🔙 Quay lại trang tải sách pdf ebook Bệnh lý Viêm Tụy Ebooks Nhóm Zalo PGS. TS. HA VAN QUYET JGUYEN c l ie u NHA XUAT BAN Y HOC HA VAN QUYET BEI\H LY VIEM THY • • (Sack chuyen khao dung cho sau Dai hoc) f 1 NHA XUAT BAN Y HOC HA NOI - 2006 LOI Gldl THIEU Nhutng nam gan day viem tuy la mot benh ly thifdng gap do nhieu nguyen nhan nhii soi mat, soi tuy, giun chui ong mat.... NhUng cung khong it cac tnidng hdp viem tuy do che do an uong thay doi nhiJ uong rutdu nhieu hon, nhieu chat dinh dtfdng hdn... Mot thay doi niia la sii hieu biet ve cd che benh ly, cac bieu hien lam sang dac biet la cac phiidng phap chan doan nhif sieu am, chup CT, cong hiidng tCf... da xac dinh r5 cac nguyen nhan cua viem tuy tvt do co nhOfng chi dinh dieu tri thich hop. Cung v6i nhCing kinh nghiem cua phau thuat kinh dien de dieu tri viem tuy, chung ta da co nhiing phifOng tien m6i nhu phau thuat noi soi va noi soi can thiep de ap dung trong dieu tri nhiing triidng hdp viem tuy cap do nguyen nhan cd hoc, lam thay doi quan niem ve viem tuy va ket qua dieu tri ngay cang tot hon. Hy vong quyen sach “Benh ly viem tuy” cua PGS.TS. Ha Van Quyet se giup trang bi them cho doc gia mot so" thong tin, kien thilc va kinh nghiem trong chan doan va dieu tri viem tuy cap va man tinh. g s . n g u y I n b u u t r ie u 3 LOI NOI DAU Trong thdi gian gan day viem tuy la mot benh ly co xu hiidng tang cao va nang ne hdn. Co hai loai viem tuy: viem tuy cap (VTC) va viem tuy man (VTM). Moi mot loai viem tuy co dac diem ton thiidng, nguyen nhan, cd che, trieu chting lam sang khac nhau nen thai do dieu tri, cung nhii phvfdng phap dieu tri khac nhau. Benh ly viem tuy g&n day difdc chu y nhieu bdi so liidng benh nhan ngay cang tang, kha nang chan doan bang tham do can lam sang nhii xet nghiem, sieu am, chup cat 16p vi tinh (CT.Scanner), chup cong hiidng tu: (CHT), sieu am noi soi (Sono Endoscopy)... da diidc thiia nhan.Vdi cac tham do nay da phat hien diidc nhieu thiidng ton, nguyen nhan de co nhiing phtfdng phap dieu tri noi khoa va phau thuat hieu qua, tranh de lai nhiing bien chufng va di chiing nang ne cua benh nhan sau phau thuat viem tuy. Mat khac, khi hieu biet ro cd che va nguyen nhan cua viem tuy co the de ra cac bien phap phong ngtia nhu dieu chinh che do an uong, han che uong riidu, chat beo, de phong cac tac nhan gay viem tuy nhif tay giun, phat hien s6m cac loai soi mat, soi tuy, roi loan co that... Xac dinh chan doan sdm khi phat hien cac trieu chtfng cua viem tuy cap trong cong dong la mot yeu to' de dieu tri kip thdi, tranh dan den tinh trang huy hoai to chiic tuy, hinh thanh cac o hoai tvi trong to ch ic tuy, to ch\ic xung quanh tuy, cac khoang trong o bung, chay doc theo r§ mac treo , dong lai d ho chau phai... co khi tao thanh nhiing ’’dong to chiic hoai tii “ len ca dudi vom hoanh, co khi ca khoang mang phoi, ca trung that. Con doi vdi viem tuy man co the d^n den chit tic ong tuy (Wirsung), nang tuy hay soi tuy, neu khong dieu tri s6m se co nhiing bien chiing nang nhuf ddt cap cua viem tuy, nang tuy, xd hoa tuy, ap xe tuy va bien chilng khac nhut viem phuc mac, roi loan toan than, chay mau tieu hoa... Tac gia hy vong 4 quyen sach nho nay cung cap them cho cac ban doc mot so kien thiic va thong tin ve benh ly viem tuy, qua do gop phan nang cao kha nang chan doan va dieu tri tot hdn loai benh ly nang ne nay. De hoan thanh quyen sach nay xin chan thanh cam dn stf cong tac tich ciic cua Bac sy Pham Tien Dat va Bac sy Le Manh CUdng cung Nha xuat ban Y hoc da giup dd in an. Quyen sach nay se khong tranh khoi nhiing sai sot, rat mong cac doc gia thong cam va dong gop y kien de cho hoan thien hdn. Xin tran trong cam dn. PGS.TS. HA VAN QUYET Chu nhiem Bo mon ngoai Dai hoc Y Ha Noi PGO Benh vien Viet Bure 5 MUC LUC Phan I. GIAI PHAU BENH LY 9 1. Giai phau tuy. 9 2. Hinh anh to ch\ic hoc cua tuy. 15 Phan II. SINH LY TUYEN TUY 17 1. Chtfc nang noi tiet: 17 2.Chile nang ngoai tiet: 18 3. Su bai tiet dich tuy: 19 4. Sii bai tiet cac chat ilc che Trypsin 21 5. Su bai tiet ion H C 03 va niidc: 21 6. Dieu hoa bai tiet dich tuy: 22 Phan III. VIEM TUY CAP 25 1. Lich sii benh viem tuy cap 27 2. Nguyen nhan gay viem tuy cap 32 3. Cd che benh sinh cua viem tuy cap. 33 4. Benh hoc va sinh ly benh cua viem tuy cap. 35 5. Giai phau benh viem tuy cap. 37 6. Phan loai 39 7. Trieu chting va chan doan. 40 8. Bien chilng cua viem tuy cap 51 7 9. Tien liidng viem tuy cap. 53 10. Dieu tri viem tuy cap 58 11.K etluan 68 Phan IV. VIEM TUY MAN VA SOI TUY 71 1. Nguyen nhan gay viem tuy man 72 2. Phan loai viem tuy man 75 3. Chan doan 75 4. Dieu tri 89 8 PHAN I s a Lirac g ia i phau 1. GIAI PHAU TUY 1.1.V| tri va hinh the ngoai cua tuy [4,6,7] Tuy di tif khuc II ta trang tcii ron lach, nam vat ngang, sat triidc cot song liing, chech len tren, sang trai, phan 16n d tang tren mac treo dai trang ngang va mot phan nho d tang diidi. Kich thiiclc tuy co the thay doi rat nhieu tuy theo ting ngiidi va chieu dai thay doi tu: 16-20 cm, tuy co hinh chi3 S hay trong giong nhii mot cai bua det theo chieu tru6c sau va 2 do cong lom ra sau de om lay cot song va lom ra trUdc de om lay da day, trong liidng trung binh tii 70 - 80 gram, to chiic tuy rat mem co mau trang nga. Cung v6i phan xuong cua ta trang, dau tuy co lien quan phla sau v6i cot song liing LI - LII, mat tru6c than tuy lom ap sat vao mat sau da day va diidc phu bdi phuc mac thanh sau cua hau cung mac noi, mat sau phang dinh vao thanh sau phuc mac di tu! phai sang trai va bat cheo dong mach chu bung. Bd tren than tuy co dong mach lach chay qua, bd dii6i thi d phia sau mac treo dai trang ngang. Tuy la tuyen thuoc bo may tieu hoa viia noi tiet vita ngoai tiet. 9 Hinh 1.1: Vi tri va hinh the ngoai Tuy nam sau phuc mac, di tit phan xuong ta trang den cuong lach nam vat ngang trifdc cot song that liing tti Lj den L3 len tren sang trai, phan ldn tuy nam d tang tren mac treo dai trang ngang, mot phan nho d difdi mac treo dai trang ngang. Tuy co hinh giong nhii chiec bua det, v6i hai mat cong lom. lom ra sau de ora lay cot song va lom ra triidc de om lav mat sau da day, tuy co hai mat: tru’dc, sau, hai bd: tren, difcii, trong lu'o'ng trung binh tii 70 - 80 gam, to chilc tuy rat mem co mau trang nga. Tuy dUdc chia lam 4 phan: Dau tuy hinh vuong co ta trang bao quanh, phia dudi dau tuy co moc tuy con goi la eo tuy. - Dau tuy: Day 3cm, cao 7cm, dai 4cm, det, gan hinh vuong, dai 4cm, cao 7cm, day 3cm, co ta trang bao quanh 10 - Phi'a difdi dau tuy co moc tuy. Giiia dau tuy va than tuy co khuyet tuy hay con goi la eo tuy. - Than tuy: tif khuyet tuy chech len tren sang trai, dai 10cm, cao 4cm, day 3cm, co ba mat: TrU6c - Sau - Du6i, co ba bd: Tren - Dudi - TrUdc - Duoi tuy: tiep theo than tuy, duoi co the dai hay ngan tron hay det, phi'a tren va trUdc duoi tuy co dong mach lach chay qua, duoi tuy dai ngan tuy theo tCfng ca the, di dong trong mac noi tuy- lach. (13) 1.2. Cac ong tiet cua tuy Tuy la tuyen vifa noi tiet via ngoai tiet: - Noi tiet: tiet ra insulin, glucagon di thang vao mau, qua cac mao mach trong tuyen - Ngoai tiet: dich tuy tiet ra tu! cac ong tiet lien tieu thuy, roi do vao cac ong tiet ldn. Dich tuy dUOc bai tiet qua hai ong tiet chi'nh do la ong tuy chinh: (ong Wirsung), ong tuy phu: (ong santorini). ong tuy chinh: chay theo true tuy doc t\f duoi tuy den than tuy hoac hoi chech len mot chut, (xem hinhl.2): dang trong giong nhu mot la cay. Ong tuy chinh Ong mat chu Hinh1.2. Ong tuy chinh va ong mat chu 11 Ong tuy phu tiep noi v6i ong tuy chinh d co tuy va do vao mat sau ta trang. + Ong tuy chinh (Wirsung): chay doc theo true cua tuy tif duoi den than tuy hoac hdi chech len mot chut, den khuyet tuy thi be cong xuong du6i qua diu tuy t6i nhu ta 16n, roi cung ong mat chu do vao bong gan - tuy (bong Vater), ong tuy chinh nhan s\i do vao cua toan bo cac nhanh ben, nen hinh dang trong giong nhii mot la cay. A/ + Ong tuy phu (Santorini): tach ra ct ong tuy chinh d co tuy di chech len tren do vao mat sau ta trang d nhu ta be (phia tren nhu ta 16n 2cm). Cac hinh anh giai phau tren day chi chiem 70 - 80% cac triidng hdp. Triidng hdp ong tuy chinh chi dan dich tuy d phan dau va moc do vao nhu ta 16n, cac tac gia goi do la hien tildng chia doi tuy (Pancreas division), day la ket qua cua s\l bien loan giai phlu bam sinh va cung la mot trong nhiing nguyen nhan gay viem tuy cap. 1.3. Bong Vater Bong Vater la sii phinh ra cua ong mat- tuy chung, hinh dang ngoai cua bong Vater gom mot cho loi len diidi niem mac, diidc goi la pheu (infundibulum), phia tren co mot nep niem mac goi la mu hay nep vong, dinh pheu co lo va phia dii6i co nep niem mac diidc goi la ham hay nep doc (Xem hinh 1.3) 12 Hinh 1.3: Hinh the ngoai nhu Vater Hinh thai cua ong mat - tuv chung cung nhii do dai ngan thay doi nhieu tuy theo tulng ngiidi, co the rat dai hoac rat ng&n tham chi' khong co, ong tuy chi'nh va phu do rieng ra 0 ta trang, cho do ra ta trang co difdng kinh trung binh t i 0 mm khi dong, den 2mm khi md (xem hinh 1.4 ) Kenh Crtung r>gin Khong 06 kenh cfiur»g Kenh ct>ung dai Hinh 1.4: Hinh thai ong mat - tuy chung 13 Ch6 do vao ta trang cua ong mat-tuy chung co cd that Oddi, khi cd nay gian hay co se md hay dong lo num ruot 16n, ca diidng mat chinh, ong tuy chinh va than chung deu co cd that rieng cua minh: cd vong diidc tao thanh bdi nhiing sdi cd trdn co nguon goc phoi thai va ch ic nang khac v6i cd trdn cua ruot non, tat ca tao thanh cd that Oddi, diidc chia thanh 3 tang: tren, giuta, diidi, tang tren la cac cd that rieng cua ong mat chu va ong tuy, tang giia la cd that chung, tang dudi cung cd that day len tham gia tao thanh lo bong Vater, tii doan tap chung cua hai ong mat-tuy niem mac cua hai ong hoa vao nhau, co hinh dang nhan nhum lai tao thanh nhiing hoc tuyen lam tach rdi nhiing sdi cd cua cd that, cd that cua doan ong chung dong gop vao sii hinh thanh pheu loi cua bong Vater, no hoa lan vao v6i 16p cd ta trang, cho hep nhat cua cho cd thit rieng, con goi la diem Hand. Hinh 1.5: Hinh cat dCfng doc qua bong Vater di/dng mat 14 Vai tro cua bong Vater va cO vong Oddi la kiem soat bai tiet dich mat tuy va djch ta trang vao hay ra ngoai ong mat, tui mat va tuy, binh thiidng, khi ap liic 6 long ta trang la OmmHg thi ap lilc d vung ong mat - tuy la lGmmHg va ap life trong long ong mat chu la 12mmHg, dieu nay ngan can sii trao ngUdc cua dich ta trang vao diidng mat va diidng tuy. 2. HINH ANH TO CHl/C HOC CUA TUY 2.1. Tuy ngoai tiet: La mot dam tuyen tui (nang) hdp lai thanh cac mui, hay thuy tuy, gan vdi nhau bdi to chlic dem trong do co chtia mach mau, ong tiet va cac dam ndron nho di tdi cac hach trong tuy, tui tuyen che tiet ra dich tuy di tu ngoai vao trong bao gom: Mang mong nhii mang day sinh ra bdi day Reticuline lien bao tuy hinh thap, d giuta la long thay doi tuy theo giai doan cua vong che tiet luc te bao nghii thi long tuyen rong. khi te bao tiet thi phinh to lam cho long tuyen hep lai [1.7]. Lat cat tuy dutH kinh hien vl do phong dai thap Cac nang Cac dao (Langerhans) Ong gian tieu thuy Vach gian tieu thuy Hinh 1.6: Hinh anh vi the cua tuy binh thiidng 15 2.2. Tuy noi tiet Tuy noi tiet bao gom cac cau true diidc goi la cac tieu dao Langerhans, nam giiia cac mui tuy, co ching 1-2 trieu tieu dao Langerhans, dong vai tro noi tiet chinh cua tuy, moi tieu dao diidng kinh chi khoang 0,3mm, co nhieu mao mach bao quanh tieu dao, m6i tieu dao chtia 3 loai te bao chinh la: Te bao be ta (60%) n£m d phan gifila cua moi tieu dao va bai tiet insulin, te bao an pha (25%) bai tiet glucagon, Te bao den ta (10%%) bai tiet Somatostatin, con lai so it cac te bao khac diidc goi la te bao PP, chung bai tiet mot hormon chiia ro chOfc nang va diidc goi la polypeptit cua tuy, nhiing nam gan day ngiidi ta cho r^ng cac noi tiet nay co the anh hiidng dieu chinh chufc nang tuy ngoai tiet. 16 PHAN II SINH LY TUYEN TUY Tuy la mot tuyen tieu hoa co hai chic nang: - C hic nang noi tiet: Tiet ra insulin va glucagon t i cac te bao a va P thuoc tieu dao Langerhans, do vao mau giup cho dieu hoa va chuyen hoa dUdng trong cd the. - C hic nang ngoai tiet: Tiet ra dich tuy trong do co cac men trypsin, anpha chymotrysine, amylase, lypase, cac ong nho bai tiet mot lvfdng ldn dung dich bicacbonat hon hdp cua tuy ngoai do vao ong Wirsung va ong nay cung vdi ong mat chu hdp lai vdi nhau d bong gan - tuy, roi do vao doan II ta trang qua cd that Oddi. 1. CHLfC NANG NOI TIET Tuy noi tiet tiet ra insulin va glucagon t i cac te bao a va P thuoc tieu dao Langerhans do vao mau giup cho dieu hoa va chuyen hoa. Cac dao Langerhans nam rai rac xen lan vdi cac tuyen nang, dao hinh bau due hoac hinh cau, moi milimet vuong co mot dao, moi dao la mot tuyen kieu liidi, xen ke vdi cac ltfdi tuyen te bao thi co liidi mao mach hinh xoang, rat phong phu va phat trien. Insulin vao mau giup chuyen hoa dufdng neu vi ly do nao do. Tuy khong bai tiet du so insulin de dtfa glucose vao cac te bao, tong hdp glucogen khong du se dan den si1 giam chuyen hoa glucid, ket qua la phan ldn glucose mau khong diMc s i dung va m ic glucose mau tang len Khi glucose mau vifdt qua 10 mmol/1 (180mg glucose trong 100 ml mau) cac ong 17 than se khong the tai hap thu duoc tat ca glucose (da bi loc vao niidc tieu) va glucose xuat hien trong nUdc tieu. Islet of Langerhans Alpha cell Beta cell Pancreatic / acini -^Red blood cells Hinh 2.1. Cau true tuy noi tiet.