Thung thiic quan co the manh xUdng bi mac lai va choc thung thuc quan, cung co the thu thuat lay xUdng qua noi soi gay thung Can het siic chu y tim dau hieu thung thiic quan trUdc, va sau soi thiic quan lay xUdng mdc
1.5 M ot so n g u y e n n h a n k hac
- Thung cac khoi u cua thiic quan hoac cac khoi u cua trung that, u phoi vd vao thiic quan
- Cac ton thUdng viem lao, hoi chiing suy giam mien dich mac phai - Uong phai cac chat an mon (acid, kiem manh)
2 SIN H B E N H H O C
TrCf cac cd che thung thiic quan tai bien cua phau thuat, noi soi, cd che cua vd thiic quan tii phat la tang ap liic dot ngot long thiic quan non hoac nac manh cd che' that tren cua thiic quan dong kin Vd hoac thung thiic quan lam long thiic quan thong vdi cac khoang te bao d phi'a tren la khoang sau hau, sau thiic quan co va phia dudi la khoang te bao cua trung that sau Hdi nuot vao, tham chi la bdm hdi bdm thiic quan lam tach cac khoang te bao long leo, gay hien tUdng tran du6i da co va tran dudi trung that Nude bot, thiic an chay vao cac khoang te bao nhanh chong dan tdi tinh trang viem trung that nhiem khuan nang Viem trung that nhiem khuan thudng xuat hien sau thung 12 gid Dich acid cua da day tran vao trung that cac trUdng hdp vd thiic quan thap, trao ngUdc dich da day len thiic quan vao trung that co the lam nang them tinh trang nhiem khuan trung that Viem trung that gay phan ling tang tiet cua phe quan, nhiem trung phoi NgUdc lai, nhiem trung phoi bi nang them vd thiic quan thong vdi mang phoi hoac thii phat cac o ap xe trung that vd vao mang phoi gav nen
Dien bien tii nhien cua qua trinh viem trung that la rat nang nhiem trung, nhiem doc va cac bien chiing ho hap nang Nguy cd co the nhe hdn cac trung that da xd hoa nhu cac trUdng hdp viem thiic quan trao ngUdc hoac sau cac viem chit hep thiic quan, sau bong thiic quan
3 G IA I P H A U B E N H
- Thung thiic quan thu thuat noi soi: ton thudng thung thiic quan thudng la cac lo thung nho, bd sac nhon, dai, cheo tii tren xuong, lo va lo ngoai lech hoac la ton thuong xe rach thiic quan tUdng ling vdi cho thiic quan benh ly
(18)- Vd thiic quan chan thiidng: thiidng gap d 1/3 tren cua thiic quan ngiic cac chan thiidng manh vao long ngiic Ton thUdng d thiic quan kern theo ton thiidng mang sau cua phe quan va cac tang long ngiic
- Vet thudng thiic quan: it gap va it la ton thUdng thiic quan ddn doc d co, vet thiidng thiic quan thiidng kern theo ton thudng cac mach mau ldn d co va quan nen trieu chiing lam sang thudng bi che lap bdi hoi chiing chay mau hoSc kho thd
- Thung thiic quan tii phat: ton thUdng la nhiing dUdng vd doc, thudng nam d bd trai cua thiic quan ngiic, tren cd hoanh Kich thudc cua dUdng vd tii - 4cm, doi tdi 10cm Dudng vd thudng lam rach tat ca cac ldp cua thiic quan, doi la dudng vd khong hoan toan, khong ton thudng het cac ldp cua thiic quan, sau do cac nhiem trung tai cho gay hoai tii hoan toan thiic quan Mot diem can liiu y la ton thiidng niem mac bao gid cung rong hdn ldp cd nen can phai md rong ldp cd trudc khau vet thudng de tranh bd sot dudng vd dudi niem mac Ngoai ra, co the gap cac ton thudng phoi hdp da co tti trudc nhu viem thiic quan, tui thiia thiic quan, co that tarn vi v.v
- Thung thiic quan di vat: thudng gap nhat la nuot phai xUdng Chieu dai xUdng va hinh dang sac nhon, goc canh ciia manh xUdng la yeu to” nguy cd quan nhat gay mac lai va gay thiing Thung thiic quan co the manh xUdng choc thiing thiic quan, cung co the thu thuat lay xUdng qua noi soi gay thiing Do vay, ton thudng thiing co the nho nhUng co rat phiic tap
- Vi tri ciia lo thiing: vi tri cua lo thiing co the d moi vi tri cua thiic quan Tuv nhien thiing thiic quan tii phat, vi tri lo thiing thudng gap nhat la thiic quan 1/3 dudi, bd trai cua thiic quan, vet thudng thiic quan va di vat thiic quan lai hay gap d doan thiic quan co Vi tri thung thiic quan hay gap nhat cac thii thuat noi soi la thiic quan ngiic va thiic quan co, dudi mieng thiic quan Thiing thiic quan chan thudng thudng gap d thiic quan ngiic 1/3 tren
4 T R IE U CHLfNG V A C H A N D O A N
Chan doan thiing thiic quan thudng kho va muon vi cac trieu chiing dac trUng thudng it gap hoac xuat hien muon Trong chan thUdng va vet thudng thiic quan cac trieu chiing thudng bi che lap bdi benh canh cua da chan thudng hoac hoi chiing chav mau, kho thd ton thudng cac mach mau ldn hoac ton thudng phe quan