[3] Khi phau thuat cat bo tuyen tuy benh nhan se bi dai thao diidng, trong viem tui mat khi tuyen noi tiet bi pha huy cung se gay nen dai thao diidng 2. CHLfC NANG NGOAI TIET Cac nang bai tiet ra dich tuy trong do co cac men trypsin, chymotrypsin, amylase, lypase. Cac ong nho bai tiet mot liidng ldn dung dich bicarbonat hon hop cua tuy ngoai tiet do vao ong Wirsung va ong nay cung vdi ong mat chu hop lai vdi nhau d bong gan tuy (bong vater) roi do vao doan I I ta trang qua cd that oddi. 18 3. SU BAI TIET D|CH TUY Moi ngay tuy tiet ra khoang 1000 ml dich. Dich tuy la dich kiem ti'nh chiem mot ltfdng 16n bicarbonat va cac men tieu hoa nhii: Amylase, lypase, trypsin chymotrypsin, carboxy polypeptydase, ca 3 men nay deu dude bai tiet diidi dang mot tien men khong hoat dong do la trysinogen, chymotrypsinogen, procarboxypolypetidase [2,5]. Common bile P a n C f e a S Small intestine Digestive enzyme secreting cells Islet of Langerhans islet ceils Hinh 2.2. Cau true tuy ngoai tiet Khi vao den ta trang mot so' phan t i trvpsinogen dude hoat hoa thanh trysin, t i day tac dong hoat hoa trd lai cac trvpsinogen khac, sau do chung tiep tuc xuc tac hoat hoa cac chymotrypsinogen thanh chymotrypsin va procarboxy peptidase thanh carboxypeptidase. 19 Tryspin va chymotrypsin phan huy protein, pepton va cac chuoi polypeptin thanh cac chuoi polypeptid nho hdn va carboxypeptidase se phan cat cac acid amin tan cung cua cac chu6i polypeptid. Diidi tac dung cua men tieu protein cua dich tuy, chi mot liidng nho protein, diidc tieu hoa hoa hoan toan thanh cac acid amin, phin con lai d dang dipeptid, tripeptid va mot so it polypeptid. Cac men tieu hoa: - Men amylase cua dich tuy co cau true giong men amylase cua niidc bot nhiing tac dung manh hdn nhieu. Men amylase tieu hoa ca tinh bot chin va song thanh diidng maltose va mot so it polyme cua glucose nhii maltosetrypose va dextrin. - Cac men tieu hoa lipid: Hau het md trong thilc an la m3 trung tinh (tryglycerid). Trong thtic an thong thiidng cung co mot liidng nho phospholipid, cholesterol va estercholesterol. - Men lypase cua dich tuy la men tieu hoa md trung tinh quan trong nhat, dich tuy co mot so liidng ldn lipase du de tieu hoa toan bo md trung tinh. Diidi tac dung cua men lipase, md trung tmh diidc phan giai thanh cac axit beo monoglycerid, va mot liidng nho diglycerid nen giai thi'ch tai sao khi thieu lipase do ton thiidng ch ic nang tuy ngoai tiet trong viem tui mat thi xuat hien ch in g ia phan md. Men (cholesteroleste hydrolase) thuy phan. Cholesteroleste de giai phong cac acid beo, men phospholipase A (diidc hoat hoa diidi tac dung cua trypsine) thuy phan lecithin (la phospholipid co trong mat) thanh lysolecithin va acid beo, lysolecithin gay ton thiidng cho mang te bao. Do do mot trong 20 nhiing nguyen nhan gay viem tui mat la do sti hoat hoa men phospholipase A. Trong ong tuy, men nay thuy phan lecithin thanh lysolecithin pha vd cac mo tuy gay hoai t i cac mo xung quanh. 4. SLT BAI TIET CAC CHAT LfC CHE TRYPSIN Trysin va cac men khac nhau co the tieu hoa chinh ban than tuyen tuy, nen cac men tieu protein cua dich tuy chi trd nen hoat dong khi chung da diidc bai tiet vao ruot non. Ngoai ra cac te bao bai tiet men tieu protein vao cac nang tuy cung dong thdi bai tiet cac chat ic che trypsin, chat nay chia trong cac bao tiidng, xung quanh cac hat zymogen. Nhii vay co ngan can sii hoat hoa cua trypsin d ben trong cac te bao bai tiet d trong cac nang va cac ong tuyen tuy, vi trypsin hoat hoa tiep theo cua cac men nay. Khi tuy bi ton thiidng, ong tuy bi tac nghen va dich tap trung nhieu d vung ton thiidng, chat ic che trypsin khong hoat dong cac men tieu protein va men phospholipase A cua dich tuy se nhanh chong diidc hoat hoa va tieu huy tuyen tuy trong vai gid day la benh viem tuy cap. Nhiing triidng hdp phau thuat vung bung nhii da day, dudng mat, sau mo viem tui mat va soi tuy gay ro dich tuy dan den viem tuy cap sau mo. 5. Stf bAI TIET ION H C 03 VA Nl/CJC Niidc va ion H C 0 3 la do cac te bao bieu mo cua ong tuyen tuy bai tiet, sii bai tiet dien ra nhii sau: CO9 khuyech tan tii mau vao te bao bieu mo, tai day diidi tac dung cua men CA, C 0 2 ket hdp vdi niidc tao thanh H2C 0 3, H2C 0 3 phan ly thanh H+ va H C 0 3, roi H C 03' diidc van chuyen tich ciic vao long ong ion H+ t i te bao vao mau de trao do vdi ion Na+ t i mau vao te bao theo cd che van chuyen tich cic, sau do Na+ diidc khuyech tan t i te bao vao long ong sii van chuyen 21 cua H C03 va Na+ t i mau vao long ong sinh ra mot bac thang tham thau de de keo niidc vao long ong tuy, ket qua tao ra dung dich bicarbonat d tuyen tuy 6. DIEU HOA BAI TIET DjCH TUY: Dich tuy diidc bai tiet theo cd che than kinh va the dich (hormon) 6.1. Cd che than kinh Kich thich day X hoac he than kinh ruot thi cac tan cung cholinergic se giai phong ra acetylcholin, acetylcholin chu yeu kich thich cac te bao nang va it tac dung len cac te bao ong tuyen tuy va ket qua la mot liidng 16n men tieu hoa diidc bai tiet nhiing dich thi rat it, khong co dich cac men tam thdi bi g ii lai trong cac nang va ong tuyen cho den khi dich diidc bai tiet du de diia chung vao ta trang 6.2. Ca che hormon Sii bai tiet dich tuy cung chiu sii dieu hoa cua cac hormon: Gastrin, cholecystokinin (CCK) va secretin - Gastrin: Khi th ic an vao da day, niem mac vung hang vi bai tiet mot liidng ldn gastrin, gastrin theo mau den kich thich nang tuy bai tiet cac men tieu hoa nhiing rat it dich - Cholecystokinin: Khi th ic an t i da day xuong ta trang, sii co mat cua proteose, pepton, cac acid beo mach dai, HC1 se kich thich cac te bao niem mac ta trang va phan tren cua hong trang bai tiet cholecystokinin, cholecystokinin theo mau den kich thich cac nang tuyen tuy bai tiet cac men tieu hoa, cholecystokinin co tac dung quan trong trong viec kiem soat stf bai tiet cac men tieu hoa cua tuyen tuy 22 - Secretin: Do cac te bao S cua niem mac ta trang va phan tren hong trang bai tiet diidi dang tien men chiia hoat dong la prosecretin, khi HC1 cua vi chap di vao ta trang, no se kich thich sii giai phong va hoat hoa secretin, secretin theo mau den kich thich tuyen tuy bai tiet mot liidng dich 16n chiia nhieu ion H C 03 (145meq/l) nhiing rat it enzym Sii bai tiet secretin dac biet quan trong vi hai ly do sau: + Khi pH d ruot non giam xuong 4,5 thi niem mac ruot non bat dau tiet secretin, bai tiet rat tang khi pH giam xuong va khi acid chuyen dan tu: ta trang xuorig hong trang, ket qua la dich tuy diidc bai tiet chiia nhieu ion H C03, bicarbonat phan ling vdi HC1 nhii sau: HC1 + NaHCO:! = NaCl + H2C 0 3 H2C 0 3 phan ly thanh C 0 2 va H20, C 0 2 hap thu vao mau va bai xuat qua phoi, dung dich NaCl trung tinh d lai ta trang, bang cach nay HC1 cua vi chap ta trang se bi trung hoa va hoat tinh tieu hoa cua dich vi bi ngan chan, day la cd che bao ve chu yeu chong lai sii phat trien cua loet ta trang bicarbonat cua dich tuy tao pH thich hdp cho cac men tieu hoa cua tuy, cac men nay co tac dung toi da trong moi triidng hdi kiem hoac trung tinh, pH cua dung dich NaHC03 la 8,0. TAI LIEU THAM KHAO 1. Bo mon mo hoc, Triidng Dai hoc Y Ha Noi (2002), “Bdi giang md hoc”, trang: 446-453 2. Bo mon sinh ly hoc. Dai hoc Y Ha Noi (1998), “Dich tuy“. Sinh ly hoc, Tap 1, NXB Y hoc trang: 239-343 23 3. Clement J, Guillemin G (1990), “Management of recurrent pain following previous surgery for chronic pancreatitis”, World Journal Surgery, 14, pp. 11-18. 4. Do Xuan Hdp ( 1997), “Tri trang va tuy tang’\ Giai phlu bung, Tap 2, trang:125-144. 5. Tran Gia Khanh (2002), “Viem tuy cap". Benh hoc ngoai, tap 1, trang 152-166. NXB Y hoc 6. Nguyen Quang Quyen (1997), "Tri trang va tuy”. Bai giai - Giai phau hoc,Tap 2, NXB Y hoc, trang: 117-128 7. Frank H. Netter (1997), “Atlas giai phau ngubi". NXB Y hoc. 24 PHAN III VIEM TUY CAP 1. m 6 o a u Viem tuy cap la mot cap ciiu thtfdng gap tren lam sang, benh dien bien cap tinh, nang ne, anh hUdng tdi sic khoe, tinh mang cua ngiidi benh. Theo ii6c tinh cua to ch ic Y te The gidi thi tan suat mac viem tuy cap khoang 25 - 50 triidng hdp/100.000 dan[3], 0 chau Au tan suat nay la 22/100.000 dan[9], theo thong ke hang nam, tai My co khoang 45.000 trUdng hop viem tuy cap vdi ty le t i vong khoang 9%[1]. Cho den nay d Viet Nam chua co mot thong ke nao cho biet tan suat benh viem tuy cap, nhiing theo ket qua nghien ciu thi t i nam 1991-1993 tai Benh vien Viet D ie Ha Noi da co 288 trUOng hdp viem tuy cap, con theo thong ke sd bo tai khoa Tieu hoa- Benh vien Bach Mai Ha Noi t i nam 2001-2002 da co 292 triidng hdp viem tuy cap[3], chiem 7,3% tong so^ benh nhan nam dieu tri noi tru tai khoa Tieu hoa, t i 1990-1995 da co 375 triidng hdp viem tuy cap dieu tri tai khoa Noi-Tieu hoa Gan- Mat cua Benh vien Trung ufdng Hue, trong do nguyen nhan do giun chiem 24,53%. Aubert la ngtfdi dau tien da mo ta ve benh nay vao nam 1579, diia tren cd sd mo t i thi, nhiing cho tdi tan cuoi the ky XIX dau the ky XX con ngiidi mdi thiic sii quan tam den viem tuy cap, nam 1882 W.Balser lan dau tien da ching minh diidc co s i hien dien cua to ch ic hoai t i md trong viem tuy cap, tiep theo la H.Chiari (1896) cung da ching minh diidc sii t i huy tuyen tuy trong viem tuy cap. 25 T i do den nay tren the gidi da co rat nhieu cong trinh nghien ciu ve viem tuy cap noi chung cung nhii viem tuy cap do soi giun diidng mat-tuy noi rieng, nhiing cac nha khoa hoc vlin chiia tim diidc sii thong nhat ve: can nguyen, benh sinh, chan doan, tien liidng va x i tri. Gan day tai hoi nghi quoc te ban ve viem tuy cap tai Atlanta Hoa Ky (1992), hoi nghi da difa ra cach phan loai m6i ve the benh cua viem tuy cap, ve nguyen nhan gay viem tuy cap thi co nhieu, nhiing cho den nay ngiidi ta cho rang hai nhom chinh la: soi - giun va riidu, day la mot trong nhiing nguyen nhan hang dau chiem tdi 60% - 85% nguyen nhan gay viem tuy cap[14], d Viet Nam GS. Ton That Tung ngiidi dau tien nghien ciu ve viem tuy cap, Ong da mo ta day du ve lam sang, can lam sang va thai do x i tri ngoai khoa trong dieu tri viem tuy cap, dac biet trong viem tuy cap do soi, giun, t i do ve sau da co nhieu tac gia khac da nghien ciu ve viem tuy cap nhiing giia cac tac gia van chiia co s\l thong nhat ve thdi diem can thiep, thai do x i tri cung nhii ket qua nghien ciu. Ngay nay vdi s i phat trien viidt bac cua khoa hoc cong nghe, sii hieu biet sau hdn ve sinh ly, sinh hoa tuy, s i ra ddi cac phiidng phap tham do enzym tuy, sieu am, chup cat ldp vi tinh, chup cong hiidng t i, thiet bi noi soi...nhd do ma chan doan, dieu tri, theo d5i va tien liidng benh viem tuy cap da diidc tot hdn. Mac d i co nhieu phiidng phap tham do ho trd nhii vay, nhiing viec ket hdp chat che giia cac tham do ho trd vdi dac diem lam sang de chan doan, theo doi, tien liidng, trong dieu tri viem tuy cap la rat can thiet, dac biet la trong hoan canh niidc ta hien nay. Viet Nam la mot niidc dang phat trien, nam trong vung dich te giun san, nen nong nghiep chiem tdi 80%-90%, trinh do dan tri chiia cao, ty le nhiem giun cao, day la nguyen nhan chu yeu dan den benh soi mat, giun va soi mat lai la mot trong nhing yeu to chinh gay viem tuy cap [6,7.8], 26 Tu: nam 1996 tai Benh vien Viet D ic,cin g vdi dieu tri viem tuy cap bang ngoai khoa, noi khoa, da trien khai, ap dung noi soi can thiep trong dieu tri noi chung va trong viem tuy cap do soi, giun noi rieng. 