Thiing thiic quan thudng dUdc phat hien va chan doan cac hoan canh sau: - Trong lam noi soi vdi gay te tai cho, benh nhan thay dau dot ngot du doi dac biet la xuat hien sau mot cii dong bat thudng hoac sau benh nhan nac manh Khi noi soi thiic quan vdi gav me toan than, khong thay diidc dau hieu dau nhung rut ong noi soi tii tii va kiem soat bang mat co the phat hien dtfdc ton thudng thiic quan
(19)- Khi nuot phai di vat, benh nhan thay dau dot ngot, khu tru, lien tuc d mot vung - Vd thuc quan tii phat dUdc nghi den benh nhan co dau ngiic, kho thd dot ngot, tran dudi da co sau non hoac nac manh
- Cac trUdng hdp chan thUdng hoac vet thudng thuc quan thudng phat hien muon hoac phat hien mo de xii ly cac ton thUdng phoi hdp d co va long ngUc
4.1 T rieu chufng lam san g
- Dau: dau la trieu chiing chinh, dau dO doi va lien tuc Dau sau xUdng lie hoac tren ron cac trUdng hdp thung thUc quan tii phat, dau cao d vung co doi vdi thung thuc quan co Dau tang nuot nen benh nhan khong dam nuot va thUdng phai nho nUdc bot
- Kho thd: rat thudng gap nhat la cac thung thiic quan ngiic vao mang phoi Kho thd kem theo dau, co the kem theo thay doi giong noi
- Tinh trang soc co the xuat hien rat sdm vdi cac dau hieu mach nhanh, nho va huyet ap tut
- Non mau la dau hieu co gia tri nhung rat it gap
- Tran dudi da vung co xuat hien sdm: co phong to len, sd thay mem va co dau hieu lep bep cua dudi da
- Trong trifdng hdp thung thuc quan co, benh nhan cam thay rat dau ngu'di thay thuoc cam vao sun giap va lac nhe sang hai ben Trong cac ton thudng thiic quan bung, co dau hieu co ciing hoac phan ling bung vung tren ron
- Trong trUdng hdp thung thiic quan 1/3 tren kem theo co rach mang sau cua quan, benh nhan co dau hieu ho, sac nuot dudng vd lam thong thiic quan vdi quan
Khi thay co sii phoi hdp cua ba trieu chiing (dau nuot, kho thd va tran dudi da co), can nghi tdi ton thudng thung thiic quan va phai ngiing cho an qua
T O •» x
nneng Lam cac tham kham can lam sang de khang dinh chan doan va dieu tri sdm
Neu khong dude chan doan va dieu tri sdm, sau vai gid se dan tdi tinh trang viem trung that nhiem khuan rat nang Benh nhan sot cao 39 - 40°C, ve mat hoc hac, tang tiet ddm dai, kho thd, tim tai
4.2 T rieu chvfng can la m sang
4.2.1 Chup X q u a n g long nguc
Chup ngiic thang, nghieng, lay ca vung co thudng thaj^T^iBTiJga^h tran dudi da vung co Hinh anh tran trung that co tii 75 - '80%- cac trufeng hdp, co thay hinh anh hdi hinh chuf V tren cd hoanh (dau hieu Nacle - Rjeo) Neu de muon, co the thay dau hieu trung that gian rong tu dich, ap xe trung that, tran
(20)dich va tran khi' mang phoi thung vao mang phoi hoSc la tran dich phan ling cua mang phoi Tren phim chup nghieng vung co co the’ th&'v dau hieu hdi sau thiic quan (dau hieu Minigerode) khoang sau thiic quan rong ra, day thiic quan va quan tnidc
4.2.2 Chup bung khong chuan bi
Chup bung khong chuan bi co the thav hdi tii o bung (dau hieu hem hdi dudi hoanh tren phim chup diing) hoac co the thay co hdi sau phuc mac cac trifdng hdp thung thiic quan bung sau phuc mac
4.2.3 Chup can quang thuc quan
Chup thiic quan vdi thuoc can quang hoa tan nude co the xac dinh dUdc 80% cac trUdng hdp thung thiic quan, ngoai giup xac dinh vi tri ton thUdng va ben thuc quan bi ton thudng de chon dUdng mo phu hdp Tren phim chup thiic quan can quang, thung thuc quan diidc kh&ng dinh co cac hinh anh sau:
- Hinh khac d thuc quan trUdng hdp ton thudng m6i chi co d thiic quan - Hinh dam thuoc can quang tren cd hoanh trai trUdng hdp vd thiic quan tii phat
- Dudng ro thuoc can quang ngoai thiic quan vao trung that, mang phoi cac ton thudng lam thung hoan toan thiic quan ngiic hoac co thap
4.2.4 Choc mang phoi
Trong cac trUdng hdp co tran dich mang phoi, choc mang phoi thay dich mang phoi co mau xanh nhat cua dich da day Xet nghiem dich co pH < Dich choc mang phoi co mau xanh sau cho benh nhan uong xanh methylen chiing to la co thong thudng gitia ong tieu hoa va mang phoi
4.2.5 Chup cat ldp vi tinh
Dau hieu thung thiic quan tren phim chup c&t ldp vi tinh co uong thuoc can quang dang nUdc la hinh anh ro thuoc can quang ngoai thiic quan vao trung that dau hieu tran trung that va to chiic phan mem d co Dau hieu tran trung that va to chiic phan mem thay rat ro tren phim chup cat ldp Ap xe trung that the hien difdi dang o djch cd hdi d giiia Chup cdt ldp co hai ldi l'ch can ban la chan doan va danh gia chinh xac toan dien cac o nhiem khuan, ap xe trung that cac trudng hop thung muon, giup lua chon dudng d i n luu o ap xe qua da
Hdn nut a, chup cat ldp la phitong tien tot nhat de chan doan ton thudng tu mau thuc quan
4.2.6 Noi soi