2. LjCH SIT BENH VIEM TUY CAP 2.1. Ljch sur nghien curu benh viem tuy cap tren the gidi [2,16] Nam 1579 Aubert ngiidi dau tien bao cao ve viem tuy cap dila tren mo t i thi. Nam 1685 Nicola Kulpe mo ta benh ly viem tuy cap qua mo til thi. Naml882 W. Balser lan dau tien ching minh co sii hien dien cua hoai t i md trong viem tuy cap. Nam 1896 H.Chiari da ching minh hien tiidng tii huy tuyen tuy. Cuoc tranh luan g iia hai thai do x i tri viem tuy cap: Dieu tri noi khoa bao ton va dieu tri phau thuat, khdi dau vao nhiing nam cuoi 1800 khi Senn va Fitz ca hai cong bo' nhiing mo ta benh ly va bieu hien lam sang cua benh nav. Nam 1866 Senn vdi tii cach la mot phau thuat vien da tan thanh quan diem phau thuat, de x i tri ton thiidng hoai tii cua tuyen tuy trong viem tuy cap, ly le cua ong diia tren hai cd sd: Co the lam ding qua trinh tien trien cua viem tuy cap bang cach lay di tuyen tuy, tranh hien tUdng tuyen tuy tiet ra cac men tiep tuc tieu huy to chic md va protein. Cac roi loan tim -mach, chuyen hoa va cac bien chiing khac co the diidc cai thien neu cac doc to, san pham cua to ch ic tuy hoai t i sinh ra, diidc dan liiu ra ngoai va khong hap thu vao he tu&n hoan chung cua cd the. 27 Nam 1889 Fitz vdi cach nhin cua mot ngiidi lam giai phau benh thi lai tin ring, can thiep phau thuat sdm la phieu ltfu mao hiem va ching giup ich gi ca, lap luan cua Fitz diia tren nhiing nhan xet ton thiidng giai phau benh cua viem tuy cap tren thiic nghiem cung nhii tren ngiidi benh: Ton thiidng xuat hien sdm nhat trong viem tuy cap la hien tUdng phu tuy, hien tiidng phu nay xay ra tren toan bo tuyen tuy va khi dien bien nang len thi hien tiidng phu lan ra ca cac to chic xung quanh tuy, cung nhii vay, hien tiidng hoai t i md, diidc coi nhii giai doan trung gian cua qua trinh dien bien nang len cua viem tuy cap, cung se lan toa ra khoi tuyen tuy, tdi cac to chiic sau phuc mac va khoang sau phuc mac, sau cung, khi phu tuy tang len se chen ep va bop nghet nhu mo tuy, din den hien tiidng hoai tii tuyen tuy. Hien tiidng hoai t i do ban huyet co the xuat hien tdi da d mot vin g nhat dinh hoac tren toan bo tuyen tuy, nhiing vi tri hay gap nhat la d cho tuy nam vat ngang cot song, hien tiidng tac mach (tinh mach, dong mach) cung tham gia vao qua trinh lam hoai t i tuyen tuy. Hien tudng chav mau trong viem tuy cap khong phai la cd ban, chi la nhing chay mau nho, khong de doa chet vi chay mau, de doa chinh la nhing roi loan va ton thiidng gay nen do hien tiidng phu tuy (Shock, roi loan tuan hoan, nguy cd hoai t i tuy do p h i ne gay chen ep tuy). N hing nhan xet cua Fitz la rat xac dang va sau nay chinh do la nhing cd sd de di den thong nhat giiia phau thuat vien vdi cac nha hoi sic: Doi vdi mot viem tuy cap, dieu tri ban dau nen la noi khoa, phau thuat chi can thiep doi vdi nhing triidng hdp viem tuy cap chay mau hoai t i va dieu quan trong la phai chon thdi diem mo cho phu hdp, cung nhii chon phiidng phap mo cho thich ing. Nam 1901 Opie cho rang sii ket cua soi trong bong Vater la nguyen nhan gay viem tuy cap. Nam 1927 Elman da phat hien ra s i tang cao amylase trong benh viem tuy cap, thiidng bat dau tang t i gid th i 12 - 24 sau khi cdn dau khdi phat, keo dai 2-3 ngay sau do giam 28 dan vao ngay th i 3-5, phat hien nay da danh dau sif in g dung sinh hoa vao nghien ciu benh ly tuy va gop mot tieu chuan quan trong trong chan doan viem tuy cap ve mat sinh hoc. Nam 1974 Ranson[17] qua nghien ciu cua minh, da diia ra bang tien liidng sdm gom 11 dau hieu. Cung trong nam 1976, Longerbeam [16] da bo sung them kinh nghiem b&ng 9 benh nhan bi viem tuy cap hoai t i nang, co 4 benh nhan diidc mo dan liiu ra ngoai (chi dinh mo muon sau mot thdi gian dieu tri noi va theo doi) va sau do co nhieu lan mo lai (tren cin g mot benh nhan), tat ca so' benh nhan nay deu khoi, cac triidng hdp con lai: 2 benh nhan mo cat loc to chic tuy hoai t i va dan liiu rong rai, ket qua: 1 khoi, 1 chet vi nhiem tring, 3 benh nhan con lai, diidc mo cat 75% - 90% tuy tat ca deu song. Nam 1979, Frey[13] da tong ket kinh nghiem trong dieu tri viem tuy cap chay mau, 52 benh nhan chi co dieu tri noi khoa ddn thuan, khong mo deu t i vong, 16 benh nhan diidc mo d thdi diem t i 1-9 ngay sau khi nhap vien, chi co 6/16 benh nhan khoi ra vien, Frey khuyen cao nen s i dung choc ria o bung, v ia vdi muc dich chan doan v ia vdi muc dich dieu tri, Frey cung cho rang neu sau khi bdm ria va hoi sic tich ciic ma tinh trang benh nhan khong kha len thi nen mo cat loc to ch ic hoai ti. Cung trong nam 1979, Ranson [17] da de xuat mot bang phan loai va tien liidng benh, qua do co the xac dinh nhing benh nhan viem tuy cap chay mau hoai t i can mo ngay va nhing benh nhan can theo doi dieu tri bao ton, 6/10 benh nhan diidc dieu tri noi khoa bao ton ddn thuan, tat ca deu song, 4 benh nhan con lai diidc mo trong vong 48 gid sau khi nhap vien, din liiu khoang tuy va thUc hien “3 md thong”, ca 4 benh nhan nay deu con song, nhiing da de lai nhieu di ching, ty le nhigm tring o bung nhieu hdn va thdi gian thd may lau hdn, thdi gian n&m vien lau hdn so vdi nhing benh nhan diidc 29 dieu tri noi khoa bao ton, Ranson cung nhan thay d 5 benh nhan khac phai mo cat tuy ban phan 48gid sau khi nhap vien: ton thUdng khi mo viem tuy hoai t i chay mau, ca 5 benh nhan nay khi mdi vao vien deu co 5 diem tinh theo bang tien liidng nguy cd cua Ranson, tat ca 5 benh nhan deu t i vong vi nhiem trung hoac suy thd trong vong 3 - 4 tuan sau mo, do do Ranson phan doi viec chi dinh mo sdm doi vdi benh nay, du la md din luu hay cat tuy. Nam 1982 Imrie mot phau thuat vien, da dua ra mot bang yeu to tien liidng benh viem tuy cap gom 8 diem, diia tren nhiing danh gia t i khi benh nhan vao vien. 2.2. Nghien curu benh viem tuy cap d Viet Nam Benh an viem tuy cap dau tien diidc cong bo' bdi Meyer May, tiep theo la cac benh an khac ve viem tuy cap cua Ho D&c Di, Vu DinhTung,TonThatTung. Nam 1945, Ton That Tung qua 54 benh an viem tuy cap da gap d Viet Nam t i 1935 den 1945, da phan tich, trinh bay kha toan dien, day du ve cac mat: Dac diem lam sang, thiidng ton giai phlu benh, doi chieu giuta lam sang va giai phau benh, t i do diia ra nhing minh ching ve can nguyen sinh benh cua viem tuy cap. Theo Ton That T in g thi, can phan biet 2 loai viem tuy cap doi lap nhau ve lam sang va ton thiidng giai phau benh: - Viem tuy cap the phi: Dau hieu cd nang rat rim ro, thiic the rat manh me, chu yeu la trieu ching co cin g thanh bung, ton thiidng giai phau benh, dau tien xuat hien d khoang ke giia cac nang tuy, dac triing bdi hien tiidng p h i ne, co khi lan rong khlp ving diidi gan. Tac gia cho ring hien tiidng phu tuy nay chu yeu co lien quan den nguyen nhan gay tac nghen cd hoc diidng dan mat chinh, cu the la do soi va giun dua. - Viem tuy cap the chay mau, hoai ti: Dau hieu cd nang rat noi troi, doi lap vcfi dau hieu thic the md nhat, khong ro rang, 30 khi mo thudng khong thay co ton thiidng d diidng mat, ton thiidng cd ban la chay mau va hoai tii md, ty le tii vong cao. Ve dieu tri, tai thdi diem do, Ton That Tung thien ve dieu tri phau thuat, vi cho rang dieu tri noi khoa bao ton la khong du hieu qua, dac biet d cac ca benh nang, khi md chi lam nhiing gi can thiet va tdi thieu, khong co chu triiOng cat tuy. Ong khuyen: (1) Doi vdi viem tuy cap the phu: hoac md thong tui mat hoac dan ltfu ong mat chu, sau khi lay sdi, giun, hoac ket hdp ca hai, thong thiidng nhat la: dan liiu tui mat kem dan liiu hau cung mac no. (2) Doi vdi viem tuy cap the chay mau: Can kiem tra ky ong mat chu va ong Wirsung vi co the co sdi nam ket d bong Vater, hoac giun chui vao ong Wirsung. Tii do den nay cung da co nhieu cong trinh nghien ciiu ve viem tuy cap. Nam 1991, Tran Van Phoi [5] qua tong ket 28 triidng hdp viem tuy cap co md, cho biet ty le tii vong la 42,85% Nam 1993, Nguyen Quang Nghia, Hoang Cong Dac tong ket dieu tri viem tuy cap trong 5 nam tai benh vien Viet Diic vdi 173 triidng hdp, cho biet ty le md la 26% va da diia ra ket luan: viem tuy cap the phu hay gap (70%), the hoai tii chay mau (30%), nguyen nhan sdi, giun diidng mat -tu y (24,3% ), tii vong (18,7%) Nam 1994, Nguyln Tien Quyet, Do Kim Sdn,Tran Gia Khanh, Nguyln Quang Nghia qua 228 trtfdng hdp viem tuy cap diidc chan doan va dieu tri tai benh vien Viet Diic tii 1991 den 1993 cho biet ty le md giam con 15%, ty le tii vong giam con 23%. Nam 2001,Ton That Bach, Nguyen Thanh Long, Kim Van Vu [1] thong bao ket qua dieu tri cho 34 benh nhan viem tuy cap hoai tii khong do nguyen nhan cd hoc, cho biet ty le tii 31 vong 2,9%, ty le tai bien 8,8%. Nam 2002, Nguyen Thi H lng [2] qua nghien ciu 50 ben’n nhan viem tuy cap tai khoa tieu hoa benh vien Bach Mai dtfa ra ket luan: Benh thiidng gap d tuoi tre, ty le nam I nil - 1,5, Amylase > 700 UI/L chiem 86%, Lypase mau >500 UI/L chiem 74% Nam 2002, Trinh Van Thao qua nghien ctiu dieu tri phau thuat 70 triidng hdp, viem tuy cap hoai t i tai benh vien Viet Die, diia ra ket luan: viem tuy cap hoai t i thudng khong co nguyen nhan ro rang chiem 74,28%, soi giun diidng mat -tuy chiem 17,15%, sau phau thuat vin g mat- tuy chiem 1,43%, ket qua tot va trung binh la 77,13%, xau 7,15%, t i vong 15,72% Nam 2003 Hoang Thi Huyen [3], da doi chieu mot so'trieu ching lam sang trong viem tuy cap vdi phan do nang nhe cua Imrie va Balthaza. 3. NGUYEN NHAN GAY VIEM TUY CAP Co nhieu nguyen nhan gay viem tuy cap: - Nguyen nhan chu yeu chiem tdi 60%-85% cac triidng hdp viem tuy cap la nhom giun-soi diidng mat -tuy va riidu[4,5,15]. - Cac nguyen nhan khac: + Do chan thiidng: chan thiidng bung + Sau mo: cac phau thuat vin g bung, gay chan thiidng, ton thiidng tuy. + Do bien ching ERCP + Do thuoc va doc to: Azathioprine, 6-Mercaptopurine, cimetidine... + Do nhiem trung: Virus, vi khuan 32 + Do di dang dUdng mat, bat thiidng bam sinh tuy: tuy chia doi + Benh cua bong Vater + Do roi loan cd vong Oddi + Benh ly chuyen hoa: tang lipid mau, tang hoat pho giap - Khong ro nguyen nhan 4. CO CHE BENH SINH CUA VIEM TUY CAP [11,14,15] Cd che benh sinh cua viem tuy cap cho den nay, con ngiidi van chiia hoan toan hieu ro, da co nhieu thuyet diidc diia ra. 4.1. Thuyet tic nghen va trao ngifdc Nam 1882 Prince da diia ra gia thuyet ve sii tac ong tuy bdi soi mat, lam bung phat viem tuy cap, gia thuyet nay cung diidc Opie khang dinh lai vao nan 1901, sau khi giai phau t i thi mot triidng hdp viem tuy cap thay co soi ket d bong Vater. Theo Fagnier, trong da so' cac triidng hdp viem tuy cap do soi mat ngiidi ta thay co hdn 80% so" benh nhan co soi trong phan, va 2/3 trong so" do co mot ong chung de dan ong mat chu va ong Wirsung. Ben canh do, nhiem doc riidu diidc coi la yeu to" lam tang triidng liic cd that Oddi cung nhii co that ta trang, v ia gay tang ap hie, v ia gay tang hoi liiu dich mat trong ong Wirsung. Nhii vay theo thuyet nay, cac yeu to" lam tac nghen diidng mat nhii soi, giun, u chen vao ong mat-tuy va nhiem doc riidu da gay ra tang ap lie ong tuy, gay viem tuy cap, dong thdi stf tSc nghen nay thiidng kem theo trao ngiidc dich ruot, dich tuy va dich mat da diidc hoat hoa d ta trang, la nhing yeu to" gay hoat hoa cac men tuy. Ngiidi ta da gay difdc viem tuy cap th ic nghiem d sic vat, khi tron lan dich mat, dich ta trang roi tiem vao ong tuy vdi ap lie thap < 20 cm H20 thi 70% cac triidng hdp gay viem tuy cap hoai t i xuat huyet va hoai t i md, 33 cac ton thiidng nay chu yeu xay ra d khoang ke, vdi stf tham nhilm te bao viem, trong 24 gid dau cac nang tuyen con nguyen ven, ve sau cac nang tuyen se bi ton thiidng. Schmit va Lan Kisch da thuc nghiem d chuot bang cach tiem dau oliu hoac acid oleic vao ong tuy da gay viem tuy cap hoai ti. 4.2. Thuyet tirtieu Diidc de xuat bdi Chiari 1896, theo thuyet nay thi: Cac men thuy phan protid nhii trypsinogen, chymotrypsinogen, proelastase, phospholipase A diidc hoat hoa ngay ben trong tuyen tuy, trong do cac yeu to" nhii noi doc to', ngoai doc to, nhiem virus, thieu mau, thieu oxy, chan thiidng, diidc nghi den nhii la yeu to' hoat hoa men, dau tien cac men thuy phan protein, nhat la trypsin khong nhiing tieu huy mo tuy va cac mo xung quanh, ma con hoat hoa cac men khac nhu elastase, phospholipase. Cac men nay diidc hoat hoa gay tieu huy mang te bao, tieu huy protein gay phu, chay mau mo ke, ton thiidng hoai tii mach mau, hoai tii md, hoai t i nhu mo tuy, cac san pham cua sii ton thiidng va hoai t i te bao lam hoat hoa, phong thich cac bradykinin, kalikrein va cac chat hoat mach gay gian mach, tang tinh tha'm, phu, do do lam thoat dich, gay giam the tich tuan hoan nang ne, gay Shock, lai lam nang them tinh trang thieu khi, thieu mau, thuc day sii hoai t i tuy. 4.3. Thuyet ong dan Binh thiidng niem mac ong tuy khong tham qua nhiing phan t i co kich thiidc > 3000 DA, s i gia tang tinh tham xay ra khi d in g liidng acid acetyl salisylic, histamin, calci, prostaglandin E2, khi do hang rao bieu mo co the tham qua cac phan t i t i 20.000- 25.000 DA, dieu nay cho phep hoai hoa cac men phospholipase ma dac biet la phospholipase A2 trypsin, elastase xam nhap vao mo ke tuy gay viem tuy cap hoai ti, tii do lai phong thich cac lysosom va cac hydrolase lam hoat hoa men va lam tieu huy ben trong te bao. 34 4.4. Thuyet oxy hoa qua mure Nam 1993 Lery dda ra thuyet oxy hoa qua m ic: Theo thuyet nay thi viem tuy cap dddc khoi phat la do sd san xuat qua m ic cac goc oxy hoa td do va cac peroxyt dddc hoat hoa bdi sd cam in g men cua he thong Microsom P 450. Do rddu, hoac mot sd cdng cap qua nhieu cd chat ma sd chuyen hoa oxy la quan trong.Cac hydrocarbon, halogen va mot sd giam cd che td ve chong lai sd oxy hoa qua m ic nay do sd giam glutathion, dieu nay giai thich vai tro cua yeu to' th ic an trong viem tuy cap. Gan day ngddi ta dda ra vai tro cia mien dich va cac cytokin, interleukin, cung nhd y e i to" hoai td U.TNF (Tumor necrotizing factor) nhat la trong viem tuy cap hoai td cung dddc de cap nhieu. 5. BENH HOC VA SINH LY BENH CUA VIEM TUY CAP 5.1. Roi loan tai cho - sir urtre djch Giam huyet ap d benh nhan viem tuy cap co the la hau qua cua giam ldu lddng tuan hoan, do sd i tre dich d sau phuc mac, xung quanh tuy, so lddng tu dich da khong dddc xac dinh ro tren ngddi nhdng Carey va cong sd ddc lddng rang, hau qua cua viem tuy cap the phu bi mat khoang 2 lit dich cua ldu lddng tuan hoan trong mau, thanh phan hoa hoc cua dich la rat thay doi, tuy nhien no chia cac enzym tuy va cac peptid khac. Sd tang hematocrit dddc nhin thay thddng xuyen d benh nhan viem tuy cap la bhng ching gian tiep lien quan tdi sd giam ldu lddng mau, vdi viem tuy cap hoai td chay mau, mat mau la rat dang ke, do vay hematocrit co the giam. Trong n h in g nghien ciu thde nghiem d cho, ngddi ta thay co the mat ldu lddng tuan hoan t6i 20% trong 2gid, 30% 35 trong 6gid sau khi gay ra viem tuy cap, khoi liidng plasma trong cho bi giam xuong 38% giia 6gid den 24gid sau khi gay viem tuy cap 5.2. Suy tuan hoan Ha huyet ap, suy tim, tang sic can ngoai bien lam giam hieu suat cua tim, thiidng gap d benh nhan viem tuy cap, trong triidng hdp benh nhan nang, nhiing dau hieu nay tUdng tii nhii trong nhiem khuan hoac xd gan, d nhiing benh nhan nay huyet ap thap keo dai nen liiu liidng mau chiic nang khong diidc phuc hoi. 5.3. Suy than Theo Austin, suy than la mot bien ching quan trong cua viem tuy cap, no ket hdp vdi ty le t i vong tdi 70% cac triidng hdp, sU thieu nieu diidc nhin thay thiidng xuyen, tham chi ngay ca khi chiia xuat hien tut huyet ap, nhiing no thiidng diidc giai quyet vdi sii day du so liidng dich trong tinh mach, sii giam huyet ap va nhiem trung co le la hau qua cua suy than, mac d i ch ic nang than trong viem tuy cap da khong diidc nghien ciu mot cach day du, tuy nhien ngiidi ta thay rang, trong viem tuy cap khi xuat hien bien ching suy than thi ty le t i vong rat cao. 5.4. Suy ho hap Giam oxy mau dong mach (P a02) thiidng xay ra trong viem tuy cap, nhiing da so benh nhan viem tuy cap song sot ma khong yeu cau phai dat noi khi quan va thong khi cd hoc, khi can nhieu s i can thiep b it buoc thi do la dau hieu cua chic nang phoi bi suy yei, ty le t i vong toan bo co the len tdi 70%. Tren phim chup Xquang phoi, nhing bien doi co the la: Sii nho cao cua cd hoanh, day mang phoi, tran dich mang phoi. N hing hinh anh nay thiidng thay d ben trai, cung co the thay 36 d ben phai hoac ca hai ben, dich mang phoi co dac diem la vo trung, nhung co the co sii tap trung cao cua amylase, bang ching cua phu phoi trong chup Xquang chiem 30% den 60% trong nhing benh nhan vdi sii giam oxy hoa da song sot trong 48gid dau cua viem tuy cap 5.5. Tang glucose Tang glucose mau trong viem tuy cap co t i 50% den 70% cac tridng hdp, tuy nhien tang glucose nieu la khong thudng xuyen va chi xay ra khoang 30% so" triidng hdp d nhing benh nhan khong co tien s i dai thao diidng, Theo Ranson va cong s i cho rang: khoang 60% benh nhan trong nhom nghien ciu vdi s i tang diidng mau da chet, tuy nhien ty le t i vong trong viem tuy cap hiem khi la ket qua cua stf tang diidng mau hoac bien ching dai thao diidng ddn doc 5.6. Giam calci mau Sii giam calci mau trong viem tuy cap xay ra la thiidng xuyen, nhiing thiic s i pham vi va anh hiidng cua no thi khong diidc biet ro, khi ham liidng calci mau xuong diidi 2mmol/ 1 thi bao hieu tien liidng nang. 6. GIAI PHAU BENH VIEM TUY CAP 6.1. Viem tuy cap the phu 6.1.1. Dai the: Tuy to hdn binh thiidng, mong nhu phong be novocaine, mau hong, tring nhdt hoac tai xam, ton thiidng co the nhan thay d dlu, than, duoi hoac toan bo tuy, s i ph i mong, co the lan rong ra cac to chic, xung quanh: khoang sau phic mac, mac treo dai trang ngang, mac noi ldn, mac noi nho, cuong gan. 37 6.1.2. Vi the: Ton thiidng ro va chiem ilu the d khoang ke, niidc phu nhieu, khuyech tan cac vach lien tieu thuy, tham nhap ca cac tui tuyen xong chiia thay co sii tham nhap cua bach cau, xung huyet mach, cac te bao bieu mo mdi thoai hoa nhe, doi khi thay ton thiidng nang hdn: nhoi mau nho tham tri co hoai tu md kin dao. Hinh 3.1: Hinh anh vi the cua viem tuy cap the phu 6.2. Viem tuy cap the hoai tur 6.2.1. Dai the: Tuy to, bd khong deu, mat do khong deu, co nhiing o hoai tii mau den, mau xam, hoai tii co the khu tru mot phan tuy hoac toan bo tuy, hay lan ra tdi cac tang lan can: Lach, dai trang, da day, ta trang, khoang sau phuc mac... 38 6.2.2. Vi the: Ton thiidng hoai tii md te bao, hoai tii tui tuy, dao Langerhans, trao mau khoang ke, hoai tii md, hoai tu cac tieu thuy tuy bao gom ca tuy noi tiet, ngoai tiet, hoai t i mach mau gay chay mau kem theo phan ting viem, do la nhiing ton thiidng dan xen lan nhau khong bao gid thieu tren vi the Hinh 3.2: Hinh anh vi the viem tuy cap the hoai tir 7. PHAN LOAI 7.1. Phan loai co dien Viem tuy cap diidc chia lam 3 the: - Viem tuy cap the phu - Viem tuy cap the chay mau - Viem tuy cap the hoai tii 39 7.2. Phan loai theo hien nay Hoi nghi quoc te ve viem tuy cap tai Atlanta (Hoa Ky) vao thang 9/1992 da thong nhat chia viem tuy cap thanh hai the: - Viem tuy cap the phu (the nhe) - Viem tuy cap the hoai t i (the nang) Phan loai theo hien nay co gia tri phu hop vdi cac chi so tien liidng cua tac gia RANSON, IMRIE... 8. TRIEU CHL/NG VA CHAN DOAN Nhieu nghien ciu dac diem dich te lam sang cua Viem tuy cap co mot so nhan xet nhu sau: - Tuoi: Qua ket qua nghien ciu chung toi trong 304 trUdng hdp Viem tuy cap tai Benh vien Viet-D ic t i 1998-2003 thay, do phan bo tuoi cua nhom benh nhan t i 13 den 88 tuoi.Tuoi trung binh 48,643 ± 18,040, cac nhom tuoi hay gap la 31-40, 41-50, 61-70 va >70, nhom 41-50 la hay gap nhat chiem ty le 21,1%, nhom tuoi <= 20 la It gap nhat chi co 4,3%.So sanh vdi mot so" nghien ciu Nguyen Thi Hang [2], tuoi trung binh 40 ± 7, nhom tuoi 41-50 la hay gap nhat.Ton That Bach va cong sii [1], viem tuy cap hay gap d nhom tuoi 30-50 Balsegaram nghien ciu tai Malaysia, qua 112 benh nhan thay do tuoi hay mac t i 25-35. d my tuoi hay mac viem tuy cap la 50-60, d mot so niidc khac nhii Europe Southern, Central Europe tuoi trung binh viem tuy cap la 55. Nhii vay ket qua nghien ciu cua ching toi tiidng tii vdi ket qua nghien ciu cia cac tac gia trong niidc, nhiing co khac vdi ket qua nghien ciu d phiidng Tay Stf khac nhau nay la do anh hiidng cua yeu to" nguyen nhan, nghien ciu cua chung toi d tren cac benh nhan viem tuy cap do sdi mat va do giun d ia gay 40 nen, soi mat d Viet Nam chu yeu la soi sac to" va soi hon hdp, giun dua khong nhiing triic tiep gay nen viem tuy cap, ma con gian tiep hinh thanh soi mat.Dieu nay dUdc the hien trong nghien ciu cua chung toi, do la do phan bo" tuoi benh rong tii 13 cho den 88 tuoi, phu hdp vdi tuoi nhiem giun, tuoi hay mac benh tii 31 den 50.Day la lia tuoi lao dong chinh cua xa hoi nen de tiep xuc vdi nguon nhiem giun trong qua trinh sinh hoat lao dong. Trong khi do viem tuy cap d cac niidc phat trien, chu yeu la do riidu manh va soi mat, soi mat d day chu yeu la soi cholesterol, cd che hinh thanh soi la do roi loan chuyen hoa, cho nen soi hay gap d tui mat, d phu nil tuoi 60-70. T i nghien ciu nay, cho thay: viem tuy cap do soi, giun dua hay gap d tuoi 31 den 50, tuoi benh thap nhat la 13, cao nhat la 88. ’ - Gidi: Trong nghien ciu cua ching toi thi, ty le benh nhan nam chiem 28% va n i 72%, ty le mac benh giia nam va n i la khac biet nhau co y nghia thong ke vdi p < 0,01, n i mac benh cao hdn nam 2,57 lan. Ket qua nghien ciu cua ching toi cung tiidng tu vdi ket qua nghien ciu cua cac tac gia khac nhif: Nguyen Quang Nghia 1995,Ty le Nam /Ni: 1,33, Ton That Bach va cong s i 2002 Nam/Ni: 1,77, d My, Anh, Phap [11,13,15] Nam/Ni: 1,5. Cd s i khac biet nay theo ching toi, la do anh hiidng cia yeu to" nguyen nhan, nghien ciu cua chung toi chi diidc tien hanh tren cac benh nhan viem tuy cap do sdi, giun. Nhii vay trong viem tuy cap do sdi, giun diidng mat- tuy thi n i gap nhieu hdn nam mac d i ty le Nam /Ni va tan suat nhilm giun cua nam va n i la khong khac nhau bao nhieu [29], theo chung toi day la mot dac diem khac vdi viem tuy cap do nguyen nhan noi chung. 41 - Nghe nghiep va dia dii: T i ket qua nghien ciu thi: ty le mac benh d nong thon (57,9%), lam ruong (43,1%) cao hdn so vdi d thanh thi (42,1%), cong nhan, tri th ic (22%), s i khac biet nay co y nghia thong ke, ket qua nay p h i hdp vdi nghien ciu cua Nguyen Thi HSng 2002 [2] ty le mac benh d nong thon 62%, lam ruong 52%, thanh pho 38%, cong nhan va tri th ic 38%. Ket qua nay cung p h i hdp vdi ty le nhiem giun dua cao d nghe nong. Co s i khac biet tren la do: Niidc ta la niidc nong nghiep, 80% dan so" lam ruong, vdi trinh do dan tri con thap, che do an uong, ve sinh cung nhii hieu biet ve phong benh chua cao, day chinh la nhing y e i to' thuan ldi de nhiem giun, mot trong nhiing nguyen nhan chu yei gay viem tuy cap - Tien s i benh: Qua nghien ciu cua ching toi cua 304 benh nhan viem tuy cap do soi, giun diidng mat- tuy thi: co 52% triidng hdp co tien s i soi, giun d diidng mat hoac tien s i dau ha siidn phai sot- vang da, 27,3% triidng hdp tien s i khong co gi dac biet va 20,7% co tien s i khac. Trong nhom benh nhan co tien sii soi giun diidng mat, thi co 59,5% da co tien s i md sdi giun diidng mat it nhat la 1 lan md va 40,5% trong tien s i chiia co dieu tri can thiep. Nhii vay trong so" nhing benh nhan cd tien s i sdi giun diidng mat- tuy, dau ha siidn phai- sot -vang da thi, viem tuy cap hay gap d nhing benh nhan co tien s i md ve sdi giun diidng mat, so vdi nhing triidng hdp chiia co dieu tri can thiep, t i nhan xet nay theo chung toi, cac thay thuoc lam sang nen than trong triidc nhing benh nhan dau bung cap co tien sii mo sdi giun diidng mat-tuy, de tranh triidng hdp cac trieu chiing cua viem tuy cap bi che lap bdi benh canh cua benh sdi giun diidng mat 42 8.1. Trieu chung lam sang 8.1.1. Trieu chung ca nang - Dau bung: La trieu chiing (Mu tien va la ly do de ngiidi benh di kham benh, thiidng xuat hien mot cach dot ngot d vung thiidng vi, co khi lan ra ha sUdn phai, ha sUdn trai, hoac ra sau liing. Neu viem tuy cap do soi mat, ngoai dau d vung thudng vi, con dau d ha siidn phai, xien ra sau liing, lan len vai phai, co the kern theo sot cao ret run. Neu viem tuy cap do giun chui ong mat, cdn dau thiidng dii doi, benh nhan thiidng n&m d tii the phu phuc chong mong hoac gac chan len tiidng, dau doc xuong thap. Neu viem tuy cap do riidu, benh thiidng khdi phat sau khi uong bia, riidu hay bufa an ngon thinh soan. - Non: Da so benh nhan co non hoac buon non luc dau non ra thiic an, sau do non ra dich da day, co khi lan ca dich mat vang dang - Bi trung tien: Benh nhan khong danh hdi, khong di ngoai, bung triidng va day tiic kho chiu 8.1.2. Trieu chung toan than Vdi da so' the nhe tinh trang toan than thiidng khong tram trong, benh nhan met moi nhiing tinh, huyet ap on dinh, khong kho thd. Vdi the nang (viem tuy cap hoai tii) co the co tinh trang shock: Ngiidi benh va mo hoi, lanh, nhdt nhat, tra ldi cham chap, mach nhanh huyet ap dong mach thap, khoang cach giia 43 huyet ap toi da va huyet ap toi thieu hep lai, ngiidi benh co the hot hoang, kich dong hoac ngUdc lai nam Id dd met moi, co nhiing mang bam tim d chan tay, than the, thd nhanh nong. Sot: Thiidng co sot nhe hoac sot cao do viem nhiem dUdng mat hay do hoai t i tuy rong. Vang da: Gap d benh nhan viem tuy cap do soi mat. T i so" lieu nghien ciu thu diidc, chung toi nhan thay: Sot (T° > 37,5°C) 49.7%, tiep theo la mach nhanh ( M>951/p) chiem 22,7%, huyet ap dong mach toi da <90 mmHg co 4,6%. Shock (M>1201/p, HA dong mach toi da <90mmHg) chi co 1%, ty le sot (49,7%) trong nghien ciu cua chung toi thap hdn so vdi ket qua nghien ciu cua Nguyln Thi H&ng 72%, Fagnier 85% Vang da chiem 58,6% cac triidng hdp, thap hdn ket qua nghien ciu cua Ton That Bach 88,4%. Day la mot dac diem cua viem tuy cap do soi giun diidng mat- tuy d niidc ta khac v6i viem tuy cap do soi d cac niidc phiidng Tay 8.1.3. Trieu chung thut the - Bung triidng: Deu, co khi triidng d vung tren ron nhieu hdn, go trong, khong co quai ruot noi, rin bo nhii trong tic ruot cd hoc, cac tac gia goi la gia tac ruot, khi o bung co dich co the go due d v in g thap. - Dau va phan in g vung thiidng vi: La trieu ching thiidng gap trong viem tuy cap, xuat hien d ha siidn phai khi nguyen nhan gay viem tuy cap la soi mat, phan in g thanh bung co khi manh nhii co cin g thanh bung, do la ly do co the nham v6i thing o loet da day- ta trang. - Mang cin g tren ron (Mass): Co the sd thay mang cing d tren ron, co khi lan sang hai ving diidi stfdn, an dau, khong di dong. 44 - Diem 811611 liing dau: Co 6 hau het cac benh nhan viem tuy cap, diem dau nay diidc Mayo Robson va Korte mo ta tit nam 1906, diidc Ton That Tung cho la mot trieu ching quan trong cua viem tuy cap - Co the kem theo gan to, tui mat to - Co the gap cac mang bam tim 6 2 ben mang siidn (dau hieu Cullen) hoac quanh ron (dau hieu Grey) nhat la trong viem tuy cap the hoai tii day la dau hieu rat dac hieu, bieu hien s i chay mau 6 vung tuy va quanh tuy. - Tran dich mang phoi: mot hoac ca hai ben tuy, de tranh triidng hdp cac trieu ching cua viem tuy cap bi che lap bdi benh canh cua benh soi giun diidng mat Ket qua nghien ciu cua chung toi thay cac trieu ching cua viem tuy cap do soi giun diidng mat - tuy hay gap la: Dau thiidng vi hoac ha siidn phai gap d tat ca cac benh nhan nghien ciu (100%), trieu ching non (84%), bi trung tien (20,5%), bung chiidng (63,9%), dau va co phan in g vung thiidng vi hoac ha siidn phai(89,l%), rat it gap cac dau hieu: sd thay khoi cf tren ron (Mass) chi co 1,3%, mot dieu ching toi nhan thay la: dau hieu bam tim diidi da va diem siidn liing dau hau nhii khong thay mo ta trong benh an, phai chang hau nhii cac benh nhan deu diidc chan doan sdm vi dau hieu bam tim diidi da hay dau diem siidn liing la hau qua cua hien tiling xuat tiet dich nang va hay gap d nhing triidng hdp VTC the nang. 8.2. Trieu chung can lam sang 8.2.1. Xet nghiem sinh hoa - Amylase mau: Khi tang cao tren 3 lan binh thiidng, ket hdp vdi cac trieu ch in g lam sang co the ch&n doan viem tuy cap. 45 Do nhay cua amylase mau trong chain doan viem tuy cap la 95% theo Sleisenger va Fontran, ti'nh dac hieu cua no la 85% theo Belghiti.J va Coll[19]. Tuy nhien amylase mau tang, khong phai chi dac hieu trong viem tuy cap, trong mot so benh khac cung gay amylase mau tang nhii: thung o loet da day - ta trang, chia ngoai til cung vd, nhoi mau mac treo ruot, viem tuyen niidc bot mang tai..., nhung thudng chi tang gap 2-3 lan tri so'binh thudng Hoac ngiidc lai amylase mau khong tang cung khong phai la yeu to' de loai tr i viem tuy cap: nhii trUdng hdp viem tuy cap cf giai doan muon, da qua giai doan tang amylase hoac tuy bi hoai tii gan nhii toan bo. Nhii vay trong da so' cac trUdng hop viem tuy cap thi Amylase mau, Amylase nieu deu tang (chu yeu la tang gap 10 lan binh thiidng), nhiing neu gap triidng hdp Amylase mau, Amylase nieu thap, ngay ca khi dudi miic binh thudng thi chung ta van chUa the loai tr i hoan toan kha nang benh nhan bi viem tuy cap. Trong nhiing triidng hdp nhii vay, chung ta can lam them cac tham do ho trd chan doan khac, de xac dinh chan doan - Lipase: Lipase mau tang > 3 l&n binh thiidng cd gia tri chan doan viem tuy cap hdn la tang amylase mau, ngoai ra do sii tang lipase mau keo dai hdn sii tang amylase mau, nen no se la mot xet nghiem de chan doan va theo doi viem tuv cap tot hdn, tuy nhien tang lipase mau cung khong chi dac hieu trong viem tuv cap, ma con tang trong cac benh ly khac nhii: thung o loet da day- ta trang, nhoi mau mac treo ruot, tac ruot, suy than - Calci mau, magie mau: giam 59,9% cac triidng hdp la Canxi mau binh thiidng, difdi 2mmol/l cd 9,8%. (day la yeu to tien liidng trong 48h dau theo Ranson), ket qua nav tiiOng tii vdi nghien ciu cua Nguyln Thi H&ng la 10%, Cac triidng hdp viem tuy cap hoai ti, s i giam can xi mau la hau qua cua qua trinh can xi ket hdp vdi axit beo tii do diidc 46 giai phong trong qua trinh phan huy lipid de tao ra hinh anh vet nen. - Ure mau: Nghien ciiu cua chung toi chu yeu cac triidng hdp la Ure mau d gidi han binh thudng (83,8%), chi cd 16,2% la tang ure mau, trong do tang tren 16mm/l cd 2,8% (yeu to tien liidng trong 48h dau theo Ranson), ure mau tang theo nghien ciiu cua Nguyen Thi Hang la 16%, Ton That Bach va cong sii la 29,4%. - Dudng mau: - Diidng mau tang, chiem 53,6%.Ty le tang diidng mautang tren llmmol/1 chi cd 3,8%. (yeu to" tien liidng gid 0 theo Ranson), cao hdn so vdi ty le tang dudng mau cua Nguyen Thi Hang 14%. - Billirubin toan phan mau: - Bilirubine tang trong trUdng cd tac mat theo ket qua nghien ciiu cua chung toi thi so" triidng hdp cd Billirubin toan phan tang tren 20mmol/l la 81,3%.Day la dau hieu gian tiep chi diem cd sii can trd liiu thong d diidng mat 8.2.2. Xet nghiem huyet hoc - Hematocrit: So" triidng hdp Hematocrit giam tren 10% co 19,3% (Bang3.18) (yeu to tien liidng trong 48h dau theo Ranson) - So' liidng bach ciu: Trong nghien ciiu cua chung toi, so' triidng hdp co ty le bach cau tang la 77,7%, trong do tang tren 15.000/mm3 chiem 32,3% (yeu to' tien liidng gid 0 theo Ranson), tiidng tii vdi ket qua nghien ciiu cua - Men transaminase (Sgot, SGPT): tang 8.3. Chan doan hinh anh 8.3.1. X quang - Chup bung khong chuan bi: Cd the thay dau hieu khong dac hieu nhii: 47 + Gian cac quai ruot vung gan tuy, co the mot doan dai trang ngang hoac mot doan ruot non, thiidng goi la quai ruot canh ve (sentinel loop). + Hinh anh cac quai ruot triidng hdi, bieu hien cua liet ruot c0 nang + Tuy calci hoa, soi tuy, soi mat - Chup phoi: Co the thay hinh anh tran dich mang phoi - Chup cat 16p theo ty trong bang may tinh (C.T.Scanner): La phildng phap chan doan hinh anh rat co gia tri trong viem tuy cap, ngay td nhiing gid dau, cung nhii trong qua trinh dien bien cua benh, no cho thay hinh anh, kich thiidc,tinh trang nhu mo, miic do va vi tri thiidng ton cua tuy, quanh va xa tuy, soi giun diidng mat (nhat la soi ket Oddi) Dau hieu viem tuy cap tren C.T.Scanner: + Dau hieu tai nhu mo: Tuy to lan toa hoac tilng vung, bd tuy khong ro net, phu ne bao quanh tuy, nhu mo khong dong ty trong, ong Wirsung binh thiidng hoac gian + Dau hieu ngoai nhu mo: Vdi the viia phai: thay sii md di cua ldp md canh tuy vdi sU tang ty trong, xoa vach md trong tuyen va day can lam bd tuy khong rd Vdi the nang: viem bieu hien bdi khoi giam ty trong, ranh gidi khong ro (20-40HU), o dich quanh hay xa tuy Trong nghien ciiu cua chung toi, chi cd 14 benh nhan cd chup CT.Scanner, vdi ket qua: Do A chiem 7,1%, Do B 28,6%, Do C 14,3%, Do D 14,3%, Do E 35,7%. Tat ca 14 benh nhan nay, deu cd ton thiidng cung nhii nguyen nhan trong mo phu hdp vdi ton thiidng va nguyen 48 nhan cltfdc xac dinh tren phim CT.Scanner, khong cd trUdng hdp nao la khong khao sat diidc tuy, dac biet cd 1 triidng hdp da phat hien dUdc soi ket Oddi khi chup cat ldp vi tinh trong khi do sieu am khong phat hien diidc. Theo Balthazar va cong sii thi phiidng phap chup cat ldp vi ti'nh cd do nhay va do dac hieu tren 90%. - Chup cong hiidng tii hat nhan (MRI) La phiidng tien tham do hinh anh khong dung tia X, no cho thay hinh anh, kich thiidc, thiidng ton d tuy va ngoai tuy, ngoai ra no con cd liu diem la cd the xac dinh dUdc khoi dich dac hay du loang de choc hut va dan liiu, tuy nhien hien con la mot phiiOng tien rat dat tien - Chup ong tuy ngiidc dong Qua noi soi ngiidc dong cd the tham do ong Wirsung rat chinh xac nguyen nhan gay viem tuy cap. Tuy nhien trong nhiing triidng hdp can xac dinh ro soi hay giun, tinh trang benh nhan on dinh.Chup de tien hanh cung dong thdi de lay soi hay giun hoac sii tri ckt cd that Oddi trong triidng hdp chit hep. 8.3.2. Sieu am: La phiidng phap tham do hinh thai khong xam nhap, ddn gian, it ton kem, cd the lam di lam lai nhieu lan, cho ket qua kha chinh xac Hinh anh viem tuy cap tren sieu am: - Tuy to, cd the toan bo hay khu tru d tin g phan dau than- duoi tuy, thiidng gap 2-3 lan so vdi kich thiidc tuy binh thiidng - Vien tuy thiidng md (binh thiidng vien tuy deu, sat net phan biet ro vdi to ch ic xung quanh), cd the thay cd cho go len tron hoac thanh mui, day la dau hieu co gia tri cao, trong chan doan viem tuy cap khi ma tuy, chiia cd thay doi ve kich thiidc. 49 - Nhiing bien doi ve do hoi am: chu mo tuy co the giam hoi am, tang hoi am hoac tham chi' khong thay doi hoi am, trUdng hdp giam hoi am la chiem da so - Bien doi ve mau hoi am: cau true hoi am cua chu mo con tUdng doi dong dang doi vdi viem tuy cap the phu ne, con trong viem tuy cap the hoai tu - xuat huyet thi cau true hoi am cua chu mo tuy mat tinh dong dang, co the thay nhUng o tang hoi am hdn so vdi nen chu mo, do tinh trang xuat huyet va nhiing o giam hoi am hdn, tham chi khong co hoi am do tinh trang hoai tu hoa dich - NhUng bieu hien do viem phu ne tuy: tren hinh anh sieu am co the thay gian ong Wirsung hoac/ va gian he thong dUdng mat do he qua cua phu ne tuy, hinh anh chen ep vao tinh mach chu du6i, tinh mach lach, tinh mach mac treo trang tren - Hinh anh xuat tiet dich: vi tri dich xuat tiet co the d trong nhu mo hay quanh tuy, hau cung mac noi, khoang canh than, cac ngach cua o bung (gan-than, lach- than, ho lach, ranh dai trang len - xuong, tui cung Douglas....) - Hinh anh nang gia tuy: vdi hinh trdn hoac bau due, bd mong rat deu, dich trong nang co the la dich dong nhat khong co hoi am, hoac dich co ldn cdn hoi am hoac co vach - Hinh anh ap xe tuy: dien hinh la o dong dich khu tru vdi vo day mong khong deu, dich ben trong ldn cdn hoi am, dac biet xuat hien cac bot hoi do boi nhiem vi khuan sinh khf - Phat hien soi, giun trong dUdng mat- tuy, cac bat thudng ve giai phau gan-mat-tuy Trong trUdng hdp bung trU6ng hdi nhieu thi vai tro cua sieu am bi han che, nhat la trong thdi gian dau cap ti'nh cua benh. So lieu nghien cUu cua chung toi trong viem tuy cap do soi giun dUdng mat-tuy thi, sieu am khao sat dUdc tuy la 79,6% (trong do phat hien dUdc tuy to la 55,4%%, dich o bung 50 la 23,2%) va khong khao sat diidc tuy la 20,4%, do nhay cua sieu am trong chan doan hinh anh tuy Sn = 60,4%, xac dinh duoc nguyen nhan giun soi gay viem tuy cap triidc dieu tri can thiep la 96,4% va khong xac dinh dUdc la 3,6%. 8.4. Chan doan the benh Balthazar - Ranson dua vao Scanner chia viem tuy cap lam 2 the 8.4.1. The phu - Tuy tang the tich toan bo hay tiing phan - Sau tiem thuoc can quang tuy giam mat do tUOng doi dong deu. - Khong co tiet dich ngoai tuy. - Benh dien bien tot. 8.4.2. The hoai tCf - Tuy tang the tich toan bo hay tin g phan - Sau tiem thuoc can quang tuy co nhing o giam mat do ro. - Bd tuy khong con ro - Co xuat tiet ngoai tuv - Benh dien bien co the diia den bien ching ap xe, nang gia tuy 9. BIEN CHL/NG CUA VIEM TUY CAP 9.1. Bien ching toan than: Hay gap d viem tuy cap the nang, cang nhieu bien ching tren nhieu cO quan, to ch ic thi tinh trang cang nang ty le t i vong cang cao 51 - Truy tim mach: Do mat mot liidng ldn huyet tiidng, thoat ra khoi he thong tuan hoan vao vung gian bao, xung quanh tuy, sau phuc mac, day la hau qua cua ton thiidng noi mac thanh mach - Suy giam ho hap: Dau va tinh trang nam lau gay ii dong ddm rai, xep phoi, viem phoi, tran dich mang phoi, tinh trang phu to chiic ke d phoi do ton thiidng mao mach phoi. Hau qua din tdi suy giam chufc nang ho hap - Suy giam chiic nang than: Hau qua cua giam khoi liidng tuan hoan va tinh trang co mach, diia tdi roi loan chiic nang d ong than, gay giam liidng niidc tieu. - Bien chiing d da day ruot: Trong nhiing ngay d&u, da day ruot thiidng gian triidng do liet nhu dong cd nang, gay non va bi trung dai tien, nang hdn la loet da day ta trang, chay mau tieu hoa - Bien chiing than kinh - Dong mau rai rac trong long mach: Do tang dong mau va hoat hoa cO che tieu sdi huyet 9.2. Bien chiing trong o bung - O dich khu tru: thiidng d quanh tuy, triidc tuy, khoang gan than, khoang lach than... Nhiing o dich nay thiidng khong cd vach ngan va thiidng tii tieu khong de lai bien chiing - O hoai tii tuy: cd the d trong nhu md, hay lan toa toan bo tuy, hay lan ra xung quanh tuy, tdi re mac treo dai trang ngang, hau cung mac noi, khoang sau phuc mac va lan di xa theo ranh thanh dai trang xuong ho' chau, tui cung Douglas. Dong hoai tii cua tuy cd the lan tdi da day - ta trang, lach, dai trang ngang, lan len trung that, khoang mang phoi gay tran dich va o dich li dong. 52 - Ap xe tuy: La o mu khu tru d tuy hoac gan tuy hau qua cua boi nhiem o hoai tii tuy, thiidng xuat hien vao tuan thii 3, 4 cua benh, luc nay benh nhan thiidng co sot cao dao dong - Nang gia tuy cap tinh: La nhiing o chiia dich tuy bao boc bdi to chiic xd hoac to chiic hat, hinh thanh trong vong 4 tuan dau cua benh, nang nay thudng thay d tuy, quanh tuy 10. TIEN LlfpNG VIEM TUY CAP Triidc benh nhan viem tuy cap, tien liidng dong vai trd quan trong, de giup cho thay thuoc cd thai do xii ly, dung dan va kip thdi, viec danh gia tien liidng phai diia tren sii theo d5i nhieu gid, nhieu ngay va diia tren nhieu yeu to": Lam sang, huyet hoc, sinh hoa va chan doan hinh anh. Tren cd sd nay, cac tac gia da diia ra cac cach tien liidng khac nhau 10.1. Difa dau hieu toan than Viem tuy cap diidc coi la nang khi cd cac dau hieu sau; - Huyet ap tdi da < 90 mmHg - Suy ho hap: P a02 < 60 mmHg - Suy than: Creatinin > 2mg/dl - Nhilm khuan: Sot >38°C, BC mau > 20. 000/ mm3 10.2. Phan do nang nhe theo lam sang dira theo tieu chuan Hoi nghj Atlanta Hoa Ky (1992 ) [9]. - Viem tuy cap the nhe: + Bung triidng nhe hoac viia + Mach, huyet ap binh thiidng + Khong kho thd 53 + Khong co tran dich da mang + Khong co bien chiing tai cho hoac toan than - Viem tuy cap the nang: Co bien chiing viem tuy cap hoai tii, bien chiing toan than + Suy ho hap cap, mach nhanh hoac truy mach, huyet ap tut + Tran dich da mang, co triidng + Suy than cap + Bung triidng cang, cam ting phuc mac toan o bung + Hoac lam sang la viem tuy cap the nhe, nhtfng qua trinh dien bien trd nen nang, xuat hien cac dau hieu mach nhanh nho, huyet ap tut, kho thd, cam ting phuc mac toan o bung, xuat hien cac bien chting tai cho hoac toan than 10.3. Bang tien lUdng cua Ranson: Gom 11 yeu to lien quan den tien trien, tien liidng cua benh [17]. * Luc nhap vien (gid 0). - Tuoi > 55 - BC > 16.000/mm3 - Diidng mau > llmmol/1 (benh nhan khong bi dai diidng triidc do) - LDH (Lactideshydrogenase) > 350UI/1 - AST (Aspartat amino tranferase) 250UI/1 (hoac SGOT) * Trong 48 gid dau - Hematocrit giam > 10% - Ure mau tang > l,8mmol/l (> 0,5mg/l) - Calci mau < 2mmol/l (< 80mg/l) 54 - Pa02 < 60mmHg - Giam bicarbonat > 4MEq/l - Liidng dich li dong lidc tinh > 6 lit. Moi xet nghiem diidc coi la mot yeu to tien liidng va la mot diem: Benh nhan co 1 -2 yeu to" ty le tii vong dudi 1% 3 - 4 yeu totu vong 16% 5 - 6 yeu to" tu vong 40% 7 - 8 yeu to" tii vong 100% Tinh diem Neu benh nhan co < 3 diem: xep loai nhe 3-5 diem: xep loai nang > 5 diem: xep loai rat nang 10.4. Bang tien Itfdng cua imrie (Glasgow) Bao gom 8 diem, diia tren nhiing danh gia tii khi benh nhan vao vien: - Tuoi > 55 - BC > 15.000mm3 - Diidng mau > 10mmol/l ( > l,8g/l) - Ure mau > 16mmol/l (> 0,45g/l) - Calci mau < 2mmol/l (80mg/l) - Pa02 < 60mmHg - Albumin mau < 32g/l - LDH > 600UI/1 55 Theo imrie neu co 3 yeu to' trd len la viem tuy cap the nang, cang nhieu yeu to', tinh trang cang nang va tien Itfdng cang xa'u. Hai bang yeu to' tien liidng nay, cung co nhiing han che, do nhiing yeu to' diidc diia ra de theo doi, danh gia, khong phai la dac hieu rieng cho viem tuy cap va chi ap dung danh gia tien liidng trong vong 48 gid dau cua benh. Tuy nhien 2 bang nay vin diidc dung rong rai de danh gia tien liidng cua viem tuy cap. 10.5. Bang tien li/dng dira tren chup c it ldp vi tinh cua Ranson- Balthazar[11]: Diia tren cac dau hieu cua chup cat ldp vi tinh. - Do A: Tuy binh thiidng 0 diem - Do B: Tuy to toan bo, bd tuy ro 1 diem - Do C: Viem tuy va cac mo quanh tuy, mat diidng vien tuy 2 diem. - Do D: Cd o dich quanh tuy 3 diem - Do E: Cd nhieu o dich quanh tuy va xa tuy 4 diem Khi cd tii 0 - 3 diem tien liidng nang 8% 4 - 6 diem tien liidng nang 35% 7 - 10 diem tien liidng nang 92% Theo bang nay, do D va E tiidng diidng vdi mile do nang cua viem tuy cap. Han che cua bang nay la: Cac yeu to' cua bang phan loai nay khong dac hieu va chiia the hien diidc mile do hoai tu va nhiem trung la 2 yeu td cd anh hiidng rat nhieu den tinh trang benh nhan va tien liidng benh. 56 10.6. Bang phan loai cua Freeny Diia tren hinh anh cua phu tuy hoac hoai tu tuy - Do A: Tuybinh thiidng: Tuy ngam thuoc thuan nhat va khong to. - Do B: Viem tuy cap the phu: Tuy to ra, bd khong ro, co phu to chiic quanh tuy. - Do C: Phan ling viem quanh tuy: tuy hoai tu < 30% nhu mo. - Do D: Tuy hoai tii 30%-50%, o dich va o hoai tii khu tru. - Do E: Tuy hoai tii > 50%, nhieu o dich va hoai tii lan toa, ap xe tuy. 10.7. Bang phan loai Ulm: Diia tren hinh anh CT.Scanner va ket qua vi trung hoc, co gia tri de danh gia tinh trang benh, tien liidng cung nhii xac dinh thai do xii tri. - Viem tuy cap the phu - Viem tuy cap hoai tii: + Hoai tii vo trung + Hoai tii nhiem trung - Ap xe tuy - Nang gia tuy 10.8. Cac marker chi diem trong huyet thanh Ngay nay vdi sii phat trien manh cua khoa hoc noi chung va nganh sinh hoc noi rieng, cac nha khoa hoc di tim cac san pham hoai tii trong viem tuy cap nhii: IL- 6, CRP khi CRP > 150mg/l d ngay thii 2-3 la viem tuy cap the nang, TAP (Trypsinogen activation peptid), yeu to' hoai tii u TNF a (Tumor necrosis factor) 57 11. DIEU TR| VIEM TUY CAP Dieu tri viem tuy cap phai diia tren sii ket hdp cua dieu tri noi khoa va ngoai, khong co mot loai dieu tri rieng biet dac hieu nao trong dieu tri viem tuy cap. 1 1 . 1 . Dieu trj noi khoa • Viem tuy cap khong do soi mat. • Dat sonde da day va hut cho den khi benh nhan co nhu dong ruot trd lai, bung xep thi rut bo • Hoi siic dieu tri tinh trang shock (Neu co): - Truyen dich: Huyet thanh man, ngot, dich keo, huyet tiidng. - Theo doi sat mach, huyet ap, nhip thd, tinh trang niidc tieu. - Dung cac thuoic van mach: Dopamin, dobutamin, adrenalin hoac noadrenalin neu can • Giam dau: - Dung mependin (Pethidin) hoac Keterolac (khong dtfdc dung morphin) - Co the dung phiidng phap phong be than kinh, gay te ngoai mang ciing. Khong nen sii dung thuoc chong viem khong steroid vi lam tang sii suy giam chiic nang than va nguy cd chay mau da day - ta trang. • Chong suy giam ho hap: - Choc hut mang phoi neu co tran dich mang phoi - Thd oxy bang dat sonde qua mui, dung ho hap ho trd vdi ap luc diidng trong triidng hdp can thiet • Giam bai tiet dich tuy: 58 - Benh nhan nhin an, hut dich da day TrUdng hdp viem tuy cap the nang, can nuoi diidng bang diidng tinh mach, vdi che do giau dinh diidng bang glucid va lipid, khi dau hieu cua viem tuy cap giam di, cd the cho an uong trd lai bang cach: + Cho an uong bang diidng mieng neu tinh trang benh nhan kha va cd the an uong bang diidng mieng. + Bdm thtic an de hap thu (dung dich acid amin, dudng, vitamin) qua sonde da day +TrUdng hdp nang can nuoi dudng dai ngay, cd the md thong hong trang de bdm thUc an de hap thu - Dung thuoc khang H2 + Cimetidin 200mg x 4 vien/24gid hay losec 40mg x 1-2 ong/2 4 gid + Sandostatin tu nhien • Dieu tri suy giam chUc nang than - Can hoi sUc tot, bu du khoi lUdng tuan hoan, dung thuoc ldi nieu (Lasix), hay chay than nhan tao neu can. • Dieu tri bien chUng dong mau rai rac trong long mach - BSng chat Uc che tieu sdi huyet va truyen tinh mach nhflng yeu to' dong mau (huyet tUdng tUdi, yeu to'VIII, tieu cau). Viec dieu tri bang heparin, calciparin dang cdn dUdc ban cai, vi cd the gay nguy cd chay mau. • Chong nhilm khuan - Chi dung khang sinh khi cd bieu hien nhiem trung dudng mat, ho hap... hay khi o hoai tu tuy nhiem trung, tot nha't la dUa tren ket qua nuoi ca'y vi khuan va khang sinh do. 59 Viec dung khang sinh du phong, nhat la trong viem tuy cap the phu la khong c&n thiet 11.2. Dieu trj ngoai khoa Chi dat ra khi co nguyen nhan ro rang, hay co bien chiing can can thiep hoac triidng hdp khong chan doan chac chan la viem tuy cap va cung khong loai trU dUdc tinh trang cap ciiu bung ngoai khoa, buoc phai mo tham do. Chi dinh: - Viem tuy cap do soi, giun (co the dieu tri qua noi soi can thiep). - Ap xe tuy. - Nang gia tuy gay bien chiing. - Viem phuc mac toan the do hoai tii tuy nang. Muc dich: - Giai quyet nguyen nhan gay tac neu co. - Lay bo to chiic hoai tii: cat tuy dien hinh hay khong dien hinh. - Dan lUu tot hau cung mac noi. - Md thong hong trang de nuoi dudng: nen ap dung trong dieu kien khong dam bao nuoi diidng diidng tinh mach. - Dan liiu tui mat. Viem tuy cap hoai tu thiidng diia t6i cac bien chiing nhii: o hoai tii, ap xe tuy, nang gia tuy, doi hoi phai dieu tri bang ngoai khoa, cian theo doi tien trien tren lam sang, ket hdp vcli can lam sang va chan doan hinh anh, tren cd sd do ma xac dinh dUdc tinh trang, mUc do, vi tri cua thudng ton de co quyet dinh ngoai khoa dung dan. 60 - O hoai tii: O hoai ta vo trung co the ttf tieu, vdi o hoai tu nhiem trung can chi dinh mo: lay to chiic hoai tii tuy va djch hoai tii, dat dan ltfu, viec cat bo tuy la phau thuat rat nang va rat kho khan ve mat ky thuat, thtfdng chi co the lam khi ton thiidng khu tru d vung duoi tuy (cat duoi tuy). - Ap xe tuy: Mo dan lUu mu va to chiic hoai tii, dan lUu tot, ttfdi riia qua ong dan ltfu sau mo. - Nang gia tuy: Mo khi nang ton tai lau, to ra, hoac that bai bang choc hut, de noi nang vdi dtfdng tieu hoa, tuy theo vi tri nang, neu khu tru d duoi tuy thi co the cat bo duoi tuy * Viem tuy cap do soi mat Viem tuy cap do soi mat hay giun dua chui len dtfdng mat can can thiep ngoai khoa de loai trr nguyen nhan gay viem tuy cap. - Viem tuy cap the nhe: mo cang sdm cang tot, loai bo nguyen nhan. Co the tien hanh f hau thuat noi soi o bung de c4t tui mat neu nguyen nhan la soi tui mat ddn thuan. - Viem tuy cap the nang (co bien loan toan than, suy giam chtic nang sinh ton, de doa tinh mang benh nhan): Can dieu tri noi khoa, hoi siic tich ctfc, khi toan trang on dinh thi mo sdm de giai quyet nguyen nhan. Ngay nay vdi stf phat trien va ap dung noi soi can thiep de tien hanh cho cac trtfdng hdp nhtf sau: - Co trtfdng hdp chi can cat cd vong va lay soi, giun dua bang noi soi, khong can phai can thiep phau thuat. 61 - Triidng hdp cd nhieu soi, soi trong gan thi thu thuat tren chi la can thiep biidc dau trong tinh trang nang, khi tinh trang benh on dinh, can mo de giai quyet triet de nguyen nhan, phong viem tuy cap tai phat. - Triidng hdp viem tuy cap do giun chui vao ong mat, hay ong tuy, thu thuat soi da day - ta trang, noi soi mat tuy ngiidc dong de lay giun dua la rat hieu qua va tranh diidc phau thuat cho benh nhan. Thdi diem can thiep: Hien nay tren the gidi van con nhieu tranh cai, ve thdi diem can thiep trong dieu tri viem tuy cap do soi diidng mat, mot so’ tac gia cho rang viec can thiep ngoai khoa sdm, da lam tang ty le bien chiing va tii vong cua viem tuy cap do soi mat. Theo J.L Boullot[18] thi d cac niidc Au-My, trong mot thdi gian dai triidc day co quan diem dieu tri bao ton, chd ddi trong nhieu thang, triidc khi dat ra mot thao tac ngoai khoa tren diidng mat, nhiing quan diem nay dan den viec, khong the con kha nang can thiep ngoai khoa tren nhiing benh nhan da qua suy sup the trang, do do hien nay ngiidi ta chu triidng can thiep ngoai khoa sdm tren diidng mat trong viem tuy cap do soi mat Nam 1981 Stone va cong sii da nghien ciiu tren 70 benh nhan viem tuy cap do soi mat, diidc chia thanh 2 nhom: Nhom mo cap ciiu va sdm trong vong 3 ngay, tinh tii luc vao vien va nhom benh nhan mo sau vai thang, tac gia nhan thay, nhom mot cd 1 benh nhan tii vong, nhom hai cd 2 benh nhan tii vong. Belghiti [19] va cong sii nghien ciiu 38 benh nhan viem tuy cap do sdi mat, diidc md sdm triidc 5 ngay, thay 90% viem tuy cap lanh tinh va cd the can thiep ngoai khoa day du tren diidng mat, cho ket qua tot Boullot vdi mot nghien ciiu 41/48 benh nhan viem tuy cap do soi mat, diidc md theo cac thdi diem khac nhau, da cho ket 62 qua nhu sau: Nhom mo sdm (Trung binh 2,2 ngay ) ty le tu vong 32%, mo cap cUu tri hoan 15%, mo muon 0%, nhung sU khac biet nay chUa co y nghia thong ke, tac gia cung cho rang so sanh sU khac nhau cua cac ket qua nghien ctiu la mot viec kho, bdi vi ty le % benh nhan nang thay doi theo tting nghien ctiu, ty le tu vong cao cua nhom mo sdm co the dUdc giai thich bang tinh trang nang ngay tti khi benh nhan vao vien Mot so" tac gia cung co quan diem nen can thiep cap ctiu doi vdi viem tuy cap do soi giun dUdng mat- tuy C) Viet Nam nam 1945 GS Ton That Tung [6] qua nghien ctiu 54 benh nhan viem tuy cap, quan diem cua tac gia la, mo cap ctiu he thong cac trUdng hdp viem tuy cap do soi mat va giun, tren nguyen tac la lam cac thu thuat can thiet va toi thieu. Trong nghien ctiu cua chung toi ve thdi diem can thiep, chung toi da chia thdi diem can thiep theo cac tac gia trong nude: cap ctiu (trong 24 gid dau), sdm (trUdc 48 gid), tri hoan (sau 48 gid) vdi ket qua la: can thiep cap ctiu 59,5%, can thiep sdm 31,9%, can thiep tri hoan chi co 8,6%. Chung toi tim moi quan he gitia ket qua dieu tri can thiep vdi thdi diem can thiep, dUa tren so lieu nghien ctiu d Bang4.44. Cho den nay tren the gidi v&n con 3 quan diem ve thdi diem can thiep doi vdi viem tuy cap do sdi mat. Cap ctiu ( Trong 24 gid dau) Sdm (Tti ngay thti 2-7): khi xet nghiem sinh hoc trd ve binh thUdng Tri hoan (Khoang 6 tuan sau giai doan cap tinh) Qua nghien ctiu cua chung toi, cung nhu quan diem cua GS.Ton That Tung, cac phau thuat vien Viet Nam cd xu hUdng can thiep cap ctiu va sdm vi cung v6i van de viem tuy cap thi 63 van de tac mat do soi, giun, nhiem trung, nhiem doc, do soi can co can thiep sdm de loai trti nguyen nhan. Quan diem nay da giup ha thap ty le tti vong trong dieu tri viem tuy cap do soi giun diidng mat-tuy - Phiidng phap can thiep: Ben canh phiiOng phap dieu tri viem tuy cap do soi giun dtfdng mat-tuy bang phau thuat la chu yeu 84,1% tai benh vien Viet Diic tii nam 1996 da trien khai va ling dung noi soi mat-tuy ngiidc dong trong dieu tri, day la mot phiidng phap it xam hai den ngiidi benh, can thiep nhe nhang va tranh cho ngiidi benh dtfdc mot cuoc mo, giai quyet dtfdc tinh trang cap ciiu nang triidc mat cua benh nhan, nhii nhiing benh nhan co tinh trang tac mat, viem diidng mat nang hay mac cac benh phoi hop nhii lao phoi..., ma neu can thiep bang phau thuat se diia nhieu nguy cd cho tinh mang ngiidi benh hoac cac trtfdng hop viem tuy cap do giun chui vao dtfdng mat-tuy. Dtfdi day la ket qua nghien ctiu cua mot so tac gia ntfdc ngoai ve vai tro cua noi soi mat tuy ngiidc dong trong cap ctiu doi vdi viem tuy cap do soi mat. Day la mot thu thuat can thiep nhe nhang dtfdc tien hanh sdm khi xac dinh ro viem tuy cap (Hinh 3.3 ) cung nhii xac dinh chinh xac nguyen nhan soi hay giun nam d cac vi tri dtfdng mat-tuy, noi soi can thiep dtfdc chi dinh khi: - VTC the nhe ( the phu), xac dinh dtfdc giun nam d Oddi hay OMC - VTC co sdi nam d OMC, soi ket Oddi. Lay soi dtfdng mat chinh: + Chi dinh lay soi OMC ddn thuan + Ldi diem cua PTNS lay soi OMC la sau mo it dinh. + Nhtfdc diem cua thu thuat la rat kho khan khi benh nhan da co tien stf mo mat vi sau mo mat thtfdng rat dinh 64 Han che: - Khong kiem tra diidng mat trong gan day du, neu khong co chup diidng mat trong mo. - Soi ket Oddi, hoac Oddi chit hep phai tien hanh md rong cd that ngiidc dong qua ERCP Hinh 3.3.Lay soi bang dung cu ( Ro) qua noi soi ngiidc dong. Khong nen chi dinh noi soi can thiep cho cac triidng hdp sau: VTC the hoai tii nang VTC co bien chiing viem phuc mac, ap xe tuy... VTC do soi tui mat + soi trong gan VTC do soi OMC + soi trong gan. 65 Trong trUdng hdp soi hoac giun lay de Oddi khong chit hep co the bdm rUa dudng mat sach, ngUdc lai neu Oddi chit hoac hep nhieu thi md cd that Oddi d vi tri llh , roi luon sonde Dormia len dudng mat hoac tuy de lay soi hoac giun va bdm rUa dudng mat, co trUdng hdp sau khi lay soi giun nen dat mot sonde Nazo- Biliare (dudng mat-mui) de dan lUu mat. Mot Uu diem ntia la khi noi soi can thiep co ket qua, thi dien bien cua VTC se nhe hdn, thdi gian dieu tri ngan hdn, chUc nang tuy hoi phuc nhanh hdn. Nhu vay noi soi mat-tuy ngUdc dong can thiep la mot phUdng phap hieu qua trong dieu tri benh ly gan mat- tuy. * Thdi do xii tri tren tuy: Tien hanh dan lUu hau cung mac noi, md bao tuy + dan lUu hau cung mac noi, lay to chUc hoai tu + dan lUu, dan lUu ap xe tuy, cat than duoi tuy, chi tham do tuy Khi thUdng ton dai the tuy la viem xuat huyet hoai til, thi thai do xii tri tUdng Ung la ngoai dong tac tham do tuy, phai hoac: Dan lUU hau cung mac noi, Md bao tuy + Dan lUu hau cung mac noi, Lay to chUc hoai tu + Dan lUu, Dan lUu ap xe tuy va khong co trUdng hdp nao cat than duoi tuy.TrUdng hdp viem tuy cap the phu, thi chi co tham do tuy. Phiidng phap can thiep tren diidng mat: Hien nay quan diem xU tri doi vdi nhiing benh nhan viem tuy cap do sdi giun dudng mat-tuy la, giai quyet nguyen nhan gay viem tuy cap, o nhiem khuan, tinh trang U mat, rieng doi vdi nhung benh nhan cd tinh trang nang trUdc md, cd nhieu yeu to nguy cd nhu tuoi cao, da md ve benh gan mat nhieu lan, mac cac benh phoi hdp...Can hoi sUc tot, chi tien hanh md khi toan trang benh nhan tot len, dn dinh va neu cd md thi, cung chi nen tien hanh nhUng thu thuat ngoai khoa can thiet va tdi thieu de giai quyet tac nghen d phan thap ong mat chu va 66 Oddi cung vdi viec dan lUu diidng mat, hoac lam noi soi can thiep budc dau, viec giai quyet triet de nguyen nhan se diidc tien hanh d lan mo sau: + Cat tui mat + md OMC de lay giun soi hay tham do + dan luu Kehr la chu yeu.Md OMC lay soi giun + dan lUu Kehr. + Cat tui mat ddn thuan trong trUdng hdp xac dinh viem tuv cap do soi tui mat bang phUdng phap mo md la chu yeu.NhUng tU 2002 den nay chung toi da tien hanh phau thuat noi soi cap cUu cho cac trUdng hdp viem tuy cap do soi tui mat den sdm.chUa co bien chUng dat ket qua tot. (xem Hinh 3.4) Hinh 3.4. Phau thuat cat tui mat noi soi. 67 12. KET LUAN Co svf khac nhau ve nguyen nhan viem tuy cap d cac niidc nhiet ddi va cac niidc Au - My. Trong khi viem tuy cap d cac niidc phat trien, chu yeu la do riidu manh va soi mat, soi mat cl day chu yeu la soi cholesterol, cd che hinh thanh soi la do roi loan chuyen hoa thi d Viet Nam viem tuy cap do soi mat va do giun dua gay nen, soi mat chu yeu la soi sac to" va soi hon hdp, giun dua khong nhiing triic tiep gay nen viem tuy cap, ma con gian tiep hinh thanh soi mat d cac liia tuoi lao dong chinh cua xa hoi do de tiep xuc vdi nguon nhiem giun trong qua trinh sinh hoat lao dong. Chan doan xac dinh viem tuy cap can phai tien hanh sdm, phat hien nhiing nguyen nhan cd hoc de chi dinh can thiep phau thuat hay noi soi can thiep,tranh dan den hoai tu to chiic tuy. TAI LIEU THAM KHAO Tieng Viet 1. Ton That Bach, Nguyen Thanh Long, Kim Van Vu (2001) “Mot so' nhan xet ve ket qua dieu tri viem tuy cap hoai tii khong do nguyen nhan cd hoc tai khoa phau thuat cap ciiu bung Benh vien Viet Diic” . Ky yeu cong trinh nghien ciiu khoa hoc ( Ky niem 95 nam Benh vien Viet Diic 1906-2001) Tap 2 trang 16-21 2. Nguyen Thi Hang (2002), “Nghien ciiu dac diem lam sang can lam sang va hinh anh sieu am cua viem tuv cap”. Luan van tot nghiep bac sy chuyen khoa cap 2 3. Hoang Thi Huyen (2004), “Doi chieu mot so trieu chiing lam sang trong viem tuy cap vdi phan do nang nhe cua Imrie va Balthaza “, Luan van thac sy Y hoc. Dai hoc Y Ha Noi 68 4. Nguyen Diic Ninh (2001),’’Viem tuy cap” Benh hoc ngoai sau dai hoc Tuy - Lach, NXB khoa hoc va ky thuat, trang 35-51 ^ 5. Ha Van Quyet, Le Quang Ciidng (2004). Nghien ciiu chan doan va dieu tri can thiep viem tuy cap do soi va giun tai B W D . Tap chi' Y hoc Viet Nam 304, 177-181. 6. Ton That Tung (1961j, “Chan doan viem tuy cap tinh d Viet Nam”, Cap cOfu ngoai. NXB Y hoc, trang 107-115 7. Nguyen Thuyen (1980), “Nghien ciiu moi tUdng quan nhan qua giiia giun chui ong mat va soi mat”. Ngoai khoa, so" 6, trang: 161-170 8. Doan Thanh Tung (2002), “Nghien ciiu ling dung: Phiu thuat noi mat - ruot theo phiidng phap Roux- En-Y v6i dau ruot dat dii6i da kieu Fagkan-Chou Tsoung cai tien de dieu tri sot soi va soi tai phat sau mo “ Luan an tien sy Y hoc. Dai hoc Y Ha Noi 9. Nguyen Khanh Trach(2002), ‘Viem tuy cap”, Tai lieu tap huan chuyen nganh tim mach, tieu hoa, noi tiet, Benh vien Bach mai 10. Nguyen Viidng (2000), “Benh cua tuy”. Giai phau benh hoc (tai ban lan thii nhat), NXB Y hoc Ha Noi trang: 346-357 Tieng Anh 11. Balthazar.E.J, Robinson.D.L, Megibow.E.J (1990J, “Acute pancreatitis: Value o f C.T in etablishing prognosis”, Radiology 174:331-336 12. Carter.D.C(1989), “Special aspects of gallstone pancreatitis Surgery of the pancreas, Edited by Michael Trede, David C Carter, p 249-26 69 13. Frey.C.F (1979), “Hemorrhagic pancreatitis”, Am. J. Surg, 137:616 14. Gastrointestinal Endoscopy (1999), “The role ofERCP in diseases of the biliary tract and pancreas”. Guidelines for clinical application of American society for Gastrointestinal Endoscopy. Gastrointestinal Endoscopy, vol 50,N0.6, p 915-920. 15. Howard.J.M (1960), “Pancreatitis Associated With Gallstones”. Surgical Diseases of the Pancreas p 169-186 16. Longerbeam.J.K(1976), “Sequestrectomy and hyperalimentation in the treatment of hemorrhagic pancreatitis”, Am.J.Surg, 132:274 17. Ranson, J.H.C(1979), “Acute pancreatitis". Curr. Probl.Surg, 16 (11): 1 Tieng Phap 18. Bouillot J.L, Alexandre J.H (1987),’Pancreatites biliaires: Quand operer?”, J.Chir (Paris) 124N°10, p 509-514 19. Belghiti.J et Coll (1987), “Traitement precoce de la lithiase biliaire au cours des pancreatites biliaires”, Gastroenterol. Clin. Biol. 11. p 786-789 70 PHAN IV VIEM TUY MAN VA SOI TUY 1. M dB A U Viem tuy man (VTM) va soi tuy la mot benh ly kha pho bien, dac biet tai cac niidc Au, My[4,6], Theo thong ke tai My (1962) ty le mac viem tuy man va soi tuy la 4/100.000 ngiidi dan, d Phap (1970) la 1/100.000 ngiidi d Thuy dien (1970) la 6,9/100.000 ngiidi cho den nam 1975 da gia tang 10/100.000 ngiidi[12], Viem tuy man va soi tuy co lien quan chat che vdi nhau. Neu soi nam trong o’ng Wirsung se gay ii dong dich tuy, lam ong tuy gian, khi lang dong calci d cac nhanh nho cua ong tuy dan den sii calci hoa, xd hoa to chiic hay soi nhu mo tuy va nhii vay day cung la hinh anh cua viem tuy man. Mot so yeu to" khac nhii riidu, che do an... cung gay ra viem tuy man. 6 Viet Nam hien chiia co cac nghien ciiu day du ve dich te trong cong dong ve soi tuy va viem tuy man. Cawley lan dau tien phat hien va mo ta nam 1788. Trai qua tren 200 nam cho den nay viec chan doan, phat hien viem tuy man va soi tuy da co nhieu tien bo nhd ap dung cac phiidng phap tham do hien dai nhii sieu am(US), chup cat ldp vi tinh (CT), sieu am noi soi (EUS), noi soi mat- tuy ngiidc dong (ERCP), chup cong hiidng tii (MRI),... da diia ra nhiing chi dinh dieu tri thich hdp. Tuy nhien viec xac dinh nguyen nhan, cd che benh sinh, nhat la dieu tri viem tuy man va soi tuy hien con gap rat nhieu kho khan. Dieu tri viem tuy man va soi tuy doi hoi phai 71 co sii ket hdp giiia thay thuoc noi khoa va ngoai khoa trong do dieu tri noi khoa dong vai tro rat quan trong. Phau thuat chi diidc dat ra khi co nhiing chi dinh cu the nhii nghi ngd ton thiidng khu tru d mot phan cua tuy, gian Wirsung, soi tuy ... Hien da co nhieu phau thuat diidc ap dung trong dieu tri viem tuy man va soi tuy nhii cat tuy ban phan, noi tuy ruot vdi cac ky thuat khac nhau. Moi mot phiidng phap phau thuat deu co nhiing chi dinh cu the va nhiing liu, nhiidc diem khac nhau do do den nay van chiia co diidc sii thong nhat trong viec liia chon phiidng phap phau thuat. d niidc ta trong nhiing nam gan day so benh nhan viem tuy man va soi tuy diidc phat hien va phau thuat ngay cang nhieu nhiing con rat it nhiing nghien ciiu sau va day du ve benh ly nay. 2. NGUYEN NHAN GAY VIEM TUY MAN Cd nhieu nguyen nhan gay viem tuy man song nguyen nhan cd the xep thanh 2 loai nhii sau: - Viem tuy man nguyen phat hay viem tuy man tii dong cdn goi la xd tuy. - Viem tuy man thii phat (nhieu nguyen nhan nhii do riidu chan thiidng, sdi mat, tac oddi...)[4,15]. 2.1. Rircfu Thiidng gap nhieu d chau Au, chau My, trung Phi va cdn gap d chau a chu yeu gap d nam gidi, nhiing benh nhan viem tuy man nay cd tuoi trung binh la 40, thdi gian uong riidu trung binh la tren 10 nam, cd tii 60-70 % sd benh nhan viem tuy man cd tien sii uong riidu keo dai (tii 6 den 12 nam) va uong nhieu riidu (150 - 175 gr / lngay) [5,10], Ngoai ra cdn cd tii 30 den 40 % sd benh nhan viem tuy man khong xac dinh ro diidc nguyen nhan, sd do dUdc xem nhii viem tuy man nguyen phat tuy nhien cd tac gia lai cho ring 72 nguyen nhan do rUdu cd ban hay gap d chau au con d nil6c chau a nhu Trung Quoc thi nguyen nhan gay ra viem tuy man lai chu yeu la cac benh lien quan den dudng mat vi du nhii soi mat, giun chui ong mat, viem tui mat... co tac gia neu len ty le nguyen nhan gay ra viem tuy man do suy dinh dudng d chau Phi va chau a la rat cao. Cac tac gia chau au dua ra nhung nghien ciiu ve cac yeu to lien quan den soi tuy va viem tuy man v6i so" lieu nhu sau: Bang 4.1: Viem tuy man lien quan den tuoi, gi6i va ri/ou con a chau Au.[15] Tac gia Ten nirdc Tuoi trung binh bj benh VTM Nam gidi % Lien quan den riidu, con % A.F.C. Phap 44,4 92,3 85,9 Estrada Tay ban nha 39 85 71,9 Servais Bi 44 72.2 74 Andersen Dan mach 48 70 62 2.2. Nguyen nhan do cirdng can giap: cac the lanh tinh hay ac tinh deu co the gay ra viem tuy man calci hoa 2.3. Nguyen nhan do di truyen: thiidng gap d liia tuoi diidi 15, benh tuy doi co lien quan den sii thay doi cua nhiem sac the 73 Dominant dorsal duct (ot Santorini) Ventral duct (of Wirsungi Hinh 4.1. Tuy doi ( Pancreas divisum) 2.4. Nguyen nhan cac benh dtfdng mat Theo Hess ty le nay la 58%.[14], do cac nguyen nhan d vung bong Vater gay chit hep nhii do u, viem nhiem, do soi mat d bong Vater. 2.5. Nguyen nhan do soi tuy Co the co soi trong ong tuy hoac calci hoa tuy d nhu mo tuy vi tri d dau tuy, than hay duoi hoac co can xi hoa d khap ca tuy. Theo Edelmann giiia soi tuy va viem tuy man cai nao la nguyen phat va cai nao la thi! phat thi kho phan biet vi soi trong ong tuy se gay nhiem khuan, gay viem tuy va calci hoa nhu mo tuy, sii lang dong calci d nhu mo va cung tao nen soi trong ong tuy. Ban chat cua soi tuy la sii ngifng ket protein trong cac ong tuyen va sau do la sii ket tua cua calci carbonat tao thanh soi. Trong dieu kien benh ly da thuc day qua trinh ket tua nay. 2.6. Nguyen nhan do viem tuy cap: Ngay nay ngiidi ta da chiing minh diidc yeu to" nay. 74 3. PHAN LOAI VIEM TUY MAN Trong phan loai cua Marseill - Rome [4,7] chia viem tuy man lam 2 loai: 1. Viem tuy man do nghen, co tac nghen va gian ong tuy tren cho tac 2. Viem tuy man calci hoa, the nay hay gap d nam gidi nguyen nhan chu yeu thudng do rUdu con. Viem tuy man la ton thiidng viem man tinh cua tuyen tuy pha huy nhu mo kem xd hoa tuyen tuy bao gom ca noi tiet va ngoai tiet, ngiidi ta nhan thay rang doi v6i viem tuy cap, sau khi tuy bi “da kich” thi nhiing thiidng ton ve mat hinh thai, cau true, chiic nang cua tuy co the trd lai binh thiidng con d viem tuy man thi nhiing thiidng ton nay se dien bien theo chieu hii<5ng xau va hau nhii khong the dao ngUdc. 4. CHAN DOAN Chu yeu diia vao cac trieu chiing dau bung, roi loan tieu hoa, vang da... trieu chiing lam sang cua benh ngheo nan, chan doan phai ket hdp vdi can lam sang dac biet la cac chan doan hinh anh. 4.1. Trieu chumg lam sang 4.1.1. Dau: Dau bung la trieu chiing lam sang chu yeu trong viem tuy man va soi tuy vi dau hieu dau bung gap d hau het cac triidng hdp benh nhan viem tuy man va soi tuy do cung la ly do chinh khien benh nhan den thay thuoc de kham benh. Dau vung tren ron, dau lan ra sau liing co the dau keo dai, dau dai ding, kho dieu tri, dau thanh tiing ddt ciidng do co the thay doi co khi dau di dau lai nhieu lan co khi co cdn dau troi len, diidc mo ta la dau quan, dau dii doi, benh nhan phai co nhiing tii the thay doi de giam dau “tu the giam dau cua viem 75 tuy man”, dau lan ra sau liing, len ngiic, co kem non hoac khong non... Cac thuoc giam dau cung chi la tam thdi tham chi' chi choc lat sau dot dau benh nhan trd lai binh thiidng vdi trieu chiing dau nhu vay benh nhan de bi chan doan nham la benh khac nhii: Loet da day ta trang soi mat soi tiet nieu viem dai trang.... Giai quyet van de dau trong viem tuy man va soi tuy cung la muc tieu can ban trong dieu tri ngoai khoa doi vdi benh nay co the goi do la phau thuat giam dau. norwai, CHROWf pancreatitis Hinh 4.2. Ton thudng than kinh trong viem tuy man - Dau trong viem tuy man diidc biet do nhieu nguyen nhan nhii to chiic xd phat trien chen ep cac nhanh than kinh va lam ton thiidng chung. Ngiidi ta nhan thay rang co mot sii thay doi cua than kinh trong viem tuy man do la sii gia tang ve kich thufOc cua diidng kinh sdi than kinh va sii tan ra bao ngoai cua bo sdi than kinh. - Dau do chit hep doan cuol ong mat chu, vi to chiic xd lam cho ii mat vang da, do chen ep mach, chen ep mon vi ta trang... - Dau do tang ap liic trong ong tuy va nhu mo tuv: Nguyen nhan diidc coi la “ Nhan to" can ban gay ra sU dau” 76 la tang ap lac trong ong tuy. Bradley, Sato va cong sii da chiing minh rang: ap lUc do dUdc trong ong tuy cua benh nhan viem tuy man cao hdn 6 nhom doi chting va dUa ra chi so la 38 ± 12,5 cm H20. Nhieu tac gia thong bao chi so" ap lac do dUdc d benh nhan viem tuy man cao hdn binh thudng. Cung sii dung ky thuat noi soi Okazaki va cong sii da do duoc ap lac trong ong tuy benh nhan viem tuy man cao (42,1 mmHg), cao hdn binh thUdng (16 ±8,7 mmHg ) va cung tim thay nhang gia tri cao hdn trong viem tuy man co dau so vdi viem tuy man khong dau, do daoc ap liic cua mo tuy trong phau thuat cao hdn so vdi chi so do dUdc sau khi da phau thuat dan lau ong tuy. [9,10]. Trong nghien ciiu cua chung toi dau hieu dau bung vung thudng vi chiem ty le rat cao (98,5%) so lieu nay phu hdp vdi ty le trong nghien ciiu cua mot so" tac gia khac. Dau bung la trieu chiing lam sang chu yeu cua VTM, benh nhan dau thudng thi dau am i vung tren ron, lan ra sau lUng hay len vai den dieu tri tai benh vien vai ngay thi khoi, chan doan khong rd rang, cung chinh vi vay benh nhan thudng bi chan doan nham vdi cac benh khac, trong nghien ciiu cua chung toi so" benh nhan co chan doan trade khi tdi benh vien 23 trUdng hdp nhang chan doan Khong phai la VTM va sdi tuy trUdc khi den benh vien Viet DUc nhu Loet da day ta trang,sdi mat... Cd nhUng benh nhan vdi nhting chan doan tren da di kham chtia nhieu ndi trong mot thdi gian keo dai nhieu nam. Benh nhan cd the dau bung thudng vi thanh cdn, du doi lan Ion hoac dau dai dang, kho dUt cdn dau, phai ngoi gap ngUdi lai mdi de chiu ( tu the giam dau dien hinh cua ngUdi benh soi tuy 4.1.2. Sut can: Benh nhan cd dau hieu sut can trong nghien cUu nay chiem ty le kha cao 89,7%, benh nhan nhap vien chu yeu cd the trang g&y chiem 86,8% chi so can nang trung binh trong nghien ctiu cua chung toi la 46,69 ± 5,27 77 Sut can d giai doan dau, sut can do roi loan tieu hoa (RLTH), do thieu ngoai tiet, an kem chan an, va den giai doan sau la suy kiet phan ldn nhiing benh nhan viem tuy man co the trang gay do ho bi roi loan hap thu. 4.1.3. Chan an, an kem,roi loan tieu hoa: ia chay keo dai hoac ia phan md, phan song gay nen hoi chiing kem hap thu.Ngoai ra nhiing dau hieu chudng bung, an khong tieu do thieu ngoai tiet cung anh hudng tdi bfia an cua ngiidi benh lam cho ho an kem dan tdi tinh trang suy kiet, trong nghien ciiu cua chung toi so' benh nhan an kem, chan an chiem ty le rat cao (95,58%) - Ia chay, ia phan md. Trong nghien ciiu cua chung toi ia chay tren benh nhan viem tuy man va sdi tuy chiem ty le 41,2. 4.1.4. Vang da: Vang da tiing dot hay tang dan cd the do tac mat, hep doan cuoi ong mat chu (OMC), vang da thiidng di kem theo ddt dau, cung cd the vang da chi thoang qua. Vang da do tac mat cd the coi la bieu hien cua bien chiing trong viem tuy man dau tuy to, to chiic xd vung dau tuy phat trien gay chen ep dudng mat, nang vung dau tuy, ty le nay theo Catter [39] la 20 - 26%. Trong nghien ctiu cua chung tdi ty le benh nhan viem tuy man va sdi tuy cd vang da chiem(32,35%). Trong 22 trUdng hdp vang da cd 16 trUdng hdp cd gian ong mat chu dUdc phat hien bang sieu am, Sieu am cd 15 trudng hdp cd gian OMC va 15 trudng hdp nay deu cd ket qua xet nghiem bilirubin cao trong do 13 trudng hdp dude mo cat khoi ta tuy cdn 2 trudng hdp md noi tuy ruot ket hdp vdi noi mat ruot. Theo Frey [13] cd 45,6% sd benh nhan viem tuy man cd tac mat nhUng chi cd khoang 5 - 10 % trong so" nhiing benh nhan nay can phai can thiep phau thuat giam ap dudng mat. 4.1.5. Dai thao dlltifng: Ty le viem tuy man cd dai thao dudng kha cao. Cd khoang 30% dai thao dudng tren benh nhan sdi tuy. Day 78 la mot trong nhiing bien chiing quan trong cua benh do thiidng ton tuy ngoai tiet dan den thiidng ton tuy noi tiet. Trong nghien ciiu cua chung toi ty le benh nhan co tien sii dai diidng, co glucose mau tang trong xet nghiem triidc mo la 17,64%. 4.2. Xet nghiem Amylase mau co the tang. Amylase mau chi tang nhe hoac khong tang. Nghien ciiu cua chung toi Amylase mau tang trong 51,47% cac triidng hdp. - Bilirubin va phosphattase kiem mau co the tang trong triidng hdp co nghen diidng mat.Nghien ciiu cua chung toi thay bilirubin tang trong 30% triidng hdp day cung la nhiing benh nhan co trieu chiing vang da. - CA19-9: Co triidng hdp diidc lam xet nghiem CA19-9.Nghien ciiu cua chung toi co 4 triidng hdp co ket qua cao > 33 U/ml, day la 4 triidng hdp nam trong nhiing triidng hdp nghi ngd u dau tuy Calci mau: Nhieu tac gia cho rin g ciidng can giap ke ca the lanh hoac ac tinh deu co the gay ra VTM va ngiidi ta tim thay dau hieu tang calci huyet d nhiing benh nhan nay. - Cholesterol mau: Binh thiidng hoac tang nhe. Nghien ciiu cua chiing toi so" co cholesterol mau tang chiem 8,7%. 4.3. Cac phi/dng tien tham do can lam sang 4.3.1. Chup mat - tuy ngupc dong qua noi soi (ERCP) Giup phat hien cau true cua ong tuy va hinh anh soi tuy thong qua hinh anh chup ong tuy co bdm thuoc, phat hien 79 nhiing bien chiing chay mau tii trong ong tuy... thong qua noi soi co the lay soi ra tii trong ong tuy hoac dat stent dan liiu dich tuy tii trong ong tuy trong nhiing triidng hop chi dinh cu the, sinh thiet de chan doan phan biet vdi cac u ac tinh vung dau tuv ta trang. Hinh 4.3. (ERCP) Hinh anh viem tuy man va soi tuy co gian Wirsung Day la mot phUdng phap tham do hien dai cho phep quan sat diidc ta trang vung dau tuy, bdm thuoc can quang va chup dude hinh anh cua ong tuy cho thay sii gian nd cua Wirsung, diidng mat, nhiing hinh khuyet cua soi tuy phat hien u nang thong vdi ong tuy va cung de loai trti nhiing benh khong phai tuy nhii loet da day ta trang, ung thii da day. ERCP con can thiep co hieu qua nhiing triidng hdp tac diidng mat tuy do di vat nhii soi, giun... dat Stent tao liiu thong. Ngoai ra theo chiing toi ERCP con rat hiiu ich trong viec xac dinh bien chiing cua VTM va Soi Tuy. Do la bien chiing chay mau tieu hoa. Chiing toi co 2 triidng hdp bi xuat huyet tieu hoa da diidc phat hien va dieu tri phau thuat kip thdi giai quyet nguyen nhan gay chay mau tuy nhien trong dieu kien nufdc ta hien nay khong phai sd sd dieu tri nao cung diidc trang bi phUdng tien nay va gia thanh de thiic hien no con cao. 80 4.3.2. Sieu am Sieu am la mot phiidng phap hflu fch giup chan doan viem tuy man va soi tuy.Sieu am biet diidc sii thay doi cau true am, bd vien va kich thiidc cua tuy, nhin thay diidc hinh anh calci hoa hay soi tuy.Tren sieu am Wirsung diidc nhin thay trong 90% triidng hdp.Binh thiidng Wirsung co diidng kinh 3mm. Trong viem tuy man Wirsung thudng gian > 3mm.[1,6]. Sieu am d benh nhan soi tuy biet diidc sii thay doi cau true am, bd vien va kich thiidc cua tuy, thay diidc hinh anh calci hoa hay soi tuy, Uu diem cua sieu am la de thiic hien, khong “xam lan”, it ton kem va cho ket qua tot trong viec chan doan phat hien viem tuy man va soi tuy. Hinh 4.4. Hinh anh sieu am cua viem tuy man va soi tuy co gian Wirsung 81